Every finding on record at Southeast Alabama Homecare, LLC

A recertification survey was conducted on 11/19/24 to 11/21/24, and Southeast Alabama Homecare was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 11/21/24 with standard deficiencies cited.

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 observations, medical record (MR) review, agency policy, and interviews it was determined the agency failed to ensure an accurate medication list was maintained for each patient. This affected one of seven home visit (HV) patients including HV # 5 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised: 7/1/24 Purpose: To provide a process to ensure continuous monitoring of medications... 2. All clinicians participating in the patient's care are responsible to assist with the maintenance of accurate patient medications throughout the episode of care. During the patient's episode of care the following will occur: ...i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies... HV # 5 was admitted on 10/22/24 with diagnoses including Type Two Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease, and Heart Failure. Review of the Home Health Certification and Plan of Care dated 10/22/24 revealed orders for SN one visit a week for nine weeks, Physical Therapy one visit for one week, two visits for three weeks, then one visit for one week, and Speech Therapy one visit a week for five weeks. A HV was conducted on 11/19/24 at 2:00 PM to observe care provided by Employee Identifier (EI) 9, Speech Therapist. EI # 7, Clinical Director, accompanied the surveyor on the HV. A review of the home medications with EI # 9 and the caregiver revealed the following current medications were in the home but were not listed on the Medicine List dated 11/19/24: Trospium Chloride 20 milligrams (mg) one tablet twice a day. The prescription was dated 10/21/24. Tizanadine 2 mg one tablet three times a day. The prescription was dated 10/21/24. Vitamin D3 25 mg take one tablet daily was listed on the Medicine List, the caregiver stated HV # 5 had been taking the Vitamin D3 twice a day since March of 2024. An interview was conducted on 11/21/24 at 9:20 AM with EI # 7 who confirmed the medication list not continuously updated per agency policy.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, medical records (MR), and staff interviews it was determined the agency staff failed to include patient specific interventions for the administration of ordered Cyanocobalamin (Vitamin B-12) injections in the Plan of Care (POC). This deficient practice did affect MR # 2, one of one MR with monthly B 12 injections, and had the potential to effect all patients requiring monthly injections served by the agency. Findings include: Agency Policy: POC Policy Number: 2.1.007 Revised Date: 9/1/24 Purpose: To assure an appropriate POC is developed and revised in a timely manner for each patient... Policy: Each patient has an individualized POC developed... Procedure: ...2. The POC includes: ...i. Patient specific interventions... 1. MR # 2 was admitted to the agency on 10/23/24 with diagnoses including Encounter for Adjustment and Management of VAD (Vascular Access Device) and Problems Related to Health Literacy. Review of the Home Health Certification (HHC) and POC dated 10/23/24 to 12/21/24 revealed an order for a skilled nurse (SN) frequency once a week for nine weeks and Cyanocobalamin 1000 micrograms/milliliter (ml) 1 ml injection monthly. Further review revealed no documentation of an intervention to administer the Cyanocobalamin monthly. Review of five of five SN visits from 10/23/24 to 11/20/24 revealed no documentation the Cyanocobalamin injection was administered, when the patient last received the Cyanocobalamin injection, or who provided the Cyanocobalamin injection. An interview was conducted on 11/21/24 at 8:47 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no intervention on the patients POC for the administration of the Cyanocobalamin and there was no documentation the patient had received the injection in the five weeks.

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 Medical Records (MR), agency policy, and staff interview the agency staff failed to. a. Flush a peripherally inserted central catheter (PICC) with only ordered medication. b. Document what was used to clean PICC site. c. Document if stat lock and biopatch were placed on a PICC site. d. Follow physician orders for wound care. This deficient practice did affect three of 17 MRs reviewed, including MR # 2, MR # 1, and Home Visit (HV) # 7, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revised: 9/1/24 ...4. Redress the wound using appropriate wound care dressing procedures following physician's orders... 3. HV # 7 was admitted on 10/12/24 with diagnoses including Laceration Without Foreign Body, Right Lower Leg and Long Term (Current) Use of Non-Steroidal Non-Inflammatory. Review of the HHC and POC dated 10/12/24 revealed physician's orders for SN one visit per week for one week, two visits per week for eight weeks, then one visit per week for one week for wound care per home health SN two times a week. Review of the Physician Order dated 11/14/24 revealed orders for wound care to the surgical incision to the right lateral distal pretibial area, cleanse with wound cleanser, pat dry, apply Santyl to wound bed, apply Alginate dressing, and cover with foam dressing two times a week. Review of the SN visit dated 11/16/24 revealed the SN documented the surgical wound to the right lateral distal pretibial area was cleansed with wound cleanser, patted dry, Alginate dressing was applied to the wound bed, and covered with gauze. There was no documentation Santyl was applied to the wound bed and no documentation a foam dressing was applied. An interview was conducted on 11/21/24 at 9:16 AM with EI # 7, Clinical Manager, who confirmed the agency failed to ensure the physician orders for wound care were followed. 1. MR # 2 was admitted to the agency on 10/23/24 with diagnoses including Encounter for Adjustment and Management of VAD (Vascular Access Device) and Problems Related to Health Literacy. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 10/23/24 to 12/21/24 revealed an order for a skilled nurse (SN) frequency once a week for nine weeks to: a. Perform site care to PICC line by cleaning site with chloroprep or alcohol and betadine, allow to dry, may apply biopatch (a hydrophilic polyurethane absorptive foam with chlorhexidine gluconate) and stat lock (stabilization device) then cover with a sterile tegaderm (transparent dressing) once a week. b. Perform lab draw from the PICC line by flushing with 10 milliliters (ml) of Normal Saline prior and post blood draw. c. Flush PICC line with 10 ml of Normal Saline at every dressing change. Further review of the HHC and POC dated 10/23/24 to 12/21/24 revealed no documentation of an order for the administration of Heparin. Review of the SN visits dated 10/30/24, 11/6/24, and 11/13/24 revealed a blood draw from the PICC and PICC site care was performed with Normal Saline 10 ml and Heparin 5 ml administered after the blood draw and during the dressing change. There was no documentation if chloroprep or alcohol and betadine was used to clean the PICC site and if a biopatch and stat lock were placed on the site. Review of the SN visit date 11/20/24 revealed PICC site care was performed with Normal Saline 10 ml and Heparin 3 ml administered. An interview was conducted on 11/21/24 at 8:47 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed the agency staff failed to follow physician orders for flushing a peripherally inserted central catheter (PICC) with only ordered medication, document what was used to clean PICC site, document if stat lock and biopatch were placed on a PICC site. 2. MR # 1 was admitted to the agency on 8/26/24 with diagnoses including Essential (Primary) Hypertension and Infection and Inflammatory Reaction due to Indwelling Urethral Catheter, Subsequent Encounter. Review of the Physician order dated 8/30/24 revealed an order for the insertion of a indwelling catheter and to change the indwelling catheter every month. Review of the SN visit dated 10/2/24 revealed the indwelling catheter was changed. Review of the MR from 10/2/24 to 11/19/24 revealed no documentation of an indwelling catheter change per the physician order. An interview was conducted on 11/21/24 at 8:33 AM with EI # 1 who confirmed there was no documentation of an indwelling catheter change since 10/2/24.

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 interviews it was determined the agency failed to ensure the provider was notified of significant changes in the patient condition. This deficient practice affected two of 17 MR reviewed including MR # 5 and MR # 2 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revised Date: 4/1/23 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge... 4. Coordination of care with physician: ...coordination of services is promoted through routine communication with the patient's physician: a. When changes occur in the patient's condition or response to treatment... In the event that a physician cannot be reached to communicate the status of a patient the following will occur: Medical Director and/or Supervisor will be contacted for assistance with contacting physician... 2. MR # 2 was admitted to the agency on 10/23/24 with diagnoses including Encounter for Adjustment and Management of VAD (Vascular Access Device) and Problems Related to Health Literacy. Review of the HHC and POC dated 10/23/24 to 12/21/24 revealed an order for a SN frequency once a week for nine weeks to perform peripherally inserted central catheter (PICC) site care. Review of the SN visit dated 10/23/24 revealed the PICC line was sutured with an exposed PICC catheter length was 0.0 centimeters (cm). Review of the SN visit dated 10/30/24 revealed the PICC line was sutured with an exposed PICC catheter length of 2.0 cm. There was no documentation the physician was notified of the increased PICC exposed catheter length of 2.0 cm. An interview was conducted on 11/21/24 at 8:47 AM with EI # 1, Executive Director, who confirmed there was no documentation the physician was notified of the increased PICC exposed catheter length of 2.0 cm. 1. MR # 5 was admitted on 10/3/24 with diagnoses including Type Two Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Long-Term Use of Insulin. Review of the Home Health Certification and Plan of Care (HHC and POC) dated 10/3/24 revealed orders for the staff to report vital signs falling outside of established parameters including pain greater than six. Review of the Skilled Nurse (SN) visit dated 11/9/24 revealed the LPN documented MR # 5 complained of a new pain to the back and left hip at a level of 9/10. There was no documentation of the cause of the pain. Review of the HHC and POC dated 10/3/24 revealed no physician's orders for interventions or medications to relieve pain. Further review of the SN visit dated 11/9/24 revealed the SN documented the Nurse Practitioner's office was closed and would notify on Monday. There was no documentation the Physician, Nurse Practitioner, Medical Director, or Supervisor were notified of the new onset of pain and inability to contact the provider on 11/9/24 or on the following Monday, 11/11/24. An interview was conducted on 11/21/24 at 9:32 AM with Employee Identifier (EI) # 7, Clinical Manager, who confirmed the agency failed to ensure the staff notified the provider of the pain level outside of the established parameters.

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 agency procedure, observation, and interviews it was determined the staff failed to maintain sterile technique for the drainage of a vacuum bottle system and dispose of drained pleural fluid per the agency procedure. This deficient practice did affect Home Visit (HV) # 2, one of one observation conducted to observe drainage of a PleurX drain (Pleural Catheter and vacuum bottle System), and had the potential to affect all patients requiring a PleurX drain at the agency. Findings include: Agency Procedure: Drainage with a Vacuum Bottle System Procedure Number: Not documented Procedure Date: Not documented ...Drainage with a Vacuum Bottle System. ...12. Remove gloves and perform hand hygiene. 13. ...Place the catheter on a clean, waterproof absorbable pad and discard the cap. 14. Prepare a sterile field. ...16. Undo the paper tape on the drainage line and lay the access tip on the sterile field... 17. Perform hand hygiene and don sterile gloves. 18. Open the sterile package containing the catheter valve cap and place the cap on the sterile field. ...22. Disinfect the catheter valve opening with an alcohol pad, using a vigorous motion. Allow to dry... 23. Insert and securely lock the vacuum bottle access tip into the catheter valve... 39. Flush the contents of the drainage bottle down the toilet. 1. An observation was conducted on 11/20/24 at 9:08 AM with Employee Identifier (EI) 4, Registered Nurse (RN), to observe the drainage of HV # 2's PleurX catheter with a vacuum bottle system. EI # 2, Patient Care Manger, was present during the observation. EI # 4 removed old dressing from the PleurX catheter site then placed the catheter on the patient's pants, failing to place the catheter on a clean, waterproof absorbable pad. EI # 4 then performed hand hygiene, donned gloves, opened the PleurX vacuum bottle, removed the paper tape on the drainage line and vacuum bottle access tip, removed the old catheter valve cap of the the PleurX catheter, inserted the vacuum bottle access tip into the catheter valve cap and drained pleural fluid into the vacuum bottle. EI # 4 failed to prepare a sterile field, remove gloves used to open sterile field, perform hand hygiene, don sterile gloves, and disinfect the catheter valve opening with alcohol. EI # 4 then opened the sterile field, using the same gloves used to drain the pleural fluid, removed gloves, picked up the right sterile gloves inside of the sterile field, placed the right sterile glove back down on top of the left sterile glove inside the sterile field which contaminated the sterile gloves and sterile field, performed hand hygiene, then donned the sterile gloves inside of the sterile field. EI # 4 failed to maintain sterile technique by opening a sterile field with previously used gloves, entering the sterile field without hand hygiene, then donning contaminated sterile gloves. EI # 4 then used contaminated sterile gloves to disinfect the catheter valve cap and perform PleurX catheter site care. EI # 4 placed the vacuum bottle with drained pleural fluid inside a regular trash bag and left it beside the patient's trash can for the caregiver to place in the outside trash. EI # 4 failed to flush the drained pleural fluid down the toilet. An interview was conducted with EI # 1, Executive Director, and EI # 2 who confirmed the agency staff failed to maintain sterile technique for the drainage of a vacuum bottle system and dispose of drained pleural fluid per the agency procedure.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on review of employee files and staff interviews, the Physical Therapist (PT) failed to meet the appropriate qualifications due to no current Cardiopulmonary Resuscitation (CPR) documentation. This deficient practice did affect Employee Identifier (EI) # 6, PT, one of one PT file reviewed. Findings include: The Home Health Agency (HHA) job description for PT requires current CPR. Review of one of one PT employee files showed no current documentation for CPR. An interview was conducted on 11/20/24 at 4:08 PM with EI # 1, Executive Director, who confirmed that there was no current CPR.

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 the agency policy and procedure, Medical Record (MR), and staff interviews the agency staff failed to provide patient education and/or document the patient or caregiver was able to provide a return demonstration to ensure competency of the following plan of care responsibilities: a. Wound Care. b. Diabetic education. This did affect four of 17 MR's reviewed including MR # 6, MR # 2, MR # 5, and Home Visit (HV) # 5, and had the potential to affect all patients served by the agency. Finding include: Agency Policy: Patient Education Policy Number: 3.001 Revised Date: 11/1/17 Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety. Policy: The agency plans, supports, and coordinates patient and caregiver education designed to promote optimal patient health and safety. Patients receive oral and/or written information for this purpose on an ongoing basis while being cared for by the agency. Procedure: ...3. The patient and caregiver receive ongoing information specific to the identified needs...including: ...b. Patient/caregiver plan of care responsibilities. 3. MR # 5 was admitted on 10/3/24 with diagnoses including Type Two Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Long Term (Current) use of Insulin. Review of the HHC and POC dated 10/3/24 revealed physician's orders including: a. SN one visit per week for nine weeks. b. Provide instructions on Diabetes Type Two including disease process, signs and symptoms, and causes of disease process. c. Instruct on American Diabetes Association (ADA) diet. d. Instruct on prescribed medications to treat diabetes. e. Instruct on diabetic foot care. f. Teach patient/caregiver on administration of insulin including proper preparation of medication, rotation of injection sites, and sharps disposal. Review of the HHC and POC, Clinal Summary revealed the provider documented MR # 5 was referred to home care for education on diabetic medication. The primary focus of care is education of diabetes and diabetic medications which cannot be performed by patient/caregiver due to documented lack of knowledge and or skill... Review of the SN visit dated 10/3/24 revealed the SN documented MR # 5 had not been taking insulin correctly and blood sugar had been out of parameters. MR # 5 needed further education on diabetes and medication management. There was no documentation MR # 5 received diabetic teaching on the initial visit. Review of the SN visit dated 10/8/24 revealed MR # 5 was instructed on skin breakdown, pain medication, and use of equipment including shower chair, Hoyer lift, grab bars, and removal of safety barriers. There was no documentation MR # 5 received diabetic teaching. There were no SN visits completed for the week of 10/12/24 due to patient refusal. Review of the next SN visit dated 10/26/24 revealed the SN provided instructions for use of prescribed medications for diabetes and side effects. Review of the SN visits dated 11/2/24 and 11/9/24 revealed no documentation MR # 5 was provided instructions for ADA diet, administration of insulin, preparation of medications, rotation of injection sites, or sharps disposal. An interview was conducted on 11/21/24 at 9:32 AM with EI # 7, Clinical Director, who confirmed diabetic education was not provided per the POC. 4. HV # 5 was admitted on 10/22/24 with diagnoses including Type Two Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease, and Heart Failure. Review of the HHC and POC dated 10/22/24 revealed physician's orders for SN one visit per week for nine weeks. SN to instruct on diabetes to include disease process, signs and symptoms of exacerbation, complications, and management. Review of the RN Oasis Admission dated 10/22/24 revealed the RN documented HV # 5 was being admitted for education on diabetes, physical therapy, occupational therapy, and speech therapy evaluation. There was no documentation diabetic education was provided on admission. Review of the SN visits dated 10/29/24 and 11/8/24 revealed diabetic education was not provided until 11/8/24. An interview was conducted on 11/21/24 at 9:19 AM with EI # 7, who confirmed the diabetic education should have begun on admission. 1. MR # 6 was admitted to the agency on 1/25/24, recertified for continued care from 7/23/24 to 9/20/24, with diagnoses including Pressure Ulcer of Left Buttock, Stage 2, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene, and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 7/23/24 to 9/20/24 revealed orders for a skilled nurse (SN) frequency of twice a week for one week then three times a week to perform/instruct the patient/caregiver on the following wound care: Clean the left heel diabetic ulcer, left lower buttock pressure ulcer stage I, and left perineum with soap and water, pat dry with gauze, apply triple antibiotic ointment and xeroform, and cover with a bordered silicone foam dressing. Clean the right leg (no documentation of the wound type), left proximal pretibial venous status ulcer, left distal pretibial venous status ulcer, and the mid pretibial venous status ulcer with soap and water, pat dry with gauze, apply triple antibiotic ointment and xeroform, cover with an abdominal pad and secure with tape. Review of seven of seven SN visits dated 7/26/24 to 8/9/24 revealed no documentation the patient or caregiver was provided education on wound care or provided a return demonstration of the wound care for the patient's wound. Review of the SN visit dated 8/9/24 revealed the SN did not provide wound care during the visit due to the caregiver had completed the care to all the patient’s wounds. An interview was conducted on 11/21/24 at 8:55 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation the patient and/or caregiver was provided education on wound care and/or provided a return demonstration of the wound care. 2. MR # 2 was admitted to the agency on 10/23/24 with diagnoses including Encounter for Adjustment and Management of VAD (Vascular Access Device) and Problems Related to Health Literacy. Review of the physician order dated 11/8/24 revealed an order for a SN to perform/instruct on wound care to the left foot including cleansing the wound with antimicrobial wound cleanser, pat dry with gauze, apply a nonadherent calcium alginate with silver to the wound bed, cover with gauze, and secure with tape every other day and the patient/caregiver to perform in SN absence. Review of the SN visits dated 11/13/24, first SN visit after the 11/8/24 order, and 11/20/24 revealed no documentation the SN provided the wound care to the left foot, the patient/caregiver was provided education of the wound care to the left foot and/or provided a return demonstration of the wound care to the left foot. An interview was conducted on 11/21/24 at 8:47 AM with EI # 1 who verbalized prior to the 11/8/24 physician order, the patient had a graft, so no wound care was ordered for the left foot. EI # 1 confirmed 11/13/24 was the first SN visit following the 11/8/24 order and there was no documentation the SN performed the wound care, provided education on the wound care to the patient/caregiver, or obtained a return demonstration of the wound care to the left foot.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy, and interview, it was determined the agency failed to ensure a discharge summary was sent to the health care provider who would be providing care after discharge. This affected one of five patients who were discharged from the agency including MR # 9 and had the potential to affect all patients discharged from this agency. Findings include: Agency Policy: Patient Discharge/Transfer Process Policy Number: 2.1.004 Revised: 10/1/23 Purpose: To ensure continuity of care when a patient is discharged, transferred, or referred... 21. A discharge summary including admission and discharge dates, reason for admission...patient's condition at time of discharge...is sent to the physician or other healthcare professional responsible for care after discharge from the agency within 5 (five) business days of patient's discharge... 1. MR # 9 was admitted on 4/24/24, recertified from 6/23/24 to 8/21/24, with diagnoses including Pressure Ulcer of Sacral Region, Stage Two, Pressure Ulcer of Left Buttock, Stage Two, and Type Two Diabetes Mellitus Without Complications. Review of the Physician Order dated 7/1/24 revealed orders to discharge patient from the agency per patient request due to moving out of the service area. Review of the Registered Nurse (RN) Discharge from Agency note dated 7/2/24 revealed the RN documented MR # 9 was no longer moving out of the service area due to cancer progression and was being discharged to hospice. There was no documentation the hospice agency or hospice physician was provided a Discharge Summary Report. An interview was conducted on 11/21/24 at 9:45 AM with Employee Identifier # 7, Clinical Director, who stated the Discharge Summary was sent to the Home Health physician and confirmed there was no documentation the Discharge Summary was sent to the receiving hospice agency or hospice physician.

A complaint survey was conducted on 12/27/21 to 12/29/21 with condition level deficiencies at 484.50 Condition: Patient Rights and related standard level deficiencies.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to follow facility policy and procedure when discharging for cause including notification of the patient and caregiver a discharge for cause was being considered by the agency, make and document efforts to resolve problems presented by the patient's behavior and/or situation and provide contact information for other agencies and/or services available to the patient and/or caregiver. This had to potential to negatively affect all patient's served by the agency. Findings include: Refer to G 432, G 462, G 464, G 466, and G 468 for findings.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure and interviews with staff, it was determined the agency failed to follow their policy for complaint investigation and documentation of complaints, their investigation and follow-up through resolution. This affected 1 of 1 Medical Record (MR) reviewed with Intravenous (IV) administration and wound care who was discharged for cause. This affected MR # 1 and had the potential to affect all patients who are admitted to this home health agency. Findings include: Agency Policy: Grievance Procedure, Patient Complaints Policy Number: 1.007 Revised date: 11/1/21 Purpose: To establish a process for patient, caregivers...to communicate areas of concern in regard to patient care and services as well as an internal process to investigate, address findings and follow-up with the individual who initiated the concern. Policy ...The agency will investigate complaints made by the patient, legal representative, caregiver, and/or family... Procedure: 1. Staff receiving complaints either in person, by phone, or through the mail shall document the patient complaint. Agencies will document the complaint with the information system: the Executive Director or Clinical Director will receive an automated workflow regarding the complaint for follow-up. 2. The Executive Director or Clinical Director interviews the patient, family, and involved staff or other individuals and takes appropriate actions to resolve the issue. ...5. After the investigation and analysis is completed, but no later than 30 days after the complaint/grievance filing, the Executive Director or Clinical Director will follow-up with the patient and/or complainant and document within the information system... 6. Agencies can access the complaint report within the information system. Any supporting documentation regarding the complaint should be kept in a confidential file. 1. The surveyor was provided the agency complaint log on 12/28/21 by Employee Identifier (EI) # 1, Executive Director. Review of the agency complaint log on 12/29/21 revealed no documentation of a complaint related to MR # 1, a patient admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, who had been receiving Intravenous infusion and wound care services from the agency and was discharged for cause on 10/24/21. An interview was conducted with EI # 1 who was asked if the agency had received a complaint involving MR # 1. EI # 1 stated, "I think the mother/father called and there was an email to return his/her call. Then it escalated. I think she/he would call continuously... I think (EI # 6, Office Manager) talked to him/her since I was out of the office. EI # 1 was asked if there was documentation of the call. EI # 1 stated, "No, I never talked to her/him." An interview was conducted with EI # 6 who was asked if the agency had received a complaint involving MR # 1. EI # 6 stated, "Yes...about discharge from service. I told her/him she/he would need to speak to (EI # 1 Identified), she/he was in the (another agency location identified), she/he was talking about she/he couldn't understand why we called DHR (Department of Human Resources). She/He talked to me about (agency nurse identified), she thought (agency nurse identified) was a friend, she told me about the drinking and she/he could only take a sip or two and would be intoxicated. She/He said she was going to call state. She/He called several times, that day was after the DHR complaint and she/he was mad. She/He was on her/his way to meet DHR at the house." EI # 6 was asked what happened with the complaint after then. EI # 6 stated, "I told her/him I would reach out to EI # 1 and let him/her know what the complaint was....I called EI # 1 and let him/her know everything that had been said on the call. EI # 6 was asked if the complainant verbalized she/he wanted to speak with EI # 1 during the call. EI # 6 stated, "yes." Due to the call not being documented there is no documentation of the date of the complainant's call. .

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to follow facility policy and procedure when discharging for cause. This affected 1 of 1 MR's review with Intravenous (IV) administration and wound care who was discharged for cause. This affected MR # 1 and had the potential to affect all patients who are admitted to this home health agency.Findings include:Agency Policy: Patient Discharge/TransferPolicy Number: 2.1.004Revised date: 11/1/21 Purpose: To ensure continuity of care when a patient is discharged... Policy: 1. Any of the following reasons may be criteria for patient discharge or transfer: …e. Agency determines a discharge for cause is appropriate because patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or ability of the agency to operate effectively is seriously impaired... Procedure: ...7. In the event a discharge for cause (i.e. disruptive, abusive, or uncooperative behavior interfering with delivery of care) is being considered, the agency will: a. Advise patient, legal representative...responsible for care after discharge of possible discharge. The clinical record will reflect identification of the problems encountered, assessment of the situation...a plan to resolve issues and results of the plan implementation. In situations when staff are threatened or endangered, the agency can take immediate actions without taking measures to resolve the issue... 1. MR # 1 was admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the MR revealed documentation the patient was receiving daily nursing visits from 10/17/21 through discharge date of 10/24/21 for daily IV antibiotic administration and wound care twice weekly. Further review of the MR revealed no documentation the patient and caregiver were notified of a possible upcoming discharge or a discharge for cause was being considered by the agency. Review of the Skilled Nurse (SN) Visit Note Report (VNR) dated 10/24/21 revealed documentation of "...upon arrival to home, patient immediately requests for RN (Registered Nurse) to go to the store and purchase cigarettes for her/him, with refusal patient began verbally abusing this nurse. Patient informed due to multiple episodes of cursing, verbal abuse and outbursts with nurse, medical and medication non-compliance and no available caregiver that patient would be discharged this date. Patient verbalized understanding. Patient refused vital sign assessment and further intervention education and requested nurse to leave residence and went to her/his room. Attempted to make contact with patients (parent identified) that lives out of town with no success..." Further review of the SN VNR dated 10/24/21 revealed documentation of "...Indicate other community service involved or needed: DHR...Is there an unstable caregiver or potential for an unstable caregiving situation? No...Indicate type of environmental safety barriers present in the home:...None..." Review of the Care Management sections revealed the patient did not require assistance with ADL's, medical procedures/treatments, assistance for supervision and safety and the patient did require assistance for medication administration which was documented as "...non-agency caregiver(s) currently provide assistance." Further review of the SN VNR dated 10/24/21 revealed no documentation of how the patient was verbally abusing the nurse and no documentation the agency staff felt threatened or endangered based on the nurse offering further assessment and intervention and the patient asking the nurse to leave while the patient went to her/his room. The patient's primary nurse was unavailable for interview due to sickness. An interview was conducted on Employee Identifier (EI) # 2, RN, on 12/29/21 at 9:10 AM, who performed a nursing visit 3 days prior to discharge of the patient. EI # 2 verbalized the agency was going to see the patient daily because the patient's primary nurse said there was some worry about the patient's cognitive ability to administer the IV antibiotics. EI # 2 stated, "She/He did try to get me to leave and go get her/him cigarettes. I do remember that. I told her/him no..." EI # 2 was asked what the patient's response was to the nurse refusing to obtain cigarettes for the patient. EI # 2 stated, "She said okay that was fine. I will get a friend to get them." EI # 2 was asked if the patient displayed any outburst, agitation or cursing during the visit. EI # 3 stated, "nothing of that nature." EI # 2 was asked is she/he was aware of any safety issues/concerns related to the patient and/or caregiver situation. EI # 2 stated, "She/He was safe with ADL's (Activities of Daily Living), there wasn't any acute mental issues. I think she/he had some occasional forgetfulness and that's what we were coming for, as reminders. There wasn't any significant altered mental status." An interview was conducted on 12/29/21 at 9:34 AM with EI # 3, RN, who performed a nursing visit 7 days prior to discharge of the patient. EI # 3 who verbalized PI # 1 "...acted okay. She/he was kind of forgetful, like when the medication was infusing, she/he would try to get up. I would say, 'hey, don't forget you have medicine infusing' and she/he would say oh ya I forgot and sit down but then she/he would do it again later..." EI # 3 was asked if the patient displayed any outburst, agitation or cursing during the visit. EI # 3 stated, "no, not with me." EI # 3 verbalized "I remember in her/his visit notes there was someone we could talk to, a cousin or aunt, someone since the mother/father lives so far away." An interview was conducted on 12/29/21 at 10:04 AM with EI # 4, Licensed Practical Nurse, who performed 2 visits within 2 weeks prior to the patient's discharge. EI # 4 verbalized the patient was a "...little unsteady" and verbalized at one of EI # 4's visit the patient fell. EI # 4 verbalized the patient was trying to feed the dogs and fell. EI # 4 verbalized the caregiver was notified and told EI # 4 she/he was on the way. EI # 4 was asked the patient displayed any outburst, agitation or cursing during the visit. EI # 4 stated, "no, just one time the (caregiver) was there and told her/him I was there and (MR # 1 identified) said just tell her/him I'm sick. I said (MR # 1 identified), I can hear you. She/He did a little cussing then but nothing out of the normal. She/He just didn't want to be seen that day. That's all." EI # 4 was asked if the cursing was directed at the staff member. EI # 4 state, "no, not at all." EI # 4 was asked if she/he recalled noticing any noncompliance from the patient. EI # 4 state, "no...she/he was always complaint when I was there." An interview was conducted on 12/29/21 at 11:05 AM with EI # 5, Occupational Therapist, who had been seeing the patient weekly until 10/20/21 when the patient was discharged for goals met. EI # 5 stated, "...she/he was very nice to me but a little wild..." EI # 5 explained the patient "there was always a giant bottle of alcohol there. She/He partied. She/He smoked but would say don't tell my (mother/father). You couldn't really tell if she/he was doing the things or not because she/he would say one time she/he did all of that and the next time would say she/he didn't. EI # 5 was asked about the bottle of alcohol and if the agency would discharge for the alcohol. EI # verbalized "it was one bottle, it was huge. As far as I could tell it was the same bottle...I wouldn't think so unless it was seriously interfering with the Plan of Care." EI # 5 was asked if the patient displayed any outburst, agitation or cursing during the visit. EI # 5 stated, "not while I was there. I mean she/he cursed when she/he talked but nothing like an outburst while I was there." EI # 5 was asked if the patient cussing was ever direct at the staff member or if the patient would become verbally abusive. EI # 5 stated, "no, with me she/he was always polite, she/he just cusses when she/he talks. It's just her/his language." EI # 5 was asked if the patient was noncompliant in anyway. EI # 5 stated, "I felt she/he wasn't doing exercises. She/He would say she/he was doing them and then also at time say...I'm not doing them. I think medication was a problem, she/he had a big set up but still think they were an issue." EI # 5 was asked about the patient's "set up". EI # 5 state, "they had a dining room table with medications in baggies with the times on them. We would come in the afternoon and she/he would just be woke up and hadn’t took her/his medications. She/He would go in there and take some. There was some confusion if she/he was taking the morning or afternoon, since she just woke up but I don't remember if I just was thinking that (talking about the agency confusion on which medication the patient was taking) or if we talked about it...I don't know that I would have gone and looked at what was taken or not taken..."EI # 5 was asked his/her if the patient was able to live alone. EI # 5 stated, "I don't know. I felt she was borderline, she was having...services before and felt it would be helpful for them to come back. I don't think she/he needed anyone there full time but someone checking on her/him." EI # 5 was asked about the caregiver's involvement with the patient. EI # 5 stated, "sometimes they were fighting, and she would be (MR # 1 identified) is going to do what (MR # 1 identified) is going to do but most of the time she was involved." In an interview on 12/29/21 at 1:42 PM with EI # 1, Executive Director and EI # 7, Performance Improvement Coordinator, verified there was no documentation of what verbal abuse occurred at the visit. EI # 1 and EI # 7 were asked was the patient's documented behavior to the extent that the delivery of care to the patient or the ability of the agency to operate effectively seriously impaired? EI # 1 stated, "I think it was just the nurse herself." EI # 7 stated, "if a patient started a verbal abuse towards me, I would not stay in the home but in addition to that I believe the nurse felt the patient needed more of a caregiver..." The surveyor asked if the agency administration had been contacted prior to the discharge about the patient's discharge. EI # 1 verbalized the nurse had not called prior to discharging the patient and EI # 1 was notified after the discharge had taken place. EI # 1 was asked per the agency policy/procedure if the agency administration were supposed to be notified prior to a discharge for cause. EI # 1 stated, "yes".

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to notify the patient and caregiver a discharge for cause was being considered by the agency. This affected 1 of 1 MR's review with Intravenous (IV) administration and wound care who was discharged for cause. This affected MR # 1 and had the potential to affect all patients who are admitted to this home health agency. Findings include:Agency Policy: Patient Discharge/TransferPolicy Number: 2.1.004Revised date: 11/1/21 Purpose: To ensure continuity of care when a patient is discharged... Policy: 1. Any of the following reasons may be criteria for patient discharge or transfer: …e. Agency determines a discharge for cause is appropriate because patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or ability of the agency to operate effectively is seriously impaired... Procedure: ...7. In the event a discharge for cause (i.e. disruptive, abusive, or uncooperative behavior interfering with delivery of care) is being considered, the agency will: a. Advise patient, legal representative...responsible for care after discharge of possible discharge... In situations when staff are threatened or endangered, the agency can take immediate actions without taking measures to resolve the issue... 1. MR # 1 was admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the Physician's order dated 10/17/21 revealed documentation the patient was to receive daily nursing visits daily IV antibiotic administration and wound care twice weekly. Review of the Skilled Nurse (SN) Visit Note Report (VNR) dated 10/24/21 revealed documentation of "...upon arrival to home, patient immediately requests for RN (Registered Nurse) to go to the store and purchase cigarettes for her/him, with refusal patient began verbally abusing this nurse. Patient informed due to multiple episodes of cursing, verbal abuse and outbursts with nurse, medical and medication non-compliance and no available caregiver that patient would be discharged this date. Patient verbalized understanding. Patient refused vital sign assessment and further intervention education and requested nurse to leave residence and went to her/his room. Attempted to make contact with patients (parent identified) that lives out of town with no success..." Further review of the SN VNR dated 10/24/21 revealed no documentation of how the patient was verbally abusing the nurse and no documentation the agency staff felt threatened or endangered based on the nurse offering further assessment and intervention and the patient asking the nurse to leave while the patient went to her/his room. Further review of the MR revealed no documentation the patient and caregiver were notified of a possible upcoming discharge or a discharge for cause was being considered by the agency prior to the patient's actual discharge. There was no documentation of another attempt to contact the patient's parent who is the caregiver of the patient and responsible for care following the discharge. In an interview on 12/29/21 at 1:42 PM with EI # 1, Executive Director and EI # 7, Performance Improvement Coordinator, verified there was no documentation of what verbal abuse occurred at the visit and no additional attempts to contact the patient caregiver were documented.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to make efforts to resolve problems presented by the patient's behavior and/or situation. This affected 1 of 1 MR's review with Intravenous (IV) administration and wound care who was discharged for cause. This affected MR # 1 and had the potential to affect all patients who are admitted to this home health agency. Findings include:Agency Policy: Patient Discharge/TransferPolicy Number: 2.1.004Revised date: 11/1/21 Purpose: To ensure continuity of care when a patient is discharged... Policy: 1. Any of the following reasons may be criteria for patient discharge or transfer: …e. Agency determines a discharge for cause is appropriate because patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or ability of the agency to operate effectively is seriously impaired... Procedure: ...7. In the event a discharge for cause (i.e. disruptive, abusive, or uncooperative behavior interfering with delivery of care) is being considered, the agency will: b. Attempt to resolve problems(s) presented by patient's behavior or other individual's behavior in home or situation. ...d. Ensure the issue of concern and efforts to resolve problems is documented in the MR. The clinical record will reflect identification of the problems encountered, assessment of the situation...a plan to resolve issues and results of the plan implementation. In situations when staff are threatened or endangered, the agency can take immediate actions without taking measures to resolve the issue... 1. MR # 1 was admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the Skilled Nurse (SN) Visit Note Report (VNR) dated 10/11/21 revealed the patient had fallen on 10/9/21, 10/11/21 and at the visit with the SN. The SN also documented the patient had just returned from a physician's appointment where the patient was found to be "severely impacted with stool" per caregiver. The SN also documented the patient's wound were found to have MRSA (Methicillin-Resistant Staphylococcus Aureus) and the patient had complained of nausea and vomiting. There was no documentation of how long the patient had been having the nausea and vomiting, how many occurrences of the vomiting the patient had, and the hydration status of the patient. Review of the SN VNR dated 10/12/21 revealed documentation of an Registered Nurse (RN) follow up due to patient fall and "...mother/father has a plan to have family keep medication oit (out) of home ane (and) come to administer multiple times daily as patient is not taking medications as ordered. She/He is becoming increasingly forgetful. Patient refuses to move in with mother/father althoigh (although) mother/father feels she/he is unsafe to live alone..." There was no documentation of how the patient was not taking the medication as ordered and the reason the parent felt the patient was unsafe to live alone. Review of the SN VNR dated 10/13/21 revealed documentation of "patient more alert and coherent today...called and spoke with...(IV infusion company identified)... was waiting to make sure patient would have help. Spoke with (agency Patient Care Manager identified)...stated we could cover assistance..." Review of the OT (Occupational Therapy) VNR dated 10/13/21 revealed documentation of "...required assistance to access pills from sandwich bag to take. Complains of some issues with swallowing pills and food the last week, requests SLP (Speech Therapist) evaluation." There was no documentation the caregiver was notified of the patient requiring assistance to access pills from sandwich bag and interventions/efforts by the agency to help resolve the required assistance to access pill in the sandwich bag(s). The was no documentation of the agency staff's interventions/efforts to resolve the issues found during the visit. Review of the physician order dated 10/13/21 revealed an order for a Speech Therapy (ST) evaluation due to "difficulty swallowing meds (medications) and food over the last week as well as increasing cognitive issues/confusion..." Review of the ST evaluation dated 10/20/21 revealed documentation the patient was alert and oriented with no abnormal neurologic, cognitive and behavioral problems identified. Further review of the ST evaluation dated 10/20/21 revealed documentation of "...complains of pills hanging in her/his throat when she/he swallows. Patient takes 8 to 10 pills at once. Educated patients on taking 1-2 at a time... no overt signs or symptoms of aspiration observed on soft solids and thin liquids...report no difficult (difficulty) with food...patients may benefit from GI (Gastrointestinal) consistency to rule out esophageal stricture..." Review of the SN VNR dated 10/22/21 revealed documentation of "patient reports fall...patient states (Neurologist Identified) changed her/his dosage of antiseizure medication, new medication not in home this date. This RN feels patient still isn't taking medications as ordered. She/He still has no one managing her/his medications as all medications are still in the home..." The nurse further documented the patient reported smoking and the caregiver verbalized the patient would be disowned if anymore cigarettes were bought, the patient attempts to call people to obtain cigarettes during the visit and "...patient asked this RN to go to the store to purchase...cigarettes. When RN refused...states she/he will ride...riding lawnmower to the store if that's what she/he has to do. Notified (MD office staff identified) of above and that patient would be discharged if when RN arrives tomorrow patient has cigarettes and tells RN she/he rode her/his lawn mower to town for them. Patient lives approx (approximately) 3-4 miles from closest store..." Further review of the SN VNR dated 10/22/21 revealed no documentation of when the antiseizure medication dosage was increased, attempts to find out what the medication dosage was increased too, an assessment of the medications to determine what medications the patient was or was not taking incorrectly, assessment of the reason the patient was taking the medication correctly, notification of the caregiver about nurses concern of the patient's medications being in the home and feeling the patient was not taking medications as ordered, the patient's fall and patient statement regarding riding the lawnmower to store for cigarettes with possibility of discharge if action occurred. The was no documentation of the agency staff's interventions/efforts to resolve the issues found during the visit. Review of the SN VNR dated 10/23/21 revealed documentation of "...patient requesting RN go and get her/him cigarettes at beginning and end of visit. Patient cursed at RN when...told...wound not. RN began infusion, assessed patient, returned to car for duration of infusion due to patient cursing at RN and returned to home to flush and disconnect. Patient states a friemd (friend) is going to pickup her/his new medications today..." There was no documentation the SN attempted to address the issue of cursing at the SN and asking agency staff to acquire cigarettes for them with the patient and/or caregiver to resolve the issue. Review of the SN VNR dated 10/24/21 revealed documentation of "...upon arrival to home, patient immediately requests for RN to go to the store and purchase cigarettes for her/him, with refusal patient began verbally abusing this nurse. Patient informed due to multiple episodes of cursing, verbal abuse and outbursts with nurse, medical and medication non-compliance and no available caregiver that patient would be discharged this date. Patient verbalized understanding. Patient refused vital sign assessment and further intervention education and requested nurse to leave residence and went to her/his room. Attempted to make contact with patients (parent identified) that lives out of town with no success..." Further review of the SN VNR dated 10/24/21 revealed documentation of "...Indicate other community service involved or needed: DHR...Is there an unstable caregiver or potential for an unstable caregiving situation? No...Indicate type of environmental safety barriers present in the home:...None..." Review of the Care Management sections revealed the patient did not require assistance with ADL's, medical procedures/treatments, assistance for supervision and safety and the patient did require assistance for medication administration which was documented as "...non-agency caregiver(s) currently provide assistance." Further review of the SN VNR dated 10/24/21 revealed no documentation of how the patient was verbally abusing the nurse and no documentation the agency staff felt threatened or endangered based on the nurse offering further assessment and intervention and the patient asking the nurse to leave while the patient went to her/his room. In an interview on 12/29/21 at 1:42 PM with Employee Identifier (EI) # 1, Executive Director and EI # 7, Performance Improvement Coordinator. The surveyor asked about the 10/11/21 SN visit and if there was an assessment performed for the amount of vomiting and/or hydration status of the patient. EI # 1 verbalized there was no documentation of the assessment because the patient had just returned from the GI physician's office. The surveyor asked about the 10/22/21 visit and if the SN had documented the reason she felt the patient was not taking the medication correctly. EI # 1 verbalized it was based on the medication being in the home and what was documented on 10/12/21 SN visit. The surveyor asked if the patient and/or caregiver had been notified of the possible discharge action documented on 10/22/21 if the patient rode the lawn mower to the store to obtain cigarettes. EI # 1 verbalized there was no documentation and according the the facility policy the patient and/or caregiver should have been notified. The surveyor asked about the 10/24/21 SN visit EI # 1 verified there was no documentation of what verbal abuse occurred at the visit. The surveyor asked asked was the patient's documented behavior to the extent that the delivery of care to the patient or the ability of the agency to operate effectively seriously impaired? EI # 1 stated, "I think it was just the nurse herself." EI # 7 stated, "if a patient started a verbal abuse towards me, I would not stay in the home but in addition to that I believe the nurse felt the patient needed more of a caregiver..." The surveyor asked if the agency administration had been contacted prior to the discharge about the patient's discharge. EI # 1 verbalized the nurse had not called prior to discharging the patient and EI # 1 was notified after the discharge had taken place. EI # 1 was asked per the agency policy/procedure if the agency administration were suppose to be notified prior to a discharge for cause. EI # 1 stated, "yes". EI # 1 and EI # 7 verified there was no further documentation of the agency's efforts to resolve the issues found then what is documented above.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to provide contact information for other agencies and/or services available to the patient and/or caregiver. This affected 1 of 1 MR's review with Intravenous (IV) administration and wound care who was discharged for cause. This affected MR # 1 and had the potential to affect all patients who are admitted to this home health agency. Findings include:Agency Policy: Patient Discharge/TransferPolicy Number: 2.1.004Revised date: 11/1/21 Purpose: To ensure continuity of care when a patient is discharged... Policy: 1. Any of the following reasons may be criteria for patient discharge or transfer: …e. Agency determines a discharge for cause is appropriate because patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or ability of the agency to operate effectively is seriously impaired... Procedure: ...7. In the event a discharge for cause (i.e. disruptive, abusive, or uncooperative behavior interfering with delivery of care) is being considered, the agency will: ...c. Provide patient and legal representative (if any) contact information for other agencies. ...In situations when staff are threatened or endangered, the agency can take immediate actions without taking measures to resolve the issue... 1. MR # 1 was admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the MR revealed documentation the patient was receiving daily nursing visits from 10/17/21 through discharge date of 10/24/21 for daily IV antibiotic administration and wound care twice weekly. Review of the Skilled Nurse (SN) Visit Note Report (VNR) dated 10/24/21 revealed documentation of "...upon arrival to home, patient immediately requests for RN (Registered Nurse) to go to the store and purchase cigarettes for her/him, with refusal patient began verbally abusing this nurse. Patient informed due to multiple episodes of cursing, verbal abuse and outbursts with nurse, medical and medication non-compliance and no available caregiver that patient would be discharged this date. Patient verbalized understanding. Patient refused vital sign assessment and further intervention education and requested nurse to leave residence and went to her/his room. Attempted to make contact with patients (parent identified) that lives out of town with no success..." Review of the SN VNR dated 10/24/21 and the MR revealed no documentation the patient and caregiver were provided contact information for other agencies and/or services available. In an interview on 12/29/21 at 1:42 PM with EI # 1, Executive Director and EI # 7, Performance Improvement Coordinator, verified there was no documentation the patient and/or caregiver were provided contact information for other agencies and/or services available.

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 agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to follow facility policy and procedure for the administration of Intravenous (IV) medications. This affected 2 of 2 MR's review with Intravenous (IV) administration. This affected MR # 1 and MR # 5 and had the potential to affect all patients who received IV administration by the agency.Findings include:Agency Policy: Administration of Medications and Fluids Through a Peripheral or Central Venous Access DevicePolicy Number:10.012Revised date: 5/1/18 Purpose: To administer medication or solutions safely through a peripheral IV or a central venous access device. ...Mid-Line catheters should be treated as peripheral IV catheters. PICC (Peripherally Inserted Central Catheter) should be treated as central venous access devices... Procedure: ...4. Document the following in the electronic health record...: a. Name of drug b. Dose ...d. Route of administration e. Duration of infusion f. Time administered and time disconnected 1. MR # 1 was admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the Physician's order dated 10/17/21 revealed an order for Skilled Nurse (SN) to administer "Tygacil 50 mg (milligrams)/100 ml (milliliters) daily over 60 minutes vis (via) elastomeric kit..." Review of the SN Visit Note Report(s) (VNR) dated 10/17/21, 10/18/21 and 10/19/21 revealed documentation the SN administered an IV infusion via a peripheral line. There was no documentation of the name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered and disconnected. Review of the SN VNR dated 10/20/21, 10/21/21, 10/22/21 and 10/23/21 revealed documentation the SN administered an IV infusion via a mid- line. There was no documentation of the name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered and disconnected. In an interview conducted on 12/29/21 at 1:42 PM, Employee Identifier (EI) # 1, Executive Director, confirmed there was no documentation of the name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered and disconnected on the above dates. 2. MR # 5 was admitted to the agency on 11/24/21 with diagnoses including Sepsis, Unspecified Organism and Severe Sepsis with Septic Shock. Review of the Home Health Certification and Plan of Care dated 11/24/21 to 1/22/22 revealed an order for the SN to "...instruct patient/caregiver on administering the following medication Ancef 1 gram in 50 ml of Normal Saline every 8 hours x (times) 3 weeks beginning 11/24/21 via esometric ball..." Review of the SN Admission Note dated 11/24/21 revealed documentation of "SN instructed ...on how to administer IV antibiotics and he/she provides correct return demonstration as follows: ...connects antibiotics to port, unclamps to allow to flow. At end of procedure he/she correctly flushes..." There was no documentation name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered. In an interview conducted on 12/29/21 at 1:26 PM, EI # 1 confirmed there was no documentation of the name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered and disconnected on 11/24/21.

Based on review of the agency Emergency Preparedness Plan and interview it was determined Southeast Alabama Homecare was in substantial compliance with 484.102 Conditions of Participation: Emergency Preparedness.

A recertification survey was conducted on 10/21/21 with standard deficiencies cited.

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 agency policy and procedure, observations, medical record (MR) review and interviews with the staff, it was determined the agency failed to ensure staff updated and maintained an accurate medication profile for each patient per the agency policy. This affected 4 of 6 Home Visits (HV), including HV # 6, # 3, HV # 2, HV # 5, and had the potential to affect all patients served by the agency. Findings include: Agency policy: Monitoring Medications Policy Number: 10.008 Revised Date: 5/1/19 Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified issues or non-compliance to the Patient Care Manager. For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode. Procedure: 1. The discipline responsible for the drug regimen review will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician order to actual medications patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams, and topical ointments. 2. All clinicians participating in their patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout their episode of care. a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies. 4. HV # 5 was admitted to the agency on 1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified and Encounter for Attention to Cystostomy. A HV was conducted 10/19/21 at 11:10 AM with EI # 8, Home Health Aide, to observe care provided. The surveyor was accompanied on the HV by EI # 6, RN. During the visit, the medications in the home were compared to the current MP provided by the agency and the following discrepancies were found and verified by the patient and EI # 6 RN: a. Calcium Carb-Vit (Vitamin) D3-Minerals 600 mg, 200 unit tablet, dose one tablet daily listed on the MP but per the patient, was discontinued about one year ago. b. Collagen Plus Vitamin C 125 mg - 740 mg capsule, dose three capsules daily listed on the MP but per the patient, was discontinued about one year ago. c. Cranberry Concentrate 500 mg capsule, dose 1 capsule daily listed on the MP but per the patient, was discontinued about one year ago. d. Evista 60 mg tablet, dose 1 tablet daily listed on the MP but per the patient, was discontinued about one year ago. e. Advil 200 mg tablets found in the home but not on the MP. Per the patient, takes two tablets daily as needed for about a year. f. BHI Diarrhea tablets found in the home but not on the MP. Directions on the bottle state one tablet every 4 to 6 hours as needed. Per the patient takes two tablets after the second loose stool as needed and has taken this medication, for "a long time". EI # 6 confirmed during the home visit the MP was not accurate. 3. HV # 2 was admitted to the agency 9/17/21 with a diagnosis of Unspecified Rotator Cuff Tear/Rupture of Left Shoulder-Not Trauma. A home visit was conducted 10/19/21 at 12:00 PM with EI # 3, Occupational Therapist, to observe treatment provided to the patient and medication reconciliation. The medications in the home were compared to the current MP provided by the agency and the following discrepancies were found. The medications were in the home and not on the Medication Profile and verified by the patient and wife: a. Sotalol HCL (Hydrochloride) 80 mg one by mouth daily-wife states has been on this medication for at least one year. b. Magnesium Oxide 400 mg by mouth Bid (twice) states has been on this medication since April 2021. c. Bumetanide 2 mg by mouth daily PRN (as needed) Has been taking since April 2021. d. Spironolactone 25 mg by mouth daily. Has been taking since April 2021. e. Senna 8.6 mg 1 by mouth daily PRN. Has been taking since September 7, 2021 f. Tylenol Extra Strength 1 tablet, 500 mg every 4 to 6 hours PRN. Has been taking for a couple weeks per wife. The following medication was on the Medication Profile and the patient’s wife stated he quit taking 6 months ago: Furosemide 40 mg 1 tablet by mouth daily. An interview was conducted on 10/21/21 at 11:00 AM with EI # 1 who confirmed the Medication Profile should have been verified and updated. 2. HV # 3 was admitted on 9/22/21 with diagnoses including Urinary Tract Infection, Pseudomonas, and Unspecified Escherichia Coli. A HV was conducted on 10/20/21 at 8:32 AM to observe care provided by EI # 4, RN (Registered Nurse). The medications in the home were compared to the Medication Profile provided by the Agency and the following discrepancies were found and verified with EI # 4 and HV # 3. a. Atorvastatin 80 mg one tablet daily was listed on the Medication Profile. Instructions on the medication bottle in the home filled on 9/2/21 was for ½ tablet daily. HV # 2 confirmed he/she has been taking ½ tablet daily since the prescription change. b. Glipizide 10 mg, 2 tablets 2 times daily was listed on the Medication Profile. Instructions on the bottle filled 8/25/21 was for 1 tablet 2 times daily. HV # 3 stated he/she has been taking the 1 tablet twice a day for a month or so. In an interview conducted on 10/21/21 at 11:10 AM, EI # 1, Executive Director, confirmed the Medication Profile had not been updated per agency policy. 1. HV # 6 was admitted to the agency 9/21/21 with diagnoses including Paraplegia and Essential Hypertension. A HV was conducted 10/19/21 at 12:30 PM with Employee Identifier (EI) # 7, Licensed Practical Nurse, to observe wound care and medication reconciliation. The medications in the home were compared to the current Medication Profile (MP) provided by the agency and the following discrepancies were found and verified by the patient and EI # 7: a. Gabapentin 300 mg (milligrams) 2 times per day with a date of 8/30/21 on the bottle was in the home. The MP profile had 3 times per day. The patient stated he/she had been taking 2 a day for a "long time." b. Niacin 1000 mg OTC 1 time per day was in the home and not listed on the MP. The patient stated the doctor had put him/her on that "over a year ago for cholesterol." EI # 7 confirmed during the home visit the MP was not accurate.

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 agency policy and procedure, review of medical records (MR) and interview with staff it was determined the agency failed to ensure the plan of care wound care orders included the frequency of dressing changes. This affected 2 of 6 records reviewed with wound care including Home Visit (HV) # 6, MR # 9 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Physician Orders Policy Number: 2.1.008 Revised Date: 02/01/20 Policy: No medications, treatments...will be administered without the order of a qualified physician... Procedure: 10. Services are provided according to the most recent orders updating the patient's Plan of Care. 1. HV # 6 was admitted to the agency 9/21/21 with diagnoses including Paraplegia and Essential Hypertension. Review of the physician's order dated 9/27/21 revealed the skilled nurse (SN) was to visit 1 time per week to perform wound care and instruct the wound care procedure to the patient / caregiver. Wound care to the left lateral foot was ordered as follows: clean with normal saline, pat dry, apply Medihoney, cover with foam dressing using clean technique. The order failed to include how often the dressing was to be changed. A HV observation was conducted 10/19/21 at 12:30 PM to observe Employee Identifier (EI) # 7, Licensed Practical Nurse, perform wound care. During the visit the surveyor asked how often the dressing was changed and the patient and nurse stated every day, performed by the paid caregiver. An interview conducted 10/21/21 at 4:15 PM with EI # 5, Clinical Manager, confirmed the wound care order failed to include how often the dressing was to be changed. 2. MR # 9 was admitted to the agency 11/17/21 and recertified on 1/16/21 with diagnoses including Pressure Ulcer of Sacral Region Stage 2 and Pressure Ulcer of Left Buttock Stage 2. Review of the Plan of Care dated 1/16/21 revealed wound care to wound # 5, left buttock, and wound # 8. right inner buttock: clean with normal saline and gauze pads, pat dry, apply skin prep to periwound, then hydrocolloid. The order failed to include how often the dressing was to be changed. An interview conducted 10/20/21 at 4:00 PM with EI # 1, Executive Director, confirmed the order failed to include how often the dressing was to be changed.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on agency policy, medical record (MR) review and interview with staff it was determined the agency failed to ensure physician verbal orders were signed by the physician within 30 days. This affected 1 of 5 discharged records reviewed including MR # 10 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Physician Orders Policy Number: 2.1.008 Revised Date: 02/01/20 Policy: No medications, treatments...will be administered without the order of a qualified physician...and that order...signed/dated by the ordering physician. 4. The Plan of Care (POC), telephone and/or verbal orders must be signed by the physician...30 days. 1. MR # 10 was admitted to the agency 3/6/21 with diagnoses including Chronic Pain Syndrome and Low Back Pain and recertified for care 5/5/21 to 7/3/21. MR # 10 was discharged goals met on 7/1/21. Review of the MR revealed the following verbal physician orders were not signed and dated by the physician: a. Physical Therapy (PT) Add On Discipline dated 6/18/21 which included the Plan of Care and visit frequency. b. Occupational Therapy (OT) Add On Discipline dated 6/21/21 which included the Plan of Care and visit frequency. c. Skilled Nurse order dated 6/17/21 which included nurse visit frequency, PT and OT evaluation. An interview conducted 10/20/21 at 4:12 PM with Employee Identifier # 1, Executive Director, confirmed the physician orders were not signed within 30 days as directed in the agency policy.

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 agency policy and procedure, medical record (MR) review and interviews it was determined the agency failed to notify the physician of deterioration of wounds affecting 1 of 6 records with wounds including MR # 7. This had the potential to affect all patients with wounds served by the agency. Findings include Agency Policy: Coordination of Care From Admit Through Discharge Policy Number: 2.1.017 Revised Date: 8/1/19 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Procedure: 4. Coordination of care with physician: a. When changes occur in the patient's condition or response to treatment. 1. MR # 7 was admitted to the agency 9/29/21 with diagnoses including Chronic Ulcer Left Foot and Type 2 Diabetes Mellitus. Review of the Home Health Certification and Plan of Care dated 9/29/21 revealed the skilled nurse (SN) was to visit 1 time the first week then 2 times per week. SN to perform and instruct patient/caregiver in the wound care procedure to wounds # 13 - right pretibial venous stasis ulcer, # 18 - left foot mid-dorsum pressure ulcer (PU) stage 2, # 19 left heel PU stage 2, # 20 - right great toe PU stage 1, and # 21 - right heel PU stage 2. Perform twice weekly: cleanse with Vashe (wound cleanser), pat dry, apply silver sulfadiazine cream to wound bed, cover with xeroform gauze, wrap with roll gauze and Coban (a compression wrap) using clean technique. Review of the MR revealed the following changes in wound status: Wound # 13 venous stasis ulcer 9/29/21: scant amount of serosanguinous exudate - deteriorated to small amount of purulent drainage on 10/19/21 and measured 6 cm (centimeters) length (L), by 6 cm width (W), by 0.25 cm depth (D). This was the first measurement of Wound # 13 documented. There was no documentation the physician was notified of the change in exudate or the size of the wound. Wound # 18 left foot PU 9/29/21: moderate amount of purulent exudate with moderate odor measured 2 cm by 8.5 cm by 0.3 cm. continued to have purulent exudate on 10/6/21, 10/8/21, and 10/15/21. There was no documentation the physician was notified of the purulent exudate. Wound # 19 left heel PU 9/29/21: small amount of serosanguinous exudate with moderate odor, measured 5 cm by 5 cm by 0.2 cm - deteriorated to purulent exudate, small amount on 10/19/21. There was no documentation the physician was notified of the purulent exudate. An interview conducted 10/20/21 at 4:20 PM with Employee Identifier (EI) # 1, Executive Director, confirmed there was no documentation the physician was notified of the changes in wound status.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of the Medical Records (MR) and agency policy and procedure the agency staff failed to ensure care was coordinated with the physician regarding patient's blood sugar monitoring and swallowing difficulty. This deficient practice affected 3 of 17 MR's reviewed, including MR # 2, MR # 4, MR # 8 and has the potential to affect all the patient's served by the agency. Findings include: Agency Policy: Coordination of Care, from Admit Through Discharge Policy Number: 2.1.017 Revised Date: 8/1/19 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Procedure: ...4. Coordination of care with physician: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's Physician..." 3. MR # 8 was admitted to the agency on 8/28/21 with diagnosis including Aftercare Following Surgery For Neoplasm and Malignant Neoplasm of Overlapping Sites of Right Female Breast. Review of the HHC and POC dated 8/28/21 to 10/26/21 revealed orders for PT (Physical Therapy) effective 8/29/21 1WK1 (once per week times one week). PT to evaluate/assess and develop PT plan of care that will be approved by the physician prior to implementation. Review of the PT VNR dated 8/31/21 revealed evaluation for PT completed and care coordinated with physician with plans for PT visits 1W4 focusing on endurance training, BLE (Bilateral Lower Extremity) strengthening, fall prevention, gait training and HEP (Home Exercise Program) Training. Further review of the medical record revealed no PT physician orders were written for 1W4, no plan of care written and no visits were completed after the initial PT evaluation. An interview conducted on 10/20/21 at 3:45 PM with EI # 5, Clinical Manager confirmed the PT did not complete the plan of care and orders for PT as discussed with the physician on 8/31/21 and MR # 8 did not receive PT as planned. 1. MR # 2 was admitted to the agency on 9/3/21 with a diagnosis of Type 2 Diabetes Mellitus Without Complications. Review of the Home Health Certification (HHC) and Plan of Care (POC) revealed a physician order for "skilled nurse (SN) to instruct on Diabetes to include...management..." with a once a week SN frequency. Review of the SN admission note dated 9/3/21 revealed documentation of "...is not currently ordered to check (his/her) blood sugar and just has A1C's (lab test) checked at (Physician identified) twice yearly..." There was no documentation the SN coordinated with the physician about the patient not monitoring Diabetic Blood Sugars in the home and determine if the physician wanted to order blood sugar monitoring. Review of 7 of 7 SN visit note reports (VNR) between the next SN visit date of 9/7/21 through 10/19/21 revealed no documentation the SN coordinated with the physician about the patient not monitoring Diabetic Blood Sugars in the home and determine if the physician wanted to order blood sugar monitoring. An interview was conducted on 10/21/21 at 10:57 AM with Employee Identifier (EI) # 1, Registered Nurse Executive Director, who confirmed there was no documentation the agency staff coordinated with the physician about the patient not monitoring Diabetic Blood Sugars in the home and determine if the physician wanted to order blood sugar monitoring. 2. MR # 4 was admitted to the agency on 5/22/21 with diagnoses including, Unspecified Asthma, Uncomplicated and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the SN VNR dated 6/9/21 revealed documentation of "patient not swallowing well. Has to do a barium swallow study on Friday" with a weight documented as 248 lbs (pounds). Review of the MR from 6/9/21 through 7/20/21 revealed no documentation of a follow up with the physician on the results of the barium swallow study nor coordination of care about the patient not swallowing well and need for Speech Therapy (ST). Review of the SN VNR dated 7/14/21 revealed documentation of "Patient reports low appetite and weight loss noted. Patient also reports that (her/his) CBG (Blood Sugar) monitor reads HI (High) instead of giving a number....MD (Medical Doctor) notified of...weight loss, CBGs..." There was no documentation of a physician return call to the SN and no documentation the SN attempted to follow up with the physician after not receiving a return call. An interview was conducted on 10/21/21 at 10:49 AM with EI # 1 who confirmed there was no documentation of the above coordination of care with the physician.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of personnel files, agency policy and interview with staff it was determined the agency failed to provide Hepatitis B vaccine when requested. This affected 1 of 3 personnel files reviewed including Employee Identifier (EI) # 7, Licensed Practical Nurse (LPN) and had the potential to affect all staff at risk for exposure to blood- borne pathogens. Findings include: Agency Policy: Staff Screening, New Hire and Annual Policy Number: 6.002 Revised Date: 09/01/21 Purpose: To establish a process to ensure appropriate staff screening prior to hire and annually thereafter. Procedure: H. Staff at Risk for Exposure to Blood-Borne Pathogens...are offered the series of Hepatitis B Vaccines, which is documented on the Hepatitis B Vaccine Consent Form... EI # 7, LPN, was hired 3/2/21. Review of the personnel file revealed EI # 7 signed the Hepatitis B Vaccination Consent form on 9/20/21. There was no documentation the Hepatitis B Vaccine series had been provided An interview conducted 10/20/21 at 4:00 PM with EI # 1, Executive Director, confirmed the Hepatitis B Vaccine had not been started for EI # 7.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on agency policy and procedure, medical record (MR) review and interviews it was determined the agency failed to ensure patients / caregivers were provided education and/or a return demonstration was obtained to ensure competency of: 1. Wound care. 2. New Medication. 3. Nebulizer use. 4. Oxygen Safety 5. Pressure Ulcer Prevention This affected 5 of 17 records including Home Visit (HV) # 6, MR # 7, MR # 4, MR # 6, HV # 5, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Patient Education Policy Number: 3.001 Revised Date: 11/01/17 Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety. Policy: The agency plans, supports, and coordinates patient and caregiver education designed to promote optimal patient health and safety... Procedure: ...3. The patient and caregiver receive ongoing information specific to the identified needs... ...b. Patient/caregiver plan of care responsibilities ...4. The patient and caregiver receive ongoing safety information specific to the identified needs... a. Basic home safety within the patient information admit packet, including: v. Home Oxygen Safety... 5. Patients and caregivers receive...information on equipment safety specific to the identified needs...Including: a. medical gases: i. Storage of medical gases in a stable, protected area ii. Protection from heat extremes iii. Response to accidents and emergencies. b. Medical equipment: i. Purpose, operating instructions, troubleshooting, and correct use of supplies/accessories... 6. ...On medication education to include: a. Dosage, route, duration. b. Description, purpose, expected actions. c. Potential side effects, contraindications, avoidance of interactions, reactions to report. ...e. Appropriate mixing...storage, safeguards against contamination. f. Self-administration and monitoring techniques ...k. High alert medications... 7. Using the progress/visit note, the clinician documents the level of patient/caregiver comprehension, patient/caregiver return demonstration of skill(s) taught, compliance and any follow-up with team members... 5. HV # 5 was admitted to the agency on 1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified ad Encounter for Attention to Cystostomy. Review of the Physician Order dated 8/22/21 revealed wound care to wound # 4 right buttocks and wound # 5 left buttocks as follows: Cleanse with saline and gauze, pat dry with gauze, apply hydrocolloid dressing using clean technique. Change weekly and PRN (as needed) soiling or dislodgement. Review of all VNRs by the nurse dated 8/22/21, 8/26/21 and 9/2/21 revealed no documentation of teaching wound care with a return demonstration by the caregiver. Further review of the VNR by the nurse dated 9/2/21 revealed, "wound care not provided:" (for wound # 4 and wound # 5) "Caregiver completed care." An interview conducted on 10/20/21 at 3:45 PM with EI # 5 confirmed there was no documentation of teaching wound care with a return demonstration by the caregiver prior to the caregiver providing the wound care. 4. MR # 6 was admitted on 5/27/21 and recertified from 7/26/21 to 9/23/21 with diagnoses including Pressure Ulcer of Other site, Stage 1, Diffuse Large B-Cell Lymphoma, and Neoplasm Related Pain. Review of the HHC and POC dated 5/27/21 revealed orders for the “Skilled Nurse to provide skilled teaching to prevent pressure ulcers, instruct on factors that contribute to skin breakdown, areas prone to breakdown and principles of skin care.” Review of the VNR, Braden Risk Assessment, dated 5/27/21 revealed the Braden Score was 15 indicating the patient was at risk for developing pressure ulcers. Further review of the POC dated 5/27/21 revealed orders for SN frequency of 1 wk 9 (1 x week x 9 weeks). Review of the SN VNR from week 1 through week 9 revealed no documentation of patient or caregiver teaching to prevent pressure ulcers. Review of the SN VNR dated 6/3/21 revealed the nurse documented MR # 6 had only one wound which was a Stage 1 Pressure Ulcer (PU) to the Mid-Perineum measuring 1 cm (centimeter) in length (L) x 1 cm width (W), and 1 cm depth (D). Review of the SN VNR dated 7/24/21 revealed the nurse documented the patient had wound # 1 Mid-Perineum PU Stage 1 measuring 4.2 L x 2.5 W x 0.2 D, wound # 2 Right lower buttock, unstageable PU measuring 0.9 L x 0.8 W x 0.1 D, and wound # 3 Left lower buttock, unstageable PU, measuring 3.0 L x 1 W x 0.2 D. In an interview conducted on 10/21/21 at 11:25 AM EI # 1, Executive Director, confirmed there was no documentation of patient or caregiver teaching of measures to prevent pressure injuries. 3. MR # 4 was admitted to the agency on 5/22/21 with diagnoses including, Unspecified Asthma, Uncomplicated and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/22/21 to 7/20/21 revealed physician orders for "SN for instruction of administration of inhalation therapy and care for equipment...SN to instruct on new...medications...high risk medications...SN to instruct patient/caregiver on administration of insulin including proper storage, preparation of medication, rotation of injection sites, and sharps disposal." The ordered SN frequency was once a week for 1 week, twice a week for 1 week, then once a week for 8 weeks. Review of the Client Medication Report (CMR) revealed documentation of Humalog Insulin 15 Units three times a day subcutaneous and Tresiba Flex touch 40 Units daily subcutaneous. Review of the 12 SN Visit Note Report (VNR) reports dated from 5/22/21 to 7/27/21 revealed documentation the patient was prescribed insulin. There was no documentation the patient or caregiver provided a return demonstration of the subcutaneous administration of the Humalog Insulin and the Tresiba Flex touch. Review of the Physician Order dated 5/27/21 revealed documentation of "new med (medication) found in home" and Ipratropium 0.5 mg (milligram) - Albuterol 3 mg/3 ml (milliters) nebulization solution 3 ml dose 4 times daily as needed. Review of the SN VNR dated 5/27/21 revealed documentation of the Ipratropium 0.5 mg - Albuterol 3 mg/3 ml nebulization solution being added to the patient CMR. There was no documentation the SN educated the patient and/or caregiver on the Ipratropium - Albuterol medication or how to administer the medication via nebulizer. Review of the 9 SN VNR from 6/2/21 to 7/27/21 revealed documentation the patient was on Oxygen 2 Liters/minute, which was documented as both continuously and intermittently. There was no documentation the patient and/or caregiver was provided education on Oxygen Storage, protection from heat, and response to accidents and emergencies. An interview was conducted on 10/21/21 at 10:49 AM with EI # 1 who confirmed there was no documentation of the patient and/or caregiver education received education on Ipratropium - Albuterol medication or how to administer the medication via nebulizer, Oxygen Storage, protection from heat, and response to accidents and emergencies or provided a return demonstration of the subcutaneous administration of the Humalog Insulin and the Tresiba Flex touch. 1. HV # 6 was admitted to the agency 9/21/21 with diagnoses including Paraplegia and Essential Hypertension. Review of the physician's order dated 9/27/21 revealed the skilled nurse (SN) was to visit 1 time per week to perform wound care and instruct the wound care procedure to the patient / caregiver. Wound care to the left lateral foot was ordered as follows: clean with normal saline, pat dry, apply Medihoney, cover with foam dressing using clean technique. The order failed to include how often the dressing was to be changed. A HV observation was conducted 10/19/21 at 12:30 PM to observe Employee Identifier (EI) # 7, Licensed Practical Nurse, perform wound care. During the visit the surveyor asked how often the dressing was changed and the patient and nurse stated every day, performed by the paid caregiver. Review of the MR revealed no documentation the paid caregiver was instructed in the wound care procedure and no documentation the SN observed a return demonstration of wound care to confirm competency in providing the care. An interview conducted 10/20/21 at 4:15 PM with EI # 5, Clinical Manager, confirmed there was no documentation the caregiver was instructed in the wound care procedure and no return demonstration was documented. 2. MR # 7 was admitted to the agency 9/29/21 with diagnoses including Chronic Ulcer Left Foot and Type 2 Diabetes Mellitus. Review of the Home Health Certification and Plan of Care dated 9/29/21 revealed the SN was to visit 1 time the first week then 2 times per week. SN to perform and instruct patient/caregiver in the wound care procedure to wounds # 13 - right pretibial venous stasis ulcer, # 18 - left foot mid-dorsum pressure ulcer (PU) stage 2, # 19 left heel PU stage 2, # 20 - right great toe PU stage 1, and # 21 - right heel PU stage 2. Perform twice weekly: cleanse with Vashe (wound cleanser), pat dry, apply silver sulfadiazine cream to wound bed, cover with xeroform gauze, wrap with roll gauze and Coban (a compression wrap) using clean technique. Review of the SN admission visit note dated 9/29/21 revealed multiple "copious draining wounds" to the lower extremities and the SN provided wound care as ordered. There was no documentation the SN instructed the patient or caregiver in the wound care procedure and no documentation a return demonstration was observed to verify competency in the wound care procedure which was ordered twice weekly. The next SN visit was 7 days later on 10/6/21. An interview conducted 10/20/21 at 4:20 PM with EI # 1, Executive Director, confirmed there was no documentation the patient or caregiver was instructed in the wound care procedure and no return demonstration was documented.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of medical records (MR) and staff interviews, it was determined the agency failed to document correctly in the clinical record. This deficient practice did affect Home Visit (HV) # 5 and had the potential to affect all patients served by the agency. Findings include: 1. HV # 5 was admitted to the agency on1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified and Encounter for Attention to Cystostomy. Review of the Home Health Certification and Plan of Care dated 8/21/21 to 10/19/21 revealed orders for skilled nurse (SN) to insert 20 Fr (French) 10 cc (cubic centimeter) balloon suprapubic catheter using aseptic technique. Change every 4 weeks beginning week of 9/5/21 and PRN (as needed)... Further review of the Home Health Certification and Plan of Care dated 8/21/21 to 10/19/21 revealed orders for SN to administer bladder irrigation/instillation with sterile water, 60 cc every week and PRN using aseptic technique. Review of the Visit Note Report by the SN dated 8/21/21 revealed patient complains of leaking catheter....SN removed old catheter, inserted new 20 Fr Catheter using sterile technique.... There was no documentation of what size balloon was used or how much fluid was used to inflate the balloon and no documentation of urine return. Review of the Visit Note Reports by the SN dated 8/26/21, 9/2/21, 10/4/21, 10/15/21 and 10/18/21 revealed, "Administration of bladder instillation/irrigation", instillation of 50 ml (milliliters) of sterile water...." There was no documentation of why 60 cc of sterile water was not used for irrigation as ordered. Review of the Visit Note Report by the SN dated 9/16/21 revealed a Suprapubic Foley Catheter size 16 Fr was inserted on 8/21/21 and not a 20 Fr Catheter as stated in the 8/21/21 Visit Note Report. Review of the Visit Note Report by the SN dated 9/29/21 revealed a Suprapubic Foley Catheter size 22 was inserted on 9/22/21. Further review of the medical record from 8/21/21 to 10/19/21 revealed no SN visit documented for 9/22/21. An interview conducted on 10/20/21 at 3:45 PM with EI (Employee Identifier) # 5 Clinical Manager confirmed the documentation was inaccurate and unclear.

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 and procedure, observation and staff interviews, it was determined the agency failed to ensure the plan of care developed for the Home Health Aide (HHA) was individualized to meet the needs of the patient. This deficient practice affected 1 of 7 medical records (MR) reviewed receiving Home Health Aides (HHA) services and did affect HV # 5 and had the potential to affect all patients receiving HHA services. Findings include: Agency Policy: Plan of Care (POC) Revised Date: 1/1/21 Purpose: To assure an appropriate POC is developed and revised in a timely manner for each patient. To ensure that physician's orders are followed. Policy: Each patient has an individualized POC developed in consultation with the patient...to address specific services being provided. Procedure: 14. An aide POC will be developed by the Registered Nurse (RN) or other appropriate skilled professional...that is familiar with the patient if aide services have been ordered. 1. HV # 5 was admitted to the agency on 1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified and Encounter for Attention to Cystostomy. Review of the Home Health Certification and Plan of Care dated 8/21/21 to 10/19/21 revealed the patient is "chair bound with weakness, contracture to right hand and foot drop to right foot." Review of the Aide Care Plan Report dated 8/21/21 included an (Activities of Daily Living) assignment of, "Stand-by assistance with ambulation every visit." A HV was conducted on 10/19/21 at 11:10 AM to observe EI (Employee Identifier) # 8 provide care for HV # 5. During the visit, the patient remained in a chair and the aide was observed providing a chair bath for the patient. An interview conducted on 10/20/21 at 3:45 PM with EI # 5, Clinical Director confirmed, the patient is unable to stand and ambulate and the aide POC was not updated to meet the needs of the patient.

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 medical records (MR), observation and staff interviews, it was determined the agency failed to ensure the Home Health Aide (HHA) notified the nurse when he/she was not able to follow the Plan of Care (POC). This deficient practice affected 1 of 7 MRs reviewed receiving HHA services and did affect HV # 5 and had the potential to affect all patients receiving HHA services. Findings include: 1. HV # 5 was admitted to the agency on 1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified and Encounter for Attention to Cystostomy. Review of the Aide Care Plan Report dated 8/21/21 included the following Activities of Daily Living (ADL) assignments: Stand-by assistance with ambulation: every visit Bathing (Chair): every visit Review of 17 Visit Note Reports by the Aide dated from 8/24/21 to 10/18/21 revealed documentation by the Aide, "Stand-by assistance with ambulation completed." A HV was conducted on 10/19/21 at 11:10 AM to observe Employee Identifier (EI) # 8, HHA perform care. During the visit the patient remained in his/her chair and the aide was observed providing a chair bath, but did not provide stand-by assistance with ambulation. Review of the Visit Note Report completed by EI # 8, HHA included the following documentation: Service: "Stand-by assistance with ambulation completed." An interview conducted on 10/20/21 at 3:45 PM with EI # 5 Clinical Manager confirmed, the patient is unable to stand and ambulate and the aide documented incorrectly on the Visit Note Reports.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on agency policy, review of on-call message documentation, medical records (MR) and interviews it was determined the agency failed to ensure staff assessed the after hours needs of the patient and responded within 30 minutes of the call as directed in agency policy. This affected 3 un-sampled patients including Un-sampled Patient (UP) # 1, UP # 2 and UP # 3 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: On-Call Process (To Include During and After Hours Care) Policy Number: 5.008 Revised Date: 03/01/19 Purpose: To establish guidelines to promote continuity of care. Procedure: 4. The respective answering service will contact the on-call clinician immediately after the patient related call is received. The total response time from patient/caregiver call to patient/caregiver contact by clinician will be no longer than 30 minutes... 5. Clinicians will document responses and outcomes of appropriate call on the On-Call Event Coordination note. 6. Clinicians will submit the On-Call Event Coordination Note and any supporting patient documentation by the next business day... Review of a random sampling of 5 on-call events revealed the following: 1. UP # 1 caregiver called the answering service on 9/25/21 at 10:28 AM with message "retaining water/extreme tightness both legs." UP # 1 called the answering service three more times, 10:57 AM, 11:21 AM and 11:58 AM. There was no documentation the on-call nurse contacted the patient / caregiver. A visit was conducted by the Licensed Practical Nurse (LPN) on 9/25/21 at 1:31 PM, 3 hours and 3 minutes later, which revealed Blood Pressure (BP) 94/78, Pulse 133 and weight 229.2 pounds. UP # 1 was transported the the Emergency Room (ER) via ambulance. UP # 1 caregiver called the answering service on 10/3/21 at 6:06 PM with message "wound vac (Vacuum Assisted Closure) message/blockage." There was no documentation the on-call nurse contacted the patient / caregiver. A visit was conducted the following day (10/4/21) at 9:46 AM, 15 hours and 40 minutes later. An interview conducted 10/20/21 at 12:18 PM with Employee Identifier (EI) # 5, Clinical Manager, confirmed there was no documentation the on-call nurse contacted the patient / caregiver as directed in agency policy. 2. UP # 2 contacted the answering service 9/19/21 at 12:03 AM with message "tightness/numbness/pressure in legs/ requested nurse assistance." There was no documentation the on-call nurse contacted UP # 2. A visit was conducted 9/19/21 at 12:23 PM, 12 hours and 20 minutes later, by the LPN which revealed a 17 pound weight gain. The physician was contacted and recommended the patient go to the ER. An interview conducted 10/20/21 at 3:55 PM with EI # 1, Executive Director, confirmed there was no documentation the on-call nurse contacted the patient as directed in agency policy. 3. UP # 3 contacted the answering service 9/24/21 at 6:11 PM with message "wound vac will not stay on/tape tore patient skin/needs to be covered/needs supplies for wound vac/urgent request for nurse visit 9/24/21." There was no documentation the on-call nurse contacted UP # 3. A visit was conducted at 9:35 PM, 3 hours and 24 minutes later. An interview conducted 10/20/21 at 3:55 PM with EI # 1, Executive Director, confirmed there was no documentation the on-call nurse contacted the patient as directed in agency policy.