Every finding on record at Rosa Coplon Jewish Home and Infirmary

The following statement of deficiencies represents the results of a partial extended re-certification survey of Rosa Coplon Jewish Home and Infirmary Certified Home Health Agency conducted on 01/29/2024 to 02/01/2024. A standard re-certification survey was initiated on 01/29/2023. Deficient practices were identified within Level I standards G-536 (medication reconciliation) resulting in a partial extended survey on 01/30/2024. The survey consisted of a review of eight (8) discharged clinical records (the agency has no active patients), one (1) personnel record, two (2) contracts, and no observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Committee Meeting minutes for the past twelve (12) months, agency’s Admission packet, the Emergency Preparedness Plan, and Complaint Log. Pre-survey activities consisted of review on 01/22/2024 of the agency’s Health Commerce System (HCS) account, Home Care Worker Registry, Criminal History Record Check, Potentially Avoidable Event Patient Listing Report for the period of 11/02/2022 to 10/23/2023, and the agency’s compliance with submission of statistical reports and emergency drills. The Chief Operating Officer/Administrator and Director of Patient Services were interviewed. Findings were reviewed at the exit conference on 02/01/2024. The following deficiencies are identified as a result of the survey: G-0516, G-0536, G-0574, G-0578, G-0598, G-0716, G-0718, G-1022, J-1156, J-1168, J- 1260, J-1301, J-1304, J-1328, and R-0510.

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview for two (2) of eight (8) patients (Patient #5 and #7), the agency failed to ensure the Physical Therapist conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient's return home, or on the physician-ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. The Physical Therapist failed to conduct the initial OASIS assessment within 48 hours of referral for therapy services as evidenced by the following: Patient #7- This 69-year-old patient with diagnoses that include Alzheimer’s disease, hyperlipidemia, and history of falls was admitted to the agency on 09/11/2023 and discharged on 09/26/2023. Review of the Referral Intake dated 09/05/2023 revealed the patient was referred to the home care agency on 09/05/2023. Review of the Comprehensive Adult Nursing Assessment dated 09/11/2023 revealed the initial Outcome and Assessment Information Set (OASIS) assessment was completed by the Registered Nurse, not a Physical Therapist. Review of the Physical Therapy evaluation revealed the initial Physical Therapy evaluation was completed on 09/14/2023, 9 days after the patient was referred to the agency for physical therapy services. During an interview on 01/31/2024 at 10:21 AM, the Director of Patient Services stated she does not know why there was a delay in the start of care and there is no documentation that the physician was notified. Patient #5- This 92-year-old with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, anemia, and vitamin D deficiency was admitted to the agency on 08/23/2023 and discharged on 09/07/2023. Review of the Referral Intake dated 08/21/2023 revealed that the patient was referred to the home care agency on 08/21/2023. Review of the Physical Therapy Comprehensive Adult Assessment Information Set Start of Care Note dated 08/24/2023 revealed the initial assessment was completed three (3) days after the patient was referred to the agency. Review of the clinical record lacks documented evidence of a physician's order to delay the start of care. During interview on 01/31/2023 at 10:35 AM, the Director of Patient Services stated there should be documentation to explain the delay in the start of care and notification to the physician, but there is not.

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 review of clinical records and interviews with agency staff, for four (4) of eight (8) patients (Patient #s: 1, 5, 6, and 8), the clinical record lacks documented evidence of a complete review of all medications the patient is currently using to ensure accuracy of the orders, identify any potential adverse effects, drug reactions or concerns. Failure to conduct a complete medication review has the potential for the patient to experience medication side effects or to receive incorrect medication dosages. Patient # 8 – This 81-year-old therapy only patient with the diagnoses of seizures, cerebral infarction, and muscle weakness was admitted to the agency on 10/25/2023 and discharged on 11/07/2023. Review of the Clinical Summary completed by the Physical Therapist on 10/25/2023 revealed the Physical Therapist documented “Medication discrepancies: clopidogrel, lisinopril, atorvastatin, aspirin, vitamin D3, vitamin B12, and fish oil.” Review of the clinical record lacks documented evidence the Registered Nurse conducted a complete medication review for possible side effects, discrepancies and drug interactions. Review of the complete clinical record lacks documented evidence the Physical Therapist or Registered Nurse notified the physician of the medication discrepancies. During interview on 01/30/2024 at 01:50 PM, the Director of Patient Services stated the Registered Nurse is responsible for reviewing the medication list obtained from the Physical Therapist. Additionally, the clinical record lacks documentation that the identified discrepancies were reported to the physician as well as documented evidence that the Registered Nurse performed the review. Patient #1- This 81-year-old therapy only patient with diagnoses that include fracture right femur, olecranon bursitis left elbow, and hypo-osmolarity and hyponatremia was admitted to the agency on 11/23/2022 and discharged on 12/14/2022. Review of the Clinical Summary completed by the Physical Therapist on 11/23/2023 revealed the Physical Therapist documented completing a medication reconciliation in the patient's home. Review of the clinical record lacks documented evidence the Registered Nurse conducted a review of all medications to identify possible side effects, discrepancies, or drug interactions. During an interview on 01/31/2024 at 10:35 AM, the Director of Patient Services stated the Physical Therapist reviews the medications in the home and then medications are reviewed by the Registered Nurse; however, the clinical record lacks documentation that this was done. Patient #5 - This 92-year-old therapy only patient with diagnoses that include atherosclerotic heart disease of native coronary artery without angina pectoris, anemia and vitamin D deficiency was admitted to the agency on 08/23/2023 and discharged on 09/07/2023. This patient resides in an Adult Living Facility. The Registered Nurse failed to conduct a complete review of all medications to verify medications are current and to determine whether there are any adverse effects of the medication regime as evidenced by the following. Review of the Physical Therapy Comprehensive Adult Nursing Assessment dated 08/24/2023 revealed the Physical Therapist completed a medication review and determined there were no issues identified during the review. Additionally, the Physical Therapist documented that the physician was contacted and that the Physical Therapist instructed the patient on high-risk drug education. Furthermore, the Physical Therapist documented that the patient is unable to take medication unless administered by another person and that staff at the Adult Living Facility administer the patient’s medications. Review of the Communication note dated 08/12/2023 to 08/27/2023 revealed the Physical Therapist documented on 0/12/2023 that medications were reviewed and there were no medication discrepancies. On 08/25/2023 at 09:15 AM the Physical Therapist documented that the physician was notified, orders were requested, and the Physical Therapist was awaiting a call back. On 08/27/2023 at 12:00 PM the Physical Therapist documented that the Registered Nurse was notified of the start of care and a list of medications was submitted to the Registered Nurse. Review of the complete clinical record revealed there is no documentation that the Registered Nurse reviewed the list of medications. Additionally, there is no documentation that the physician verified order. A.) Review of the Home Health Certification and Plan of Care for certification period 08/23/2023 to 10/21/2023 revealed the following orders: -Bismatrol 262/15 milliliters every 4 hours as needed for diarrhea. -Guaifenesin 100 milligrams/5 milliliters every 4 hours as needed for cough. - Mi-Acid 200-200-20 30 milters as needed for indigestion. - Milk of Magnessia 30 milliliters by mouth every 24 hours as needed for constipation. Review of the Mobil Primary Referral dated 07/27/2023 revealed there is no order for Bismatrol, guaifenesin, mi-acid, and milk of magnesia. There is no documentation in the medical record that the medication discrepancies were identified by the Physical Therapist or Registered Nurse, and no documentation that the physician was made aware of the discrepancies. B.) Review of the Physician Referral dated 07/27/2023 revealed the following orders: - Clobetasol Propionate 0.05% apply bilateral to neck back and shoulders three times a day for 14 days than alternate with Hydrocortisone. -Hydrocortisone 1% apply bilateral to neck back and shoulders three times a day for 14 days than alternate with Clobetasol Propionate. Review of the Home Health Certification and Plan of Care for certification period 08/23/2023 to 10/21/2023 lacks orders for Clobetasol and Hydrocortisone. There is no documentation in the medical record that the medication discrepancies were identified by the Physical Therapist of Registered Nurse, and no documentation that the physician was made aware of the discrepancies. During interview on 01/30/2024 at 01:50 PM, the findings were presented. The Director of Patient Services stated the Registered Nurse is responsible for reviewing the medication list obtained from the Physical Therapist. Additionally, the clinical record lacks documentation that the identified discrepancies were reported to the physician as well as documented evidence that the Registered Nurse performed the review. Patient # 6 - This 88-year-old therapy only patient with diagnoses that include acute respiratory failure with hypoxia, gastrointestinal hemorrhage, and anemia was admitted to the agency on 08/14/2023 and discharged on 08/20/2023. This patient resides in an Adult Living Facility. The Physical Therapist failed to conduct a complete review of all medications to verify medications are current as evidenced by the following. Review of the Physical Therapy Comprehensive Adult Nursing Assessment dated 08/14/2023 revealed the Physical Therapist completed a medication review and documented that the Physical Therapist instructed the patient on high-risk drug education. Additionally, the Physical Therapist documented that the patient is unable to take medication unless administered by another person and the patient care giver organizes medications. Review of the Communication note dated 08/10/2023 to 08/16/2023 revealed the Physical Therapist documented on 08/16/2023 at 05:00 PM that the Registered Nurse reported potential drug interactions to the physician. Review of the complete clinical record revealed there is no documentation that the Registered Nurse reviewed the list of medications. Additionally, there is no documentation that the physician verified order. A.) Review of the Home Health Certification and Plan of Care for certification period 08/14/2023 to 10/12/2023 revealed the following orders: -Sennosides 8.6 milligrams 1 tablet every day by mouth -Folic Acid 1 milligram 1 tablet every day by mouth -Levothyroxine Sodium 100 micrograms 1tablet every day by mouth -MiraLAX 17 grams scoop every day by mouth. -Proair HFA (albuterol sulfate Inhalation Aerosol) 108 micrograms 1 puff as needed for asthma. -Imodium A – D 2 milligrams as needed every six hours for loose stools. -Diclofenac 1% gel 1 application every day for pain. -Melatonin 3 milligrams 1 tablet ay bedtime by mouth. -Meclizine HCL 25 milligrams 1 tablet every four hours as needed for dizziness. -Lisinopril 5 milligrams 1 tablet everyday by mouth. Review of the Discharge Summary date 08/10/2023 lacks orders for Sennosides, Folic Acid, Levothyroxine Sodium, Miralax, Proair, Imodium, Diclofenac, Melatonin, Meclizine and Lisinopril. B.) Review of the Rehab Discharge Summary dated 08/10/2023 revealed the following orders: - Albuterol Sulfate 108 (90Base) 2 puffs every two hours as needed. - Lasix 20 milligrams daily. - Levothyroxine 125 micrograms daily. - Lidocaine patch 4% to shoulders daily. Review of the Home Health Certification and Plan of Care for certification period 08/14/2023 to 10/12/2023 lacks orders for Albuterol Sulfate, Lasix, Levothyroxine and Lidocaine patch. There is no documentation in the medical record that the medication discrepancies were identified by the Physical Therapist of Registered Nurse, and no documentation that the physician was made aware of the discrepancies. Review of the complete clinical record lacks documented evidence the Physical Therapist or Registered Nurse notified the physician of the medication discrepancies. During interview on 01/31/2024 at 10:06 AM, the findings were presented. The Director of Patient Services stated the Registered Nurse is responsible for reviewing the medication list obtained from the Physical Therapist. Additionally, the clinical record lacks documentation that the identified discrepancies were reported to the physician as well as documented evidence that the Registered Nurse performed the review.

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 review of clinical records and interviews with agency staff for five (5) of eight (8) patients (Patient #s: 1, 5, 6, 7, and 8), the agency failed to ensure a comprehensive Plan of Care was developed, based on interdisciplinary assessments, to meet the individualized needs of the patients. Failure to develop a complete Plan of Care that is comprehensive and addresses patient needs has the potential to result in patient harm. Patient # 8 – This 81-year-old patient with the diagnoses of seizures, cerebral infarction, and muscle weakness was admitted to the agency on 10/25/2023. Review of the Referral Intake dated 10/24/2023 revealed the patient was referred to the agency to receive Physical Therapy and Occupational Therapy services. Review of the clinical record lacks documented evidence of an order for Occupational Therapy to evaluate and/or treat the patient. Additionally, there is no documented evidence the Occupational Therapist attempted to contact the patient and/or caregiver or that the patient refused Occupational Therapy services. During interview on 01/31/2024 at 02:03 PM, the Director of Patient Services stated there is no order for Occupational Therapy on the start of care medical orders, but she would look for an interim order or communication note to explain why Occupational Therapy was not involved at the start of care. No further information was provided. Patient #5 - This 92-year-old with diagnoses that include atherosclerotic heart disease of native coronary artery without angina pectoris, anemia, and vitamin D deficiency was admitted to the agency on 08/23/2023. Review of the Home Health Certification and Plan of Care for certification period 08/23/2023 to 10/21/2023 revealed the order for Triamcinolone Acetonide External Cream 0.1% 1 application at bedtime. The medication order is missing a location for topical application. During interview on 01/30/2024 at 11:40 AM, the Director of Patient Services stated that the order should indicate where to apply the cream. Patient #1 - This 81-year-old patient with diagnoses that include fracture right femur, olecranon bursitis left elbow, and hypo-osmolarity and hyponatremia was admitted to the agency on 11/23/2022. A.) Review of the Medication Reconciliation form (form used to complete medication reconciliation but not an order) dated 11/23/2022 revealed the patient was prescribed calcium carbonate/Vitamin D 600 milligram/400 milligram tablet two (2) tablets by mouth daily. Review of the Home Health Certification and Plan of Care for certification period 11/23/2022 to 01/21/2023 lacks an order for calcium carbonate/Vitamin D 600 milligram/400 milligram tablet two (2) tablets by mouth daily. During interview on 01/31/2024 at 10:31 AM, the Director of Patient Services stated the medication was not included in the plan of care. B.) Review of Home Health Certificate and Plan of Care Clinical Summary for certification period 11/23/2022 to 01/21/2023 revealed the Physical Therapist documented the patient is currently taking methotrexate 10 milligram weekly. Review of the Home Health Certification and Plan of Care for certification period 11/23/2022 to 01/21/2023 lacks an order for methotrexate. During interview on 01/31/2024 at 10:34 AM, the Director of Patient Services stated methotrexate should be on the plan of care and it is not. C.) Review of the Case Management Note dated 11/23/2023 revealed the Physical Therapist documented patient’s daughter checks patient’s blood sugar once daily. Review of the Home Health Certification and Plan of Care for certification period 11/23/2022 to 01/21/2023 lacks an order for daily blood sugar testing and parameters for when to notify physician. During an interview on 01/31/2024 at 10:32 AM, the Director of Patient Services stated there are no orders for diabetic management on the plan of care. D.) Review of the Clinical Summary dated 11/23/2022 revealed the Physical Therapist documented patient has a rolling walker, tub bench, and bed rail. Review of the Home Health Certification and Plan of Care for certification period 11/23/2022 to 01/21/2023 lacks orders for the rolling walker, tub bench, and bed rail. During an interview on 01/31/2024 at 10:41 AM, the Director of Patient Services stated the plan of care does not include orders for the patient's equipment. Patient #7 - This 69-year-old patient with diagnoses that include Alzheimer’s disease, hyperlipidemia, and major depressive disease was admitted to the agency on 09/11/2023. This patient resides in an Adult Living facility. A.) Review of the (Assisted Living) Medication Administration Record schedule for September 2023 revealed patient takes a Boost supplement every evening. Review of Home Health Certification and Plan of Care for certification period 09/11/2023 to 11/09/2023 lacks an order for Boost. During an interview on 01/31/2023 at 10:24 AM, the Director of Patient Services stated there is not an order for boost. B.) Review of Comprehensive Adult Nursing Assessment dated 09/11/2023 revealed the Registered Nurse documented the patient uses the following incontinence product: Depends. Review of Home Health Certification and Plan of Care for certification period 09/11/2023 to 11/09/2023 lacks an order for Depends. During an interview on 01/31/2024 at 10:15 AM, the Director of Patient Services stated there is no order for Depends on the plan of care. C.) Review of the Referral Intake dated 09/05/2023 revealed the patient was referred to the agency to receive Physical Therapy services. Review of Home Health Certification and Plan of Care for certification period 09/11/2023 to 11/09/2023 lacks an order for Physical Therapy. Additionally, there is no documented evidence the Physical Therapist attempted to contact the patient and/or caregiver or that the patient refused Physical Therapy services. During an interview on 01/31/2023 at 10:20 AM, the Director of Patient Services stated the patient should have had an order to receive Physical Therapy services, but it was not ordered.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for one (1) of eight (8) patients (Patient # 3), the agency failed to provide services in accordance with physician orders. Failure to ensure patient care is provided in accordance with physician orders has the potential for patients to receive poor care and for health care needs to go unmet. Patient #3- This 51-year-old patient with diagnoses that include pressure ulcer of right heel, stage 3, pressure ulcer of left heel, stage 2, and hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage was admitted to the agency on 11/11/2019 and discharged on 04/21/2023. This record was reviewed as a potentially avoidable event: Increase in number of pressure ulcers and discharged to community with an unhealed stage 2 pressure ulcer. A.) Review of the Home Health Certificate and Plan of Care for certification period 02/23/2023 to 04/23/2023 revealed the Skilled Nurse is to provide services twice a week for eight (8) weeks. Review of the clinical record from 03/05/2023 to 03/11/2023 revealed the Skilled Nurse conducted a visit on 03/09/2023, one (1) less visit than is ordered by the physician. Review of the clinical record lacks documented evidence the physician was notified of the missed visit. During interview on 01/31/2024 at 10:53 AM, the Director of Patient Services stated the Skilled Nurse did not provide services as ordered by the physician. B.) Review of the Home Health Certificate and Plan of Care for certification period 02/23/2023 to 04/23/2023 revealed the order to measure the patient's wound at least weekly. Review of the clinical record from 02/19/2023 to 02/25/2023 lacks documentation of a wound measurement. During an interview on 01/31/2024 at 10:52 AM, the Director of Patient Services stated wound should be measured weekly and it was not.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on clinical record review and interview with agency staff, for one (1) of eight (8) patients who were discharged from the agency (Patient # 8), the agency failed to ensure that discharge planning was communicated with the responsible physician prior to discharge from the agency. Failure to communicate discharge planning has the potential for unmet patient needs. Patient # 8 – This 81-year-old patient with the diagnoses of seizures, cerebral infarction, and muscle weakness was admitted to the agency on 10/25/2023 and discharged on 11/07/2023. Review of the Care Summary Including OASIS (Outcome and Assessment Information Set) Elements for Transfer Note for Inpatient Facility completed by the Physical Therapist on 11/07/2023 revealed the patient was discharged to an inpatient facility on 11/07/2023. Review of the clinical record lacks documented evidence discharge planning was communicated with the responsible physician prior to discharge from the agency. During interview on 01/31/2023 at 03:05 PM, the Director of Patient Services stated she was unable to find documentation regarding planning for the patient's discharge, or why he was now in need of care provided in an inpatient facility.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with staff, for one (1) of eight (8) patients (Patient #3), the agency failed to ensure all clinical notes are complete and accurate and contain all pertinent information about the patient’s status. Failure to document complete and accurate clinical and progress notes has the potential for unmet patient needs. Patient #3- This 51-year-old patient with diagnoses that include pressure ulcer of right heel, stage 3, pressure ulcer of left heel, stage 2, and hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage was admitted to the agency on 11/11/2019 and discharged on 04/21/2023. Review of the Home Health Certification and Plan of Care for certification period 02/23/2023 to 04/23/2023 revealed an order for no added salt diet. Review of the Nursing Visit Notes dated 02/27/2023, 03/09/2023, 03/13/2023, 03/21/2023, 03/28/2023, 04/04/2023, 04/11/2023, and 04/18/2023 revealed the skilled nurse documented regular diet. Review of Discharge Assessment dated 04/21/2023 revealed the Skilled Nurse documented regular diet. Review of the Discharge Instructions dated 04/21/2023 revealed the Skilled Nurse provided instructions for regular diet. During interview on 01/31/2024 at 10:52 AM, the Director of Patient Services stated the clinicians incorrectly documented the patient's diet on the assessments.

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 review of clinical records and staff interview for one (1) of eight (8) clinical records (Patient # 3), the agency failed to ensure there was effective communication and follow-up with the physician involved in the patient’s plan of care. Failure to communicate with the physician involved in the patient's care has the potential for unmet patient needs and negative outcomes. Patient #3 - This 51-year-old patient with diagnoses that include pressure ulcer of right heel, stage 3, pressure ulcer of left heel, stage 2, and hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage was admitted to the agency on 11/11/2019 and discharged on 04/21/2023. This record was reviewed as a potentially avoidable event: Increase in number of pressure ulcers and discharged to community with an unhealed stage 2 pressure ulcer. A.) Review of the Home Health Certification and Plan of Care for certification period 02/23/2023 to 04/23/2023 revealed the following wound care orders: - Right Heel- cleanse with soap and water, pat dry, apply ammonium lactate to intact skin, apply calcium alginate AG (silver) to wound bed, cover with foam dressing, two (2) times a week and as needed by Certified Home Health Agency nurse if soiled/not intact. Review of the Wound Assessment Flow Sheet dated 03/21/2023 revealed the Registered Nurse documented the following right heel wound assessment: - Length (cm): 0.0 cm - Width (cm): 0.0 cm - Depth (cm): 0.0 cm - [Tissue type]: Epithelialized 100% - Drainage amount: none - Drainage color: none - Surrounding skin: erythematous - Edges of wound: closed Review of the Wound Assessment Flow Sheet revealed the Registered Nurse documented changes to the right heel wound on 03/25/2023 as follows: - Length (cm): 0.7 cm - Width (cm): 0.3 cm - Depth (cm): 0.2 cm - [Tissue type]: Granulation 100% - Drainage amount: moderate - Drainage color: serous - Surrounding skin: macerated - Edges of wound: open Review of the clinical record lacks documented evidence the Registered Nurse notified the physician of the changes in length, width, depth, tissue type, drainage amount, drainage color, surrounding skin and edges of wound. B.) Review of the Home Health Certification and Plan of Care for certification period 02/23/2023 to 04/23/2023 revealed the following wound care orders: - Left Heel- cleanse with soap and water, pat dry, apply ammonium lactate to intact skin, apply aquacel AG (silver) to wound bed, apply skin prep to peri wound area, cover with foam dressing two (2) times a week and as needed by Certified Home Health Agency nurse if soiled/not intact. Review of the Wound Assessment Flow Sheet dated 04/04/2023 revealed Registered Nurse documented the following changes to left heel wound assessment: - Length (cm): 2.3 - Width (cm): 2.3 cm - Drainage color: sanguinous Review of the Wound Assessment Flow Sheet revealed the Registered Nurse documented changes to the left heel wound on 04/11/2023 as follows: - Length (cm): 3.0 cm - Width (cm): 2.5 cm - Drainage color: serosanguinous Review of the clinical record lacks documented evidence the Registered Nurse notified the physician of the changes in length, width, and drainage color. During interview on 01/31/2024 at 10:55 AM, the Director of Patient Services stated the Registered Nurse was expected to document notifying the physician of the changes, however the clinical record lacks documented evidence that changes were communicated with the physician.

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 review of clinical records and interviews with agency staff, for seven (7) of eight (8) discharged patients (Patient #1, 3, 4, 5, 6, 7, and 8), the agency failed to develop a complete a discharge summary and send it to the primary care practitioner within 5 (five) business days of the date of the order for discharge. Failure to develop a complete a discharge summary and send it to the primary care practitioner within the required timeframe's has the potential for unmet patient needs and an unsafe discharge. Patient # 8 – This 81-year-old patient with the diagnoses of seizures, cerebral infarction, and muscle weakness was admitted to the agency on 10/25/2023. Review of the Care Summary Including OASIS (Outcome and Assessment Information Set) Elements for Transfer for Inpatient Facility Note completed by the Physical Therapist on 11/07/2023 revealed the patient was discharged to an inpatient facility on 11/07/2023. Review of the clinical record lacks documented evidence the agency completed a discharge summary to send to the primary care practitioner within 5 (five) business days of the date of the order for discharge. During interview on 01/31/2024 at 02:06 PM, the Director of Patient Services said she would look for the discharge summary, no further information was provided. Patient #1- This 81-year-old patient with diagnoses that include fracture right femur, olecranon bursitis left elbow, and hypo-osmolarity, and hyponatremia was admitted to the agency on 11/23/2022. Review of the Physician Telephone order dated 12/14/2022 revealed the patient was discharged on 12/14/2022. Review of the Discharge/Case Not Taken On Notification (discharge summary) dated 12/14/2022 lacks evidence of the following items: Admission and discharge dates; Physician responsible for the home health plan of care; Reason for admission to home health; Type of services provided and frequency of services; Laboratory data; Medications the patient is on at the time of discharge; Patient's discharge condition; Patient outcomes in meeting the goals in the plan of care; and Patient and family post-discharge instructions. Review of the clinical record lacks documented evidence the discharge summary was sent to the physician. During an interview on 01/30/2024 at 02:08 PM, Director of Patient Services stated the discharge summary is incomplete and there is no evidence that it was sent to the physician. Patient #3- This 51-year-old patient with diagnoses that include pressure ulcer of right heel, stage 3, pressure ulcer of left heel, stage 2, and hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage was admitted to the agency on 11/11/2019. This record was reviewed as a potentially avoidable event: increase in number of pressure ulcers and discharged to community with an unhealed stage 2 pressure ulcer. Review of the Physician Telephone order dated 04/21/2023 revealed the Registered Nurse documented discharge from homecare services as no signing physician available- Mobile primary inactivated patient on 04/03/2023; caregiver to continue wound care. Review of the Discharge/Case Not Taken On Notification (discharge summary) dated 04/21/2023 lacks evidence of the following items: Admission and discharge dates; Physician responsible for the home health plan of care; Reason for admission to home health; Type of services provided and frequency of services; Laboratory data; Medications the patient is on at the time of discharge; Patient's discharge condition; Patient outcomes in meeting the goals in the plan of care; and Patient and family post-discharge instructions. Review of the clinical record lacks documented evidence the discharge summary was sent to the physician. During an interview on 01/31/2024 at 02:38 PM, the Director of Patient Services stated discharge summary is incomplete and there is no evidence that it was sent to the physician. Patient #7- This 69-year-old patient with diagnoses that include Alzheimer’s disease, hyperlipidemia, and major depressive disease was admitted to the agency on 09/11/2023. This patient resides in an Adult Living facility. Review of the Physician Telephone order dated 09/26/2023 revealed the Physical Therapist documented the patient was discharged from the agency on 09/26/2023 due to multiple refusals. Review of the Discharge/Case Not Taken On Notification (discharge summary) dated 09/26/2023 lacks evidence of the following items: Admission and discharge dates; Physician responsible for the home health plan of care; Reason for admission to home health; Type of services provided and frequency of services; Laboratory data; Medications the patient is on at the time of discharge; Patient's discharge condition; Patient outcomes in meeting the goals in the plan of care; and Patient and family post-discharge instructions. Review of the clinical record lacks documented evidence the discharge summary was sent to the physician. During an interview on 01/31/2024 at 10:18 AM, the Director of Patient Services stated the discharge summary is incomplete and there is no evidence that it was sent to the physician. Patient # 4 - This 88-year-old with the diagnosis of chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, and low back pain was admitted to the agency on 09/28/2022. Review of the Care Summary Including Physician Telephone Order completed by the Physical Therapist on 11/22/2022 revealed the patient was discharged on 11/22/2022. Review of the clinical record lacks documented evidence the agency completed a discharge summary to send to the primary care practitioner within 5 (five) business days of the date of the order for discharge. During interview on 01/31/2024 at 10:06 AM, the Director of Patient Services stated she would look for the discharge summary, no further information was provided. Patient #5 - This 92-year-old with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, anemia, and vitamin D deficiency was admitted to the agency on 08/23/2023. Review of the Care Summary Including OASIS (Outcome and Assessment Information Set) Elements for Discharge Not to An Inpatient Facility Note completed by the Physical Therapist on 11/07/2023. Review of the clinical record lacks documented evidence the agency completed a discharge summary to send to the primary care practitioner within 5 (five) business days of the date of the order for discharge. During interview on 01/30/2024 at 11:40 AM, the Director of Patient Services said she would look for the discharge summary, no further information was provided. Patient #6 -This 88-year-old with diagnoses that include acute respiratory failure with hypoxia, gastrointestinal hemorrhage and anemia was admitted to the agency on 08/14/2023. Review of the Care Summary Including OASIS (Outcome and Assessment Information Set) Elements for Discharge Not to An Inpatient Facility Note completed by the Physical Therapist on 08/23/2023. Review of the clinical record lacks documented evidence the agency completed a discharge summary to send to the primary care practitioner within 5 (five) business days of the date of the order for discharge. During interview on 01/31/2024 at 10:11 AM, the Director of Patient Services said she would look for the discharge summary, no further information was provided.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of clinical records and interview with agency staff for one (1) of five (5) patients (Patient #3), the agency failed to provide services in accordance with physician's orders. Failure to ensure patient care is provided in accordance with physician orders has the potential for patients to receive poor care and for health care needs to go unmet. Patient #3 - This 97-year-old patient with diagnoses that include an unspecified open wound of right hand, anemia and hyperlipidemia was admitted to the home health agency on 10/06/2022. A.) Review of the Physician Telephone Order dated 10/25/2022 revealed an order to extend the Skilled Nurse (SN) frequency to two times a week for two weeks and two PRN (as needed) visits for wound care or complications. Review of the clinical record for the week of 10/23/2022 to 10/29/2022 revealed the SN made one (1) visit for the week on 10/25/2022. The agency failed to provide SN services in accordance with the physician orders. During interview on 11/02/2022 at 11:15 AM, the Registered Nurse (RN) stated she planned to see the patient on 10/28/2022 but failed to schedule and conduct a second visit that week. B.) Review of the Home Health Certification and Plan of Care for certification period 10/06/2022 to 12/04/2022 revealed orders to evaluate the right hand skin tear for healing and measure wound at least weekly. Review of the clinical record for the week of 10/16/2022 to 10/21/2022 revealed patient cancelled a SN visit on 10/18/2022 and received one (1) SN visit on 10/21/2022. Review of the Nursing Visit Note dated 10/21/2022 lacks documented evidence the RN obtained wound measurements of the right hand wound. Review of the clinical record for the week of 10/23/2022 to 10/29/2022 revealed the patient received one (1) SN visit on 10/25/2022. Review of the Nursing Visit Note dated 10/25/2022 lacks documented evidence the RN obtained wound measurements of the right hand wound. The agency failed to provide weekly wound measurements in accordance with physician orders. During interview on 11/02/2022 at 11:22 AM, the RN stated she measured the right hand wound at both identified visits but failed to document the measurements.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for two (2) of five (5) patients (Patient #'s: 3 and 5), the agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes. Failure to prepare or document complete clinical and progress notes has the potential for unmet patient needs. Patient #3 - This 97-year-old patient with diagnoses that include an unspecified open wound of right hand, anemia and hyperlipidemia was admitted to the home health agency on 10/06/2022. Review of the Physician Telephone Order dated 10/10/2022 revealed new wound care orders to the right hand skin tear to include: cleanse with wound cleanser, pat dry, apply skin prep to peri wound area, cover with foam dressing 2x/wk (two times per week) and PRN (as needed) if soiled/ not intact by CHHA (certified home health agency) Nurse. SN (Skilled Nurse) frequency 2W2 (two times a week for two weeks), 2 (two) PRN for wound care/ complications. Review of the Nursing Visit Note dated 10/21/2022 revealed the Registered Nurse (RN) documented the following: “WC (wound care) completed to right hand. Wound bed remains pink and moist with no S/SX (signs and symptoms) of infection. Pt. (patient) tolerated tx (treatment) well.” The documentation is inconsistent. It is unclear what wound care was completed to the right hand skin tear. Review of the Nursing Visit Note dated 10/25/2022 revealed the RN documented the following: “WC completed, wound bed remains pink and moist with small amt (amount) of serosanguinous drainage noted during cleansing. No S/SX of infection and pt. tolerated tx well.” The documentation is inconsistent. It is unclear what wound care was completed to the right hand skin tear. During interview on 11/02/2022 at 11:25 AM, the RN stated she failed to complete the wound sheet specifying the wound care procedure performed during both identified nursing visits. Patient #5 – This 88-year-old patient with diagnoses that include hypertension, an unspecified open wound of the buttocks and dementia was admitted to the home health agency on 09/30/2022. Review of the Home Health Certification and Plan of Care for certification period 09/30/2022 to 11/28/2022 revealed the following wound care orders: - Bilateral buttocks diffuse open areas- cleanse with wound cleanser, apply skin prep peri wound and cover with foam adhesive 3x/week (three times weekly) by CHHA Nurse. Review of the Skilled Nursing Follow Up Visit Note dated 10/05/2022 revealed the RN documented the following: “Wound care to bil. (bilateral) buttocks completed. No drainage or S/SX of infection noted. Previous bandage had fallen off prior to SN arrival. Will cont. (continue) to apply bandages 3x/wk (week). Client tol. (tolerated) well, no acute distress noted.” The documentation is inconsistent. It is unclear what wound care was completed to bilateral buttocks wounds. Review of the Skilled Nursing Follow Up Visit Note dated 10/07/2022 revealed the RN documented the following: “Wound care to bil. buttocks completed. No drainage or S/SX of infection noted. Client tol. well, no acute distress noted.” The documentation is inconsistent. It is unclear what wound care was completed to bilateral buttocks wounds. Review of the Skilled Nursing Follow Up Visit Note dated 10/12/2022 revealed the RN documented the following: “Wound care to buttocks completed without issue. No drainage or S/SX of infection. Areas are improved and client stated she is not longer having pain when sitting. Client tol. well, no acute distress noted.” The documentation is inconsistent. It is unclear what wound care was completed to bilateral buttocks wounds. Review of the Skilled Nursing Follow Up Visit Note dated 10/19/2022 revealed the RN documented the following: “Wound care to buttocks completed. No drainage or S/SX of infection noted. Client tol. well, no acute distress noted.” The documentation is inconsistent. It is unclear what wound care was completed to bilateral buttocks wounds. Review of the Skilled Nursing Follow Up Visit Note dated 10/21/2022 revealed the RN documented the following: “Wound care to bil. buttocks completed without issue. No drainage or S/SX of infection noted. Client tol. well, no acute distress noted.” The documentation is inconsistent. It is unclear what wound care was completed to bilateral buttocks wounds. During interview on 11/02/2022 at 11:57 AM, the RN stated she completed the identified wound care documentation as she had been instructed to. During interview on 11/02/2022 at 12:00 PM, The Director of Homecare stated the wound documentation discrepancies are a “system issue” that will need to be addressed.

A post certification visit (PCV) survey for Rosa Coplon Jewish Home and Infirmary Home Health Agency was initiated on 11/16/2021 as a follow up to the recertification survey that was conducted on 03/18/2021. Deficient practices were identified at condition level non-compliance in the following Conditions of Participation: 484.60- Care planning, coordination, quality of care (G570) 484.75- Skilled professional services (G700) 484.105- Organization and administration of services (G940) The survey consisted of a review of ten (10) clinical records including one (1) discharge record, two (2) personnel records, Quality Assurance Performance Improvement and Governing Authority meeting minutes, staff training, along with pertinent policies and procedures. The survey also consisted of a review of the agency's implementation of the New York State Department of Health (NYS DOH) Guidance as it pertains to COVID-19. The agency reports zero (0) patients who are COVID-19 positive. The Home Health Agency active patient census was fifty-six (56) patients. Interviews were conducted with the Director of Patient Services and various clinical staff. All findings were discussed during the exit conference on 12/14/2021. The following deficiencies have been corrected: G- 0374, G- 0608, G- 0660, G- 0716, G- 0718, G- 1024, J- 0404, J- 0548, J- 1108, J- 1128, J- 1412 and J- 1512 and L- 0001. The following deficiencies remain uncorrected: G- 0440, G- 0526, G- 0536, G- 0574, G- 0586, G- 0598, G- 0984 and J-1156. The following deficiencies were identified as a result of this survey: G- 0544, G- 0570, G- 0580, G- 0590, G- 0610, G- 0700, G- 0702, G- 0940, G- 0942, G- 1010, J- 1260 and L- 0002.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on clinical record review and staff interview for two (2) of ten (10) patients (Patient #s: 1 and 4), the agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. The issues are: - The Registered Nurse (RN) failed to document a comprehensive prenatal assessment of the patient (Patient #1). - The RN failed to document a complete comprehensive assessment of the patient's nutritional status (Patient #4). Failure to ensure the comprehensive assessment accurately reflects the patient status and needs has the potential for unmet patient needs and negative patient outcomes. Patient #1 – This 24-year-old patient with diagnoses that include hyperemesis, dehydration and pregnancy within the first trimester was admitted to the home care agency on 10/13/2021. Review of the Home Health Certification and Plan of Care for the period from 10/13/2021 to 12/11/2-21 revealed a diagnosis of hyperemesis gravidarum (persistent nausea and vomiting during pregnancy) and orders for the Skilled Nurse (SN) to assess nutrition, hydration and infuse one (1) liter of intravenous (IV) fluids daily. Review of the Comprehensive Adult Assessment dated 10/13/2021 lacks a prenatal assessment of the patient. The RN failed to perform a prenatal comprehensive assessment. During interview on 11/17/2021 at 11:50 AM, the Director of Patient Services stated the agency had never cared for a prenatal patient and was unprepared to complete a prenatal assessment of the patient. Patient #4 – This 77-year-old patient with diagnoses that include an unstageable pressure ulcer of the left buttocks, hemiplegia (paralysis on one side of the body) and atrial fibrillation was admitted to the home care agency on 10/16/2021. Review of the Home Health Certification and Plan of Care for the period from 10/16/2021 to 12/14/2021 revealed the patient has a history of a stroke affecting the right side of the body and an unstageable pressure ulcer of the buttock. Orders include the SN evaluating the patient’s nutrition and hydration status. Review of the Comprehensive Adult Assessment dated 10/16/2021 revealed the RN documented the following: Nutrition: Regular diet Restrictions: None Appetite: Blank Swallowing Difficulty with foods: Blank Swallowing Difficulty with fluids: Blank. The RN failed to perform a complete assessment of the patient’s nutrition status. During interview on 11/17/2021, the RN stated it was an oversight that she left the identified items blank on the assessment.

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 clinical record review and interviews with agency staff, for four (4) of ten (10) clinical records (Patient #'s: 1, 4, 5 and 9) lacked documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns. The issues are: - The Registered Nurse (RN) failed to identify and reconcile all medication discrepancies identified in the referral for services and the Plan of Care (POC) (Patient #'s: 1, 4, 5 and 9). - The RN failed to include an end date for a short-term medication (Patient #9). Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for the patient harm. Review of the agency policy entitled “Drug Regimen/ Allergy Review” revised 05/27/2021 revealed the following: “the clinician will complete the allergy/ medication reconciliation (i.e. identify any discrepancy between the discharge list of allergies/ medications and the patient reported allergies/ medications that are on hand or states that they are taking, or not taking.) The clinician will notify the physician, by phone, and document the discrepancy in allergies/medications and the response of the physician in the case management note.” Patient #1 – This 24-year-old patient with diagnoses that include hyperemesis, dehydration and pregnancy within the first trimester was admitted to the home care agency on 10/13/2021. A.) Review of the physician referral for home care services dated 10/11/2021 revealed an order for IV (intravenous) hydration, 1 liter D5LR (lactated ringers in 5% dextrose) at 250 cc/hr (cubic centimeters per hour) daily x1 (for one) week. Review of the Home Health Certification and Plan of Care from 10/13/2021 to 12/11/2021 revealed the following orders: - D5LR 250 cc every day IV 250cc/ hr daily x 7 (seven) days; and - Administer D5LR 1 liter @250 cc/hr IV daily (It is unclear if the patient is to receive 250cc or 1 liter of D5LR daily). Review of the clinical record lacks documented evidence that the physician was contacted regarding the discrepancy identified between the referral and POC. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/17/2021 at 11:35 AM, the RN stated the patient was to receive 1 liter of D5LR daily and she made typographical error on the POC. B.) Review of the physician referral for home care services dated 10/11/2021 revealed the patient is ordered Ketorolac Tromethamine 10 mg (milligrams) by mouth every 6 (six) hours as needed for pain. Review of the Home Health Certification and Plan of Care from 10/13/2021 to 12/11/2021 lacks an order for Ketorolac Tromethamine. Review of the clinical record lacks documented evidence that the physician was contacted regarding the discrepancies identified during the medication reconciliation. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/17/2021 at 11:32, the RN stated the patient reported she was not taking the medication and the RN did not notify the physician of the discrepancy. C.) Review of the Home Health Certification and Plan of Care from 10/13/2021 to 12/11/2021 revealed the following orders: - Cetirizine HCL by mouth tablet 10 mg (milligram) 1 (one) tab every day; and - Azelastine HCL 0.1% 1 (one) spray every day to each nostril. Review of physician referral for home care services dated 10/11/2021 lacks orders for Cetirizine HCL and Azelastine HCL. Review of the clinical record lacks documented evidence that the physician was contacted regarding the discrepancy identified between the referral and POC. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/17/2021 at 11:35 AM, the RN stated the patient reported taking the identified medications that were prescribed by an alternate physician and she did not notify the referring physician of the discrepancy. Patient #9 – This 58-year-old patient with diagnoses that include prosthetic hip infection, acute post procedural pain and polyneuropathy was admitted to the home care agency on 11/13/2021. Review of the IV prescription dated 11/10/2021 included with the agency Referral Intake dated 11/12/2021 revealed an order Ceftriaxone Sodium Solution reconstituted 2 gm, 2 gm intravenously one time a day for infection until 11/25/2021. Review of the Home Health Certification and Plan of Care from 11/13/2021 to 01/11/2022 revealed an order for Ceftriaxone 2 gm/ 20 ml (reconstituted by vendor) via PICC (peripherally inserted central catheter) IV push over 2 (two) to 4 (four) minutes, daily. A.) Review of the clinical record lacks documented evidence the physician was notified the medication was to be administered IV push instead of by IV infusion. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/23/2021 at 12:25 PM, the RN stated the medication came from the infusion vendor reconstituted in a syringe to be administered IV push and she did not notify the physician of the discrepancy. B.) Review of the Home Health Certification and Plan of Care from 11/13/2021 to 01/11/2022 lacks an end date for the IV ceftriaxone order. Review of the clinical record lacks documented evidence that the physician was contacted regarding the discrepancy identified between the referral and POC. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/30/2021 at 11:30 AM, the RN stated she mistakenly left the end date of the medication off the POC. Patient #4 – This 77-year-old patient with diagnoses that include an unstageable pressure ulcer on the left buttocks, hemiplegia and atrial fibrillation was admitted to the home care agency on 10/16/2021. A.) Review of the facility rehabilitation Discharge Summary dated 10/15/2021 revealed the patient was discharged on the following medications: - Bumex tablet 1 mg by mouth one time a day; - Vitamin C tablet 1000mg 1 (one) tablet by mouth at bedtime; and - Sustane solution 0.4-0.3% 1 (one) drop in left eye two times a day. Review of the Home Health Certification and Plan of Care from 10/16/2021 to 12/14/2021 revealed the following orders: - Bumex 1.5 mg every day PO (by mouth); - Vitamin C by mouth tablet 500 mg 1 (one) tab at bedtime PO; and - Systane 0.4/0.3% 1 gtt (drop) PRN OS (left eye) twice a day as needed for dry eyes. Review of the clinical record lacks documented evidence the physician was contracted regarding the discrepancies identified between the referral and the POC. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/17/2021 at 01:19 PM, the RN stated the patient reported taking the doses documented on the POC. The RN stated the physician was notified of the discrepancies but she did not document this. B.) Review of the facility rehabilitation Discharge Summary dated 10/15/2021 revealed the patient was discharged on Vitamin D3 capsule 125 mcg (microgram’s) (5000 U) (units) 1 (one) capsule by mouth at bedtime. Review of the Home Health Certification and Plan of Care from lacks documented evidence of an order for Vitamin D3. Review of the clinical record lacks documented evidence the Physician was contacted regarding the discrepancy. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/17/2021 at 01:22 PM, the RN stated the patient reported not taking Vitamin D3. The RN stated she notified the Physician of this but did not document this. C.) Review of the Home Health Certification and Plan of Care from 10/16/2021 to 12/14/2021 revealed the following medication orders: - Hydralazine 25 mg 1 (one) tab twice a day PO; - Lisinopril- Hydrochlorothiazide by mouth tablet 10-12.5 mg 1 (one) tab twice a day PO; - Stinging Nettle Root 500 mg every day PO - Equate laxative 25 mg PRN PO every day as needed for constipation; and - Cod Liver Oil by mouth capsule 1000 mg 1 (one) cap every day PO. Review of the facility rehabilitation Discharge Summary dated 10/15/2021 lacks documented evidence the patient was discharged on Hydralazine, Lisinopril- Hydrochlorothiazide, Stinging Nettle Root, Equate laxative and Cod Liver Oil. Review of the clinical record lacks documented evidence the Physician was contacted regarding the identified discrepancies. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/17/2021 at 01:25 PM, the RN stated the patient reported taking the identified medications. The RN stated the Physician was contacted regarding the discrepancies but she did not document this. Patient #5 – This 93-year-old patient with diagnoses that include acute and chronic respiratory failure, a stage II pressure ulcer to the right buttock and heart failure was admitted to the home care agency on 10/27/2021. A.) Review of the facility rehabilitation Discharge Summary dated 10/25/2021 revealed the patient was discharged on the following medications: - Artificial Tears Solution 1.4% 1 (one) drop in both eyes four times a day; and - Miralax Powder 17 gm/scoop 17 gram by mouth at bedtime. Review of the Home Health Certification and Plan of Care from 10/27/2021 to 12/25/2021 revealed the following medication orders: - Artificial Tears 1.4% 1 gtt PRN OU (right eye) four times a day as needed for dry eyes; and - Miralax by mouth powder 17 gm PRN PO every day at bedtime as needed for constipation. Review of the clinical record lacks documented evidence the Physician was contacted regarding the identified discrepancies. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/17/2021 at 12:44 PM, the RN stated she notified the Physician of the dose the patient reported taking but she failed to document this. B.) Review of the facility rehabilitation Discharge Summary dated 10/25/2021 revealed the patient was discharged on Tramadol HCL tablet 50 mg 1 (one) tablet two times a day. Review of the Home Health Certification and Plan of Care from 10/27/2021 to 12/25/2021 lacks documented evidence of an order for Tramadol HCL. Review of the clinical record lacks documented evidence the Physician was notified of the medication discrepancy. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/17/2021 at 12:45 PM, the RN stated the patient’s daughter reported the patient was not taking Tramadol. The RN said she notified the Physician of the discrepancy but did not document it. C.) Review of the Home Health Certification and Plan of Care from 10/27/2021 to 12/25/2021 revealed the following medication orders: - Tylenol 500 mg 1 (one) tab PRN PO every 4-6 hours as needed for pain; - Quetiapine Fumarate by mouth tablet 25 mg 1 (one) tab at bedtime PO; and - O2 (Oxygen) 2 liters via NC (nasal cannula) PRN and every HS (bedtime). Review of the facility rehabilitation Discharge Summary dated 10/25/2021 lacks documented evidence the patient was discharged on Tylenol, Quetiapine Fumarate and Oxygen. Review of the Clinical Record lacks documented evidence the Physician was notified of the medication discrepancies. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/17/2021 at 12:48 PM, the RN stated the Physician was notified of the medication discrepancies but the RN did not document this.

The following statement of deficiencies represents the results of a partial extended re-certification and focused COVID-19 infection control survey of Rosa Coplon Jewish Home and Infirmary Certified Home Health Agency conducted on 03/15/2021 through 03/18/2021. A standard re-certification survey was initiated on 03/15/2021. Deficient practices were identified within Level 1 standards in G-574 (Plan of Care) resulting in a partial extended survey. The survey consisted of a review of seven (7) clinical records including two (2) discharged records, three (3) personnel records of professional personnel and three (3) observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past twelve (12) months, agency's Admission Packet, infection control policies and protocols regarding COVID-19, the Emergency Preparedness Plan, and Complaint Log. Pre-survey activities consisted of review on 03/11/2021 of the agency's Health Commerce System account, Certification and Survey Provider Enhanced Reports (CASPER) for the period 12/2019 through 11/2020 and the agency's compliance with report submissions for the 2019 statistical report and the Emergency Drill conducted 06/11/2019 through 06/13/2019. The Director of Patient Services, Chief Operating Officer and various professional staff were interviewed. Findings were reviewed at the exit conference on 03/15/2021. The following deficiencies are identified as a result of the survey: G- 0374, G- 0440, G- 0526, G- 0536, G- 0574, G- 0586, G- 0598, G- 0608, G- 0660, G- 0716, G- 0718, G- 0984, G- 1024, J- 0404, J- 0548, J- 1108, J- 1128, J- 1156, J- 1412, J- 1512 and L- 0001.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on review of the agency's Outcome and Assessment Information Set (OASIS) submission, clinical record, and interview with agency staff for one (1) of seven (7) patients (Patient #1), the agency failed to ensure the OASIS data accurately reflects the patient's status at the time of the assessment; specifically, the Physical Therapist failed to identify the patient's urinary tract infection. Failure to ensure accurate documentation of OASIS data has the potential for negative outcomes. Findings are: Patient #1 - This 64-year-old patient with diagnoses that include hepatic encephalopathy, cirrhosis and type II diabetes mellitus was admitted to the home care agency on 03/01/2021.\ Review of the Medication Record revealed an undated order for nitrofurantoin 100 mg (milligrams) PO (by mouth) BID (twice daily) for UTI (urinary tract infection). Review of the Physical Therapy Comprehensive Adult Assessment dated 03/01/2021 revealed the Physical Therapist (PT) documented the patient's genitourinary status as follows: - Urinary incontinence or urinary catheter presence: Patient is incontinent. - Has this patient been treated for a urinary tract infection in the past 14 (fourteen) days? No. During interview on 03/17/2021 at 02:15 PM, the PT (Employee I) stated she failed to document the UTI diagnosis in the comprehensive assessment. Additionally, she stated the patient was on nitrofurantoin at the start of care for five (5) days duration for a UTI.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, agency staff did not inform seven (7) of seven (7) patients (Patient #'s: 1, 2, 3, 4, 5, 6, and 7) of the extent of insurance coverage for various services available through home care. Failure to inform a patient about current fees for services violates patients' rights. The findings are: Patient #1 - This 64-year-old patient with diagnoses that include hepatic encephalopathy, cirrhosis and type II diabetes mellitus was admitted to the home care agency on 03/01/2021. Review of the Physical Therapy Comprehensive Adult Assessment dated 03/01/2021 revealed the patient is to receive Physical Therapy (PT) and Medical Social Work (MSW) services for certification period from 03/01/2021 to 04/29/2021. Review of the Liability for Payment Form signed by the patient on 03/01/2021 revealed the form lacks evidence that the patient was informed of the extent of insurance coverage. Patient #2 - This 96-year-old patient with diagnoses that include abnormalities of gait and mobility, atrial fibrillation, and atherosclerotic heart disease was admitted to the home care agency on 03/02/2021. Review of the Home Health Certification and Plan of Care for the certification period from 03/02/2021 to 04/30/2021 revealed the patient is to receive PT and Occupational Therapy (OT) services. Review of the Liability for Payment Form signed by the patient on 03/02/2021 revealed the form lacks evidence that the patient was informed of the extent of insurance coverage. Patient #3 - This 94-year-old patient with diagnoses that include unspecified open wound of right elbow, dementia and atrial fibrillation was admitted to the home care agency on 03/03/2021. Review of the Home Health Certification and Plan of Care for the certification period from 03/03/2021 to 05/01/2021 revealed the patient is to receive Skilled Nursing (SN) and PT services. Review of the Liability for Payment Form signed by the patient on 03/03/2021 revealed the form lacks evidence that the patient was informed of the extent of insurance coverage. Patient #4 - This 104-year-old patient with diagnoses that include hypertension, rhabdomyolysis, and unspecified open wound left lower leg was admitted to the home care agency on 02/17/2021. Review of the Home Health Certification and Plan of Care for the certification period from 02/17/2021 to 04/17/2021 revealed the patient is to receive SN, PT and OT services. Review of the Liability for Payment Form signed by the patient on 02/26/2021 revealed the form lacks evidence that the patient was informed of the extent of insurance coverage. Patient #5 - This 69-year-old patient with diagnoses that include pneumonia, pleural effusion, and end stage renal disease was admitted to the home care agency on 03/05/2021. Review of the Home Health Certification and Plan of Care for the certification period from 03/05/2021 to 05/03/2021 revealed the patient is to receive SN, PT, OT, and MSW services. Review of the Liability for Payment Form signed by the patient on 02/26/2021 revealed the form lacks evidence that the patient was informed of the extent of insurance coverage. Patient #6 - This 87-year-old patient with diagnoses that include atherosclerotic heart disease, history of falling, and dementia was admitted to the home care agency on 04/11/2020. Review of the Home Health Certification and Plan of Care for the certification period from 04/11/2020 to 06/09/2020 revealed the patient is to receive SN and PT services. Review of the Liability for Payment Form signed by the patient on 04/11/2020 revealed the form lacks evidence that the patient was informed of the extent of insurance coverage. Patient #7 - This 87-year-old patient with diagnoses that include methicillin susceptible staphylococcus aureus infection, acute respiratory failure and cerebral infarction was admitted to the home care agency on 02/05/2020 and discharged on 04/21/2020. Review of the Home Health Certification and Plan of Care for the certification period from 02/05/2020 to 04/04/2020 revealed the patient is to receive SN, PT and OT services. Review of the Liability for Payment Form signed by the patient on 02/05/2020 revealed the form lacks evidence that the patient was informed of the extent of insurance coverage. The agency staff failed to notify all patients of the extent of insurance coverage for various services available through home care. During interview on 03/17/2021 at 12:45 PM, the Director of Patient Services stated the agency runs each patient's insurance and financial liability in the office, then calls them to review it over the phone. The patient does not sign anything that indicates they have been notified of the extent of insurance coverage for services provided by the agency.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on clinical record review and staff interview for 3 (three) of seven (7) patients (Patient #'s: 1, 3, and 4), the agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. The issues are: - The Registered Nurse (RN) failed to document a complete assessment of the patient's vital signs (Patient #4). - The RN failed to document a complete assessment of the patient's ability to communicate (Patient #4). - The RN failed to document a complete assessment of the patient's risk for skin issues (Patient #4). - The RN failed to document a complete assessment of the patient's cough (Patient #4). - The Physical Therapist (PT) failed to document a complete assessment of the patient's pain status (Patient #1). - The PT failed to document a complete assessment of the patient's endocrine system to include a diabetic assessment (Patient #1). - The PT failed to document a complete assessment of emergency planning/fire safety (Patient #1). - The PT failed to document an assessment of upper body strength and range of motion (Patient #3). Failure to ensure the comprehensive assessment accurately reflects the patient status and needs has the potential for unmet patient needs and negative patient outcomes. Findings are: Patient #4 - This 104-year-old patient with diagnoses that include hypertension, rhabdomyolysis, and unspecified open wound left lower leg was admitted to the home care agency on 02/17/2021. Review of the Home Health Certification and Plan of Care for certification period 02/17/2021 to 04/17/2021 revealed the order for SN (Skilled Nursing) two (2) times a week for six (6) weeks, then once a week for two (2) weeks. A.) Review of the Comprehensive Adult Nursing Assessment dated 02/17/2021 revealed the following vital signs assessment: - Blood pressure at rest: 110/68 - Temperature: 98.8 F (Fahrenheit) - Pulse: 60 - Pulse oximetry: 100% - Respiration's: Blank [not documented] The RN failed to document a complete assessment of the patient's vital signs. B.) Review of the Comprehensive Adult Nursing Assessment dated 02/17/2021 revealed the following communication assessment: - Primary language: English - Understanding of verbal content in patient's own language: sometimes understands: frequently requires cues to understand. - Speech and oral (verbal) expression of language: expresses complex ideas, feelings, and needs clearly - Minimal to moderate difficulty in expressing needs. May speak in phrases or short sentences. Needs minimal or moderate prompting. - Patient current ability to use the telephone safely: blank The RN failed to document a complete assessment of the patient's ability to communicate. C.) Review of the Comprehensive Adult Nursing Assessment dated 02/17/2021 revealed the following assessment of the patient's integumentary status: - Disorder(s) of skin, hair, nails (details): blank (there is a option to check "no problem" if this issue is not applicable and that is also blank) - Turgor: dry - Does the patient appear to be at risk for acquiring any type of integumentary problem(s) based on the clinical factors (e.g. immobility, incontinence, skin thinning, impaired sensory, poor nutrition, skin disorder, poor circulation, etc.)? blank The RN failed to document a complete assessment of the patient's integumentary status. D.) Review of the Comprehensive Adult Nursing Assessment dated 02/17/2021 revealed the following assessment of the patient's cardiopulmonary status: - Breath sounds: clear throughout - Oxygen saturation: 99 % - Intermittent treatments (e.g. cough and deep breath, medicated inhalation treatments, etc.): blank [there is a option to check "no problem" if this issue is not applicable and that is also blank] The RN failed to document a complete assessment of the cardiopulmonary status. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 03/18/2021 at 09:05 AM, the RN (Employee F) stated the expectation is that all fields in the nursing assessment are completed; however, she failed to fully complete each part of the assessments. Patient #1 - This 64-year-old patient with diagnoses that include hepatic encephalopathy, cirrhosis and type II diabetes mellitus was admitted to the home care agency on 03/01/2021. Review of the referral provided by the Nurse Practitioner at the primary care physician's office dated 02/09/2021 revealed a request for a home care evaluation for Physical Therapy for strengthening, stair training and Social Work for assisting with alternate housing for the patient. A.) Review of the Physical Therapy Comprehensive Adult Assessment dated 03/01/2021 revealed the PT documented the following: - Frequency of pain interfering with activity or movement: Daily, but not constantly; and - What makes pain better? Rest and medication. The 03/01/2021 Comprehensive assessment completed by the PT lacked documented evidence of the following pain assessments: - Is there a pattern to the pain? - How often is breakthrough medication needed? - Current pain control medications adequate? The PT failed to document a complete assessment of the patient's pain status. During interview on 03/17/2021, the PT (Employee I) stated the patient was on gabapentin for pain control since being admitted to the home care agency but she failed to include this medication on the plan of care orders. Additionally, the PT stated it was an oversight that she did not complete the pain assessment in its entirety on the comprehensive assessment. B.) Review of the Physical Therapy Comprehensive Adult Assessment dated 03/01/2021 revealed the PT documented the patient had diabetes under the endocrine assessment. Additionally, the PT failed to document the following under the endocrine assessment: - Type of diabetes; - Onset; - Diet; - Oral medications taken for diabetes; - Injectable medications taken for diabetes; - Date patient first started using diabetic medication; - Identify who administers diabetic medication; - Blood sugar ranges; - Who monitors blood sugars; - Frequency of monitoring; and - Competency with use of glucometer. The PT failed to document an assessment of the patient's diabetic status. During interview on 03/17/2021 at 02:25 PM, the PT (Employee I) stated the patient was on a regular diet but she failed to assess and document the patients diabetic status. C.) Review of the Physical Therapy Comprehensive Adult Assessment dated 03/01/2021 lacked documented evidence the PT assessed the home for the following: - Fire extinguisher; - Smoke detectors on all levels of home; - Smoke detectors tested and functioning; - Emergency exit plan and location; - Plan for power failure; - Carbon monoxide detector; - Oxygen use in home; and - Safety plan indicated. The PT failed to document a complete assessment of emergency planning/fire safety in the patient's home. During interview on 03/17/2021 at 02:35 PM, the PT (Employee I) stated it was an oversight that she did not complete the emergency planning/fire safety assessment during her comprehensive assessment. Patient #3- This 94-year-old patient with diagnoses that include unspecified open wound of the right elbow, dementia and atrial fibrillation was admitted to the home care agency on 03/03/2021. Review of the Home Health Certification and Plan of Care for the certification period 03/03/2021 to 05/01/2021 revealed the patient is to receive Skilled Nursing (SN) and PT services. A.) Review of the Physical Therapy Evaluation dated 03/05/2021 revealed the PT documented the following during the initial assessment: - Range of motion to right upper extremity: See Occupational Therapy (OT) assessment; - Range of motion to left upper extremity: See OT assessment; - Strength of right upper extremity: See OT assessment; and - Strength of left upper extremity: See OT assessment. The PT failed to document an assessment of upper body strength and range of motion. During interview on 03/17/2021 at 12:05 PM, the PT (Employee J) stated she incorrectly believed OT was providing services to the patient and for this reason did not assess the patient's upper extremity strength and range of motion.

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 clinical record review and interview with agency staff, for five (5) of seven (7) clinical records (Patient #'s: 1, 2, 3, 6 and 7) lacked documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns. The issues are: - The Registered Nurse (RN) failed to identify and reconcile all medication discrepancies identified in the referral for services and the Plan of Care (POC) (Patient #'s: 1, 2, 3, 6 and 7). - The Physical Therapy (PT) failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC (Patient #'s: 1 and 2). - The PT failed to clarify medication allergy discrepancies in the referrals for home care (Patient #1). - The RN failed to clarify medication allergy discrepancies in the referrals for home care (Patient #1). Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for the patient harm. Findings are: Review of the agency policy entitled "Drug Regimen Review" dated 06/07/2018 revealed the following: 1. The clinician performing the comprehensive adult assessment will record all medications reportedly taken by the patient on the medical record... A. If the clinician is not a Registered Nurse, the completed medication record will be forwarded to the Registered Nurse Case Manager within 24 (twenty-four) hours of the comprehensive adult assessment... 2. The Registered Nurse will complete a full drug regimen review of all items listed on the medication record, utilizing an online pharmaceutical encyclopedia, i.e., "drugs.com", to determine if there are any potential major drug interactions... 11. The RN Case Manager will document the Drug Regimen Review results, notification to the physician (if potential major drug interactions were identified) in the OASIS (Outcome and Information Assessment Set) note, or clinical note (if the OASIS was completed by a therapist). Patient #1 - This 64-year-old patient with diagnoses that include hepatic encephalopathy, cirrhosis and type II diabetes mellitus was admitted to the home care agency on 03/01/2021. Review of the facility discharge medication list dated 12/26/2020, that was provided to the agency as part of the home care referral, revealed the following: - Allergies: codeine, haldol, latex and penicillin - Medications: - Epclusa 400-100 milligrams (mg) one (1) tablet by mouth (PO) daily - Ribavirin 200 mg PO daily - Xifaxan 550 mg PO daily - Primidone 50 mg PO daily - Prazosin 1 mg PO daily - Potassium chloride CR 10 milliequivalents (meq) PO daily - Omeprazole 20 mg PO daily - Olanzapine 2.5 mg PO daily - Gabapentin 100 mg PO three (3) times daily {not ordered on the agency Medication Record} - Furosemide 40 mg PO daily - Fluphenzine 5 mg PO daily - Fluticasone 50 micrograms (mcg)/actuation, one (1) spray into each nostril once daily - Quetiapine 100 mg PO daily at night - Nitrofurantoin 100 mg PO twice daily for five (5) days, end date 12/31/2020 Review of the referral from the primary care physician's office dated 02/09/2021 revealed the following: - Allergies: Penicillamine, latex, haldol, artane, hydroxyzine [The allergies listed are inconsistent with the allergies listed on the facility discharge medication list.] - Medications (No dosages are listed on referral): - Loratidine [not on facility discharge medication list and agency Medication Record] - Lidocaine [not on facility discharge medication list and agency Medication Record] - Ferrous sulfate [not on facility medication list and agency Medication Record} - Cyclobenzaprine HCL [not on facility discharge medication list and agency Medication Record] - Ipratropium Bromide/albuterol sulfate nebulizer [not on facility discharge medication list and agency Medication Record] - Potassium chloride - Fluticasone propionate - Albuterol sulfate HFA (hydrofluoroalkane) [not on facility discharge medication list and agency Medication Record] - Gabapentin [not ordered on the agency Medication Record] - Omeprazole - Xifaxan - Primidone - Enulose [not on facility discharge medication list and agency Medication Record] - Folic acid [not on facility discharge medication list and agency Medication Record] - Vitamin B-1 [not on facility discharge medication list and agency Medication Record] - Furosemide - Spironolactone [not on facility discharge medication list and agency Medication Record] - Ribavirin - Epclusa - Fluphenazine HCL Review of the undated agency Medication Record (active medication list that will be on Home Health Certification and Plan of Care for the certification period from 03/01/2021 to 04/29/2021 once compiled) revealed the RN reviewed and signed the Medication Record on 03/02/2021 and included the following allergies and medications: - Allergies: haldol, codeine - Medications: - Epclusa 400-100 mg one (1) tablet PO daily - Ribavirin 200 mg PO daily - Xifaxan 550 mg PO daily - Primidone 50 mg PO daily - Prazosin 1 mg PO daily [not on 02/09/2021 medication list provided by primary care physician office] - Potassium chloride 10 meq PO daily - Omeprazole 20 mg PO daily - Olanzapine 2.5 mg PO daily [not on 02/09/2021 medication list provided by primary care physician office] - Furosemide 40 mg PO daily - Fluphenazine 5 mg PO daily - Fluticasone 50 mcg/actuation one (1) spray into each nostril daily - Quetiapine 100 mg PO daily at night {not on 02/09/2021 medication list provided by primary care physician office} - Nitrofurantoin 100 mg PO twice daily [specified as medication completed on 12/31/2020 on facility discharge list dated 12/26/2020 and not on 02/09/2021 medication list provided by primary care physician office] A.) Review of the clinical record lacks documented evidence of the discrepancy and follow-up clarification with the physician of the patient's allergies as identified on the facility discharge referral, the primary care physician referral for home care and the agency Medication Record. The PT and RN failed to identify and reconcile the patient's allergies identified in the referral for services and the POC. During interview on 03/17/2021 at 02:10 PM, the PT (Employee I) stated she clarified the allergy discrepancies with the physician but failed to document this. During interview on 03/17/2021 at 01:48 PM, the RN (Employee C) stated she checked the Medication Record for drug interactions only during her medication reconciliation. B.) Review of the clinical record lacked documented evidence that the physician was contacted regarding the patient's medications during medication reconciliation. The PT and RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 03/17/2021 at 02:15 PM, the PT (Employee I) stated she wrote down all the medications the patient stated she was currently taking on the Medication Record and submitted the list of medications to the RN to review. The PT additionally stated she did not reference the physician and facility discharge referral medication lists provided as she believed that occurred during the RN drug regimen review. During interview on 03/17/2021 at 01:50 PM, the RN (Employee C) stated she did not have the discharge referral from the facility or the physician referral when she completed the drug regimen review. She additionally stated she checked each medication identified on the Medication Record for potential interactions using "drugs.com" and recorded the interactions, signed and dated the Medication Record once completed. Patient #2 - This 96-year-old patient with diagnoses that include abnormalities of gait and mobility, atrial fibrillation, and atherosclerotic heart disease was admitted to the home care agency on 03/02/2021. Review of the referral to the home care agency dated 02/25/2021 revealed the patient takes the following medications: - Refresh celluvisc gel 1% 1 drop in both eyes every 12 hours - Protonix tablet delayed release 40 mg (milligrams) by mouth once daily - Cholecalciferol tablet 1000 unit 2 tablets by mouth at bedtime - Lidoderm patch 5% topically every day and evening shift - Miralax powder 17 gm (gram)/scoop 17 grams by mouth in the morning - Crestor tablet 20 mg by mouth at bedtime - Capsaicin cream 0.025% topically every day shift - Diclofenac sodium gel topically every 6 hours - Metoprolol succinate ER tablet extended release 24 hour 25 mg 0.5 tablet by mouth one time daily - Nystatin powder 100,000 unit/gm topically every day and night shift Review of the Home Health Certification and Plan of Care for certification period 03/02/2021 to 04/30/2021 revealed the following orders: - Lidoderm patch 5% topically every day and evening shift - Omeprazole 40 mg every day by mouth - Vitamin D3 25 mg every day by mouth - Acetaminophen 500 mg every 6 hours by mouth - Diclofenac sodium gel 4 g (grams) 1 application every 6 hours topical - Risperidone by mouth tablet 0.25 mg twice a day by mouth - Warfarin 2 mg every day by mouth The following medications were on the referral to the home care agency dated 02/25/2021 but not on the POC: - Refresh celluvisc gel 1% 1 drop in both eyes every 12 hours - Protonix tablet delayed release 40 mg (milligrams) by mouth once daily - Cholecalciferol tablet 1000 unit 2 tablets by mouth at bedtime - Miralax powder 17 gm (gram)/scoop 17 grams by mouth in the morning - Crestor tablet 20 mg by mouth at bedtime - Capsaicin cream 0.025% topically every day shift - Metoprolol succinate ER tablet extended release 24 hour 25 mg 0.5 tablet by mouth one time daily - Nystatin powder 100,000 unit/gm topically every day and night shift The following medications were on the POC but not on the referral to the home care agency dated 02/25/2021: - Omeprazole 40 mg every day by mouth - Vitamin D3 25 mg every day by mouth - Acetaminophen 500 mg every 6 hours by mouth - Risperidone by mouth tablet 0.25 mg twice a day by mouth - Warfarin 2 mg every day by mouth Review of the clinical record lacked documented evidence that the physician was contacted regarding the patient's medications during medication reconciliation. The PT and RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 03/17/2021 at 12:06 PM, the PT (Employee J) stated during the start of care visit she reviewed the patient's referral and medications in the home with the patient and verified which medications were correct. During the visit she created a new medication list with the proper medications (according to the patient). The medication list was sent to the RN who runs the medications for drug interactions and reviews for discrepancies. The RN is then responsible for calling the physician if there are issues. During interview on 03/18/2021 at 09:20 AM, the RN (Employee D) stated that usually when she receives a medication list from the PT, she reviews it against the referral and calls the physician to discuss discrepancies. She stated that she does not recall doing that for this patient and can't explain why. Patient #3 - This 94-year-old patient with diagnoses that include an unspecified open wound of the right elbow, dementia and atrial fibrillation was admitted to the home care agency on 03/03/2021. Review of the referral for home care received by the agency on 03/03/2021 revealed a medication order for Vitamin B 12-1,000 mcg PO every other day. Review of the Home Health Certification and Plan of Care for certification period 03/03/21 to 05/01/2021 revealed the following order for vitamin B 12: - Vitamin B 12- 1,000 mcg PO daily Review of the clinical record lacked documented evidence that the physician was contacted regarding the patient's medications during medication reconciliation. The RN failed to identify and reconcile the medication discrepancy between the referral and the POC. During interview on 03/17/2021 at 12:50 PM, the RN (Employee C) stated she incorrectly transcribed the order for the B 12 on the POC. She stated that the order should have been written for administration of the medication every other day. Patient #6 - This 87-year-old patient with diagnoses that include atherosclerotic heart disease, history of falling, and dementia was admitted to the home care agency on 04/11/2020. Review of the referral to the home care agency dated 04/11/2020 revealed the patient takes the following doses of Quetiapine: - Quetiapine 25 mg (milligrams) 1 tablet by mouth in the morning - Quetiapine 50 mg (milligrams) 1 tablet by mouth at 02:00 PM Review of the Home Health Certification and Plan of Care for certification period 04/11/2020 to 06/09/2020 revealed the following orders for Quetiapine: - Quetiapine 25 mg (milligrams) 1 tablet by mouth in the morning Review of the clinical record lacked documented evidence that the physician was contacted regarding the patient's medication dosage and frequency as part of the medication reconciliation. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 03/17/2021 at 12:30 PM, the RN (Employee C) stated the second dose of the medication should have been added to the medical orders but was missed. Patient #7 - This 87-year-old patient with diagnoses that include methicillin susceptible staphylococcus aureus infection, acute respiratory failure and cerebral infarction was admitted to the home care agency on 02/05/2020. Review of the Home Health Certification and Plan of Care for the certification period from 04/05/2020 to 06/03/2020 revealed the following medication order: - Keflex 500 mg PO twice daily Review of the assisted living Medication Administration Record revealed the patient completed a course of keflex prior to 04/01/2020 and was no longer taking the medication on 04/05/2021, when the new certification period started. The RN failed to identify and reconcile the medication discrepancy identified in the facility Medication Administration Record and the POC. During interview on 03/17/2021 at 01:40 PM, the RN (Employee C) stated she incorrectly documented the patient was taking keflex on the POC. She stated the assisted living facility's Medication Administration Record contains the most updated medication orders for the patient and the keflex was not an active order for the patient at the time she completed the patient's recertification.

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 review of clinical records and staff interviews for three (3) of seven (7) patients (Patient #'s: 1, 2, and 4) the agency failed to ensure a comprehensive Plan of Care (POC), based on clinical assessments, was developed to meet the individualized needs of the patients. The issues are: - The POC lacked an end date for a short-term antibiotic (Patient #1). - The POC lacked a location for a topical medication (Patient #2). - The POC lacked a frequency for wound care orders (Patient #4). Failure to ensure the POC is comprehensive to meet the patient's needs has the potential for staff to provide inappropriate care. Findings are: Patient #1 - This 64-year-old patient with diagnoses that include hepatic encephalopathy, cirrhosis and type II diabetes mellitus was admitted to the home care agency on 03/01/2021. Review of the undated agency Medication Record revealed an order for nitrofurantoin 100 milligrams (mg) by mouth (PO) twice daily. The POC lacked an end date for the ordered antibiotic. During interview on 03/17/2021 at 02:15 PM, the Physical Therapist (PT) (Employee I) stated the antibiotic was ordered for five (5) days duration but she failed to specify this on the Medication Record for the POC. Patient #2 - This 96-year-old patient with diagnoses that include abnormalities of gait and mobility, atrial fibrillation, and atherosclerotic heart disease was admitted to the home care agency on 03/02/2021. Review of the Home Health Certification and Plan of Care for certification period from 03/02/2021 to 04/30/2021 revealed the order for diclofenac sodium gel 4 g (grams) 1 application every six (6) hours topical. The location for application of the medication is not documented. The POC lacked a location for a topical medication. During interview on 03/18/2021 at 11:10 AM, the Director of Patient Services (DPS) stated the order lacked a location, but should have included one. Patient #4 - This 104-year-old patient with diagnoses that include hypertension, rhabdomyolysis, and unspecified open wound left lower leg was admitted to the home care agency on 02/17/2021. Review of the Home Health Certification and Plan of Care for certification period 02/17/2021 to 04/7/2021 revealed the following wound care orders: - cleanse right and lower extremities with cleanser, pat dry, cover with CaAlg (calcium alginate), cover with gauze optilock and hydrofoam - sacral ulcer cleanse with NS (normal saline) calcium alginate optifoam Review of the Home Health Certification and Plan of Care for certification period 02/17/2021 to 04/7/2021 lacked documented evidence of a frequency for wound care. The POC lacked a frequency for wound care orders. During interview on 03/18/2021 at 09:00 AM, the RN (Employee F) stated the frequency for the wound care is twice a week but she did not document that on the POC.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on review of clinical records and interviews with agency staff for one (1) of seven (7) patients (Patient #7), the agency failed to ensure the Plan of Care (POC) is reviewed and revised to reflect the patient's current status. The issues are: - The POC lacks a frequency for performing bilateral lower extremity wound care. - The POC lacks a route for ordered medications. Failure to ensure the POC is updated and revised to reflect patient needs, has the potential to result in negative patient outcomes. Findings are: Patient #7 - This 87-year-old patient with diagnoses that include methicillin susceptible staphylococcus aureus infection, acute respiratory failure and cerebral infarction was admitted to the home care agency on 02/05/2020 and discharged on 04/21/2020. Review of the Comprehensive Adult Nursing Assessment dated 03/11/2020 revealed the Registered Nurse (RN) performed a Resumption of Care (ROC) assessment on 03/11/2020 after the patient had been hospitalized and then treated in a rehabilitation facility from 02/12/2020 to 03/10/2020. Review of the Physician Telephone Order dated 03/11/2020 revealed the RN documented the following: - "ROC for the certification period 02/05/2020 to 04/04/2020. - SN (Skilled Nursing) frequency 2 (two) week 1 (one), 3 (three) week 1 (one), 2 (two) week 2 (two) and 2 (two) PRN (as needed) visits; - BLE (bilateral lower extremities)- cleanse with soap and water, pat dry, apply puracol (collagen wound dressing) to open areas, cover with DCD (dry clean dressing), secure with tape and coban (self-adherent wrap); - New Medications: lasix 20 mg (milligrams) qd (daily), potassium ER (extended release) 20 meq (milliequivalent's) q hs (every bedtime), align 4 mg qd, keflex 500 mg bid (twice daily), and plavix 75 mg q hs." A.) Review of the Physician Telephone Order (ROC orders) dated 03/11/2020 lacked documented evidence of a frequency for BLE wound care to be performed. During interview on 03/17/2021 at 01:45 PM, the RN (Employee C) stated she mistakenly left the frequency of the wound care to be performed off the ROC orders. B.) Review of the Physician Telephone Order (ROC orders) dated 03/11/2020 lacked documented evidence of a route of administration for the medications: lasix, potassium ER, align, keflex and plavix. During interview on 03/17/2021 at 01:25 PM, the RN (Employee C) stated she mistakenly left out the route of administration for the identified medications in the ROC orders.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy and procedure, and interview with agency staff, for one (1) of two (2) discharged patients (Patient #7), the agency failed to ensure that discharge planning was communicated with the responsible physician prior to discharge from the agency. Failure to communicate discharge planning has the potential for unmet patient needs. Findings are: Review of the agency policy entitled "Admission, Continuation, And Discharge Of Clients" revised 12/27/2017 revealed "1. A patient may be discharged only after consultation as appropriate, with the patient's authorized practitioner, the patient, the patient's family and any other professional personnel including any other case management entity involved in the plan of care." Patient #7 - This 87-year-old patient with diagnoses that include methicillin susceptible staphylococcus aureus infection, acute respiratory failure and cerebral infarction was admitted to the home care agency on 02/05/2020 and discharged on 04/21/2020. A.) Review of the Physical Therapy Progress Note dated 04/13/2020 revealed the Physical Therapist (PT) documented the patient has decreased strength and plans to continue maintenance physical therapy to maintain level of function and prevent falls. Review of the Nursing Visit Note dated 04/14/2020 at 10:50 AM revealed the Registered Nurse (RN) documented the patient fell in her bathroom and went to the emergency room for an evaluation. The patient sustained right hip pain and a laceration to her left forearm that requires wound care. The RN additionally documented the patient had x-rays taken that were negative and she returned back to the assisted living facility on 04/14/2020. Review of the Physician Telephone Order dated 04/14/2020 revealed the PT notified the physician that the patient was being discharged from PT on 04/14/2020 because the insurance denied further therapy coverage. Review of the patient care record lacked documented evidence that the patient's primary care physician was notified of the patient's discharge prior to the patient's discharge from Physical Therapy. The agency failed to follow its policy and fully inform the physician of the agency's intent to discharge the patient. During interview on 03/17/2021 at 04:00 PM, the PT (Employee K) stated she was unaware of the patient's fall, emergency room visit and new onset hip pain when she notified the physician and discharged PT services on 04/14/2020. During interview on 03/17/2021 at 04:05 PM, the Director of Patient Services stated the agency often continues to see patients after the insurance denies payment until a discharge plan is in place. B.) Review of the Physician Telephone Order dated 04/14/2020 revealed the RN obtained a new order for wound care to the left forearm after the patient fell on 04/14/2020: "cleanse area with wound cleanser, pat dry, apply skin prep to peri wound and cover with foam adhesive dressing two (2) times a week." Review of the Follow Up Visit Note dated 04/16/2020 revealed the RN made a home visit and performed the ordered wound care to the left forearm. Review of the Case Management Note dated 04/21/2020 revealed the RN documented she was notified that an appeal filed on behalf of the patient for insurance coverage for additional home care was denied and all home care services were to discontinue on 04/21/2020. Additionally, the RN documented the Nurse Manager at the assisted living facility where the patient resides was notified of the agency discharge and current wound care needs. Review of the Discharge Assessment dated 04/21/2020 revealed the RN documented the following: - Patient has left shoulder pain rated five (5) out of ten (10); - Patient has a skin tear to the left forearm measuring 4 cm length, 2 cm width and 0.1 cm, draining small amount of serosanguinous drainage; - Assisted living staff able to perform wound care independently post discharge and - Physician notified on 04/21/2020 of discharge from agency due to denial of insurance coverage for home care services. Review of the patient care record lacked documented evidence that the patient's primary care physician was notified of the patient's discharge prior to the patient's discharge from the agency. The agency failed to follow its policy and fully inform the physician of the agency's intent to discharge the patient. During interview on 03/17/2021 at 01:40 PM, the RN (Employee C) stated the physician was notified of the discharge the same day the agency discharged the patient due to the insurance no longer covering the home care services.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with agency staff for one (1) of seven (7) patients (Patients #7), the agency failed to coordinate care delivery and ensure patient needs are addressed. Specifically, the Registered Nurse (RN) failed to ensure the patient received compression stockings. Failure to coordinate care delivery has the potential for negative patient outcomes. Findings are: Patient #7 - This 87-year-old patient with diagnoses that include methicillin susceptible staphylococcus aureus infection, acute respiratory failure and cerebral infarction was admitted to the home care agency on 02/05/2020 and discharged on 04/21/2020. Review of the Nursing Visit Note dated 03/23/2020 revealed the RN documented that she called the physician's office and left message to request an order for compression stockings for bilateral lower extremities. Review of the clinical record lacked documented evidence the patient received the compression stockings, or that that the RN followed-up with the physician's office to ensure the stockings were ordered. During interview on 03/17/2021 at 01:33 PM, the RN (Employee C) stated compression stockings were never obtained for the patient. Additionally, she could not recall whether the physician's office called back regarding the order request.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on review of the agency's Professional Advisory Committee (PAC) program minutes and staff interviews, the Governing Authority failed to ensure that the quality improvement and patient safety program is defined, implemented, and maintained. Failure to ensure that the quality improvement and patient safety program is defined, implemented, and maintained, has the potential risk for negative patient outcomes. Findings are: Review of the PAC quarterly meeting minutes revealed the PAC met on the following dates for 2018: 06/07/2018, 08/03/2018, 11/01/2018 and 01/24/2019 (identified as fourth quarter for 2018). Review of the PAC quarterly meeting minutes revealed the PAC met on the following dates for 2019: 05/16/2019, 08/01/2019, 11/07/2019 and 03/11/2020 (identified as fourth quarter for 2019). Review of the PAC quarterly meeting minutes for 2020 revealed the 03/11/2020 PAC meeting minutes are identified as the minutes for the fourth quarter of 2019. Review of the 2020 PAC meeting minutes lacked documented evidence that after the 03/11/2020 meeting, the PAC conducted quarterly meetings to include ongoing audits for quality improvement and assessments for performance improvement. The Governing Authority failed to ensure a Quality Assurance Performance Improvement Program was in place and active during the year 2020. During interview on 03/18/2021 at 11:25 AM, the Director of Patient Services stated that after the 03/11/2020 fourth quarter PAC meeting for 2019, she had to prioritize other responsibilities related to the Pandemic and did not hold any additional PAC meetings in 2020. Additionally, she stated she continued to submit agency specific Board Reports monthly to the Governing Board for the duration of 2020.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for four (4) of seven (7) patients (Patient #'s: 1, 3, 6, and 7), the agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes. The issues are: - Documentation is inconsistent regarding the patient's pain status (Patient #'s 1 and 3). - Documentation is incomplete regarding the patient's medications (Patient #3). - Documentation is inconsistent regarding the patient's integumentary status (Patient #6). - Documentation is inconsistent regarding the patient's wound care (Patient #7). Failure to prepare or document complete clinical and progress notes has the potential for unmet patient needs. Findings are: Patient #3 - This 94-year-old patient with diagnoses that include an unspecified open wound of the right elbow, dementia and atrial fibrillation was admitted to the home care agency on 03/03/2021. A.) Review of the Nursing Visit Note dated 03/10/2021 revealed the Registered Nurse (RN) documented the following regarding medications: - New or changed since last visit: (left blank); - Instructed on: (left blank); and - Administered by: staff at assisted living facility. The documentation regarding the patients medication status is incomplete. During interview on 03/17/2021 at 12:55 PM, the RN stated it was an oversight that she did not complete medication assessment entirely. B.) Review of the Nursing Visit Note dated 03/10/2021 revealed the RN documented the following regarding the pain assessment: - Pain: yes; - Location: left knee; The 03/10/2021 Nursing Visit Note lacked documented evidence of the following pain assessment: - Type; - Quality; - Precipitated by; - Relieved by; - Intensity; - Functional impact; - Limits; - MD (physician) notified; - Medication; - Last taken; - Taken as directed; and - Relief. The documentation regarding the patient's pain status is incomplete. During interview on 03/17/2021 at 12:57 PM, the RN stated it was an oversight that she did not complete the pain assessment entirely. During interview on 03/17/2021 at 01:00 PM, the Director of Patient Services stated it is the expectation that all sections of the Visit Note are to be completed and not be left blank. Patient #1 - This 64-year-old patient with diagnoses that include hepatic encephalopathy, cirrhosis and type II diabetes mellitus was admitted to the home care agency on 03/01/2021. Review of the Physical Therapy Progress Note dated 03/05/2021 revealed the Physical Therapist (PT) documented the following pain assessment: - Pain location: lower stomach; - Type: chronic and acute; - Intensity: 6 (six) out of 10 (ten); - Relieved by: medications/rest; - Pain medication: (left blank); and - Taken as Rx'd (ordered): yes. Review of the Physical Therapy Progress Note dated 03/12/2021 revealed the PT documented the following pain assessment: - Pain location: abdomen- hernia; - Type: chronic and constant; - Intensity: 6 (six) out of 10 (ten); - Relieved by: medications; - Pain medication: gabapentin 100 milligrams (mg) by mouth TID (three times daily); and - Taken as Rx'd (ordered): yes. Review of the undated agency Medication Record lacked documented evidence of an order for pain medication. The documentation is inconsistent. It is unknown if the patient is taking pain medication and whether the documentation accurately reflects the patient's current status. During interview on 03/17/2021 at 02:25 PM, the PT (Employee I) stated the patient had been taking gabapentin for pain control since the PT completed her medication reconciliation at the start of care visit on 03/01/2021. Additionally, she stated she had not included it on the Medication Record at that visit or subsequent visits. Patient #6 - This 87-year-old patient with diagnoses that include atherosclerotic heart disease, history of falling, and dementia was admitted to the home care agency on 04/11/2020. This patient is listed on the agency's Potentially Avoidable Event Report dated 12/02/2019 to 11/30/2020 for discharge to the community with increased number in pressure ulcers. Review of the Home Health Certification and Plan of Care for certification period 04/11/2020 to 06/09/2020 revealed the following order for wound care to the left elbow: - Cleanse with wound cleanser, pat dry, apply Plurogel, cover with Versatle, skin prep peri wound, cover with foam adhesive per SN (Skilled Nurse) frequency; and - SN once week for one (1) week, twice a week for two (2) weeks, once a week for two (2) weeks. Review of the Physician Telephone Order dated 04/21/2020 revealed the RN documented the following order signed by the physician: "d/c (discharge) wound care to left elbow - wound healed." Review of the Physical Therapy Discharge Assessment dated 05/08/2020 revealed the PT documented the following integumentary assessment: - Does this patient have at least one unhealed pressure ulcer/injury at stage 2 or higher or designated as unstageable?: 0 -No; - The oldest stage 2 pressure ulcer that is present at discharge: 1 - Was present at the most recent SOC (start of care)/ROC (resumption of care); and - Additional comments: skin tear left elbow. Documentation is inconsistent regarding the patient's integumentary status. During interview on 03/17/2021 at 03:23 PM, the PT (Employee H) stated the skin tear was documented in error. The skin tear was healed prior to discharge as stated in the nursing note. The patient did not have any wounds or pressure ulcers at discharge. Patient #7 - This 87-year-old patient with diagnoses that include methicillin susceptible staphylococcus aureus infection, acute respiratory failure and cerebral infarction was admitted to the home care agency on 02/05/2020 and discharged on 04/21/2020. A.) Review of the Physician Telephone Order dated 03/11/2020 revealed an order for wound care to bilateral lower extremities to include cleansing the areas with soap and water, patting the areas dry, application of purocol (collagen dressing) to open areas, covering with dry dressing, wrapping with kerlix (gauze bandage) and securing with coban (self-adherent wrap). Review of the Case Management note dated 03/12/2020 revealed the RN documented wound care to the bilateral lower extremities was completed. Additionally, the RN documented the application of tubigrip (an elasticated tubular bandage) to secure kerlix wraps. Review of the medical record lacked an order for tubigrip application to the patient's lower extremities. The documentation regarding the application of tubigrip is inconsistent with physician orders. During interview on 03/17/2021 at 01:25 PM, the RN (Employee C) stated she made an error in her documentation, she documented tubigrip in her Case Management note but meant to document coban (self-adherent wrap) was placed over the kerlix dressings.

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 clinical record review and staff interview for one (1) of seven (7) clinical records (Patient #5), the agency failed to ensure agency staff communicated with the patient's physician regarding the patient's urine Foley catheter (a sterile tube that is inserted into the bladder to drain urine). Failure to communicate with the physician involved in the patient's care has the potential for unmet patient needs and negative outcomes. Findings are: Patient #5 - This 69-year-old patient with diagnoses that include pneumonia, pleural effusion, and end stage renal disease was admitted to the home care agency on 03/05/2021. Review of the referral to the home care agency dated 02/28/2021 revealed "(patient) was hospitalized from 01/25/2021 to 02/02/2021 with increased weakness and inability to care for himself ... He had a Foley inserted while hospitalized for urinary retention. He was hospitalized again when he had diffuse abdominal pain (02/11/2021) .... He had urinary retention and was discharged with a Foley catheter." Review of the Home Health Certification and Plan of Care for certification period 03/05/2021 and 05/03/2021 revealed the RN (Registered Nurse) documented the following: - Genitourinary: catheter: indwelling - 22 (twenty-two) French inflate balloon with 10(ten) mL (milliliters) normal saline - CHHA (certified home health agency) nurse may irrigate catheter with 20 (twenty) ml of sterile water as needed to maintain patency - Clinical summary: Currently with Foley cath (catheter) and states he is able to attach leg bag and wear during the day without difficulty. Awaiting his appointment with urology at which time f/u (follow-up) care will be determined. Review of the clinical record lacked documented evidence the RN followed-up with the patient's physician regarding the date the Foley catheter was inserted, when it is due for change, and the frequency for changes going forward. The agency failed to ensure agency staff communicated with the patient's physician regarding the patient's urine Foley catheter. During interview on 03/18/2021 at 09:11 AM, the RN (Employee D) stated the patient's son told her yesterday (03/17/2021, 12 (twelve) days after start of care) that the patient was scheduled for an appointment with the urologist next Tuesday 03/23/2021. She stated she did not call the physician at the start of care to obtain information regarding when the Foley was inserted and when it was due to be changed. She stated she looked at the referral and knew that it was placed approximately one (1) month prior to admission to the home care agency but did not document that date anywhere in the clinical record.

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 review of clinical records, agency policies and procedures and staff interview for four (4) of seven (7) patients (Patient #'s 1, 2, 4 and 7), the agency failed to ensure staff follow current clinical practice guidelines and agency policies and procedures. The issues are: - The agency failed to ensure medication review documentation is in accordance with agency policy (Patient #'s: 1, 2 and 7). - The agency failed to ensure wounds are measured in accordance with agency policy (Patient #4). Failure to ensure compliance with current clinical practice guidelines and agency policy has the potential to result in unmet patient needs and inadequate care. Findings are: A.) Review of the agency policy entitled "Drug Regimen Review" revised 05/21/2018 revealed the following: "1. The clinician performing the comprehensive adult assessment will, at start of care, resumption of care or recertification, record all medications reportedly taken by the patient on the medication record. If the clinician is not a Registered Nurse (RN), the completed medication record will be forwarded to the RN Case Manager within twenty-four (24) hours of the comprehensive adult assessment. 2. The RN will complete a full drug regimen review of all items listed on the medication record to determine if there are any potential major drug interactions. 11. The RN Case Manager will document the Drug Regimen Review results, notification to the physician (if potential major drug interactions were identified), in a clinical note if the Outcome and Assessment Information Set (OASIS) was completed by a therapist." Patient #1 - This 64-year-old patient Therapy Only patient with diagnoses that include hepatic encephalopathy, cirrhosis and type II diabetes mellitus was admitted to the home care agency on 03/01/2021. Review of the Physical Therapy Comprehensive Adult Assessment dated 03/01/2021 revealed the Physical Therapist (PT) completed the start of care for home care services visit and documented that a drug regimen review was completed. Additionally,a list of medications was submitted to the Home Health Agency (HHA) RN for drug regimen review. Review of the Medication Record revealed the RN's signature and review occurred on 03/02/2021. Review of the medical record lacked documented evidence of a RN clinical note detailing the outcome of the drug review and physician notification. The RN failed to follow agency policy regarding documentation of the drug regimen review. During interview on 03/17/2021 at 01:50 PM, the RN (Employee C) stated she was unaware of the agency policy and has always signed and dated the Medication Record once she completes the review. Patient #2 - This 96-year-old patient with diagnoses that include abnormalities of gait and mobility, atrial fibrillation, and atherosclerotic heart disease was admitted to the home care agency on 03/02/2021. Review of the clinical record revealed the PT completed the initial comprehensive adult assessment on 03/02/2021. The initial assessment lacks documented evidence that a medication reconciliation was completed by the PT. During interview on 03/17/2021 at 12:06 PM, the PT (Employee J) stated she left that part of the assessment blank because the RN is responsible for the full completion of the medication reconciliation. She stated that during the start of care visit she reviewed the patient's referral and medications in the home with the patient and verified which medications were correct. During the visit she created a new medication list with the proper medications (based on the patient's report). The medication list was then sent to the RN who runs the medications for drug interactions and reviews it for discrepancies. The RN is then responsible for calling the physician if there are issues. During interview on 03/18/2021 at 09:20 AM, the RN (Employee D) stated that usually when she receives a medication list from the PT, she reviews it against the referral and calls the physician to discuss discrepancies, then writes a clinical note. Review of the medical record lacked evidence the RN documented a clinical note regarding completion of the drug regimen review results. The RN failed to follow agency policy regarding documentation of the drug regimen review. During interview on 03/18/2021 at 09:20 AM, the RN (Employee D) stated that she does not recall completing a medication reconciliation for this patient and can't explain why. Patient #7 - This 87-year-old Therapy Only patient with diagnoses that include methicillin susceptible staphylococcus aureus infection, acute respiratory failure and cerebral infarction was admitted to the home care agency on 02/05/2020 and discharged on 04/21/2020. Review of the Physical Therapy Comprehensive Adult Assessment dated 02/05/2020 revealed the PT completed the start of care visit for home care services on 02/05/2020 and documented that a drug regimen review was performed during the assessment. The assessment lacked documented evidence that the PT submitted a list of medications to the RN for drug review. Review of the Medication Record revealed the RN's signature and review occurred on 02/06/2020. Review of the medical record lacked documented evidence of a clinical note completed by the RN of the drug regimen review results. The RN failed to follow agency policy regarding documentation of the drug regimen review. During interview on 03/17/2021 at 01:15 PM, the RN (Employee C) stated she was unaware of the agency policy and has always signed and dated the Medication Record once she completes the review. B.) Review of the agency's policy entitled "Wound Care" dated 06/07/2018 revealed the following: 2. With each dressing change an evaluation of the wound will be completed. The evaluation will include, but is not limited to: b. Type of wound 3. At a minimum, a weekly wound measurement will be completed. Wound measurements will be taken using the greatest extent of perpendicular length (l), and then width (w) of the wound, following by the depth (d). Patient #4 - This 104-year-old patient with diagnoses that include hypertension, rhabdomyolysis, and unspecified open wound left lower leg was admitted to the home care agency on 02/17/2021. Review of the Home Health Certification and Plan of Care (POC) for certification period 02/17/2021 to 04/07/2021 revealed the following wound care orders: - cleanse right and lower extremities with cleanser, pat dry, cover with CaAlg (calcium alginate), cover with gauze optilock and hydrofoam - sacral ulcer cleanse with NS (normal saline) calcium alginate optifoam Review of the Home Health Certification and Plan of Care for certification period 02/17/2021 to 04/07/2021 lacked an order specifying how often wound care should be completed. During interview on 03/18/2021 at 09:00 AM, the RN (Employee F) stated the frequency for the wound care is twice a week but she did not document that on the POC. 1. Review of the wound care sheet with wound measurements for the right lower leg dated 02/17/2021, 02/24/2021, 03/02/2021, and 03/08/2021 lacked documentation of the type of wound that is on the right lower leg. Review of the clinical record lacked documented evidence stated what type of wound is on the right lower leg. The RN failed to follow agency policy regarding documentation of the type of wound. During interview on 03/18/2021 at 09:10 AM, the RN (Employee F) stated she would normally document what type of wound she is measuring but did not do so in this case. 2. Review of the wound care sheet with wound measurements for the right lower leg dated 02/17/2021, 02/24/2021, 03/02/2021, and 03/08/2021 revealed the following measurements: - 02/17/2021: 2.5 cm x 1.0 cm x 0.10 cm - 02/24/2021: 2 cm x 1.0 cm x blank - 03/02/2021: 1.5 cm x 1.0 cm x blank - 03/08/2021: 1.5 cm x 1.0 cm x blank The RN failed to follow agency policy regarding documentation of a depth for each wound measurement. During interview on 03/18/2021 at 09:10 AM, the RN (Employee F) stated she should have documented a zero (0) if there was no depth to the wound.

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 review of clinical records and interview with staff, for one (1) of seven (7) patients (Patient #7) the agency failed to ensure all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice. Failure to authenticate documentation with a signature and professional credentials has the potential for patients to receive care from unlicensed staff. Patient #7 - This 87-year-old patient with diagnoses that include methicillin susceptible staphylococcus aureus infection, acute respiratory failure and cerebral infarction was admitted to the home care agency on 02/05/2020 and discharged on 04/21/2020. Review of the Follow Up Visit Note dated 03/26/2020 revealed the note lacked documented evidence of the Registered Nurse's (RN) signature and credentials. The agency failed to ensure all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice. During interview on 03/17/2021 at 01:35 PM, the RN (Employee C) stated it was an oversight that she did not include her signature and credentials on the visit note.