Every finding on record at Ste Genevieve County Memorial Hospital Home Health Agency

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 03/06/2025. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 03/06/2025. The provider had 37 current patients.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to maintain an accurate/updated medication profile in one of three home visit observations conducted (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider's policy titled, "Medication, Regimen Review Comprehensive," reviewed 09/2024, showed in part: -At the time of admission an accurate, current and complete list of all prescription and over-the counter medications, as well as herbal medications, taken by the patient will be maintained on the medication profile; -The clinician will compare the medication list to those on the referral and any discrepancies will be reconciled with the physician and documented in the clinical record; and -Review/Update of medications will be done at each visit. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health on 02/12/2025 with a diagnosis of atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), and had additional diagnoses of hypertensive heart disease without heart failure (changes in the heart related to chronic elevation in blood pressure), contusion of left front wall of thorax (bruise to the rib) related to a recent fall, and type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). He/she lived alone in an apartment. Review of the clinical record showed: -Review of the "Home Health (HH) Nursing Registered Nurse (RN) Admission Visit" note, dated 02/12/2025 (date of admission) showed in part, "(patient) does report he/she does have constipation issues that he/she takes a stool softener every other day and is effective." This medication was not listed on the hospital discharge list or the provider's medication list; -Review of the "HH Nursing RN Visit note, dated 02/20/2025, showed the patient had been prescribed a "z-pack" (antibiotic). The medication list dated 03/04/2025 at 8:57 AM failed to include this medication as a current or discontinued medication; and -The clinical record failed to contain documentation related to reporting/clarifying the medication discrepancies. Observation and interview on 03/04/2025 at 1:25 PM, during the patient's home visit, showed the medications in the patient's home did not match the provider's medication list dated 03/04/2025 at 8:57 AM, or the hospital discharge medication list dated 02/11/2025. The patient stated the medications he/she used were on the kitchen table and some were in the bedroom in the bedside table. During the medication review, with the physical therapist (PT) present, the state agent (SA) noted several of the medications the patient was currently taking had the lid removed from the bottle. The following medication discrepancies were identified: -The hospital discharge medication list showed the patient was taking Melatonin (hormone used for a sleep aid) 3 milligrams (mg) daily at bedtime as needed for insomnia (inability to sleep). The provider's medication list showed the patient was taking Melatonin 3 mg daily at bedtime as needed for insomnia. The patient had a bottle of Melatonin 5 mg that he/she stated they were taking daily as needed at bedtime; -The hospital discharge medication list showed the patient was taking acetaminophen (analgesic for pain or fever) 325 mg, take two tablets every six hours as needed for pain. The provider's medication list showed the patient was taking acetaminophen 325 mg, take two tablets every six hours as needed for pain. The patient had a bottle of acetaminophen 500 mg tablets in the home that he/she was taking as needed; -The patient had a bottle of over-the-counter aspirin (treat mild to moderate pain) 81 mg that was with the group of medications he/she was using, and the lid was removed. The medication was not on the hospital discharge list or the provider's medication list; and -The patient had a bottle of over-the-counter Nexium (decreases stomach acid) 20 mg beside his/her chair. When asked if that was being used, he/she stated "yes," it is used for his/her "stomach when needed." The medication was not on the hospital discharge list or the provider's medication list. During an interview, 03/06/2025 at 1:15 PM, the administrator stated that the medications in the home should match the provider's medication list. Discrepancies from the hospital discharge should be documented in the record, and medications would show up as discontinued on the medication list if they were added to the med list and an end date was entered.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the provider failed to ensure the plan of care (POC) included all required treatments, in one of six records reviewed (Record/Patient #3). This deficient practice has the potential to affect the provision of care for all the patients served by the provider. Findings included: Review of the provider's policy titled, "Plan of Care," revised 12/30/2024, showed in part, the initial plan of care must include all treatments. RECORD/PATIENT # 3: Review of the clinical record showed the patient was admitted to home health on 02/14/2025 with a diagnosis of moderate protein-calorie malnutrition (nutritional disorder) and had additional diagnoses including influenza , unspecified bacterial pneumonia (lung infection), metabolic encephalopathy (a problem in the brain), and type 2 (two) diabetes mellitus (DM; a group of diseases that results in too much sugar in the blood). He/she lived at home with a spouse. Review of the "Home Health (HH) Nursing Registered Nurse (RN) Admission Visit", dated 02/14/2025 (date of admission), included a "Prepare Patient Care: (Visit) Note" that showed: -A wound to the patient's inner left buttock area that had a cream in place for treatment; and -The patient's son managed the patient's insulin (routine (set amount) and sliding scale (varies according to blood sugar readings)). Review of the POC dated 02/14/2025 to 04/14/2025, showed the POC failed to include: -Wound Care Orders-for the type of wound, location (left inner buttock area), cleaning instructions, or who was responsible for the treatment (the "cream" was listed on the medication list to "apply to affected area daily for wound treatment"; and -Orders related to who was responsible for managing the patient's insulin/DM. During an interview on 03/06/2025 at 1:15 PM, the administrator stated orders should be listed on the plan of care.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the provider failed to ensure staff provided physician/allowed practitioner services as ordered on the plan of care (POC) in, two of six records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to impact the care provided to all the patients served by the provider. Findings included: Review of the provider's policy titled, "Plan of Care," revised 12/30/2024, showed in part, the plan of care will serve as physician's orders for patient care, and all staff providing services will be in compliance with the orders. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health on 02/12/2025 with a diagnosis of atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), and had additional diagnoses of hypertensive heart disease without heart failure (changes in the heart related to chronic elevation in blood pressure), contusion of left front wall of thorax (bruise to rib area) related to a recent fall, and type 2 (two) diabetes mellitus (DM; a group of diseases that results in too much sugar in the blood) without complications. He/she lived alone in an apartment. Review of the POC, with certification dates 02/12/2025 to 04/12/2025, showed in part, the following: -Health Management Order(s): *"Physician notification Physician Notify" - * Blood Glucose > (greater than) 300 or in accordance with specific parameters that has been determined by the physician; and *"Physician Notification Physician notification" - *Weight gain: > 5 (five) lbs (pounds) in 1 week or 3 (three) pounds or more in 1 day; *Resting Heart Rate: >110 or (greater than) 300 or in accordance to specific parameters that has been determined by the physician; -"Physician Notification Physician notification" - *Weight gain: >5lbs in 1 week or 3lbs or more in 1 day; and -Failed to indicate who was responsible for diabetic management (patient is insulin dependent). Review of the clinical record showed: -"HH Nursing RN Admission Visit" dated 02/14/2025 that showed: *The RN documented in the "Prepare Patient Care: (Visit) Note" section; the patient's son managed the insulin injections; *The note failed to include a blood sugar assessment (POC included order to notify physician of blood glucose over 300); and *The RN documented in the "Assess Weight and Measurements" section; an undated weight of 145 pounds (most recent measure in last 30 days). No new weight was documented for the date of admission to monitor the patient for weight gain per POC orders. -"HH Nursing RN Visit" dated 02/17/2025, failed to include an assessment/documentation of the patient's weight; and -"HH Nursing RN Visit" 02/21/2025 failed to include an assessment/documentation of the patient's weight or blood sugar. During an interview on 03/06/2025 at 1:15 PM, the administrator stated that staff should change the parameter orders to meet the needs of the patient and should remove any parameters that do not apply to the patient.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the provider failed to ensure the staff developed or sent a discharge summary in one of two discharge records reviewed (Record/Patient #6). This deficient practice has the potential to affect the ongoing provision of care for all the discharged patients. Findings included: Review of the provider's policy titled, "Discharge / Transfer, Patient," reviewed 09/2024, showed in part, the Discharge/Transfer Summary will be completed by the discharging discipline. The discharge summary will be sent within five business days of the patient's discharge. RECORD/PATIENT #6: Review of the clinical record showed an order, written 11/26/2024, to discharge the patient from the provider's services effective 10/24/2024. The clinical record failed to include a discharge summary. During an interview on 03/06/2025 at 1:15 PM, the home health administrator stated that there was no nursing discharge summary in the medical record.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 04/06/2022. During the survey it was determined Sainte Genevieve County Memorial Hospital Home Health Agency is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

An extended survey for Medicare certification for Sainte Genevieve County Memorial Hospital Home Health Agency was completed on 04/06/2022. The agency had 33 current patients. One condition-level deficiency was identified during this survey. A condition-level deficiency is identified at §484.60 Condition of Participation: Care Planning, coordination of services, and quality of care. A home health agency that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f)(3) - see Tag G788.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on review of the agency’s admission folder, home visit observation, and interview, the agency failed to provide patients with the correct hours of operation for the state toll free home health hotline telephone number. This deficient practice has the potential to affect the exercise of patient rights for all agency patients. Findings included: Review of the admission folder, provided by the agency on 04/04/2022, included a booklet that contained the state home health hotline number on pages twenty-five and thirty-four that showed the hours of operation as 7:00 AM to Midnight, 7 days a week. (The correct hours of operation are 7:00 AM to 8:00 PM, 7 days a week.) RECORD/PATIENT #1: During a home visit on 04/05/2022 at 11:00 AM, review of the agency provided home health handbook showed the state home health hotline hours as 7:00 AM to Midnight. RECORD/PATIENT #2: During a home visit on 04/04/2022 at 2:00 PM, review of the agency provided home health handbook showed the state home health hotline hours as 7:00 AM to Midnight. During an interview on 04/04/2022 at 1:30 PM, the administrator stated that he/she was not aware that the state home health hotline hours had changed.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the registered nurse performed an accurate review/update of all medications the patient was currently using in, but not limited to, two (Records/Patients #1 and #2) of five full records reviewed. This deficient practice has the potential to affect the agency’s ability to ensure safe and effective use of medications for all patients served by the agency. Findings included: Review of the agency’s undated policy titled, “Medication, Regimen Review Comprehensive,” showed the following: - The registered nurse (RN) will be responsible for monitoring the patient’s medication regimen through a collaborative effort with the multi-disciplinary team and physician involved in the patient’s care; - All required comprehensive assessments will include 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; - At the time of admission an accurate, current and complete list of all prescription and over-the-counter (OTC) medications, as well as herbal medications, taken by the patient will be maintained on the medication profile; - The clinician will compare the medication list to those on the referral or other documents provided to the agency; - Any discrepancies will be reconciled with the physician and documented in the clinical record; - Every effort will be made to reconcile any discrepancies with the physician or designee the next calendar day of the assessment; - The clinician will document this contact and any difficulties experienced in obtaining physician response; - The clinician will notify the director of patient services / clinical manager if there is no response from the physician on medication reconciliation; and - Review of the medications will be ongoing. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services with a primary diagnosis of congestive heart failure (a condition in which the heart is unable to pump enough blood to meet the body’s metabolic needs). The patient resided in his/her own home with 24-hour supervision provided by his/her children who live close to the patient. The plan of care (POC) contained orders for nursing (SN), physical therapy (PT), and occupational therapy (OT). Review of the medication list provided at intake from the hospital on 03/22/2022 showed that the patient was to take: - Allopurinol 300 milligrams (mg) daily (to treat a build-up of uric acid in the body, gout); and - Hydralazine 25 mg as needed for hypertension (high blood pressure). Review of patient’s documents from the physician’s appointment on 03/30/2022 showed the patient was to take hydralazine 25 mg two times per day as needed for high blood pressure. Review of the plan of care, dated 03/24/2022, showed: - Orders for Allopurinol 300 mg daily on Monday, Wednesday, Friday, and Saturday; and - The plan of care did not show orders for hydralazine. Review of the agency’s medication profile showed hydralazine was not included on the medication list. During an interview on 04/06/2022 at 9:50 AM, the administrator stated that there was not documentation explaining the discrepancy in the Allopurinol frequency or to show why the POC did not contain orders for hydralazine. RECORD/PATIENT #2: Review of clinical record showed the patient was admitted to home health services on 03/18/2022 with a primary diagnosis of congestive heart failure (a condition in which the heart fails to pump enough blood to meet the body’s metabolic needs), and secondary diagnoses of dementia, diabetes (a disease in which the body fails to process blood sugar to meet metabolic needs) with diabetic chronic kidney disease, pressure ulcer of the sacral region, personal history of pneumonia. He/she resided in his/her own home with his/her spouse. The plan of care contained orders for physical therapy, occupational therapy, speech therapy, and nursing services. Review of the agency medication list showed the patient was taking Colace (a stool softener). Review of the patient’s medication planner during a home visit on 04/04/2022 at 2:00 PM, showed the medication planner had pills through Thursday and did not contain Colace. Per an interview conducted during a home visit at 2:25 PM on 04/04/2022, the patient’s spouse stated that the paid caregiver had removed the Colace from the patient’s medication planner because he/she was having diarrhea. During an interview at 2:35 PM, the patient stated that he/she did not know anything about the names of the pills, but was having a lot of loose stools. During an interview on 04/06/2022 at 9:50 AM, the administrator stated that the agency’s clinicians needed to check with the person filling the medication planner for the patient, and the person filling the medication planner had an obligation to report medication changes to the agency.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to provide care and services that met the requirements for the Condition of Participation: Care Planning, Coordination of Services and Quality of Care. The agency failed to: - Include all the elements of an individualized plan of care (G574); - Ensure drugs, services, and treatments are administered only as ordered by a physician (G580); and - Promptly alert the physician to any changes in the patient’s conditions or needs that suggest outcomes are not being achieved, and/or that the plan of care should be altered (G590). The cumulative effect of these deficient practices has the potential to affect individualized and physician ordered care provided to all the agency’s patients.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to include all the elements of an individualized plan of care in, but not limited to, three (Records/Patients #1, #2, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy titled, “Plan of Care,” showed: - An individualized plan of care is developed utilizing the comprehensive and initial assessment; - The individualized plan of care identifies patient specific measurable outcomes and goals; - The initial plan of care must include, at a minimum, the following patient specific items: * All pertinent diagnoses; * Types of services, supplies, and equipment required; * Functional limitations; * Activities permitted; * Nutritional requirements; * All medications including dose, frequency, and route, including over the counter medications; * All treatments; * Safety measures to protect against injury; * The patient’s mental, psychosocial, and cognitive status; * Problems/needs of the patient’s and caregivers; and * Interventions and education. Review of the agency’s policy titled, “Wound Care Policy and Procedure,” dated/reviewed 5/31/2019, showed: - Each patient admitted for service shall receive a complete wound assessment so that a plan of care can be developed to best meet the needs of the patient; - The frequency of the wound assessment shall be every visit and as needed for changes in condition; - Changes in wound condition will be assessed by a nurse between clinic visits if a significant change in the wound is noted by the patient, family or other caregiver; - Upon completion of the initial admission assessment, an individualized prioritized plan of care will be developed in consultation with the patient/significant other; and - Any change in the patient’s condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services with a primary diagnosis of congestive heart failure (a condition in which the heart is unable to pump enough blood to meet the body’s metabolic needs). The patient resided in his/her own home with 24-hour supervision provided by his/her children who live close to the patient. The plan of care (POC) contained orders for nursing (SN), physical therapy (PT), and occupational therapy (OT). Review of the medication list provided at intake from the hospital on 03/22/2022 showed that the patient was to take hydralazine 25 milligrams (mg) as needed for hypertension (high blood pressure). Review of the plan of care, dated 03/24/2022, showed: - The clinician to report blood glucose (sugar) results greater than 200 milligrams per deciliter (mg/dl) or lower than 50 mg/dl; - The patient did not have a diagnosis of diabetes (a long term condition that affects the way the body processes blood sugar) or an order for blood glucose testing; and - The plan of care did not contain an order for hydralazine 25 mg as needed for hypertension. During an interview on 04/06/2022 at 9:50 AM, the administrator stated that there was not documentation to explain why the plan of care did not contain orders for hydralazine or why the plan of care erroneously contained diabetes parameters. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/18/2022 with a primary diagnosis of congestive heart failure (a condition in which the heart fails to pump enough blood to meet the body’s metabolic needs), and secondary diagnoses of dementia, diabetes (a disease in which the body fails to process blood sugar to meet metabolic needs) with diabetic chronic kidney disease, pressure ulcer of the sacral region, personal history of pneumonia. He/she resided in his/her own home with his/her spouse. The POC contained orders for PT, OT, speech therapy (ST), and SN services. Review of the hospital discharge summary, dated 03/17/2022, showed: - The patient had aspiration pneumonia (the inhaling of food or fluids into the lungs causing an infection), heart failure, dementia, and diabetes; and - The patient was to have a 4 gram sodium (salt) diet with a 2000 milliliter fluid restriction per day, with nectar thickened liquids, and was not to use a straw. Review of the comprehensive nursing assessment, dated 03/18/2022, showed: - The patient was to receive a cardiac diet with nectar thickened liquids; - The patient and his/her spouse both have dementia; - A diabetic assessment note stating, “Treatment does not include glucose monitoring;” - The patient had a pressure ulcer (a wound caused by pressure against a boney prominence on the body) on his/her sacrum (the tailbone area); - The nurse would educate on home medications and home safety; - A private pay caregiver sets up the patient’s medications; and - The patient weighs every day. Review of the PT evaluation visit, dated 03/18/2022, showed: - The patient utilized the following durable medical equipment (DME) to assist with mobility in the home, a wheeled walker, straight cane, and a chair lift; and - The patient had diagnoses of, but not limited to, aspiration pneumonia, hypokalemia, and congestive heart failure. Review of the OT evaluation visit, dated 03/18/2022, showed that the patient was required to have 24-hour care (not including the spouse). Review of the POC, dated 03/18/2022, showed the document: - Failed to: * List a wheeled walker or chair lift as DME for the patient; * Include orders for the management of diabetes, including but not limited to, checking of the blood sugar level using a glucometer (a device for measuring the concentration of glucose in the bloodstream); * Include orders for the treatment of the pressure ulcer to the sacrum; * Include orders for the fluid restriction, sodium restriction, and nectar thickened liquids; and * Include safety measures that identified the need for 24-hour supervision that did not include the spouse; - Contained orders for: * Notification of the physician of blood sugars greater than 200 mg/dl or less than 50 mg/dl and a weight gain of greater than five pounds in one week; * The skilled nurse to assess and teach the patient’s medication; and * Education/instruction on a low salt, heart healthy diet. Review of the skilled nursing visit, dated 03/25/2022, showed the nurse reviewed the importance of applying calmoseptine (an over-the-counter medicated barrier cream used to prevent skin irritation) to buttocks as instructed to help heal and protect skin. During an interview on 04/06/2022 at 9:50 AM, the administrator stated that: - The DME for the patient was in the visit notes but did not flow to the POC, and they should have been on the POC; - The POC should address diabetes, even if the agency will not be doing anything to manage the disease process; - The POC did not contain orders for the treatment of the pressure ulcer or use of Calmoseptine and the orders should have been on the POC; - The diet orders on the POC did not contain orders for nectar thick liquids, fluid or sodium restriction and the orders should have been included on the POC; and - The POC should have contained information about the paid caregiver filling the medication planner and directions on coordination of medication management. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 12/17/2021 with a primary diagnosis of post-surgical complications after a coronary artery bypass graft (a surgical procedure to restore normal blood flow to an obstructed coronary artery). The patient was re-hospitalized on 12/20/2022 and re-admitted to the agency on 01/11/2022. The patient resides in his/her own home with his/her spouse. The plan of care contained orders for PT, OT, and SN services. Review of the agency’s medication profile, dated 01/27/2022, showed the patient took the following medications: - Lorazepam (a medication used for anxiety) 0.5 mg one tablet three times daily; - Pantoprazole (a medication used for acid reflux) 40 mg one capsule daily; and - Warfarin (a blood thinner listed on the agency’s high risk medication roster that requires lab testing to ensure proper dosing) 2 mg daily. Review of the comprehensive assessment, dated 12/17/2022, showed the patient had the following surgical incisions: - Midline (center) chest, 5.6 centimeters (cm) long by 0.2 cm wide that is pink with well approximated (fit neatly together) edges; - Upper middle abdomen, 1.7 cm long by 1 cm wide that is pink with open edges; - Upper right abdomen, 1.7 cm long by 0.9 cm wide that is pink with open edges; and - Upper left abdomen, 1.1 cm long by 0.9 cm wide that is pink with open edges and a small amount of serosanguineous (discharge that contains both blood and a clear yellow liquid known as blood serum) drainage. Review of the hospital discharge summary, dated 01/07/2022 showed that the patient’s primary physician was to manage the warfarin dosing. Review of the skilled nursing visit, dated 01/13/2022, showed the nurse documented “The wound to the left abdomen is white, moist. Husband has already done the dressing change today.” Review of the plan of care, dated 12/17/2021 through 02/14/2022, showed the agency failed to include: - Orders for lorazepam 0.5 mg one tablet three times daily; - Orders for pantoprazole 40 mg one capsule daily; - Instructions/information on who would manage warfarin dosing; - Instructions/education on bleeding precautions; - Orders for assessment of surgical wounds to midline chest or abdomen; - Documentation of any changes in the left abdominal wound on the left abdomen, (wound became white and moist); and - Orders for a dressing/treatment to the left abdominal wound. During an interview on 04/06/2022 at 9:35 AM, the administrator stated that the omission of the medications from the plan of care/physician orders were due to operator error. The registered nurse who entered the orders into the computer system, clicked the wrong button and the medications did not pull over to the orders. The instructions on who would manage warfarin dosing, the bleeding precautions, the incisions/abdominal wound and any dressing/treatment orders just got missed and were not put on the plan of care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure drugs, services, and treatments are administered only as ordered by a physician in one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy titled, “Plan of Care,” showed: - Physician orders are to be obtained prior to the initiation of any care, including all support services related to patient care, and any services requiring the administration of medication and prescribed treatment(s); - The plan of care will serve as physician’s orders for patient care and all staff providing services will be in compliance with the orders; and - Authorized staff may only administer medications or treatments as ordered by the physician. RECORD/PATIENT #5: Review of the hospital discharge instructions, dated 12/16/2022, showed there were no orders to flush peripherally inserted central venous catheter (a long catheter inserted through a peripheral vein into a larger vein above the heart used when intravenous treatment is required over a long period, PICC line). Review of the plan of care, dated 12/17/2021 through 02/14/2022, showed there were no orders to flush PICC line. Review of the skilled note, dated 1219/2022, showed the registered nurse (RN) flushed the patient’s PICC line without a physician’s order. During an interview on 04/06/2022 at 9:35 AM, the administrator stated the order for PICC line flushes was overlooked by the admitting nurse. He/she agreed that an order should have been obtained prior to performing PICC line flushes.

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 policy review, clinical record review, and interview, the agency failed to promptly alert the physician to any changes in the patient’s conditions or needs that suggest outcomes are not being achieved, and/or that the plan of care should be altered in three (Records/Patients #1, #2, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy titled, “Physician Plan of Care / Physician Orders,” showed: - The relevant physician must be notified of any changes in the patient condition or needs that suggest that outcomes are not being met and/or the plan of care should be revised; and - Any revision to the plan of care, due to a change in patient status, must be communicated to the physician responsible for the plan of care. Review of the agency’s undated policy titled, “Contents of Clinical Records,” showed the patient’s clinical record shall include: - Any change in the patient’s condition; - Any patient/patient’s family instructions given; and - Evidence of coordination of service/care provided by the organization with others who may be providing care. Review of the agency’s policy titled, “Pressure Ulcer Prevention Program,” dated/reviewed 07/07/2017, showed: - Staff will remain alert to potential changes in a patient’s skin condition and will evaluate and document identified changes on a daily basis; and - Changes in the patient’s skin condition will be reported to the attending physician. RECORD/PATIENT #1: Review of the nursing comprehensive assessment, dated 03/24/2022, showed the patient’s blood pressure was 132/48 and the patient had no signs of orthostatic hypotension (symptoms that occur with position changes that may include dizziness). Review of the plan of care, dated 03/24/2022, showed orders for: -The clinician to report to the physician if the vital signs are outside of the following parameters: * Resting systolic blood pressure (the top number of the blood pressure) greater than 170, or less than 80; and * Resting diastolic blood pressure (the bottom number of the blood pressure) greater than 100 or less than 50. Review of the clinical visits showed the patient’s diastolic blood pressure readings were out of the ordered parameters on (but not limited to) the following dates: - 03/24/2022, occupational therapy (OT) visit, the blood pressure was 140/48; - 03/31/2022, skilled nursing (SN) visit, the blood pressure was: * 104/40 left arm, sitting; * 94/38 re-check in left arm, sitting; and * 99/44 right arm, sitting. During an interview on 04/06/2022 at 9:50 AM, the administrator stated that there was not documentation in the clinical record that the nurse had notified the physician of the low blood pressure readings. RECORD/PATIENT #2: Review of the plan of care, dated 03/18/2022, showed SN visits: - One visit a week for one week; - Then two visits a week for two weeks; and - Then one visit a week for six weeks. Review of the clinical record showed a missed visit for the second week of skilled nursing visits during the week of 03/20/2022. During an interview on 04/06/2022 at 9:50 AM, the administrator stated that the visit was missed because of a physician’s appointment but they did not have documentation showing the physician was notified of the missed visit. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 02/28/2022 with a primary diagnosis of a stage 2 pressure ulcer (partial-thickness skin loss/injury resulting from prolonged pressure on the skin) on the left tibial (the inner of two bones of the lower leg) stump following a left below the knee amputation (BKA). The patient wears a left below the knee prosthesis (artificial limb) and has secondary diagnoses of type 2 diabetes mellitus (a chronic disease that affects the way the body processes blood sugar) and coronary artery disease (damage or disease in the heart’s major blood vessels, usually caused by a buildup of plaque). Review of the comprehensive assessment, dated 02/28/2022, showed: - The patient had a non-healing stage 2 pressure ulcer on the left BKA stump; and - The patient’s blood glucose level was 412 milligrams per deciliter (mg/dl). Review of the plan of care, dated 02/28/2022, showed: - Skilled nurse (SN) to notify the physician if blood glucose is less than 50 mg/dl or greater than 200 mg/dl after two consecutive daily readings; - SN to assess wound and skin condition; and - The patient was on an 1800 calorie American Diabetic Association (ADA) diet. Review of the SN note, dated 03/03/2022, showed the patient: - Was non-compliant with leaving the dressing on his/her stump; - Was non-compliant with taking his/her insulin; - Had a blood glucose level of 401 mg/dl; and - The SN failed to notify the physician of the non-compliance or elevated blood glucose. Review of the SN note, dated 03/07/2022, showed: - The patient was wearing his/her old prosthesis; - The patient reported he/she had 5 Mountain Dew sodas the previous day; - The patient was not complying with the ordered diet, does not watch his/her food intake for dietary restrictions, and does not monitor his/her sugars regularly; - The patient experienced phantom pain (pain experienced as pain in the absent/amputated limb); - The patient complained of seeing “lights in my eyes” and dizziness; - The patient’s blood glucose was 458 mg/dl; and - The SN did notify the physician of the complaint of seeing light in his/her eyes and dizziness but failed to notify the physician of the non-compliance or elevated glucose. Review of the SN note, dated 03/10/2022, showed: - The patient had not taken his/her insulin or checked his/her blood glucose since the previous SN visit; - The patient’s blood glucose reading during the visit was greater than 600 mg/dl; - The patient is non-compliant with the diabetic diet; - The patient has new red areas to the bony prominences of the left knee from his/her prosthesis; - The stage 2 pressure ulcer identified on admission was now a stage 3 ulcer (full-thickness skin/tissue loss, resulting from prolonged pressure on the skin); - The patient was not wearing his/her stump sock (used by amputees to provide a more comfortable prosthetic fit, reduce friction, absorb perspiration and reduce discomfort); - The SN instructed the patient to use his/her new prosthesis; and - The SN failed to notify the physician of the non-compliance, the new areas of redness on the left stump, the worsened stage of the left stump pressure ulcer or the elevated blood glucose. Review of the SN note, dated 03/14/2022, showed: - The patient missed bedtime medication doses last week on Monday and Wednesday (does not specify which medications were missed); - The patient was drinking a regular root beer soda and had a large container of orange slice candy sitting on his/her table; - The patient was non-compliant with his/her diet and diabetes management after repeated instructions about his/her food and drink choices; - The memory on the glucometer (a device used to measure blood sugar levels) showed the following blood glucose readings over the weekend: * 336 mg/dl and 388 on 03/12/2022; * 458 mg/dl on 03/11/2022; * “HI” on 03/10/2022 (typically occurs when the blood glucose is above the maximum reading for the glucometer, usually 600 mg/dl but some glucometers can go up to 750 mg/dl); - The patient had excessive fluid consumption; - The SN did not enter a blood glucose reading for that days visit; - The patient c/o “hit and miss” pain in his/her left stump from the open areas but it was not severe; - The patient had an open area to the anterior (near the front) left stump that was documented as moist pink tissue, with no drainage or redness; - The patient had an area to the lateral (toward the side) left stump that was documented as open in the center with moist, white tissue, and scant “tannish” drainage; and - The SN failed to notify the physician of the missed medication doses, the patient’s non-compliance, the elevated blood glucose readings, the pain and new open area to the left stump. Review of the SN note, dated 03/17/2022, showed: - The patient had not been checking his/her blood sugars; - He/she was drinking regular root beer soda; - The wounds to the left stump had healed; - The blood glucose reading was 461 mg/dl; and - The SN failed to notify the physician of the patient’s non-compliance or the elevated blood glucose reading. Review of the SN note, dated 03/24/2022, showed the patient: - Admitted to not taking insulin except on days the SN visits; - Continued to drink Mountain Dew and root beer sodas; - Had a blood glucose reading greater than 600 mg/dl; and - The SN failed to notify the physician of the patient’s non-compliance or the elevated blood glucose reading. During an interview on 04/06/2022 at 0935 AM, the administrator stated that he/she was unable to produce any documentation that showed the nurse notified the physician regarding any of the patient’s non-compliance, changes in skin condition, or elevated blood glucose levels. He/she agreed that the physician should have been notified of the changes in the patient’s condition.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on policy review, review of employee records, and interview, the agency failed to develop and implement policies and procedures that include a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Review of the agency’s policy titled, “COVID-19 Vaccination Exemption,” dated/revised 03/21/2022, showed: - Employees are required to establish that they have received a designated COVID-19 vaccine or, alternatively, have obtained an approved exemption as an accommodation; - In the event an employee does meet criteria for exemption, said employees shall be required to wear appropriate personal protective equipment (PPE) at all times (Refer to COVID Tiered Operations Plan); and - When in active COVID tiered operations, agency personnel may take off the mask only during meals and breaks during working hours. Review of employee records showed that some agency staff had been approved for exemption from COVID-19 vaccination. During an interview on 04/04/2022 at 1:30 PM, the administrator and the infection preventionist stated that the agency was no longer operating under their COVID-tiered operations plan because community COVID cases were low. Community COVID cases are monitored every day and, if the community numbers go up, the agency would re-implement the COVID-tiered operations plan. Currently, the agency was following standard transmission based precautions. Clinicians, regardless of vaccination status, were not required to wear a mask unless they are experiencing signs or symptoms of illness. The wearing of masks in the clinical setting was not required but left to each individual clinician’s discretion. All employees are required to self-screen for and report any signs or symptoms of illness. During an interview on 04/06/2022 at 11:30 AM, findings were reviewed with the administrator and, via teleconference, the infection preventionist, the chief operating officer, the director of human resources, and the head of quality assurance/risk management. All confirmed that the agency was no longer operating under the COVID tiered operations plan but had reverted to observation of standard precautions due to no longer being in a COVID outbreak. Since the agency was no longer operating under the COVID tiered operations plan, the COVID-19 vaccination exemption policy no longer contained a process for the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for unvaccinated staff. None of the interviewed agency leadership could provide evidence that any additional precautions were in place.

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 policy review, home visit observation, and interview, the agency failed to ensure skilled professional services were delivered according to the agency’s policies and procedures in one (Record/Patient # 1) of three home visit observations conducted. This deficient practice has the potential to affect all the patients served by the agency. Findings included: Review of the agency’s policy titled, “COVID Standard PPE Guidelines,” dated/reviewed 07/22/2021, showed: - The agency shall follow the Centers for Disease Prevention and Control’s (CDC) recommendations for the utilization of personal protective equipment (PPE); and - When in a clinical, patient-facing setting, standard PPE for routine patient care, regardless of patient presentation, shall include a surgical mask. RECORD/PATIENT #1: During a home visit observation on 04/05/2022 at 11:00 AM, the fully vaccinated registered nurse, failed to wear any type of face mask during the provision of direct patient care. During an interview on 04/04/2022 at 1:30 PM, the administrator and the infection preventionist stated that the agency was no longer operating under their COVID-tiered operations plan because community COVID cases were low. Community COVID cases are monitored every day and, if the community numbers go up, they would re-implement the COVID-tiered operations plan. Currently, the agency was following standard transmission based precautions. Clinicians, regardless of vaccination status, were not required to wear a mask unless they are experiencing signs or symptoms of illness. The wearing of masks in the clinical setting was not required but left to each individual clinician’s discretion. All employees are required to self-screen for and report any signs or symptoms of illness.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure that an ongoing interdisciplinary assessment of the patient was performed in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Pressure Ulcer Prevention Program,” dated/reviewed 07/07/2017, showed: - Staff will remain alert to potential changes in the patient’s skin condition; - Staff will evaluate and document identified changes on a daily basis; - Changes in the patient’s skin condition will be reported to the reported to the physician; and - All bony prominences of at-risk patients will be assessed once a day. RECORD/PATIENT #2: Review of the comprehensive assessment, dated 03/18/2022, showed: - The patient and his/her spouse both have dementia; and - The patient had a pressure ulcer (a wound caused by pressure against a boney prominence on the body) on his/her sacrum (just above the tailbone). Review of the skilled nurse visit, dated 03/28/2022, showed the nurse failed to assess the patient’s skin including the pressure ulcer on the patient’s sacrum. During an interview on 04/06/2022 at 9:50 AM, the administrator agreed with the findings and stated that the visit note failed to contain a skin assessment.

Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure the supervision of skilled professional assistants in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy titled, “Contents of Clinical Records,” showed: - The patient’s clinical record shall include: * Evidence of coordination of service; * Care provided by the organization with others who may be providing service/care; and * Documentation of supervision of physical therapy assistants (PTA) and certified occupational therapy assistants (COTA) by the qualified clinician. RECORD/PATIENT #2: Review of the occupational therapy (OT) evaluation visit, dated 03/18/2022, showed the patient was required to have 24-hour care (not including the spouse). Review of the PTA visit, dated 03/21/2022, showed: - Upon the therapist’s arrival to the home, the spouse was unaware of the patient’s location; and - The PTA failed to notify the supervising physical therapist (PT) or the clinical manager of this occurrence. Review of the PTA visit, dated 03/28/2022, showed: - Upon arrival to the home, the patient was unsupervised; - During the visit, the spouse arrived at the home and stated that he/she was at their child’s business in town; and - The PTA failed to notify the supervising physical therapist or the clinical manager that the patient was left unsupervised. During an interview on 04/06/2022 at 9:50 AM, the administrator stated that there was no documentation in the chart that the PTA had communicated the concerns about the patient’s safety to the supervising PT or the clinical manager.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in non-compliance with one Condition of Participation: Care Planning, coordination of services, and quality of care, the agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 04/06/2024.

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on review of the agency’s contractual agreement and interview, the agency failed to ensure that the contract for speech therapy services contained the statements that the home health agency must maintain overall responsibility for the services provided under arrangement as well as the manner in which the services are furnished and that the agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment, (ii) Been excluded or terminated from any federal health care program or Medicaid, (iii) Had its Medicare billing privileges revoked, or (iv) Been debarred from participating in any government program. This deficient practice has the potential to affect the contracted services for all of the agency patients. Findings included: Review of the speech-language pathologist services agreement dated 10/25/2021, showed the contract did not contain statements that the home health agency must maintain overall responsibility for the services provided under arrangement as well as the manner in which the services are furnished and that the agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment, (ii) Been excluded or terminated from any federal health care program or Medicaid, (iii) Had its Medicare billing privileges revoked, or (iv) Been debarred from participating in any government program. During an interview on 04/05/2022 at 2:00 PM, the findings were reviewed with the administrator. He/she provided a memo, dated 04/05/2022 from the therapy company that stated the therapy company’s “employees meet all of the screening requirements as required in the Agreement.” The administrator did not provide any additional contracts between the agency and the therapy company that contained the required statements.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional who will be responsible for providing services to the patient after discharge or a completed transfer summary is sent within two business days of a planned transfer or within two 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 agency becomes aware of the transfer in three (Records/Patients #3, #5, and #6) of six records reviewed. This deficient practice has the potential to affect the ongoing care of all patients served by the agency. Findings included: Review of the agency’s undated policy titled, “Coordination of Care,” showed the agency will ensure that all services are integrated to assure the identification of patient needs and factors that affect patient safety and treatment effectiveness, the coordination of care provided by all disciplines and the communication with the physician(s). Review of the agency’s undated policy titled, “Discharge/Transfer, Patient,” shows the agency will discharge and/or transfer patients in a timely, coordinated manner when the patient meets the agency discharge/transfer criteria. Review of the agency’s undated policy titled, “Medication, Regimen Review Comprehensive,” showed: - The clinician will communicate a complete list of the patient’s medications to the next service provider when the patient is referred or transferred to another setting service, practitioner or level of care within or outside the organization; and - The communication is documented in the clinical record. RECORD/PATIENT #3: Review of the clinical record shows the patient was admitted to home health services on 03/24/2022 with a primary diagnosis of acute kidney failure and was transferred to the hospital that afternoon for anemia (a condition marked by a deficiency of red blood cells or hemoglobin in the blood) associated with complications following a lithotripsy (a treatment using ultrasound shock waves to break up kidney stones into small particles that can be passed out by the body). The clinical record failed to show that a transfer summary was sent to the receiving facility. During an interview on 04/06/2022 at 9:50 AM, the administrator stated that they do not have a written transfer summary that they send to the receiving facility, and they usually call the receiving facility with report. RECORD/PATIENT # 5: Review of the clinical record shows the patient was admitted to home health services on 12/17/2021 with a primary diagnosis of post-surgical complications after a coronary artery bypass graft (a surgical procedure to restore normal blood flow to an obstructed coronary artery). The patient was re-hospitalized on 12/20/2022 and re-admitted to the agency on 01/11/2022. The patient resides in his/her own home with his/her spouse. Review of the physician’s orders showed: - Home health services were placed on hold on 12/21/2021 due to the patient being admitted to the hospital on 12/20/2021; - The patient was readmitted to the agency on 1/11/2022; and - The patient was discharged from services on 1/27/2021. Review of the clinical record showed: - The agency failed to send a transfer summary on for the 12/20/2021 hospital transfer; and - The discharge summary, dated 12/17/2021 through 02/14/2022, showed the summary failed to include a list of medications the patient was taking at discharge. During an interview on 04/05/2022 at 1:30 PM, the administrator stated that they do not usually send a medication list with the discharge summary, they pick highlights from the clinician’s notes and put them to into a summary. During an interview on 04/06/2022 at 9:50 AM, the administrator stated that they do not have a written transfer summary that they send to the receiving facility, and they usually call the receiving facility with report. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to home health services on 12/21/2021 with a primary diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe. Review of the physician’s orders, dated 01/04/2022, showed the patient was discharged from home health services due to patient request and goals were met. Review of the discharge summary, dated 12/21/2021 through 02/18/22, showed the summary failed to include a list of medications the patient was taking at discharge. During an interview on 04/05/2022 at 1:30 PM, the administrator stated that they do not usually send a medication list with the discharge summary, they pick highlights from the clinician’s notes and put them to into a summary.