Every finding on record at Samaritan Home Health, Inc.

This Statement of Deficiencies report includes the results of a review of the agency's compliance with emergency preparedness requirements completed during the recertification survey conducted 02/14/24 - 02/22/24. The following information was reviewed, on 02/06/24, during the pre-survey preparation: accuracy of contact information in the Health Commerce System. The following information was reviewed during the survey: the agency's emergency preparedness policies and procedures, the emergency patient roster and staff call down list. Interviews were conducted with the Administrator/Director of Patient Services and Clinical Manager. No deficiencies related to emergency preparedness were cited.

The following statement of deficiencies represents the results of a partial extended recertification survey of Samaritan Home Health, Inc. Certified Home Health Agency conducted 02/14/24 through 02/22/24. A standard recertification survey was initiated on 02/14/24. Deficient practices were identified within Level 1 standards in the Conditions of 484.60 Care Planning, Coordination, Quality of Care and 484.80 Home Health Aide Services on 02/15/24 resulting in a partial extended survey. The survey consisted of reviews of 17 clinical records including 5 discharge records, 10 personnel records for professional and paraprofessional personnel, 2 contracts, and 7 observational home visits. The survey included review of pertinent policies and procedures, Quality Improvement and Governing Body Meeting minutes for the past 12 months, the agency's Admission Packet, the Emergency Preparedness Plan, and Complaint Log. The patient census at the time of survey was 161. Pre-survey activities consisted of review on 02/06/24 of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for the period of 11/2022 to 10/2023, and the agency's compliance with report submissions for required statistical reports. The Administrator/Director of Patient Services (DPS) and Clinical Manager were interviewed throughout the survey. The findings were reviewed with the DPS and Clinical Manager at the exit conference on 02/22/24. The following deficiencies are identified as a result of the survey: Federal: G 526 Content of comprehensive assessment; G 536 A review of all current medications; G 574 Plan of care must include the following; G 602 Communication with all physicians; G 606 Integrate all services; G 654 Track adverse patient events; and G 798 Home Health Aide Assignment and Duties. State: J 1276 Governing authority; J 1456, and 1460 Personnel.

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, observational home visits and interviews with the Administrator/Director of Patient Services (DPS) and Clinical Manager, it was determined in 7 of 17 records (patients #2, 7, 10, 12, 14, 16, and 17) comprehensive assessments were incomplete and not of sufficient scope to identify all patient needs. Evidence was as follows: Patient #5 was admitted to the agency on 11/08/23 with diagnoses of post-operative prosthetic joint infection (right shoulder), hypertension, high cholesterol, gastro-esophageal reflux disease, anxiety/depression, arthritis, and thyroid disease. The skilled nurse failed to perform a complete and/or accurate comprehensive assessment of the patient's needs. On 11/08/23 the skilled nurse visited the patient and documented a blood pressure of 160/90 using an alternate site (instead of a bilateral upper extremity) because the patient had a recent surgical incision to the right upper arm and a central line in the left upper arm. The 11/08/23 Plan of Care included orders for the skilled nurse to assess vital signs and to notify the physician if systolic blood pressure was >160 and 90 and On the 11/10/23, 11/13/23, and 11/20/23 the skilled nurse documented that blood pressures were not checked because the patient's bilateral upper extremities could not be used. The skilled nurse failed to use another part of the arm to check the blood pressure as done in multiple other assessments. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #16 was admitted to the agency on 06/20/23 with diagnoses of irradiation cystitis with hematuria (blood in urine), urine retention, prostate cancer, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, congestive heart failure, and anemia. The skilled nurse failed to perform a complete and/or accurate comprehensive assessment of the patient's needs. On 06/20/23 the skilled nurse documented the patient had no pressure ulcers/injuries and the patient’s integumentary (skin) system was intact. On 06/27/23 and 07/06/23 the skilled nurse documented the patient’s current integumentary system was intact. On 07/11/2023 the skilled nurse visited the patient and documented the patient reported they had a pressure ulcer on the right heel since hospitalization and was told to leave it open to air. The skilled nurse assessed the pressure ulcer and documented it as an unstageable/deep tissue injury sized as 6 CM wide, 6 CM long, 0 CM depth. On 02/21/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #12 was admitted to the agency on 01/12/24 with diagnoses of surgical site infection following a procedure, hypertension and type 2 diabetes. The 01/09/24 discharge referral included Admelog Solostar (fast-acting) insulin per sliding scale three times daily before meals. The sliding scale was 0 units if blood glucose was less than 120, 2 units if blood glucose was 121-200 units, and 4 units if 201-251. The referral also included insulin glargine (long-acting) 50 units every morning and 30 units every evening. On 01/12/24 the skilled nurse visited the patient for the initial assessment and failed to perform a complete assessment of diabetes management. The nurse documented the patient was competent with use of the glucometer. They did not document how this was ascertained. They documented that the patient did not check their blood glucose frequently and had not checked it in the past three days. There was no evidence the skilled nurse observed the presence of the glucometer in the home, the patient use of the glucometer and the patient competence with administering injections. The skilled nurse documented that the patient was competent in in administration of all current medications and required no further medication education. The skilled nurse documented the patient was on albuterol sulfate HFA 90mcg/actuation aerosol inhaler 2 puffs every 4 hours as needed for shortness of breath/wheezing. The skilled nurse failed to assess the last time the patient needed to use the inhaler or if the patient could demonstrate proper use of the inhaler. On 02/22/24 at 10 a.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #2 was admitted to the agency on 02/01/24 with diagnoses aftercare following surgery on the circulatory system, atrial fibrillation and chronic obstructive pulmonary disease. On 02/01/24 the skilled nurse performed an initial assessment and found that the patient’s hands were having a blue-ish discoloration that started the night before and continued that morning. The medical doctor was called and informed by message. A nurse from the medical provider’s office called the skilled nurse back while in the home and stated that it was important for the patient to monitor their capillary refill. According to the 02/01/24 visit narrative, the patient/caregiver were instructed to monitor the patient’s capillary refill when the extremities change color. If the capillary refill was greater than 3 seconds, they were to notify the medical doctor. The patient and caregiver verbalized understanding. The skilled nurse never included monitoring of capillary refill on the patient’s plan of care or to notify the medical doctor or the agency if the capillary refill was greater than 3 seconds. No capillary refill was documented for visits on 02/08/24 or 02/15/24 by the skilled nurse. On 02/20/24 at 1 p.m. the surveyor reviewed the findings with the Administrator/Director of Patient Service and the Clinical Manager. They acknowledged the findings and no additional information was provided. Home Visit Patient #7 was admitted to the agency on 07/01/23 with diagnoses of circulatory system surgery, right lower leg ulcer, peripheral vascular disease, type 2 diabetes and history of deep vein thrombosis. The 06/27/23 hospital discharge instructions included Basaglar (long-acting) insulin 30 units injected once daily, Novolog (short-acting) insulin 8 units injected three times a day before meals, Trulicity (anti-diabetic weekly medication) 3 mg injected once weekly and Metformin (oral anti-diabetic medication). On 07/01/23 the skilled nurse visited the patient for the initial assessment and failed to perform a complete assessment of diabetes management. The nurse documented the patient had a glucose of 101 and the patient had a "glucometer-brand not available". There was no evidence the skilled nurse observed the presence of the glucometer in the home, the patient use of the glucometer and the patient competence with administering injections. The skilled nurse documented the patient stated competency with injections. On 02/16/24 the surveyor conducted an observational home visit with the skilled nurse. Following the visit, the surveyor interviewed the patient who stated when admitted the nurse did not observe the patient using the glucometer or administering injections. The patient stated "I have been doing it for a long time". On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #10 was admitted to the agency on 02/02/24 with diagnoses of recent COVID-19 pneumonia, epilepsy, dysphagia (difficulty swallowing) and atrial fibrillation. The 02/02/24-04/01/24 Plan of Care included Home Health Aide services to assist with personal care. The skilled nurse failed to perform a complete assessment of the patient/caregiver understanding of interventions to prevent aspiration. The 01/24/24 hospital discharge instructions and progress note revealed the speech therapist had recommended a modified diet and aspiration precautions to minimize aspiration risk. On 02/02/24 the skilled nurse visited the patient and documented the patient had shortness of breath with minimal exertion and had a meter dose inhaler, incentive spirometer and was following a pureed diet with nectar thick liquids. There was no evidence the skilled nurse assessed patient/caregiver understanding of signs and symptoms of swallowing difficulties and aspiration and positioning or other interventions to minimize risk. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #17 was admitted to the agency on 02/06/24 with diagnoses of chronic atrial fibrillation on an anticoagulant, recent fall with a large hematoma to the left chest and acute blood loss anemia requiring a blood transfusion, congestive heart failure, hypertension and chronic wounds to lower legs. The skilled nurse failed to perform a complete assessment of the patient's needs. Anticoagulant The 02/02/24 hospital discharge instructions directed the patient to hold Eliquis 2.5mg twice daily for 5 days and then resume. On 02/06 /24 the skilled nurse visited the patient for the initial assessment and failed to assess whether the patient had stopped the medication and when it was to be resumed. Pain management The hospital discharge instructions included the following interventions for pain: -Tylenol 650 mg every 8 hours as needed -Oxycodone10 mg four times daily -Tramadol 50 mg three times daily as needed for severe breakthrough pain The skilled nurse documented the patient had a pain level of 7 on a scale of 1 to 10 to back and leg, alleviating factors included body position, rest and medications. The skilled nurse failed to assess how often the patient was using the as needed medications. On 02/21/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Failure to ensure comprehensive assessments are complete and accurately reflect the patient's status has the potential for negative outcomes for the agency patient population. Patient #14 was admitted to the agency on 01/31/23 with diagnoses of inflammatory disorders of the scrotum, diabetes, and heart failure. The patient was selected to review from the 11/2022 to 10/2023 Centers for Medicare and Medicaid Services (CMS) potentially avoidable event listing for emergency care for hypo/hyperglycemia with a discharge date of 03/17/23. The skilled nurse (SN), failed to perform a complete comprehensive assessment of the patient’s needs. Diabetes management The 01/27/2023 hospital discharge summary included Lantus (long-acting) insulin 35 units daily at bedtime, Trulicity (injectable diabetes medication) 1.5 milligrams weekly, Januvia (oral diabetes medication) 25 milligrams daily. There were no orders addressing if patient should or should not test blood sugars at home. On 01/31/23 the skilled nurse visited the patient for the initial comprehensive assessment and documented the patient demonstrated “competency with inhaled and subcutaneous injections via verbal step by step competency as no subcutaneous medication is due at this time.” The comprehensive assessment failed to address blood sugar monitoring or diabetes management. The 01/31/23-03/31/23 Plan of Care included Lantus insulin, Trulicity, and Januvia as listed on the discharge summary and the following orders: “patent does not check fingerstick blood sugar (FSBS) in home. A1C monitored routinely by primary care physician” and “monitor glucometer readings for variations and compliance; notify MD if FSBS >450 or The skilled nurse failed to visit to observe the caregiver performing wound care and scheduled the next visit for one week later. On 02/21/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information.

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 a review of clinical records, observational home visits and interviews with the Administrator/Director of Patient Services (DPS), and Clinical Manager, it was determined for 2 of 17 patients (Patients #2 and 11), the skilled nurse (SN) failed to perform complete and accurate medication reviews. Home Visit Patient #2 was admitted to the agency on 02/01/24 with diagnoses aftercare following surgery on the circulatory system, atrial fibrillation and chronic obstructive pulmonary disease. On 02/15/24 at 10:30 a.m. the surveyor performed a supervisory home visit with the skilled nurse. The skilled nurse went over the patient’s medications and made changes due to medications being discontinued and new medications being prescribed at the patient’s last doctor visit. The skilled nurse asked about the last time they had taken any “as needed” medications, including their Miralax 17 gm oral powder packet daily as needed for constipation. The patient stated they did not take they Miralax, they used a “stool softener”. After the skilled nurse had finished the visit and left, the surveyor asked the patient about the medications they were taking and compared it to the medication list on the plan of care. The surveyor asked what stool softener the patient was taking and they provided a bottle of docusate sodium 50mg-sennoside 8.6mg with instructions on the bottle to take 1 capsule as needed daily for constipation. The patient reported using that medication in the last week. The patient also provided a bottle of acetaminophen 325 mg and stated that they took 1 capsule as needed for pain and had taken it once since they had been discharged from the hospital. The skilled nurse failed to identify these medications in their medication review and include them on the patient’s plan of care. On 02/20/24 at 1 p.m. the surveyor reviewed the findings with the Administrator/Director of Patient Service and the Clinical Manager. They acknowledged the findings and no additional information was provided. Failure to perform complete and accurate medication reviews has the potential for patients taking medications inconsistent with the physician's intentions, and possible negative patient outcomes. Patient #11 was admitted to the agency on 01/22/24 with diagnoses of surgical repair of left fractured femur, hypotension, atrial fibrillation, hypertension, and depression. The skilled nurse failed to ensure the medications were clarified and updated on the Plan of Care. The 01/18/24 hospital discharge instructions did not include orders for pain medication. On 01/22/24 the skilled nurse visited the patient for the initial comprehensive assessment and documented the patient was taking acetaminophen 1000mg twice a day and this did not control the post-surgical pain, the physician was notified, and visit documentation states physician sent prescription for Percocet to patient's pharmacy. There is no documentation to support dose or frequency of Percocet clarified and medication was not added to the medication profile. The skilled nurse failed to reconcile all medications and update the plan of care to include the new Percocet orders. Multiple medications including prednisone, vitamin C, esomeprazole magnesium, and l-methylfolate were included on the medication profile with “awaiting review” status, some of which were duplicate medication entries. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. The director of patient services reported that some clinicians prefer to observe medication bottle in the home prior to entering, however, stated a verbal order obtained from the physician should have been entered. The Director of Patient Services also stated medications in “awaiting review” status are still present when all medications are reviewed. Patient #14 was admitted to the agency on 01/31/23 with diagnoses of inflammatory disorders of the scrotum, diabetes, and heart failure. On 01/31/23 the skilled nurse visited the patient and documented the “patient is taking vitamins in home that were not listed on discharge summary. Informed nurse at MD office.” Multiple medications including warfarin, magnesium oxide, and torsemide were on the medication profile with “awaiting review” status, some of which were duplicate medication entries. The skilled nurse failed to clarify and update the medications to include vitamins not listed on the discharge summary and reconcile all medications including those “awaiting review”. On 02/21/24 at 1 p.m. the surveyor reviewed the findings with the Administrator/Director of Patient Service and the Clinical Manager. They acknowledged the findings and no additional information was provided.

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 a review of clinical records, observational home visits and interviews with the Administrator/Director of Patient Services (DPS), and Clinical Manager, it was determined in 4 of 17 records (patients #1, 4, 5, and 14) the agency failed to develop individualized plans of care that were complete, accurate, and addressed the total needs of the patients. This was evidenced by: Patient #4 was admitted to the agency on 01/15/24 with diagnoses of right humerus (arm) fracture, nasal (nose) fracture, chronic back pain, anxiety/depression, migraines, gastro-esophageal reflux disease, and lichen planus (skin rash). The plan of care was incomplete and/or not updated to reflect the needs of the patient. Pain: The 01/15/24 Plan of Care instructions for pain mitigation included taking pain medication, frequent rest periods, changing position, and relaxation techniques. On 01/17/24 the physical therapist visited the patient for the initial evaluation and documented instructing the patient on using ice to help with pain management. There was no evidence the physical therapist updated the plan of care to include the use of ice including location, frequency, and duration of application. On 01/22/24 and 01/29/24 the skilled nurse visited the patient and documented instructing the patient in pain reduction methods including “heat/cold usage as instructed by the surgeon”. The skilled nurse failed to recognize these interventions were not included in the plan of care. On 01/26/24 the occupational therapy assistant visited the patient and documented the application and use of kinesiology tape (therapeutic tape) for pain as well as family instruction on taping. The 01/15/24 Plan of Care failed to include orders for using heat/ice or Kinesiotape and there is no evidence that the skilled nurse or physical therapist obtained subsequent orders. There was no evidence the physical therapist updated the plan of care to include the use of kinetic tape including location, frequency, and duration of application. Wound/Incision: The 01/15/24 Plan of Care orders for wound care stated the right arm surgical dressing is to remain on until ortho (physician) follow-up. On 01/15/24 the skilled nurse visited the patient and documented the patient had a non-removable dressing in place on the right upper arm. On 01/22/24 the skilled nurse visited and documented the patient no longer had a non-removable dressing and now had steri-strips to the surgical incision on the right arm. There was no evidence the skilled nurse obtained updated orders for wound care following the removal of the dressing. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #5 was admitted to the agency on 11/08/23 with diagnoses of post-operative prosthetic joint infection (right shoulder), hypertension, high cholesterol, gastro-esophageal reflux disease, anxiety/depression, arthritis, and thyroid disease. The plan of care was incomplete and/or not updated to reflect the needs of the patient. The 11/07/2023 hospital After Visit Summary listed allergies to aspirin, Demerol, fenofibrate, paroxetine, sulfa antibiotics, and tadalafil as well as instructions for activity restrictions of the operative shoulder/arm including no shoulder motion, no lifting, remain non-weight bearing, and no movement/exercises of shoulder. The 11/08/23 Plan of Care failed to include: -allergies to aspirin and Demerol -activity restrictions On 11/10/23 the skilled nurse visited the patient and documented the patient was using ice for pain relief and swelling. There was no evidence the skilled nurse updated the plan of care to include the use of ice including location, frequency, and duration of application. The 11/08/2023 Plan of Care included orders for the skilled nurse to assess vital signs and to notify the physician if systolic blood pressure was >160 and 90 and On 11/10/23, 11/13/23, and 11/20/23 the skilled nurse visited the patient and documented that blood pressures were not checked because the patient’s bilateral upper extremities could not be used due to the recent surgery and the central line. There was no evidence the skilled nurse updated the plan of care to include orders holding blood pressure monitoring until an upper extremity could be used. The 11/08/23 Plan of Care included the following wound care orders: -skilled nurse to remove old saturated dressing to right shoulder -cleanse site with normal saline and gauze -gently pat the site dry -apply a folded abdominal pad over surgical site vertically -cover with an adhesive telfa dressing -secure dressing in place with tegaderm tape The Plan of Care failed to include how often the dressing could/needed to be changed. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #12 was admitted to the agency on 01/12/24 with diagnoses of surgical site infection following a procedure, hypertension and type 2 diabetes. The skilled nurse failed to ensure the medications were clarified and updated on the Plan of Care. The 01/09/24 discharge referral included Admelog Solostar (fast-acting) insulin per sliding scale three times daily before meals. The sliding scale was 0 units if blood glucose was less than 120, 2 units if blood glucose was 121-200 units, and 4 units if 201-251. The 01/12/24 plan of care included Admelog Solostar insulin three times a day per sliding scale. The sliding scale for how much insulin to administer was not included in the plan of care. On 01/12/24 an order was obtained from the medical doctor to change the Admelog Solostar insulin to 10 – 30 units daily at night. It failed to include specific orders on how many units of insulin the patient should take and what the parameters were for taking a specific dose of the Ademlog Solostar. On 01/18/24 an order was obtained for acetaminophen 160mg/5mL oral elixir, 15-30 mL every 4 hours as need for pain, with a maximum daily dose of 3000mg. The order does not specify how much of the medication to take depending on how much pain the patient is in. On 01/26/24 an order was obtained for ibuprofen 200mg tablet, 1 to 4 tablets every 8 hours as needed for pain, with a maximum daily dose of 12 tablets. The order does not specify how much of the medication to take depending on how much pain the patient is in. On 02/22/24 at 10 a.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #14 was admitted to the agency on 01/31/23 with diagnoses of inflammatory disorders of the scrotum, diabetes, and heart failure. The patient was selected to review from the 11/2022 to 10/2023 Centers for Medicare and Medicaid Services (CMS) potentially avoidable event listing for emergency care for hypo/hyperglycemia with a discharge date of 03/17/23. The plan of care was incomplete and/or inaccurate. Blood Glucose Monitoring The 01/27/2023 discharge summary directed the patient to take Lantus (long-acting) insulin 35 units daily at bedtime and other medications for diabetes including Trulicity 1.5mg injection weekly, and Januvia 25mg tab daily. There were no orders addressing if patient should or should not tests blood sugars at home. On 01/31/23 the skilled nurse visited the patient and documented the patient demonstrated “competency with inhaled and subcutaneous injections via verbal step by step competency as no subcutaneous medication is due at this time.” The comprehensive assessment did not address blood sugar monitoring or diabetes management. The 01/31/23 Plan of Care was inconsistent, including the following orders: “Patient does not check fingerstick blood sugar (FSBS) in home. A1C monitored routinely by primary care physician” and “monitor glucometer readings for variations and compliance; notify MD if FSBS >450 or Ice/heat treatments On 01/31/23 the skilled nurse documented the patient had 5/10 pain to back at time of visit and denied use of pain medication; there was no mention of use of heat or ice for pain relief. The 01/31/23 Plan of Care included the following order: instruct patient/caregiver “Patient may use heat/ice as a method of pain relief. Instruct patient to apply heat/ice to affected area for 20 minutes using barrier between skin and heat/ice with removal for a least 20 minutes between application.” The Plan of Care was incomplete and failed to address which area(s) heat/ice should be applied and when to use these treatments. On 02/21/24 at 1 p.m. the surveyor reviewed the findings with the Administrator/Director of Patient Service and the Clinical Manager. They acknowledged the findings and no additional information was provided. Home Visit Patient #1 was admitted to the agency on 02/06/24 with diagnoses of chronic osteomyelitis, staphylococcal arthritis, methicillin resistant staphylococcus aureus infection, long-term use of antibiotics, and vascular access device. Pain management On 02/06/24 the skilled nurse visited the patient and documented the patient reported pain to left shoulder at a level of 9 on a 0-10 scale. The skilled nurse documented the patient reported the physician was aware of the high level of pain and the patient was scheduled for appointment with a pain management specialist. The 02/06/23 Plan of Care included an order for oxycodone-acetaminophen 5mg/325mg 1-2 tablets every 6 hours as needed for moderate pain and tizanidine 4mg tablet every 6 hours as needed for moderate pain, muscle spasms. The order failed to specify when the patient should take one tablet versus two tablets of oxycodone-acetaminophen. The Plan of Care failed to identify parameters to notify the physician regarding level of reported pain. On 02/15/24 the surveyor conducted an observational home visit with the skilled nurse. During the visit the patient reported icing the shoulder. The 02/06/24 Plan of Care did not include an order for ice to the shoulder and there was no subsequent order obtained to include the frequency and duration the treatment should be applied. Vascular access device On 02/06/24 the skilled nurse documented the patient had a single lumen peripherally inserted central catheter (PICC) to the right upper arm without noting catheter size or length. The 02/06/24 Plan of Care included orders for dressing change to peripherally inserted central catheter (PICC) and blood draws weekly for CMP, ESR, CBC with auto diff, and CRP. During the 02/15/24 observational home visit the patient reported discomfort to site where PICC suture site and requested gauze be placed to pad the area. The 02/06/24 Plan of Care failed to include the day of the week to change the PICC dressing and draw blood and the dressing orders did not include the application of gauze to the suture site. The skilled nurse failed to update the Plan of Care to include this intervention. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and no additional information was provided. Failure to ensure that a comprehensive, individualized plan of care is developed has the potential for unmet patient needs.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on review of clinical records, and interview with the Administrator/Director of Patient Services (DPS) and Clinical Manager, it was determined for 1 of 17 patients (patient #16) the agency failed to ensure there was communication with all involved physicians in the patient's plan of care. Evidence was as follows: Patient #16 was admitted to the agency on 06/20/23 with diagnoses of irradiation cystitis with hematuria (blood in urine), urine retention, prostate cancer, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, congestive heart failure, and anemia. The agency failed to coordinate patient care to ensure the specialist was consulted regarding management of the urinary catheter. The 06/20/23 hospital Patient Visit Report at discharge included a scheduled follow-up appointment with the urology physician on 07/03/23. The 06/20/23 Plan of Care included a plan for the catheter to be managed by the urologist and problems could be reported to the urology group. On 06/20/23 the skilled nurse visited the patient and documented the patient had an 18 french catheter with a 10 mL balloon last changed on 06/15/23 and the catheter would be managed by the urologist. The patient had a follow up visit scheduled for 07/02/23. On 06/27/23 the skilled nurse visited the patient and documented the patient stated they did not have an appointment scheduled with urology yet. There was no evidence that the skilled nurse reminded the patient that an appointment was already scheduled. On 07/06/23 the skilled nurse visited the patient and documented the patient’s catheter “would be due for a monthly change next week”. The skilled nurse called and left a message about the foley catheter with the primary care physician. There was no evidence that the skilled nurse asked the patient about their scheduled visit with urology or consulted with the urologist regarding the plan for changing the catheter. On 07/11/23 and 07/18/23 the skilled nurse visited the patient and documented the primary care physician was called and messages were left regarding the foley catheter. The skilled nurse failed to recognize the urologist was managing the catheter and consult with the specialist regarding the catheter. On 07/25/23 and 08/02/23 the skilled nurse visited the patient and documented the patient was unsure when the next foley catheter change was and was waiting for the primary care physician to approve the skilled nurse to change it at home and it would be discussed when they see the physician at the 08/07/23 appointment. On 08/02/23 the skilled nurse documented calling the urology group for clarification on who was managing the patient’s catheter since the patient reports never having a follow-up with the urologist and despite the order stating the urologist was managing the foley care. On 08/07/23 the skilled nurse visited the patient and documented the patient stated they still did not know when they would be able to have the catheter changed and they did not want to see the urologist. The skilled nurse documented the patient was informed the skilled nurse would not be able to change the foley catheter in the home, the patient could see a different physician in the urology group, or the patient could go to the emergency room to have the foley catheter changed. There was no evidence the skilled nurse consulted with the urologist to facilitate the catheter change. On 08/16/23 the patient was discharged from home health services. There was no evidence the catheter issue was resolved. On 02/21/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Failure to ensure there is communication with all responsible physicians places patients at risk for negative outcomes and potential for hospital admission.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on review of patient records, observational home visits, and interviews with the Administrator/Director of Patient Services (DPS) and Clinical Manager it was determined in 4 of 17 patients (patients #1, 6, 14 and 16) the agency failed to coordinate care to meet the needs of the patients. Evidence was as follows: Patient #16 was admitted to the agency on 06/20/23 with diagnoses of irradiation cystitis with hematuria (blood in urine), urine retention, prostate cancer, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, congestive heart failure, and anemia. The agency failed to coordinate patient care to ensure social work services were provided for all the identified needs. The 06/20/23 Plan of Care included an order for a Medical Social Worker evaluation. On 06/25/23 the social worker documented in the patient activity log they had a phone conversation with the patient regarding filling out an application for Volunteer Transportation, referring to home delivered meals, and setting up an in person visit to complete an application for Medicaid. On 06/27/23 the social worker visited with the patient and documented the patient did not qualify for Veteran’s Administration benefits or for the “EISEP” program (Expanded In-Home Services for the Elderly). On 07/26/23 the patient was discharged from social services. There was no evidence the patient was assisted in completing the Medicaid application, Volunteer Transportation arranged for the patient, needs had been met and/or the patient had no further needs. On 02/21/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Home Visit Patient #6 was admitted to the agency on 06/21/23 with diagnoses of stage 2 pressure ulcer of the right buttock and type 2 diabetes. Follow-up Coordination On 11/17/23 the skilled nurse showed up to the adult home for a visit with the patient. They were informed by adult home staff that the patient had been transferred to the emergency department and would probably be back the following day. No reason was documented why the patient went to the emergency room. The skilled nurse notified the Director of Patient Services. No follow-up was conducted the following day, 11/18/23, to see if the patient had returned from the emergency room and needed a visit from the agency to follow-up. The next visit was on 11/20/23. The skilled nurse documented the patient did not have a dressing on their stage 2 pressure injury and reported that the dressing came off after being seen in the emergency department. The patient went multiple days with no dressing to their pressure ulcers. The agency failed to coordinate with the adult home to ensure that the patient’s needs were being met. Dressing removal At a skilled nurse visit on 09/01/23, the skilled nurse instructed the patient not to wear the dressing in the shower because it was saturated with water and the skilled nurse could not distinguish between the water and the wound drainage. During the supervisory home visit on 02/15/24 at 9:00 a.m., the patient already had the dressing off prior to the skilled nurses arrival. The skilled nurse questioned why the dressing was off and the patient responded that he took the dressing off to shower everyday and then he would put it back on after if the nurse was not coming that day. The skilled nurse acknowledged that the patient did shower daily and usually had the dressing off prior to their arrival. In the narrative section of the 02/15/23 visit summary, the skilled nurse documented they encouraged the patient to leave the dressing in place while showering and if the dressing became compromised to call the agency so another dressing could be placed. There is no evidence that the skilled nurse contacted the medical doctor to discuss that the patient was taking the dressing off to shower and if another dressing would be more appropriate. After the visit, the skilled nurse notified the nursing manager of the adult home that the patient had been re-certified and care would be continuing twice a week. The skilled nurse did not discuss that the patient had been taking off their dressing prior to showering and that should be avoided. The surveyor interviewed the adult home nurse manager and asked if they were aware of any issues with the patient taking off their dressing and re-applying it. They stated that they were not aware that it was happening. They stated that if they had been told this was a problem, they could have helped to encourage the patient to wash up a different way or help protect the dressing so that it did not become saturated. The skilled nurse failed to communicate to the adult home and to the medical doctor that the patient was removing and re-applying their dressing in-between visits. Patient #14 was admitted to the agency on 01/31/23 with diagnoses of inflammatory disorders of the scrotum, diabetes, and heart failure. The patient was selected to review from the 11/2022 to 10/2023 Centers for Medicare and Medicaid Services (CMS) potentially avoidable event listing for emergency care for hypo/hyperglycemia with a discharge date of 03/17/23. The plan of care was incomplete and/or inaccurate. Blood Glucose Monitoring The 01/27/2023 discharge summary directed the patient to take Lantus (long-acting) insulin 35 units daily at bedtime and other medications for diabetes including Trulicity 1.5mg injection weekly, and Januvia 25mg tab daily. There were no orders addressing if patient should or should not tests blood sugars at home. On 01/31/23 the skilled nurse visited the patient and documented the patient demonstrated “competency with inhaled and subcutaneous injections via verbal step by step competency as no subcutaneous medication is due at this time.” The comprehensive assessment did not address blood sugar monitoring or diabetes management. The 01/31/23 Plan of Care was inconsistent including both the “Patient does not check fingerstick blood sugar (FSBS) in home. A1C monitored routinely by primary care physician”; and “monitor glucometer readings for variations and compliance; notify MD if FSBS >450 or Ice/heat treatments On 01/31/23 the skilled nurse documented the patient had 5/10 pain to back at time of visit and denied use of pain medication; there was no mention of use of heat or ice for pain relief. The 01/31/23 Plan of Care included the following order: instruct patient/caregiver “Patient may use heat/ice as a method of pain relief. Instruct patient to apply heat/ice to affected area for 20 minutes using barrier between skin and heat/ice with removal for a least 20 minutes between application.” The Plan of Care was incomplete and failed to address which area(s) heat/ice should be applied and when to use these treatments. On 02/21/24 at 1 p.m. the surveyor reviewed the findings with the Administrator/Director of Patient Service and the Clinical Manager. They acknowledged the findings and no additional information was provided. Home Visit Patient #1 was admitted to the agency on 02/06/24 with diagnoses of chronic osteomyelitis, staphylococcal arthritis, methicillin resistant staphylococcus aureus infection, long-term use of antibiotics, and vascular access device. Pain management On 02/06/24 the skilled nurse visited the patient and documented the patient reported pain to left shoulder at a level of 9 on a 0-10 scale. The skilled nurse documented the patient reported the physician was aware of the high level of pain and the patient was scheduled for appointment with a pain management specialist. The 02/06/23 Plan of Care included an order for oxycodone-acetaminophen 5mg/325mg 1-2 tablets every 6 hours as needed for moderate pain and tizanidine 4mg tablet every 6 hours as needed for moderate pain, muscle spasms. The order failed to specify when the patient should take one tablet versus two tablets of oxycodone-acetaminophen. The Plan of Care failed to identify parameters to notify the physician regarding level of reported pain. On 02/15/24 the surveyor conducted an observational home visit with the skilled nurse. During the visit the patient reported icing the shoulder. The 02/06/24 Plan of Care did not include an order for ice to the shoulder and there was no subsequent order obtained to include the frequency and duration the treatment should be applied. Vascular access device On 02/06/24 the skilled nurse documented the patient had a single lumen peripherally inserted central catheter (PICC) to the right upper arm without noting catheter size or length. The 02/06/24 Plan of Care included orders for dressing change to peripherally inserted central catheter (PICC) and blood draws weekly for CMP, ESR, CBC with auto diff, and CRP. During the 02/15/24 observational home visit the patient reported discomfort to site where PICC suture site and requested gauze be placed to pad the area. The 02/06/24 Plan of Care failed to include the day of the week to change the PICC dressing and draw blood and the dressing orders did not include the application of gauze to the suture site. The skilled nurse failed to update the Plan of Care to include this intervention. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and no additional information was provided. Failure to coordinate patient care has the potential for unmet patient needs, and possible negative patient outcomes.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on a review of the agency's Quality Assessment Performance Improvement (QAPI) Program, interviews with the Administrator/Director of Patient Services (DPS), and Clinical Manager, it was determined that the agency failed to adequately review records of patients with adverse events, analyze their causes and implement preventive actions. Evidence was as follows: Professional Advisory Committee (PAC) meeting minutes for the past year and Quality Assessment Performance Improvement (QAPI) minutes for the last 9 months were provided by the Administrator/Director of Patient Services. The PAC and QAPI minutes do not reflect reporting on potentially avoidable events. During an interview with the Administrator/Director of Patient services (DPS) and the Clinical Manager on 02/22/24, it was reported that the agency has not completed any record reviews for 2023 Potentially avoidable events stating that they only run the Centers for Medicare and Medicaid Services (CMS) Potentially Avoidable Event (PAE) report annually and have not yet run a report in 2024 to identify 2023 potentially avoidable events. According to DPS and Manager, there is currently no process to identify potentially avoidable events. Additionally, in reviewing infections or transfers, it is possible a potentially avoidable event is identified but there is no formal tracking or ongoing auditing of these events. Once the CMS Potentially Avoidable Event report is run annually, a few of the records are randomly selected for review. Failure to adequately review and analyze adverse events risks negative outcomes for the agency patient population.

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 clinical records for 2 patients receiving home health aide (HHA) service (patients #8 and 10), and interviews with the Administrator/Director of Patient Services (DPS) and Clinical Manager, for 1 of 2 records (patient #10) the skilled nurse failed to develop complete and accurate aide written instructions. This was evidenced by: Patient #10 was admitted to the agency on 02/02/24 with diagnoses of recent COVID-19 pneumonia, epilepsy, dysphagia (difficulty swallowing) and atrial fibrillation. The 02/02/24-04/01/24 Plan of Care included Home Health Aide services 2 times a week for 2 weeks and once a week for 2 weeks to assist with personal care. The agency failed to ensure the home health aide care plan included all necessary instructions to maintain patient safety. The 01/24/24 hospital discharge instructions and progress note revealed the speech therapist had recommended a modified diet and aspiration precautions to minimize aspiration risk. The 02/04/24 case coordination notes revealed the patient lived alone in an apartment and was waiting to transfer to assisted living once it could be arranged, and a Home Health Aide was requested until the patient regained strength, The patient's diet was pureed, nectar thickened liquids for difficulty swallowing which had been a chronic problem. The family was coming in multiple times per day to feed the patient and give medications. The 02/07/24 Non-Skilled Care Plan included the modified diet, however, failed to include aspiration precautions. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Failure to ensure that home health aide care plans are complete has the potential for unmet patient needs.

The following statement of deficiencies represents the results of a partial extended re-certification survey of Samaritan Home Health, Inc., Certified Home Health Agency conducted 03/16/2021 through 03/25/2021. A standard re-certification survey was initiated on 03/16/2021. Deficient practices were identified within Level 1 standards in the Conditions of 484.60 Care Planning, Coordination, Quality of Care and 484.80 Home Health Aide Services on 03//23/2021 resulting in a partial extended survey. The survey consisted of reviews of 17 clinical records including 5 discharge records, 14 personnel records for professional and paraprofessional personnel, 3 contracts, and 7 observational home visits. The survey included review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past 12 months, the agency's Admission Packet, the Emergency Preparedness Plan, and Complaint Log. Pre-survey activities consisted of review on 03/15/2021 of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Certification and Survey Provider Enhanced Reports (CASPER) for the period 12/2019 to 11/2020, and the agency's compliance with report submissions for the 2018 statistical report and the Emergency Drill conducted 06/11/2019 through 06/13/2019. The Director of Patient Services (DPS), Quality Assurance (QA) manager and staff were interviewed throughout the survey. The finding were reviewed with the DPS and QA manager at the exit conference on 03/25/2021. The following deficiencies are identified as a result of the survey: Federal: G 526 Content of Comprehensive Assessment; G 606 Integrate All Services; G 574 Plan of Care Must Include the Following and G 798 Home Health Aide Assignment and Duties. State: J 1456 Personnel.

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 a review of clinical records, and interviews with the Director of Patient Services (DPS) and Quality Assurance (QA) manager, it was identified in 6 out of 17 records, (patients # 8, 9, 14, 15, 16 and 17), that the comprehensive assessments were incomplete and/or inaccurate and failed to identify patient needs. Evidence as follows: 1. Patient # 16 was admitted to the agency on 07/10/20 with diagnoses of post- surgical abdominal wound, high blood pressure, diverticulosis and end stage renal disease with dialysis. The skilled nurse (SN), failed to perform a complete and/or accurate comprehensive assessment of the patient's needs. Pressure Ulcer The SN documented in the 07/10/20 initial assessment the patient had no history of a pressure ulcer healed or unhealed. On 07/16/20 another SN visited the patient for re-assessment and documented the patient was known to have a pressure ulcer. The SN also documented the patient stated that she applied protective cream to the area daily. The SN assessed and documented the patient had a stage 2 pressure ulcer on the coccyx measuring 4.2 cm x 1.0 cm x 450 and no sliding scale orders. The patient's 08/06/20 medication order included a corticosteroid, prednisone 10 mg tablets, 2 tablets in the morning, 1.5 tablets at noon, and 0.5 tablet at bedtime. On 08/06/20 the SN visited the patient and documented a blood glucose level of 365. There was no assessment of ranges of blood glucose levels and the time of the elevated reading was not documented. On 08/10/20 the SN visited the patient and documented a blood glucose level of 329 in the morning, however the SN failed to assess the ranges of reading over the last four days. During follow-up visits the SN failed to assess the ranges of blood glucose levels and there was never a mention of a sliding scale: - 08/19/20 349. The SN documented the patient report normals were in the 300's. - 08/26/20 212 - 08/31/20 263 On 09/10/20 the SN visited the patient for the discharge visit and documented caregiver demo of ability to administer insulin coverage was achieved and the caregiver was knowledgeable regarding coverage parameters with no evidence the patient had coverage in use throughout the admission. On 03/23/21 at 2:15 PM the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. 6. Patient # 17 was admitted to the agency on 05/15/20 with diagnoses of stroke, heart rhythm problems, bacteremia, diabetes, and hypertension. The SN failed to perform comprehensive assessments of the patient's needs. The referral information included a 05/08/20 history and physical which detailed a history of pain to medial right ankle, swelling and a rash. The 05/14/20 report of a peripherally inserted central catheter (PICC) to administer an intravenous antibiotic, ceftriaxone 2 grams daily for 4 weeks for right ankle cellulitis and probable endocarditis. The report did not include a baseline arm circumference or external length of the catheter. The 05/14/20 progress note included redness to the right foot, tenderness to the heel and swelling of the right leg. On 05/15/20 the SN visited the patient for the initial assessment and documented the patient had a single lumen PICC line to the left arm and the arm was not measured due to the line just being inserted. There was no assessment of the external length so no baseline of either measurement. The patient had a surgical incision to the chest and no other wounds documented. The SN documented the patient reported shooting pain to the bottom of the right foot aggravated by walking and the patient had redness to the right lower extremity with no further description. The 05/15/20 Plan of Care included an order to measure the mid arm circumference and exposed PICC and report any increase. On 05/18/20 the SN visited the patient and failed to assess the external length of the PICC and documented 34.5 as the baseline mid arm circumference. The SN documented the patient had decreased redness to the right lower extremity with no further details. On 05/19/20 the physical therapist (PT) documented the patient reported pain to the right heel with weight bearing. There was no evidence the area was assessed and the change reported. On 05/26/20 the SN visited the patient and documented the mid arm circumference was 34.5 as baseline. The SN documented redness to the right lower extremity was decreased and the patient was seeing a wound specialist for a wound to the right ankle/foot, the patient's caregiver was taught to perform wound care at the appointment and awaiting orders. The SN failed to assess the area and document the type of dressing present to the area. On 06/01/20 the SN visited the patient and documented the patient had a stage 2 pressure ulcer to the R inner ankle and failed to measure the wound . On 03/23/21 at 2:15 PM, the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. Failure to ensure comprehensive assessments are complete and accurately reflect the patient's status has the potential for negative outcomes for the agency patient population.

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 may choose to include. This ELEMENT is not met as evidenced by: Based on a review of clinical records, and interviews with the Director of Patient Services (DPS) and Quality Assurance (QA) manager, it was determined in 3 out of 17 records, (patients # 8, 9, and 14), the SN failed to develop individualized plans of care that were complete, accurate, and addressed the total needs of the patient. Evidence as follows: 1. Patient # 14 was admitted to the agency on 11/11/20 with diagnoses of post-surgical infection of abdominal wound, type 2 diabetes, irregular heartbeat and chronic obstructive pulmonary disease. The plan of care was incomplete and/or inaccurate. Wound Vac Dressing The plan of care dated 11/11/20 included the following wound care orders: Vacuum Assisted Closure (VAC) system - change VAC dressing 3 times per week - remove old dressing, cleanse wound with normal saline and 4 x 4 gauze, pat dry, drape periwound with transparent dressing. Cut to fit black sponge and place in wound bed, cover with transparent dressing, cut quarter inch hole over black sponge, attach suction hose above hole in dressing and connect tubing to container and turn on vac. Pressure to be at 125 mmHg continuous pressure. The plan of care failed to include a plan for application of an alternate dressing in the event of wound VAC failure either as per policy or patient specific physician's order, including the length of time the system can be without negative pressure, frequency for changing alternative dressing, type of dressing, cleansing agent, and person responsible to provide care. Bleeding Time Monitoring The 11/11/20 plan of care included the patient was on Coumadin (blood thinner) 5 mg tablets, 5 days per week and 7 mg tablets, 2 days per week. The plan of care listed a PT/INR (bleeding time) monitoring machine. The plan of care failed to include: - person responsible for testing - frequency of testing - instructions for reporting results to the physician Edema On 11/17/20 the SN documented in a patient activity note the patient was to monitor weight daily and report changes to the physician. The SN failed to update the plan of care to include an order for the patient to obtain daily weights with specific parameters to report changes to the physician. On 03/22/21 at 2:15 PM, the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. 2. Patient # 9 was admitted to the agency on 02/03/21 with diagnoses of COVID-19, high blood pressure and congestive heart failure. The plan of care was incomplete and/or inaccurate. Edema On 02/03/21 the SN documented in the initial assessment the patient had 1+ pitting edema to bilateral lower extremities. The plan of care contained instructions for the patient to obtain weight daily every AM after emptying bladder/bowels and before breakfast, report to physician weight gain of 2 pounds or more in 24 hours or if gain more than 5 pounds in one week. On 02/10/21 the SN obtained a physician's order to discontinue daily weight due to the patient's inability to stand on the scale. The SN failed to develop a new plan in collaboration with the physician to monitor the patient's edema. Leg Brace On 02/03/21 the SN documented the patient wears a brace to the right lower extremity. The 02/03/21 plan of care failed to include a plan for the patient to use a leg brace including type, location and frequency of application/removal. On 03/22/21 at 1:00 PM, the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. 3. Patient # 8 was admitted to the agency on 02/05/21 with diagnoses of atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease (COPD), respiratory failure, sleep apnea and chronic kidney disease. The plan of care was not updated to reflect changes in the patient's condition. Oxygen On 02/05/21 the SN visited the patient for the initial assessment and documented the patient had continuous oxygen at 4 liters via nasal cannula. The 02/05/21 plan of care included continuous oxygen at 4 liters via nasal cannula and reporting of oxygen saturation of less than 90%. The 02/10/21 PT order included an order to notify the MD if the oxygen saturation fell below 90% and do not return with a 2 minute seated rest. On 02/10/21 the physical therapist (PT) visited the patient and documented the oxygen was set at 3.5 liters per minute. There was no evidence the PT reported or updated the plan of care. From 02/11/21 to 03/15/21 visiting clinicians documented ranges of oxygen in use with no update of the plan of care. On 02/11/21 the occupational therapist (OT) visited the patient and documented oxygen was at 3.5 liters per minute. On 02/16/21 the SN visited the patient and documented the oxygen was at 3 liters and the caregiver stated they don't have an order to wean down oxygen, but tries to keep oxygen saturation at 88-92% and the RN would call the primary care provided to try to obtain an order to decrease oxygen. There was no evidence this was done. On 02/19/21 the OT documented the oxygen was at 2.5 liters. On 02/23/21 the SN documented the patient had decreased the oxygen to 2.5 and reported the 4 liters was "way too high", the patient had been on 2.5 liters for more than a week and monitored oxygen saturation levels at home. There was no update of the plan of care to reflect this change. Between 02/24/21 to 03/12/21 clinicians documented oxygen setting of 2-2.5 liters . On 03/15/21 the SN documented the patient was weaning off the oxygen and at this time an order was received to discontinue oxygen 4 liters nasal cannula and the patient could titrate 1.5-2 liter as needed and that due to the history of COPD the patient was not letting the oxygen level go above 96%. Pain Management On 02/05/21 the SN documented the patient had used 0.25 ml morphine the previous night to help with sleep and had Tylenol available but did not use it often. The 02/05/21 plan of care included morphine (narcotic) 0.25-1 ml sublingually every 2 hours as needed for moderate pain. The morphine order lacked detail on the concentration (mg/ml) and instructions regarding how to use the lower versus the higher dose. Bowel Management On 02/09/21 the SN visited the patient and documented the patient's last bowel movement was on 02/06/21. The medication list included Ferrous sulfate (iron) 325 mg three times per day and morphine. The SN failed to update the 02/05/21 plan of care to include bowel management and monitoring. On 02/10/21 the PT documented the patient's last bowel movement was on 02/06/21, 4 days prior. The PT documented the patient was unsure but did say two small ones since home and the patient used a laxative that day. The PT failed to recognize the plan of care did not include any laxatives, and contact the physician to obtain order for the medication to update the plan of care. On 03/22/21 at 1:00 PM the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on a review of 17 clinical records, and interviews with the Director of Patient Services (DPS) and Quality Assurance (QA) manager, it was determined in 5 records, (Patients # 8, 9, 10, 13 and 16), the clinicians failed to effectively coordinate patient care. Evidence as follows: 1. Patient # 16 was admitted to the agency on 07/10/20 with diagnoses of post- surgical abdominal wound, high blood pressure, diverticulosis and end stage renal disease with dialysis. The agency failed to coordinate patient care. On 07/30/20 the SN documented in the visit note, the patient was refusing to allow the SN to perform wound care to the coccyx wound and contacted the the physician's office for guidance. On 08/06/20, the SN documented the patient refused wound care at the visit, notified the physician's office nurse about a missed dialysis appointment but, it was unclear if wound care non-compliance was reported, or if the office had any guidance for staff to encourage the patient to accept help. Case coordination notes dated 08/11/20 and 08/25/20 included patient non-compliance and refusal of wound care to pressure ulcer remained barriers to meeting goals. There was no evidence the SN coordinated with the physician or other clinicians to address barriers to the patient's acceptance of the treatment plan. On 03/23/21 at 2:15 PM, the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. 2. Patient # 10 was admitted to the agency on 02/03/21 with diagnoses of increased confusion, delirium and high blood pressure. The agency failed to coordinate patient care. Medication Reconciliation On 02/03/21 the SN documented in the initial assessment the following medication discrepancies: Prilosec (antacid) take 40 mg daily. Per note, patient stated she takes the medication only as needed, not daily and Lipitor (cholesterol lowering medication) take 40 mg daily. Per note, the patient stated she takes 20 mg not 40 mg daily. The SN documented she was awaiting clarification from the physician. The 02/03/21 plan of care contained orders for Prilosec 40 mg daily and Lipitor 40 mg daily. There was no evidence the SN contacted the physician to discuss the conflicting medication information and clarify the medication orders. Home Health Aide (HHA) Services On 02/03/21 the SN documented in the initial assessment the patient and care giver were interested in HHA services pending Occupational Therapy (OT) evaluation. On 02/11/21 the OT visited the patient. The OT documented the patient's daughter would like to get the patient in the shower, but the patient has no desire to get into shower and no skilled OT was needed. There was no evidence the OT addressed need/benefit of HHA services and failed to coordinate a plan with the physician, SN or other clinicians to ensure personal care needs of the patient were met. On 03/22/21 at 1:00 PM, the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. 3. Patient # 9 was admitted to the agency on 02/03/21 with diagnoses of COVID-19, high blood pressure and congestive heart failure. The agency failed to coordinate patient care. On 02/03/21 the SN documented in the patient activity notes the admission assessment included the patient had short term memory loss and confusion. The patient's primary care giver in the home was 91 years old, and not able to provide a lot of assistance, and a referral for social worker (SW) evaluation was made. On 03/09/21, 5 weeks following initial SW referral, the SN documented in the patient activity notes issues included patient family concerns about mental status decline and think nursing home placement was most appropriate, SW referred, however; there was no evidence the SW assessed the patient. The SN failed to coordinate a plan to ensure the patient/caregiver had access to resources to address financial and short/long-term care needs. On 03/22/21 at 1:00 PM, the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. 4. Patient # 13 was admitted to the agency on 08/07/20 with diagnoses of atrial fibrillation, congestive heart failure, chronic kidney disease, and peripheral vascular disease. The agency failed to coordinate to ensure all ordered services were provided. Home Health Aide (HHA) On 08/07/20 the skilled nurse (SN) visited the patient for the initial assessment and documented the patient needed assistance with grooming, dressing, hygiene, transfers and bathing and requested a HHA. The 08/07/20 Plan of Care, physician orders, included Aide to assist with activities of daily living two times a week for four weeks. There was no aide visit until 08/26/20 and no documentation the physician was notified the service was delayed. Additionally the patient only received a total of two visits, the second on 09/09/20. Social Work Services On 08/26/20 the SN visited the patient and documented the patient had moved to stay with a different family member, the caregiver requested a social worker visit and the social worker was notified. The 08/26/20 verbal order included a referral for MSS (social worker) to assist with Medicaid set up for medical expenses. The 08/27/20 patient activity note documented a patient case conference occurred with no discussion of the pending MSS referral. On 08/31/20 the SN visited the patient and documented the social worker visit was pending. There was no evidence the social worker contacted the caregiver or visited the patient prior to discharge on 09/28/20. On 03/23/21 at 2:15 PM the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. 5. Patient # 8 was admitted to the agency on 02/05/21 with diagnoses of atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, respiratory failure, sleep apnea and chronic kidney disease. The agency failed to adequately coordinate patient care. Home Health Aide On 02/05/21 the SN visited the patient and documented the patient requested a HHA for assistance with activities of daily living. The 02/05/21 Plan of Care included the occupational therapist (OT) to assess for need for HHA and if determined to be needed will be placed in the home the week of 02/15/21 twice weekly for 3 weeks and once weekly for 2 weeks. On 02/11/21, 6 days after admission, the occupational therapist (OT) visited the patient and documented the patient was independent with ADLs, however the patient had continuous oxygen and was reluctant to transfer into the tub due to the shower chair wiggling a little. On 02/16/21 the SN visited the patient and documented the patient would like assistance with taking a shower and the SN would try to schedule a HHA for the next week. The 02/22/21 patient activity note case coordination meeting included the SN documented potential HHA placement this week. The HHA was never implemented and on 02/23/21 an order to discontinue the HHA referral due to patient declining HHA service. Social Work Services On 02/05/21 the SN documented the patient requested a social worker to assist with obtaining community resources. The 02/05/21 Plan of Care included a social work visit for evaluation. There was no evidence the social worker contacted or visited the patient or the consultation was cancelled. On 03/22/21 at 1:00 PM the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. Failure to coordinate patient care has the potential for unmet patient needs and possible negative patient outcomes.

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 clinical records for patients receiving home health aide (HHA) service, (patients # 9, 11 and 13) and interviews with the Director of Patient Services (DPS) and Quality Assurance (QA) manager, it was determined in 3 of 3 records, the skilled nurse (SN) failed to developed complete and accurate aide written instructions. Evidence as follows: 1. Patient # 9 was admitted to the agency on 02/03/21. The 02/03/21 Plan of Care included a home health aide (HHA) twice weekly for 4 weeks and once a week for 2 weeks to meet personal care needs. The SN failed to ensure the patient's aide care plan included complete instructions. Vital Signs The aide care plan dated 02/03/21 included instructions to the aide to take the patient's blood pressure, pulse, respirations and temperature at every visit. The SN failed to provide patient specific parameters for the aide to report abnormal findings to the SN. Leg Brace On 02/03/21 the SN documented in the initial assessment the patient wears a brace to the right lower leg. The SN failed to include the leg brace in the aide care plan with instructions to the aide regarding application and removal of the brace. Pressure Relieving Plan The initial nursing assessment note included the patient was at high risk for pressure injury. The aide care plan failed to include a plan for pressure relieving measures such as a frequency for repositioning the patient, shifting weight when seated or using pillows or other devices for additional support with off-loading. Incontinence Care The SN documented in the initial assessment the patient was incontinent of bowel and bladder. The aide care plan failed to include incontinence care with instructions to check the patient at specific intervals, use of incontinence products such as adult briefs and protective pads, skin cleansing with mild soap and water, medicated wipes, application of protective creams/ointments/lotions. Edema The 02/03/21 initial assessment included the patient had 1+ pitting edema to bilateral lower extremities and was instructed to elevate her legs as often as possible. The SN failed to include instructions for edema management including elevate legs, report increased swelling to the SN. On 03/22/21 at 1:00 PM, the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. 2. Patient # 11 was admitted to the agency on 01/19/21 with diagnoses of Alzheimer's disease, type 2 diabetes, and kidney failure. The 01/19/21 Plan of Care included a HHA twice weekly for one week and once a week for 4 weeks to meet personal care needs. The SN failed to ensure the patient's aide care plan included complete instructions. Vital signs The 01/19/21 aide care plan included instructions for the aide to check blood pressure, temperature, pulse and respirations at each visit. On 01/19/21 the SN visited the patient for the initial assessment and documented the patient had a fistula for dialysis to the left lower arm and there should be no blood pressure measurements to the left arm. The SN failed to ensure the aide care plan included these instructions. The SN failed to provide patient specific vital sign parameters for the aide to report to the supervisor. Diabetes On 01/19/21 the SN documented the patient was taking insulin two times daily and the caregiver was checking blood sugars daily. The HHA plan failed to include diabetes precautions. Bleeding risk The 01/19/21 Plan of Care included Aspirin 81 mg per day. On 01/19/21 the SN documented instructing the patient regarding reporting abnormal bleeding, however, failed to include bleeding/bruising precautions in the aide care plan. On 03/22/21 at 1:00 PM, the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. 3. Patient # 13 was admitted to the agency on 08/07/20 with diagnoses of atrial fibrillation, congestive heart failure, chronic kidney disease, and peripheral vascular disease. The 08/07/20 Plan of Care included a HHA twice weekly for 4 weeks to meet personal care needs. The SN failed to ensure the patient's aide care plan included complete instructions. The 08/13/20 aide care plan instructed the aide to measure blood pressure, respirations, pulse, and temperature at every visit, however failed to include parameters or instruction regarding measurements requiring reporting to the supervisor. On 03/23/21 at 2:15 PM the record was reviewed with the DPS and QA manager. They acknowledged the findings and no additional information was provided. Failure to ensure that home health aide care plans are complete has the potential for unmet patient needs.