Every finding on record at Saad Enterprises, Inc.

A recertification survey was conducted from 4/1/25 to 4/3/25. The agency was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 4/1/25 to 4/3/25 at Saad Healthcare. Standard level deficiencies were citied that will require an acceptable plan of correction.

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 medical records (MR), observations, agency policy, and interviews with staff, patients and caregivers, it was determined the agency failed to ensure the medications were reconciled per agency policy to include all current medications. This deficient practice did affect five of seven Home Visit (HV) patients including HV # 1, HV # 2, HV # 5. HV # 7, and HV # 6, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Medication Profile Process Policy Number: Not Listed Revised: 2/2025 Purpose/Objective: 1.1 To provide a source of information for all patients/clients receiving drug therapy. Policy: 2.1 A Plan of Care with Medication Profile will be completed on every patient upon admission to the agency and verified with physician for accuracy. All disciplines with the exception of Home Health Aides (CNA), will reconcile medication every visit and as needed for medication changes and updates... 4. HV # 7 was admitted on 2/23/25 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Orthopedic Aftercare Following Surgical Amputation, and Type One Diabetes Mellitus with Diabetic Chronic Kidney Disease. A HV was conducted on 4/1/25 at 9:45 AM to observe wound care provided by EI # 8, Registered Nurse (RN). A review of the medications in the home was conducted with EI # 8 and HV # 7's cg and compared to the CMR dated 4/1/25. The following is a list of the medication discrepancies observed: a. Amitriptyline 100 mg take one and one-half tablets at bedtime, prescription dated 1/28/25, was in the home but not listed on the CMR. The cg stated HV # 7 is currently taking the medication each night. b. Methocarbamol 500 mg take one tablet twice a day as needed, prescription dated 1/30/25, was in the home but not listed on the CMR. The cg stated HV # 7 is currently taking the medication daily for pain. c. Ramelteon 8 mg, take one tablet at bedtime, prescription dated 3/4/25, was in the home but not listed on the CMR. The cg stated HV # 7 currently takes the medication each night for rest. d. Hydralazine 25 mg, take one three times a day as needed, prescription dated 3/8/25, was in the home but not listed on the CMR. The cg stated HV # 7 is currently taking the medication daily as needed. An interview was conducted on 4/3/25 at 11:05 AM with EI # 1 who confirmed the agency failed to ensure the medications were reconciled per agency policy. 5. HV # 6 was admitted on 3/10/25 with diagnoses including Atherosclerotic Heart Disease, Type 2 Diabetes Mellitus, and Repeated Falls. A HV was conducted on 4/1/25 at 1:00 PM to observe care provided by EI # 7, Physical Therapist Assistant (PTA), A review of the medications in the home was conducted with HV # 6 and compared to the CMR dated 4/1/25. The following medication discrepancies were observed: a. Montelukast 10 mg take one daily, prescription dated 1/3/25, was in the home but not listed on the CMR. HV # 6 confirmed he/she was currently taking the Montelukast daily. b. Collagen + C (brand name) 2,500 mg over the counter (OTC) bottle was in the home but not listed on the CMR. HV # 6 stated he/she had been taking the vitamin daily for over a year. c. Quercetin 500 mg OTC bottle was in the home but not listed on the CMR. HV # 6 stated he/she had been taking the vitamin daily for over a year. d. Vitamin D 3 (brand name) 200 mg OTC bottle was in the home but not listed on the CMR. HV # 6 stated he/she had been taking the vitamin for over a year. An interview was conducted on 4/3/25 at 11:05 AM with EI # 1 who confirmed the agency failed to ensure the medications were reconciled per agency policy. 2. HV # 2 was admitted on 12/4/2024 and recertified on 2/2/2025 to 4/2/2025 with diagnoses including Parkinsonism Unspecified and Dysphagia, Oropharyngeal Phase. A HV was conducted on 4/1/25 at 11:20 AM to observe care provided by EI # 3, Occupational Therapist. A review of the medications in the home was conducted with HV # 2's cg and compared to the CMR dated 4/1/25. T3 (Liothyronine) 30 mcg (micrograms) / T4 (Levothyroxine) 76 mcg (Methocel) E4M caps with instructions to take one cap each morning. Filled date 3/17/25. The CG reported HV # 2 has been taking the medication for a very long time. There was no documentation of the T3/T4 caps on the agency CMR. An interview was conducted on 4/3/25 at 10:31 AM with EI # 1 who confirmed the agency failed to ensure the medications were reconciled per agency policy. 3. HV # 5 was admitted on 2/14/25 with the diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputee and Type Two Diabetes with Diabetic Peripheral Angiopathy with Gangrene. A HV was conducted on 4/1/25 at 2:02 PM to observe care provided by EI # 6, Health Aide. A review of the medications in the home was conducted with HV # 5 and the cg and compared to the CMR dated 4/1/25. The following medications were on the CMR, but not in the home: a. Aspirin 81 mg tablet, delayed release, one tablet daily. HV # 5 stated, I should be taking aspirin, but never started the medication. b. Farxiga 10 mg tablet one tablet daily. HV # 5 and the cg reported they were unaware of the medication. c. Miralax 17 gram dose oral powder twice daily. HV # 5 and the cg reported they were unaware of the medication. An interview was conducted on 4/3/25 at 10:25 AM with EI # 1, who confirmed the agency failed to ensure the medications were reconciled per agency policy. 1. HV # 1 was admitted to the agency on 3/7/25 with diagnoses including Cerebral Infarction due to Embolism of Bilateral Carotid Arteries and Nonrheumatic Aortic (Valve) Stenosis. A HV was conducted on 4/1/25 at 11:26 AM to observe wound care provided by Employee Identifier (EI) # 2, Speech Therapist. A review of the medications in the home was conducted with EI # 2 and HV # 1's caregiver (cg) and compared to the Client Medication Report (CMR). The following is a list of the medication discrepancies observed: a. Atorvastatin 40 milligram (mg) one tablet daily, prescription dated 3/14/25, was in the home. The cg verbalized the patient had been taking the 40 mg dose since returning home on 3/6/25. Atorvastatin 10 mg one tablet at bedtime was on the agency CMR. b. Miralax 17 grams daily was on the agency CMR. The cg verbalized Miralax was discontinued three weeks prior. c. Omega 3-6-9 1200 mg daily was on the agency CMR. The cg verbalized Omega 3-6-9 was discontinued prior to the patient returning home on 3/6/25. An interview was conducted on 4/3/25 at 10:49 AM with EI # 1, Director of Nursing, who confirmed the agency failed to ensure the medications were reconciled per agency policy.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy, and interview with staff, it was determined the agency failed to ensure physician's orders were followed. This deficient practice affected one of four diabetic patients reviewed including MR # 7 and had the potential to affect all diabetic patients admitted to this agency. Findings include: Agency Policy: Physician Notification and Physician Orders Policy Number: Not Listed Revised: 2/2025 Section 1: Purpose/Objective 1.1 To ensure that the physician is notified of all changes in patient status... 1.2 To ensure that all disciplines follow all orders, to include the 485/487 and Physician Change Orders... 1. MR # 7 was admitted on 8/16/24 with diagnoses including Dysphagia Following Cerebral Infarction, Peripheral Vascular Disease, and Type 2 Diabetes Mellitus. Review of the Resumption of Care (ROC) dated 8/28/24 revealed physician's orders for Skilled Nurse (SN) one visit per week for seven weeks. SN to perform blood glucose analysis every visit and report blood glucose levels greater than 250 milligrams (mg)/deciliter(dl) and less than 70 mg/dl. Review of the SN Visit Note Report dated 9/10/24 revealed no documentation the SN obtained the blood glucose level. Review of the SN Visit Note Report dated 9/12/24 revealed the SN documented the blood glucose was 45 mg/dl and MR # 7 was taken to the Emergency Room. An interview was conducted on 4/3/25 at 11:04 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency failed to ensure the staff followed physician orders for performing blood glucose analysis every visit.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure the physician was notified of significant changes. This deficient practice did affect two of seven Home Visit (HV) patients including HV # 7 and HV # 6, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Physician Notification and Physician Orders Policy Number: Not Listed Revised: 2/2025 Section 1: Purpose/Objective 1.1 To ensure that the physician is notified of all changes in patient status ... Section 4: Procedure ...4.2 Reasons to obtain a new order, or provider physician notification, will include but are not limited to the following: ...e. Change in patient status and/or need for additional services. ...g. Any parameters outside those listed above... 1. HV # 7 was admitted on 2/3/25 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Orthopedic Aftercare Following Surgical Amputation, and Type 1 Diabetes Mellitus with Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/23/25 revealed physician's orders for Skilled Nurse (SN) three visits per week for one week then two visits per week for seven weeks. SN to assess/evaluate co-morbid conditions including ... Diabetes Mellitus... Further review of the HHC and POC dated 2/23/25 revealed physician's orders for SN to perform blood sugar analysis every visit and to report to the physician blood glucose levels greater than 250 milligrams (mg)/decaliter (dl) or less than 70 mg/dl. Review of the SN Visit Note Report dated 3/4/25 revealed the SN documented the blood sugar reading was 435 mg/dl, patient asymptomatic. There was no documentation the physician was notified. An interview was conducted on 4/3/25 at 10:30 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency failed to ensure the physician was notified. 2. HV # 6 was admitted on 3/10/25 with diagnoses including Atherosclerotic Heart Disease, Type 2 Diabetes Mellitus, and Repeated Falls. Review of the HHC and POC dated 3/10/25 revealed physician's orders for Physical Therapist (PT) two visits per week for four weeks. Review of the PTA Visit Note Report dated 4/1/25 revealed the patient's last bowel movement was on 3/27/25, which was greater than 3 days. Instructions under the Gastrointestinal section was to notify the Nurse Supervisor if greater than three days. Further review of the PTA Visit Note Report dated 4/1/25 revealed no documentation the physician was notified of the no bowel movement of greater than three days. An interview was conducted on 4/1/25 at 1:05 PM with EI # 1, who confirmed the agency failed to ensure the physician was notified of no bowel movement greater than three days.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on medical record (MR) review, observations, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure agency policy for infection prevention was followed. This deficient practice affected one of seven home visit (HV) patients including HV # 7 and had the potential to affect all patients receiving wound care. Findings include: Agency Policy: Hand Washing Indications Policy Number: 11160.20 Revised: 2/2022 Section 1: Purpose/Objective 1.1 To prevent nosocomial infections... ...4.6 Employees should sanitize their hands before and after touching inanimate sources that are likely to be contaminated with virulent or infections microorganisms... 1. HV # 7 was admitted on 2/3/25 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Orthopedic Aftercare Following Surgical Amputation, and Type 1 Diabetes Mellitus with Chronic Kidney Disease. A HV was conducted on 4/1/25 at 9:45 AM to observe wound care provided by Employee Identifier (EI) # 8, Registered Nurse. EI # 8 performed hand hygiene, donned gloves, retrieved measuring tape, cotton swab, and marking pen from clean barrier, then dropped the marking pen onto the floor. EI # 8 picked up the marking pen with a gloved hand then continued to measure the open wound with the measuring tape and cotton swap. EI # 8 failed to remove gloves and perform hand hygiene after touching contaminated surface. An interview was conducted on 4/3/25 at 10:30 AM with EI # 1, Director of Nursing, who confirmed the agency failed to ensure the agency policy for infection prevention was followed.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policies and procedures, and interviews it was determined the agency failed to ensure: 1. Negative Pressure Wound Therapy (NPWT) black foam number removed and/or inserted into the wound was documented per policy. 2. Soiled wound VAC dressing was removed and a wound assessment completed in response to an unresolved on-call problem. 3. Blood draws from a PICC (peripherally inserted central catheter) were documented per the agency policy. 4. Wounds were measured per policy. This deficient practice affected five of 17 MRs reviewed including MR # 1, MR # 5, Home Visit (HV) # 1, HV # 3, HV # 4, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: NPWT Policy Number: Not documented Revised: 2/25 Section 1: Purpose and objective 1.1 To standardize the management of wounds where NPWT is indicated. 1.2 To ensure all patients are receiving treatment that is in keeping with best practice guidelines for wound care. ...Section 4: Procedure ...4.3 The removal of NPWT: ...Check that the number of gauze and foam pieces removed from the wound is the same as the number that was originally placed in the wound... 4.4 The application of NPWT: ...The number of pieces of foam inserted into the wound must be documented in the coordination note... Section 5: Documentation 5.1 Record application of NPWT in wound care record and coordination note. Include: ...Type and number of foam pieces removed/inserted/applied... Agency Policy: On Call Procedure Policy Number: Not documented Revised: 2/25 Section 1: Purpose/Objective 1.1 To implement, maintain, and promote Home Health...patient after hours regarding all patient related issues... Section 4: Procedure 4.1... On-call personnel will be notified for follow up on the patient to attempt to resolve the issue by phone and follow up or direct if a visit is warranted based on report and signs and symptoms. Office personnel will place an order for a scheduled visit if needed after hours to resolve any issues... Agency Policy: Wound Care Policy Number: Not documented Revised: 4/18 Section 1: Purpose and Objective 1.1 To provide and environment conductive to wound healing. 1.2 To prevent infection. 1.3 To effectively treat and document wound healing performance. Section 2: Policy 2.1 Wound measurement and photos are done on Admission...on a weekly basis... Section 5: Documentation 5.1 Document...length, width, and depth of wound... Agency Policy: PICC Line Irrigation or Blood Draw Policy Number: Not documented Revised: 2/25 Section 1: Purpose/Objective...To maintain the patency of the catheter. Section 2: Policy and Criteria. 2.1... Agency protocol is as follows: A. With 10 cc (cubic centimeter) Saline...prior to blood sampling. B. Withdrawal of blood - 10 cc and discard. C. With 20 cc Saline...after blood sample withdrawal. ...Section 4: Procedure Document procedure performed... 4. HV # 3 was admitted to the agency on 3/30/25 with a diagnose of Disruption of External Operation (surgical) Wound. Review of the HHC and POC dated 3/30/25 to 5/28/25 revealed an order for a SN frequency twice weekly for one week, and once weekly for eight weeks to perform/teach wound care to left lower back, cleanse with Normal Saline, pat dry, and leave open to air using clean/aseptic technique. Derma bond in place. Review of the SN visit note dated 3/30/25 revealed no documentation of weekly wound measurements for wound # 2, Left Mid-Back Surgical Incision (SI), and wound # 3, Medium Mid-Back SI per the agency policy. An interview was conducted on 4/3/25 at 11:15 AM with EI # 1 who confirmed wound measurements were not performed on admission per agency policy. 5. HV # 4 was admitted to the agency on 3/14/25 with a diagnosis of Encounter for Surgical Aftercare Following Surgery on the Nervous System. Review of the HHC and POC dated 3/14/25 to 5/12/25 revealed an order for SN frequency of once weekly for one week, and twice weekly for eight weeks. Review of the physician order dated 3/21/25 revealed an order for the SN to cleanse # 2 Left Axillary Surgical incision with wound cleanser/normal saline, pat dry, then leave open to air daily. Review of SN visit note dated 3/24/25 and 3/28/25 revealed no documentation of wound measurements for wound # 2, Left Axillary, Surgical Incision the week of 3/23/25 per agency policy. An interview was conducted on 4/3/25 with EI # 1 who confirmed there were no wound measurements performed weekly per agency policy. 1. MR # 1 was admitted to the agency on 3/5/25 with diagnoses including Sepsis, Unspecified Organism and Pressure Ulcer of Sacral Region, Stage 4. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/5/25 to 5/3/25 revealed an order for a skilled nurse (SN) frequency twice weekly for one week, once weekly for one week, then twice weekly for seven weeks to cleanse stage IV to sacral, pat dry, cut to fit and fill wound cavity with black foam, cover with transparent drape, apply trac pad (part of the NPWT dressing) then NPWT at 125 mmHg (millimeter of mercury) continuously on Tuesday and Friday. SN to instruct as needed NPWT protocol for malfunction including to clean with normal saline, pat dry, pack wound with Dakin's moistened gauze, cover with dry gauze, and secure with tape. Review of the two nursing notes dated 3/7/25 and 3/27/25 revealed no documentation of the number of black foam pieces removed from and placed in the sacral wound. Review of the two nursing notes dated 3/14/25 and 3/19/25 revealed no documentation of the number of black foam pieces removed from the sacral wound. Review of the On Call note dated 3/18/25 revealed the caregiver called to report the patient had a large bowel movement and the area around the NPWT and the wound was filled with stool. The cg reported there remained stool under the NPWT and the wound area after the cg had cleaned the stool off of the patient. There was no documentation the patient and/or caregiver had been educated and was able to remove the NPWT dressing, the NPWT dressing had been removed, or the agency offered an after hours SN visit to change the NPWT dressing and assessment the wound due to stool remaining under the NPWT and wound area per the caregivers report. An interview was conducted on 4/3/25 at 11:24 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency failed to document the black foam number removed and/or inserted into the wound per policy. EI # 1 confirmed there was no documentation the NPWT dressing was removed or a SN visit was offered on 3/18/25. EI # 1 verbalized a nursing visit would have been expected by the agency with the unresolved problem of stool remaining under and around the NPWT dressing per the caregiver. 2. MR # 5 was admitted to the agency on 3/7/25 with diagnoses including Osteomyelitis of Vertebra, Lumbar Region and Intraspinal Abscess and Granuloma. Review of the HHC and POC dated 3/7/25 to 5/5/25 revealed an order for a SN frequency once weekly for eight weeks then twice weekly for one week to perform venipuncture or use PICC line to obtain a complete blood count with differential (CBC), a comprehensive metabolic panel (CMP), erythrocyte sedimentation rate (ESR), and c-reactive protein test (CRP) weekly. Review of the SN visits dated 3/10/25, 3/17/25, 3/24/25, and 3/31/25 revealed the nurse obtained the CBC, CMP, ESR, and CRP via the patient PICC line. There was no documentation the PICC line was flushed prior to or following the blood draw and 10 cc's of blood was withdrawn and discarded. An interview was conducted on 4/3/25 at 10:47 AM with EI # 1 who confirmed the agency failed to document blood draws from a PICC per the agency policy. 3. HV # 1 was admitted to the agency on 3/7/25 with diagnoses including Cerebral Infarction due to Embolism of Bilateral Carotid Arteries and Nonrheumatic Aortic (Valve) Stenosis. Review of the HHC and POC dated 3/7/25 to 5/5/25 revealed an order for a SN frequency once weekly for one week, twice weekly for two weeks, then once weekly for six weeks to perform/teach wound care to the left hand skin tear cleanse with wound cleanser, pat dry, apply silver alginate to wound bed, cover with dry gauze, wrap with rolled gauze, and secure with coban every other day. Review of two of two nursing notes for the week of 3/9/25 to 3/15/25 revealed no documentation of a wound measurement for the left hand skin tear. An interview was conducted on 4/3/25 at 10:51 AM with EI # 1 who confirmed the wound was not measured per the agency policy.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on review of medical records (MRs), agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure patient education and return demonstration was provided for all medications and treatments. This deficient practice did affect four of 17 MR reviewed including MR # 6, Home Visit (HV) # 3, MR # 9, and HV # 1 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Patient/Family Education Process for Medications Policy Number: Not Listed Revised 10/2018 Section 1: Purpose/Objective 1.1 To provide a systematic and coordinated methodology for teaching and documenting medication instructions... Section 4: Procedure 4.1 On admission and throughout the care stay, medication teaching will be incorporated with each assessment and care of the patient. 4.2 Patient teaching will also include assessment of learning needs and evaluations of emotional barriers to learning... 4. HV # 1 was admitted to the agency on 3/7/25 with diagnoses including Cerebral Infarction due to Embolism of Bilateral Carotid Arteries and Nonrheumatic Aortic (Valve) Stenosis. Review of the HHC and POC dated 3/7/25 to 5/5/25 revealed an order for a SN frequency once weekly for one week, twice weekly for two weeks, then once weekly for six weeks to perform/teach wound care to the left hand skin tear cleanse with wound cleanser, pat dry, apply silver alginate to wound bed, cover with dry gauze, wrap with rolled gauze, and secure with Coban. Caregiver to perform wound care every other day and as needed when soiled between nurse visits. Review of five of five nursing notes from 3/7/25 to 3/20/25 revealed no documentation a return demonstration was obtained from the patient and/or caregiver to ensure competency in providing wound care. An interview was conducted on 4/3/25 at 10:51 AM with EI # 1 who confirmed there was no documentation a return demonstration was obtained from the patient and/or caregiver to ensure competency in providing wound care. 2. HV # 3 was admitted to the agency on 3/30/25 with a diagnose of Disruption of External Operation (surgical) Wound. Review of the HHC and POC dated 3/30/25 to 5/28/25 revealed a SN frequency twice weekly for one week, and once weekly for eight weeks to infuse Ertapenem 1 gram in 100ML via eclipse bulb every 24 hours via intravenous (IV) access to the right upper extremity (RUE) midline and SN to perform/teach wound care to left lower back, cleanse with Normal Saline, pat dry, and leave open to air using clean/aseptic technique. Derma bond in place. Caregiver to perform wound care daily and as needed when soiled between nurse visits. Review of the SN visit note dated 3/30/25 and 4/1/25 revealed no documentation of return demonstration of wound care or intravenous infusion. An interview was conducted on 4/3/25 at 11:15 AM with EI # 1 who confirmed the agency failed to ensure staff provided return demonstration of wound care or intravenous infusion. 3. MR # 9 was admitted to the agency on 10/5/24 with a diagnosis of Chronic Osteomyelitis with Draining Sinus, Left Ankle Foot. Review of the HHC and POC dated 10/5/24 revealed a SN frequency weekly for ten weeks to infuse Vancomycin 1 gram in 250 ML via eclipse bulb over 90 minutes every 12 hours via IV access to the right upper extremity peripherally inserted central catheter. Review of the SN visit note dated 10/5/24 to 12/3/24 revealed no documentation of return demonstration of intravenous infusion or SN visits to infuse the Vancomycin every 12 hours. An interview was conducted on 4/3/25 at 11:14 AM with EI # 1 who confirmed the agency failed to ensure staff provided return demonstration of intravenous infusion. 1. MR # 6 was admitted on 10/26/23 and recertified from 6/22/24 to 8/20/24 with diagnoses including Hypertensive Heart and Chronic Kidney Disease, Chronic Diastolic (Congestive) Heart Failure, and Type 2 Diabetes Mellitus. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 6/22/24 revealed physician's orders for Skilled Nurse (SN) one visit per week for eight weeks. SN for observation and assessment of pain, effectiveness of pain management and skilled teaching related to pain management. SN may instruct and reinforce medication teaching related to use of medications. Further review of the HHC and POC dated 6/22/24 revealed physician's orders for Tramadol 50 milligrams (mg) every eight hours as needed for pain. Review of the SN Visit Note Reports from 6/22/24 through 7/31/24 revealed no documentation patient teaching for the medication Tramadol was provided. Review of the SN Visit Note Report, Transfer to Inpatient Facility, dated 8/6/24 revealed MR # 6 was transferred to an inpatient facility due to an overdose of Tramadol. An interview was conducted on 4/3/25 at 10:45 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency failed to ensure staff provided patient teaching for pain control medications.

Based on the recertification survey conducted on 5/12/22, Saad Healthcare was found to be in substantial compliance with the standards for Emergency Preparedness.

A recertification survey was conducted from 5/10/22 to 5/12/22 at Saad Healthcare and standard level deficiencies were cited.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on review of Medical Records (MR), review of the Home Folder Packet, observations from Home Visits (HV), and interviews, it was determined the agency failed to ensure all patients were provided information for the State Hotline Number and grievance process. This deficient practice affected 6 of 7 HV including HV # 1, HV # 2, HV # 3, HV # 4, HV # 5, HV # 7, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Home Folder Provided to the surveyors on 5/12/22 Date: No date or number on policy ...The patient's home folder should contain the following: 1. Copies of the forms that are signed in the Electronic Medical Record: a. Patient Bill of Rights - with attention to the Hotline number... Agency patient form: Saad Healthcare Services. Patient Disclosure and Notice; Patient's Consent; Patient's Bill of Rights and Responsibilities Provided to the surveyors on 5/12/22 ... C. Patient Bill of Rights (Saad Healthcare agrees to do the following in the performance of the healthcare services): Each person receiving care from Saad Healthcare shall have the right: ...12. To be informed of the State toll free Bureau of Licensure and Certification Hot Line... 1. A copy of a current admission pack to be provided to patients on admission was provided to the surveyors on 5/10/22 at approximately 10:00 AM. Review of the new admission pack revealed no statement of the State Hotline Number. 2. In home visits conducted on 5/10/22 and 5/11/22 on HV # 1, HV # 2, HV # 3, HV # 4, HV # 5, and HV # 7 revealed no documentation of the State Hotline Number in either of the patient's home health folders. In an interview conducted on 5/12/22 at 11:10 AM, Employee Identifier (EI) # 8, Registered Nurse Supervisor, confirmed not all patients had the State Hotline Number in the home. EI # 8 stated the signature sheet with the State Hotline Number had been left out of the new admission packs.

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 medical records (MR), facility policy, and interviews, it was determined the agency failed to ensure medication profiles were updated for all patients. This affected 2 of 7 Home Visits (HV) conducted, and did affect HV # 1, HV # 6, and had the potential to affect all patients served by the agency. Findings include: Facility Policy: Medication Profile Process Policy number: None listed Date revised: 01/21 ...Section 2: Policy 2.1 A Plan of Care with Medication Profile will be completed on every patient upon admission to the agency and verified with physician for accuracy. All disciplines with the exception to Home Health Aides will reconcile medications every visit and as needed for medication changes and updates... 2. HV # 6 was admitted to the agency on 3/10/22 with diagnoses including Essential (Primary) Hypertension and Acute Embolism and Thrombosis Unspecified Deep Veins of Unspecified Lower Extremity. A HV was conducted on 5/11/22 at 9:40 AM to observe the SN (Skilled Nurse) provide care. During the visit, EI # 3, RN reviewed the medications with the patient, caregiver and surveyor and the following discrepancies were found: Amlodipine 10 mg tablet daily listed on the CMR printed for the surveyor on 5/10/22 at 1:46 PM and per HV # 6 and the caregiver, was discontinued between July of 2021 and January of 2022 by "the Cancer doctor." Lipitor 40 mg tablet daily at bedtime was listed on the CMR, but per HV # 6 and the caregiver, was discontinued March 21, 2022. Magnesium Oxide 500 mg, one tablet twice daily found in the home and not on the CMR. The date on the bottle revealed October 20, 2021 and per HV # 6 and the caregiver, the medication was restarted about one month ago. An interview conducted on 5/12/22 at 12:50 PM with EI # 9, Clinical Educator confirmed the medication profile was not updated per policy. 1. HV # 1 was admitted to the agency on 4/20/22 with diagnoses including Spinal Stenosis Lumbar Region without Neurogenic Claudication, and Muscle Spasm of Calf. Review of the Home Health Certification and Plan of Care, dated 4/20/22 to 6/18/22, revealed orders for PT (Physical Therapy) 1WK (Week) 1, 2 WK 4, and OT (Occupational Therapy) effective 5/1/22, 2 WK 4. A HV was conducted on 5/10/22 at 2:15 PM to observe care provided by EI # 5, Occupational Therapist. During the HV, the surveyor compared the current Client Medication Report (CMR), printed on 5/10/22 at 11:54 AM, with the medications in the home. The following discrepancy was observed: Baclofen 10 mg (milligrams) tablet, 1 tablet, 3 times daily was listed on the CMR. The caregiver stated HV # 1 could not tolerate that dose, and the doctor's office had instructed to give 1/2 tablet, two times a day, on 5/1/22. An interview was conducted on 5/12/22 at 12:54 PM with EI # 8, RN (Registered Nurse), Supervisor, who confirmed staff failed to update the medication profile.

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 Medical Records (MR), Agency Policy and Procedure, and interviews, it was determined the agency failed to ensure the visit frequency was followed in 1 of 12 active records reviewed including MR # 6 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Missed/... Visits Last Review and Revision: 02/2020 ...Procedure: 4.1 If any discipline arrives at the home of a patient and cannot gain entry to the home, the following steps will be followed: A. Attempt to reach the patient by telephone. B. If this is not successful, contact the caregiver or contact person... D. If all attempts to locate a patient are unsuccessful, the visit status will be changed to Rescheduled in the Electronic Medical Record and sent to the back office where the Scheduling Coordinator will be notified... 1. MR # 6 was admitted to the agency on 4/16/22 with diagnoses including Fistula of Intestine and Other Symptoms and Signs Concerning Food and Fluid Intake. Review of the Home Health Certification and Plan of Care dated 4/16/22 revealed orders for Skilled Nurse (SN) 1 x a week x 9 weeks. Review of the Client Coordination Note Reports (CCNR) dated 4/22/22 revealed documentation of a missed visit for 4/21/22. Review of the CCNR dated 5/2/22 revealed documentation of a missed visit for 4/29/22. There were no SN visit notes provided for the weeks of 4/17/22 and 4/24/22 and no other attempts documented to reschedule the visits. Review of the CCNR dated 5/9/22 for the visit on 5/5/22 revealed “…Patient has non healing surgical wound to abdomen. Wound Vac (Vacuum) dressing in place…Patient reports noticing purulent drainage oozing from underneath Vac tape this am…Copious amounts of purulence under drape…” There was no SN Visit Note Report provided for the 5/5/22 visit. In an interview conducted on 5/12/22 at 1:10 PM, Employee Identifier (EI) # 10, Registered Nurse (RN), Supervisor, confirmed no other visits had been completed since admission on 4/16/22. EI # 10 stated MR # 6 was admitted to the hospital on 5/10/22 and was scheduled for a debridement of the wound.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on review of agency policies and procedures, medical record (MR) reviews and staff interviews, it was determined the agency failed to ensure physician's orders were obtained prior to providing wound care. This deficient practice affected 1 of 6 MR's reviewed with wounds and 1 of 3 MR's reviewed with PICC (Peripherally Inserted Central Catheter) including Home Visit (HV) # 6, MR # 6, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Wound Care Revised Date 4/18 2.5 Wound care protocols are by physician orders. Agency Policy: Physician Notification and Physician Orders Date Revised: 3/18 Purpose / Objective 1.1 To ensure that the physician is notified of all changes in patient status and that all changes to the Plan of Care are addressed in a Physician Change Order and/or Coordination Note. Procedure: 4.2 Reasons to obtain a New Order, or provider physician notification, will include but are not limited to the following: c. New or Changed Wound Care Protocols. 2. MR # 6 was admitted to the agency on 4/16/22 with diagnoses including Fistula of Intestine and Other Symptoms and Signs Concerning Food and Fluid Intake. Review of the HHC and POC dated 4/16/22 revealed no orders for the care and flushing of the PICC line. Review of the VNR dated 4/16/22 revealed the nurse documented the PICC line "flushes easily". There was no documentation of what the PICC line was flushed with. In an interview conducted on 5/12/22 at 1:10 PM, EI # 10, Registered Nurse, Supervisor, confirmed there was no order on 4/16/22, the day of admission, to flush the PICC line. 1. HV # 6 was admitted to the agency on 3/10/22 with diagnoses including Essential (Primary) Hypertension and Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/10/22 to 5/8/22 revealed Skilled Nurse (SN) to observe and assess integumentary status to identify changes and intervene to minimize complications....SN to report significant changes in status to physician for early intervention. Review of the Visit Note Report (VNR) by the SN dated 3/16/22 revealed, "New wound assessed to left calf. Wound care orders implemented....Image obtained....Instructed on materials used in wound care." There was no documentation the physician was contacted to inform him/her of the new wound and obtain wound orders for care and no documentation of what wound care and supplies were used in the care of the wound. Review of the VNR by the SN dated 3/22/22 revealed, "Wound care completed to Left Calf using Clean technique and sterile supplies per MD orders". There was no documentation of physician orders for the wound care provided. An interview conducted on 5/12/22 at 12:50 PM with Employee Identifier (EI) # 9, Clinical Educator confirmed the SN provided wound care on 3/16/22 and 3/22/22 without documented physician's orders.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, facility policies and procedures, CDC (Centers for Disease Control and Prevention) Hand Hygiene Recommendations, and interviews, it was determined the facility failed to ensure staff: 1) Removed contaminated gloves and performed hand hygiene prior to cleaning non-disposable equipment. 2) Performed hand hygiene when performing wound care per agency policy. This affected 3 of 7 Home Visits (HV) conducted, and did affect HV # 3, HV # 1, and HV # 5, and had the potential to affect all patients served by the agency. Findings include: Facility Policy: Hand Washing Indications Policy number: 11160.20 Date revised: 01/22 Section 1: Purpose/ Objective 1.1 To prevent nosocomial infections. ...Section 2: Policy 2.1 All employees will follow CDC Hand Washing Recommendations... Section 4: Procedure ...4.3. Employees should always sanitize their hands BEFORE and AFTER touching wounds. 4.4. Employees should sanitize theirs hands BEFORE and AFTER situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood or bodily fluids, secretions, or excretions. Source: CDC Website Topic: Hand Hygiene Recommendations Guidance for Healthcare Providers about Hand Hygiene and COVID-19 Updated: May 17, 2020 Hand Hygiene Guidance The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient’s immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal 3. HV # 5 was admitted to the agency on 3/25/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery of the Digestive System, Perforation of Intestine, and Peritoneal Abscess. A HV was conducted on 5/10/22 3:05 PM to observe wound care provided by EI # 7, RN. EI # 7 performed hand hygiene, donned gloves then removed the soiled surgical dressing from the abdomen. EI # 7 then applied wound cleanser to a clean 4 x 4 and cleaned the open wound site. EI # 7 then removed gloves and performed hand hygiene. EI # 7 failed to remove gloves and perform hand hygiene after removing the soiled dressing. In an interview conducted on 5/12/22 at 1:15 PM, EI # 8 confirmed the staff failed to follow agency policy for hand hygiene when performing wound care. 1. HV # 3 was admitted to the agency on 12/28/21 with diagnoses including Encounter for Attention to Gastrostomy, and Dysphagia Following Cerebral Infarction. A HV was conducted on 5/10/22 at 12:30 PM to observe care provided by Employee Identifier (EI) # 6, HHA (Home Health Aide). EI # 6 performed hand hygiene, donned gloves and checked HV # 3's blood pressure. Using the same gloves, EI # 6 cleaned the blood pressure cuff and stethoscope. Continuing with the same gloves, EI # 6 checked HV # 3's oxygen (O2) saturation, then cleaned the O2 monitor while wearing the same gloves. EI # 6 failed to remove contaminated gloves and perform hand hygiene prior to cleaning equipment used on HV # 3. An interview was conducted on 5/12/22 at 11:41 AM with EI # 8, RN (Registered Nurse), Supervisor, who confirmed staff failed to remove gloves and perform hand hygiene prior to cleaning equipment. 2. HV # 1 was admitted to the agency on 4/20/22 with diagnoses including Spinal Stenosis Lumbar Region without Neurogenic Claudication, and Muscle Spasm of Calf. A HV was conducted on 5/10/22 at 2:15 PM to observe care provided by EI # 5, Occupational Therapist. EI # 5 performed hand hygiene, donned gloves, and checked HV # 1's blood pressure and pulse. Wearing the same gloves, EI # 5 cleaned the stethoscope and blood pressure cuff. EI # 5 failed to remove contaminated gloves and perform hand hygiene prior to cleaning equipment used on HV # 1. An interview was conducted on 5/12/22 at 12:24 PM with EI # 8, who confirmed staff failed to remove gloves and perform hand hygiene prior to cleaning equipment.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy, and interviews, it was determined the agency failed to ensure wounds were assessed and measured weekly per policy. This deficient practice affected 2 of 6 MR of patients with wounds including Home Visit (HV) # 5, HV # 6, and had the potential to affect all patients with wounds. Findings include: Agency Policy: Wound Care Last Review and Revision: 04/2018 ...Policy 2.1 Wound measurements and photos are done on ... a weekly basis... 2.4 Wound assessments and reassessments will be completed on each skilled nursing visit. ...Documentation 5.1 Document ... length, width, and depth of wound. Include location and measurements of any undermining and/or tunneling... 2. HV # 6 was admitted to the agency on 3/10/22 with diagnoses including Essential (Primary) Hypertension and Acute Embolism and Thrombosis Unspecified Deep Veins of Unspecified Lower Extremity. Review of the HHC and POC orders dated 3/10/22 to 5/8/22 revealed a SN frequency of 1WK9 (one time per week for nine weeks) Review of the SN VNR dated 3/16/22 revealed a new wound to the left lower calf and wound care orders implemented, but no documentation of a wound assessment or measurement. Review of the SN VNR dated 3/22/22 revealed wound care completed to left calf using clean technique and sterile supplies per MD orders but no wound assessment or measurement was documented. An interview conducted on 5/12/22 at 12:50 PM with EI # 9, Clinical Educator confirmed the wound was not assessed and measured per policy. 1. HV # 5 was admitted to the agency on 3/25/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System, Perforation of Intestine, and Peritoneal Abscess. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/25/22 revealed a Skilled Nurse (SN) frequency of 2 x a week x 2 weeks, 3 x a week x 2 weeks, then 1 x a week x 2 weeks. Review of the SN Visit Note Reports (VNR) for the week of 4/3/22 including 4/4/22 and 4/6/22 revealed no documentation of weekly wound measurements. In an interview conducted on 5/12/22 at 1:00 PM, Employee Identifier (EI) # 8, Registered Nurse (RN), Supervisor, confirmed wound measurements were not performed weekly per agency policy.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, medical record (MR) reviews and staff interviews, it was determined the agency failed to ensure patients and/or caregivers were educated on: 1. Wound care to include teaching with return demonstration. 2. Diabetes care to include blood glucose testing and insulin injections. This deficient practice affected 2 of 6 records reviewed with wounds and did affect Home Visit (HV) # 6, MR # 10, and 1 of 3 records reviewed with a diagnosis of diabetes and did affect MR # 8, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Oasis (Outcome and Assessment Information Set) Based Admission and Resumption of Care Assessments Policy Revised Date: 1/20 Procedure: 4.4, c. Patient/Caregiver will provide and get a return demonstration of ALL procedures specified to be performed in the POC (Plan of Care) between the specified Skilled Nurse (SN) Frequency and documented in the EMR (Electronic Medical Record). 3. MR # 8 was admitted to the facility on 4/12/22 with diagnoses including Unspecified Fracture Right Patella, Subsequent for Open Fracture Type 3A/B/C with Routine Healing, and Unspecified Fracture Lower End of Right Tibia, Subsequent for Closed Fracture with Routine Healing. Review of the HHC and POC dated 4/12/22 to 6/10/22 revealed a SN frequency of 1 WK 9. Further review of the HHC and POC revealed orders for the SN for instructions/ reinforcement of diabetic care to include: ...blood glucose testing... and administration of insulin. Further review of the HHC and POC revealed the following orders: Skilled nurse for administration of SQ (Subcutaneous) insulin PRN (as needed). Skilled nurse for instructions/ reinforcement of administration of prescribed insulin injection. Review of the RN (Registered Nurse) Oasis Admission, dated 4/12/22, revealed no documentation the nurse obtained a return demonstration for blood glucose testing or administration of insulin from the patient or caregiver. Review of the following 2 weeks VNR's, dated 4/19/22 and 4/26/22, revealed no documentation of return demonstration for blood glucose testing or administration of insulin. An interview was conducted on 5/12/22 at 11:15 AM with EI # 9, who confirmed staff failed to document a return demonstration for blood glucose testing or insulin administration. 2. MR # 10 was admitted to the agency on 4/25/22 with diagnoses including Pyogenic Arthritis, Methicillin Susceptable Staphylococcus Aureus, and Essential (Primary) Hypertension. Review of the HHC and POC dated 4/25/22 revealed orders including SN 2 x a week for 1 week then 1 x a week for 8 weeks and SN to perform/teach wound care to incision/suture site located on right shoulder. Further review of the HHC and POC dated 4/25/22 revealed orders for wound care including "cleanse with SNS, pat dry, apply Mepilex AG Foam, Cover with gauze...Patient to perform daily in the absence of SNV..." Review of the SN VNR dated 4/25/22, 4/27/22, and 4/2/22 revealed no documentation of patient or caregiver teaching or return demonstration of wound care. Review of the SN VNR dated 5/11/22 revealed MR # 10 was re-admitted to the hospital on 5/3/22. In an interview conducted on 5/12/22 at 11:22 AM, EI # 8, Supervisor, confirmed there was no documentation of patient or caregiver teaching or return demonstration in either of the 3 visit notes. 1. HV # 6 was admitted to the agency on 3/10/22 with diagnoses including Essential (Primary) Hypertension and Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity. Review of the Home Health Certification (HHC) and POC) dated 3/10/22 to 5/8/22 revealed a SN frequency of 1WK9 (Once per Week for Nine Weeks). Review of the SN Visit Note Report (VNR) dated 3/16/22 revealed, "New wound assessed to left calf. Wound care orders implemented and instructions given to check the wound daily for signs of infection." Review of the Physician Order dated 3/23/22 revealed SN to perform/teach wound care to left lateral mid lower extremity; using clean technique, cleanse with wound cleanser/SNS (Sterile Normal Saline), pat dry, apply foam island dressing. Review of the SN VNR's dated 3/23/22 and 3/29/22 revealed wound care provided..."change dressing 3 times a week, CG (Caregiver) to perform WC (Wound Care) between nurse visit." There was no documentation of caregiver teaching with return demonstration. Review of the Physician Order dated 4/5/22 revealed SN to perform/teach wound care to left lateral mid lower extremity; using clean technique, cleanse with wound cleanser/SNS, pat dry, apply medihoney to wound bed, cover with foam island dressing. Review of the SN VNR's dated 4/5/22, 4/14/22, 4/27/22 and 5/4/22 revealed an on-going wound to the left calf and no documentation the SN had taught wound care with a return demonstration by the patient and/or caregiver. Review of the HHC and POC dated 5/9/22 to 7/7/22 revealed SN frequency of 1WK9 and orders for skilled nurse to perform/teach wound care to left lateral mid lower extremity trauma superficial injury using clean technique as follows: Cleanse with wound cleanser/SNS, pat dry, apply medihoney to wound bed, and cover with foam island dressing. Wound care to be completed each visit. Wound care to be performed daily in the absence of the SN. A home visit was conducted on 5/11/22 to observe the SN provide wound care to the left calf. During the visit the caregiver reported to the SN that he/she had only changed the dressing to the left calf one time since the patient has had the wound. The patient reported to the nurse that he/she does not change the dressing and the only time the dressing is changed is when the SN visits one time per week. An interview conducted on 5/12/22 at 12:50 PM with Employee Identifier (EI) # 9, Clinical Educator confirmed the SN did not provide patient/caregiver teaching of wound care with a return demonstration per policy.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of agency policy, medical records (MR) and interviews, it was determined the agency failed to ensure medical record documentation was accurate and complete with all events, and treatments administered which included OASIS (Outcome and Assessment Information Set) documentation and ….. This affected 1 of 12 active MRs including MR # 9, and 1 of 4 discharge records including MR # 4, and had the potential to negatively affect all patients served by this agency. Agency Policy: OASIS Based Admission and Resumption of Care Assessments Last Review & Revision: 1/20 Section 2: Policy 2.3 A Start of Care/Resumption of Care Form Utilizing OASIS, will be completed by an RN/PT/ST (Registered Nurse/Physical Therapist/Speech Therapist) within 48 hours of referral or on the physician ordered start of care date (admission)... Section 5: Documentation 5.1 Documentation on assessments for Start of Care... are to be complete and adequately describe the patients/client’s condition. 1. MR # 9 was admitted to the agency on 4/4/22 with diagnoses including Other Chronic Pain and Pain in Left Knee and Joints of Left Foot. Review of the Transitional Care Worksheet revealed the referral date was 3/30/22. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/4/22 to 6/2/22 revealed, "PT: 2wk4,1wk1 (2 times a week for 4 weeks, then 1 time a week for 1 week). Review of the PT OASIS Admission dated 4/4/22 revealed the PT documented "4/4/22" to the question, "Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA (Home Health Agency)". The PT failed to accurately document the date of referral, which was 3/30/22. An interview was conducted on 5/12/22 at 10:58 AM with Employee Identifier (EI) # 8, RN Supervisor, who confirmed the referral date was 3/30/22 and the PT failed to accurately document the date of referral in the OASIS Start of Care Assessment as directed per agency policy. 2. MR # 4 was admitted to the agency on 9/15/21 with diagnoses including Unilateral Primary Osteoarthritis Right Knee and Presence of Right Artificial Knee Joint. Review of the HHC and POC dated 9/15/21 to 11/13/21 revealed, "PT: 2wk1,3wk1,1wk1. Review of the 9/29/21 PT Discharge From Agency Visit Note revealed, "Yes" to the question, "Has this patient been treated for a urinary tract infection (UTI) in the past 14 days?". There was no documentation in the medical record that MR # 4 had been treated for a UTI in the past 14 days. An interview was conducted 5/12/22 at 12:38 PM with EI # 9, Clinical Educator, who stated MR # 4 had not been treated for a UTI in the past 14 days. EI # 9 confirmed the PT failed to accurately document in the MR per agency policy.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on review of agency policy, medical record (MR) review and interview with staff it was determined the agency failed to ensure the Registered Nurse (RN) developed and maintained an individualized Home Health Aide (HHA) assignment to meet the needs of each patient. This deficient practice affected 1 of 4 MR’s reviewed with HHA services and did affect MR # 11 and had the potential to negatively affect all patients receiving HHA services. Findings include: Agency Policy: Plan of Care/Description of Services/Health Care Finance Administration (HCFA) 485 and 487 Date Revised: 1/19 Purpose: Section 1 Purpose/Objective 1.1 To provide… coordinated and comprehensive format that addresses patient/client physical… needs. 1.2 To establish and maintain a measurable and quantifiable method of evaluating the care process. Agency Policy: Section 2 Policy 2.1 On admission and recertification a Plan of Care (POC) shall be developed under the direction of the attending physician. 2.3 The POC will be individualized… 2.4 The POC will be updated and revised as needed. 1. MR # 11 was admitted to the agency on 4/7/2020 and recertified on 4/7/22 with diagnoses including Type 2 Diabetes Mellitus Without Complications and Unspecified Osteoarthritis, Unspecified Site. Review of the Home Health Certification and Plan of Care dated 4/7/22 to 6/5/22 revealed the HHA was to visit once a week for eight weeks and provide HHA services for assistance with personal care and ADL's (Activities of Daily Living) secondary to functional limitation which prevent self-care. Review of the physician’s order dated 11/24/2021 states, “skilled nurse (SN) to remove patient’s Foley catheter on Wednesday, December 1, 2021.” Review of Aide Care Plan Report dated 4/7/2022 revealed routine catheter care at every visit and empty urinary drainage bag per patient request. Review of the Aide Visit Note Reports dated 4/8/22, 4/13/22, 4/20/22 and 5/5/22 revealed the HHA documented catheter care and emptied urinary drainage bag each visit. Review of the SN Visit Note Reports dated 4/13/22, 4/20/22, 4/27/22, and 5/9/22 revealed genitourinary system, "bladder incontinent". There were no indications the patient had a Foley catheter. An Interview conducted on 5/12/22 at 11:30 AM with Employee Identifier (EI) # 8, Nurse Supervisor, confirmed the SN failed to update the aide care plan after removal of the Foley catheter.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on review of agency policies and procedures, medical record (MR) review and staff interview, it was determined the agency failed to ensure the Home Health Aide (HHA) provided care as ordered in the plan of care. This deficient practice affected 2 of 4 MR’s reviewed receiving HHA services and did affect MR # 11, and HV (Home Visit) # 3, and had the potential to negatively affect all patients receiving HHA services. Findings include: Agency Policy: Home Health Aide Date Revised: 1/21 Procedure: The role of the HHA includes… The HHA is responsible for reporting any abnormal issues to the Clinical Supervisor at time of visit. Agency Policy: Supervision for Home Health Aide Date Revised: 3/20 Agency Policy: Section 2 Policy 2.1 All HHA shall … carry out assigned responsibilities … Procedure: Section 4: Procedure 4.5 The HHA Care Plan will be utilized by the Aide and maintained by the Nurse to ensure that the care provided follows an Established Plan of Care. Agency Policy: Home Health Aide Date Revised: 1/21 HHA is responsible for reporting any abnormal issues to the Clinical Supervisor at time of visit. 2. HV # 3 was admitted to the agency on 12/28/21, and recertified for care 4/27/22 to 6/25/22, with diagnoses including Encounter for Attention to Gastrostomy, and Dysphagia Following Cerebral Infarction. Review of the Home Health Certification and Plan of Care dated 4/27/22 to 6/25/22 revealed a HHA effective 5/1/22, 1 WK (Week) 7. Review of the Aide Plan of Care, effective date 4/27/22, included orders for perineal care, every visit. A HV was conducted on 5/10/22 at 12:30 PM to observe care provided by EI # 6, HHA. During the visit, the CG stated she/he had recently changed the patient's briefs. EI # 6 did not perform perineal care. Review of the Aide Visit Note dated 5/10/21 revealed the aide documented the following for perineal care, "N" (No) CG (caregiver) changed briefs and washed perineal and bottom areas." There was no documentation the aide notified the nurse of tasks not performed, per policy. An interview was conducted on 5/12/22 at 8:14 AM with EI # 1, Director of Nursing, who confirmed the aide failed to notify the nurse of tasks not completed. 1. MR # 11 was admitted on 4/7/2020 and recertified on 4/7/22 with diagnoses including Type 2 Diabetes Mellitus Without Complications and Unspecified Osteoarthritis, Unspecified Site. Review of the Home Health Certification and Plan of Care dated 4/7/22 to 6/5/22 revealed orders for HHA services once a week for eight weeks and to provide assistance with personal care and Activity of Daily Living (ADL)… Review of the Aide Care Plan report dated 4/7/22 revealed orders of Foley catheter care every visit and empty urinary drainage bag per patient request. Review of the aide visit note reports dated 4/8/22, 4/13/22, 4/20/22 and 5/5/22 revealed Foley catheter care and empty urinary drainage bag was completed. Review of the Skill Nurse (SN) Visit Note Reports dated 4/13/22, 4/20/22, 4/27/22 and 5/9/22 revealed there was no documentation that the patient had a Foley catheter. An Interview conducted on 5/12/22 at 11:30 AM with Employee Identifier (EI) # 8, Registered Nurse Supervisor confirmed the HHA failed to notify the nurse MR # 11 did not have a Foley catheter. EI # 8 also confirmed the HHA documented incorrectly that Foley catheter care was provided, and urinary drainage bag was emptied.