Every finding on record at Suncrest Home Health of Alabama, Inc.

A recertification survey was conducted at Suncrest Home Health from 9/17/24 to 9/19/24. The agency was found to be in compliance with the Centers for Medicare and Medicaid Services requirements for Emergency Preparedness.

A recertification survey was conducted at Suncrest Home Health from 9/17/24 to 9/19/24. Standard level deficiencies were cited and will require an acceptable Plan of Correction.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on medical record (MR) reviews, agency policy, and interviews with staff it was determined the agency failed to ensure the comprehensive assessment, including Occupational Therapy (OT) and Physical Therapy (PT) were started within five days of the Start of Care (SOC). This deficient practice affected two of nine MR reviews with therapy orders including MR # 9 and MR # 10 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Patient Assessment, Initial and Reassessment Policy Number: 2.1.002 Revised: 9/1/24 ...Policy: All patients admitted to the agency will receive an initial assessment...comprehensive assessments are completed at patient admission on all adult patients. ...the assessing clinician may obtain input from the patient...within the comprehensive 5 (five) day window timeframe...The date assessment completed...will indicate the last day the assessing clinician received input to complete the comprehensive assessment... 2. MR # 10 was admitted on 8/17/24 with diagnoses including Malignant Neoplasm of Prostate and Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbances. Review of the HHC and POC dated 8/17/24 revealed physician's orders for SN, PT and OT effective 8/18/24. Review of the OT VNR dated 8/24/24 revealed the OT Evaluation was completed seven days after the SOC. An interview was conducted with EI # 2, PCM, who confirmed the comprehensive assessment was not completed within five days of the SOC per agency policy. 1. MR # 9 was admitted on 8/15/24 with diagnoses including Acute Cystitis with Hematuria, and Unspecified Cirrhosis of Liver. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/15/24 revealed physician's orders for Skilled Nurse (SN), PT and OT effective 8/18/24. Review of the OT Visit Note Report (VNR) dated 8/21/24 revealed the OT Evaluation was completed six days after the SOC. Review of the PT VNR dated 8/23/24 revealed the PT Evaluation was completed eight days after the SOC. An interview was conducted with Employee Identifier (EI) # 2, Patient Care Manager (PCM), who confirmed the comprehensive assessment was not completed within five days of the SOC per agency policy.

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 procedure, and interviews, it was determined the agency failed to maintain a complete and accurate list of all current medications and dosages. This deficient practice affected three of five Home Visits (HV) including HV # 1, HV # 4, HV # 3, 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 in the patient's home. Policy: A drug regimen review will be performed on all patients...all clinicians will participate in medication review and reconciliation throughout the episode... Procedure: 1. The discipline responsible for the drug regimen review will: ...b. Review all medications including over the counter (OTC) medications... 2. All clinicians participating in the patient's care are responsible to assist with the maintenance of accurate patient medication information... a. Through a collaborative process the care team will: ...Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies... 1. HV # 1 was admitted on 8/25/24 with diagnoses including COVID-19, and Chronic Obstructive Pulmonary Disease. Review of the Home Health Certifications (HHC) and Plan of Care (POC) dated 8/26/24 revealed physician's orders for Physical Therapy (PT) two times a week for four weeks then one time a week for five weeks and Occupational Therapy (OT) one time a week for one week, two times a week for three weeks, then one time a week for four weeks. A HV visit was conducted on 9/17/24 at 1:00 PM to observe care provided by Employee Identifier (EI) # 6, OT. During the HV, the surveyor observed an oxygen (O2) concentrator and O2 cylinders in the home. HV # 1's caregiver stated he/she had been on O2 at 2 liters per minute as needed since returning home from the hospital. Review of the Client Medication Report (CMR) dated 9/17/24 revealed no orders for O2. Further review of the HHC and POC revealed no initial order for O2, but O2 was listed as a DME (Durable Medical Equipment) Supply. An interview was conducted on 9/19/24 at 3:35 PM with EI # 2, Patient Care Manager (PCM), who confirmed the agency failed to reconcile the medications per agency policy. 2. HV # 4 was admitted on 7/5/24 and recertified for home care from 9/3/24 to 11/1/24 with diagnoses including Unspecified Atrial Fibrillation, and Other Fracture of Fifth Lumbar Vertebrae. Review of the HHC and POC dated 9/3/24 revealed physician's orders for Skilled Nurse (SN) one time a week for nine weeks, PT two times a week for four weeks then one time a week for one week, and Speech Therapy (ST) one time a week for one week. A HV was conducted on 9/18/24 at 11:15 AM to observe care provided by EI # 4, Speech Therapist. A review of current medications was conducted with EI # 4 and the caregiver and compared with the CMR dated 9/17/24. The follow discrepancies were identified. Aspirin 325 mg was observed in the home and not on the CMR. HV # 4's caregiver stated the patient takes the Aspirin as needed for headaches. The last dose was a couple of months ago. Levetiracetam 250 mg tablets, take two tablets two times a day, was on the CMR. The caregiver stated HV # 4 has been on Levetiracetam 250 mg one time a day for an unknown amount of time. Lisinopril 20 mg tablets, take two tablets daily, was on the CMR. The caregiver stated HV # 4 has been taking Lisinopril 20 mg one tablet daily since his/her doctor changed the dosage a couple of months ago when he/she came out of the hospital. An interview was conducted on 9/19/24 4:00 PM with EI # 2 who confirmed the agency failed to ensure the CMR was updated with the current medications. 3. HV # 3 was admitted on 7/20/24 and recertified for home care from 9/18/24 to 11/16/24 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System and Secondary Malignant Neoplasm of Brain. Review of the HHC and POC dated 9/18/24 revealed physician's orders for SN one time a week for nine weeks, PT one time a week for one week, two times a week for four weeks, then one time a week for four weeks, and OT one time a week for four weeks. A HV was conducted on 9/18/24 at 2:30 PM to observe wound care provided by EI # 5, Licensed Practical Nurse. During the HV a review of the current medications was conducted with EI # 5 and the caregiver. The following discrepancies were identified: Levothyroxine 125 mg, take one capsule daily was listed on the CMR. Levothyroxine 100 mg, take one capsule daily was in the home. The caregiver stated the dosage had been changed by the patient's physician two weeks prior. Midodrine 5 mg, take one tablet three times a day, was listed on the CMR. The caregiver stated HV # 3 had not been taking the Midodrine for two weeks due to high blood pressure. An interview was conducted on 9/19/24 at 3:35 PM with EI # 2 who confirmed the agency failed to reconcile the current medications per agency policy.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on medical record (MR) reviews, agency policy, and interviews it was determined the agency failed to ensure: 1. Physician's orders were followed for obtaining body measurements. 2. Physician's orders for the administration of oxygen (O2) were included in the Plan of Care (POC). This deficient practice affected one of three patients with orders for ankle measurements and one of one patients receiving O2 including MR # 8, Home Visit (HV) # 1, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Physician Orders Policy Number: 2.1.008 Revised: 10/1/23 Purpose: To outline the process of receiving and documenting physician or authorized practitioner orders. Policy: No medications, treatments, ... will be administered without the order of a qualified physician or authorized practitioner... 10. Services are provided according to the most recent orders updating the patient's Plan of Care... 1. MR # 8 was admitted on 5/11/23 and recertified for home care from 9/2/24 to 10.31.24 with diagnoses including Pressure Ulcer of Other Site, Stage Two, and Other Cerebrovascular Vasospasms and Vasoconstriction. Review of the Home Health Certification (HHC) and POC dated 9/2/24 revealed physician's orders for Skilled Nurse (SN) two times a week for eight weeks then one time a week for one week. SN to obtain body measurements of ankle every visit and notify physician of two-centimeter (cm) increase. Review of the SN Visit Note Reports (VNR) dated 9/3/24 and 9/9/24 revealed no documentation of ankle measurements. An interview was conducted on 9/19/24 at 3:33 PM with Employee Identifier (EI) # 2, Patient Care Manager, who confirmed the agency failed to ensure the orders for obtaining body measurements were followed. 2. HV # 1 was admitted 8/26/24 with diagnoses including COVID-19, and Chronic Obstructive Pulmonary Disease. Review of the HHC and POC dated 8/26/24 revealed physician's orders for Physical Therapy (PT) two times a week for four weeks then one time a week for five weeks and Occupational Therapy (OT) one time a week for one week, two times a week for three weeks, then one time a week for four weeks. PT to instruct patient/caregiver regarding O2 management including administration, care of equipment, and safety. Further review of the HHC and POC 8/26/24 and the Client Medication Report dated 9/17/24 revealed no documentation of a physician's order for O2 therapy. An interview was conducted on 9/19/24 at 3:35 PM with EI # 2 who confirmed there was no documentation of a physician's order for O2.

Based on the recertification survey conducted on 6/8/21 to 6/10/21, Suncrest Home Health was found to be in substantial compliance with the Conditions for Participation for Emergency Preparedness.

A recertification survey was conducted on 6/8/21 to 6/10/21 with standard level deficiencies cited.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on review of agency policy, medical records (MR), observations, and interviews with the staff it was determined the agency failed to ensure the staff updated each patient's Client Medication Report (CMR) and followed agency policy with changes in the patients medications for 3 of 7 home visits (HV) records reviewed. This affected HV # 1, HV # 4, HV # 6 and had the potential to negatively affect all patients served by the agency. Policy: Monitoring Medications Policy Number: 10.008 Revised Date: 05/01/19 Purpose: To provide a process to ensure continuous monitoring of medications in the patient's home. 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... The physician is contacted immediately if any discrepancies between agency information and patient medications are found. ... * Home Visit (HV) # 4 was admitted to the agency on 5/12/21 with diagnoses including Other Specified Soft Tissue Disorders, Pain in Left Hand, and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. A HV was conducted on 6/8/21 at 3:40 PM with EI # 4, Occupational Therapy (OT), to observe care provided. During the HV the following medication discrepancies were found in home when compared to the patient Client Medication Report (CMR) and verified by the patient. Dulcolax Stool Softener 100 mg (milligrams) 1 daily was documented on the CMR. Dulcolax Stool Softener 100 mg 1 tablet four times a day was found in home, which the patient verbalized she/he had been taking for “about a month or two.” Tramadol 50 mg 1 tablet twice daily was documented on the CMR. Tramadol 50 mg ½ tablet four times a day was found in home, which the patient verbalized she/he had been taking “since February.” An interview was conducted on 6/10/21 at 9:56 AM with Employee Identifier (EI) # 1 who confirmed the agency staff failed to ensure the patient’s CMR was current. * HV # 6 was admitted to the agency on 11/14/2020, and recertified for continued care from 3/14/21 to 5/12/21, with diagnoses including Encounter for Attention to Cystostomy and Encounter for Attention to Colostomy. A HV was conducted on 6/9/21 at 9:56 AM with EI # 5, Licensed Practical Nurse, to observe care provided. During the HV the following medication discrepancies were found in home when compared to the patient CMR and verified by the patient. Alprazolam 1 mg 1 tablet daily was documented on the CMR. Alprazolam 1 mg 1 tablet twice daily was found in home, with the date of 5/22/21 on the bottle. Ferrous Sulfate 325 mg (65 mg Iron) 1 tablet twice daily documented on the CMR. Ferrous Sulfate 325 mg (65mg Iron) not found in home. The patient verbalized he/she “no longer taking, it keeps me constipated. I take them like twice a week.” Patient verbalized “..for a month or so” when asked how long he/she had been taking the medication twice a week. Metoprolol Succinate ER (extended release) 25 mg twice daily as needed for heart rate greater than 100. Metoprolol Succinate ER not found in home and the patient verbalized he/she does not take it. The patient was unable to remember when he/she stopped taking the Metoprolol Succinate ER. Baclofen 10 mg at bedtime started on 4/27/21 documented as discontinued on 5/3/21 documented on the CMR Baclofen 10 mg 1 tablet at bedtime as needed for spasms found in home with date on the bottle of 4/27/21. Patient verbalized he/she still takes the Baclofen. An interview was conducted on 6/10/21 at 9:52 AM with EI # 1 who confirmed the agency staff failed to ensure the patient’s CMR was current. * HV # 1 was admitted to the agency on 5/21/21 with diagnoses including Unspecified Dementia with Behavioral Disturbances, Anemia in Chronic Kidney Disease, and Hypertensive Chronic Kidney Disease with Stage 1- 4 Unspecified. A home visit was conducted on 6/8/21 at 12:15 PM to observe care provided by the Home Health Aide (HHA). The surveyor requested to review medications. The patient’s caregiver said, “He/she only takes 2 medicines Eliquis and Iron. The surveyor requested to see the bottles and was provided a clear plastic container with several bottles of medications. Review of the current CMR revealed Eliquis 2.5 milligram (mg) 1 tablet (tab) twice daily. The following medications were listed on the current CMR as “Discontinued by: Process, Readmission”: Calcitrol 0.25 mg capsule (cap) 1 every Monday, Wednesday and Friday. Diltiazem Extended Release (ER) 24 360 mg, take 1 cap daily. Ezetimbe 10 mg tabs, take 1 tablet once daily. Iron 325 mg tabs, take 1 tab daily. Levocetrizine 5 mg tabs, take 1 tab daily for allergies. The surveyor was provided a plastic box that contained the above listed medications along with a bottle of Centrum Silver multivitamins and 2 clear zip lock bags. The zip lock bags were labeled as: Tylenol 500 mg 2 every (Q) 6 hours (hrs). Benadryl 1 Q 4 – 6 hrs for itching, allergy. There was no strength labeled for the pink caplets. In an interview conducted on 6/10/21 at 9:16 AM, Employee Identifier (EI) # 1, Executive Director, stated he didn't know what the "Discontinued by: Process, Readmission” meant. He confirmed the staff failed to ensure the CMR was current.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on review of medical records (MR), agency policy and interviews, it was determined the agency staff failed to follow the plan of care orders for: 1. Obtain patient weights and provide education to patient and caregiver of the importance of keeping a weight log. 2. Frequency of Occupational Therapy (OT), Skilled Nurse (SN) and Physical Therapy (PT) visits. 3. Provided education on the safety and emergency procedures related to tracheostomy (trach). 4. Report a Random Blood Sugar reading outside of physician ordered parameters. This affected 6 of 12 active patient records reviewed, including Home Visit (HV) # 1, MR # 5, MR # 2, HV # 4, MR # 8, HV # 3, and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Plan of Care (POC) Revised Date: 1/1/21 Purpose: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician orders are followed. Policy: Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. Procedure: 1. A POC is developed for all patients and updated no less that every 60 days... 2. The POC includes... b. Types, frequency, and duration of services required... f. Medications and treatments... i. Patient specific interventions and education; measurable outcomes and goals identified by the agency and patient... n. All patient care orders. 3. The qualified clinician develops and revises the POC under the direction of the physician. The POC is established prior to providing services... 5. Physician's orders are obtained to update the POC and may include problems and goals... 7. Alterations to the POC are made only with the physician's approval... * MR # 2 was admitted to the agency on 5/15/21 with diagnoses including Malignant Neoplasm of Larynx, Unspecified, Encounter for Attention to Tracheostomy and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/15/21 to 7/13/21 revealed the following physician’s order: “SN (Skilled Nurse)for instructions/reinforcement of…safety and emergency procedures related to the tracheostomy (trach)” with a SN frequency of once a week for 9 weeks. Review of the 4 of 4 SN Visit Note Reports dated 5/15/21 through 6/9/21 revealed no documentation the patient and/or caregiver was provided education on the safety and emergency procedures related to the “new” trach. An interview was conducted on 6/10/21 at 10:08 AM with EI # 1, who confirmed there was no documentation the patient and/caregiver were provided education on the safety and emergency procedures related to the trach. * HV # 4 was admitted to the agency on 5/12/21 with diagnoses including Other Specified Soft Tissue Disorders, Pain in Left Hand, and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. Review of the HHC and POC dated 5/12/21 to 7/10/21 revealed a physician’s order to “…report vital signs falling outside of the following established parameters…RBS (random blood sugar) less than 70 greater than 350…” A HV was conducted on 6/8/21 at 3:40 PM with Employee Identifier (EI) # 4, Occupational Therapy (OT), to observe care provided. During the HV the patient reported a random blood sugar of “69” at lunch. The OT did not attempt to assess the patient’s blood sugar or ask the patient to reassess the blood sugar at the visit to determine if the blood sugar was within established parameters. Review of the OT VNR dated 6/8/21 revealed no documentation of the patient reported 69 random blood sugar nor that the physician was notified of the reported blood sugar. An interview was conducted on 6/10/21 at 9:56 AM with EI # 1 who confirmed the blood sugar should have been reported to the physician. * MR # 8 was admitted to the agency on 11/13/2020, and recertified for continued care from 1/12/21 to 3/12/21, with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris and Essential (Primary) Hypertension. Review of the HHC and POC dated 1/12/21 to 3/12/21 revealed a physician order for a SN frequency of once every 2 weeks for 2 weeks then once a week for 2 weeks. Review of the SN Visit Note Reports revealed no documentation of a SN visit for the week of 1/12/21 through 1/16/21. An interview was conducted on 6/10/21 at 9:12 AM with EI # 1 who confirmed there was no documentation of a SN visit for the week of 1/12/21 through 1/16/21. * HV # 1 was admitted to the agency on 5/21/21 with diagnoses including Unspecified Dementia with Behavioral Disturbances, Anemia in Chronic Kidney Disease, and Hypertensive Chronic Kidney Disease with Stage 1- 4 Unspecified. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/21/21 to 7/19/21 revealed physician orders for the Skilled Nurse (SN): SN to obtain weight every visit and notify RN (Registered Nurse)/MD (Medical Doctor) of weight gain or loss of 5 pounds (lbs) within 5 days. Instruct patient/caregiver (cg) importance of obtaining weight and keeping a weight log. Baseline weight is 137.5 lbs. Review of the 5/21/21 Start of Care (SOC) visit note revealed no documentation the SN provided education for weighing the patient/cg or maintaining a weight log as ordered. Review of the 5/25/21 and 6/2/21 SN visit note revealed no documentation of the patient’s weight or education regarding importance of weighing patient as ordered. In an interview conducted on 6/10/21 at 9:16 AM, Employee Identifier (EI) # 1, Executive Director confirmed there was no documentation the SN followed physician orders. * MR # 5 was admitted to the agency on 5/13/21 with diagnoses including Age-related Osteoporosis with Current Pathological Fracture, Left Lower Leg, Subsequent Encounter for Fracture with Routine Healing, Hypertensive Chronic Kidney Disease with Stage 1-4 Unspecified Chronic Kidney Disease, and Major Depressive Disorder, Single Episode, Unspecified. Review of the Resumption of Care (ROC) physician orders dated 5/25/21 revealed the frequency for Physical Therapy (PT) 1 week 1 effective week of 5/23/21. Review of the 5/27/21 PT Evaluation (Eval) Visit note revealed no documentation of the planned frequency was discussed with the patient and physician. Review of the 5/27/21 Physician Orders revealed the PT frequency as 1 week 1, 3 times a week for 2 weeks and 1 time a week for 4 weeks. Further review of the 5/27/21 Physician Orders was marked as Do Not Send for physician’s signature. Review of the MR revealed completed PT Assistant notes dated 5/31/21, 6/2/21, and 6/4/21. The agency failed to send physician orders to physician for signature. In an interview conducted on 6/10/21 at 10:25 AM, EI # 1 confirmed the agency failed to submit PT orders to physician for signature. * HV # 3 was admitted to the agency on 4/23/21 with diagnoses including Critical Illness Myopathy, Pressure Ulcer of Sacral Region, Stage 4, and Hypertensive Chronic Kidney Disease. Review of the Plan of Care dated 4/23/21 revealed orders for Occupational Therapy (OT) effective 4/25/21, 1 visit per week for 5 weeks. Review of the Visit Note Reports for the week of 5/2/21 revealed no documentation of an OT visit. There was no documentation the physician was notified of the missed visit. An interview was conducted on 6/10/21 at 10:00 with EI # 1, who confirmed there was no OT visit for week # 2.

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 medical records (MR) and interviews with the staff it was determined the agency failed to ensure the Plan of Care (POC) contained patient-specific intervention(s). This affected for 1 of 7 patients reviewed with wounds, including MR # 8, and 1 of 1 patients reviewed with a Tracheostomy (trach), including MR # 2, and had the potential to negatively affect all patients served by the agency. * MR # 8 was admitted to the agency on 11/13/2020, and recertified for continued care from 1/12/21 to 3/12/21, with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris and Essential (Primary) Hypertension. Review of the Home Health Certification (HHC) and POC dated 1/12/21 to 3/12/21 revealed the following physician order, “skilled nurse (SN) to instruct (/) monitor closed incision site for s/s (signs and symptoms) of infection.” Further review of the HHC and POC dated 1/12/21 to 3/12/21 revealed no documentation of where the incision site was located on the body, incision wound care, how the incision site was closed and when and by whom the sutures to the right lower extremity would be removed. Review of the SN Visit Note Report (VNR) dated 1/22/21, which was the first SN visit in the recertification, revealed documentation of “…pt (patient) still has sutures in leg…” Review of the SN VNR dated 1/28/21 revealed documentation of “…pt still has not been to MD (Medical Doctor) office for removal of sutures…wound care provided…” Review of the SN VNR dated 2/6/21, discharge visit, revealed documentation of “…stitches intact to right lower extremity…” An interview was conducted on 6/10/21 at 9:12 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation of where the incision site was located on the body, incision wound care, how the incision site was closed and when and by whom the sutures to the right lower extremity would be removed in the patient’s POC. * MR # 2 was admitted to the agency on 5/15/21 with diagnoses including Malignant Neoplasm of Larynx, Unspecified, Encounter for Attention to Tracheostomy (Trach) and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the HHC and POC dated 5/15/21 to 7/13/21 revealed the following physician’s order: “SN for instructions/reinforcement of tracheostomy care, including stoma care, suctioning and dressing change…” There was no documentation of the frequency and what is to be used for the trach care, suctioning, and dressing change. An interview was conducted on 6/10/21 at 10:08 AM with EI # 1, who confirmed there was no documentation of the frequency and what is to be used for the trach care, suctioning, and dressing change.

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 review of agency policies and procedures, medical records (MR) and interviews with the staff it was determined the agency failed to ensure the staff notified the physician of: 1. Changes in the patient(s) condition. 2. Expired medication found in home 3. Patient and/or caregiver non-compliance with suture removal 4. Discharge of patient due to caregiver non-compliance. 5. Patient drinking, depression, anger, caregiver conflict and need of counseling services. 6. Medication differences on admission to agency. This affected for 6 of 17 records reviewed, including HV # 1, MR # 3, MR # 4, MR # 8, HV # 6, MR # 2 and had the potential to negatively affect all patients served by the agency. Findings Include: Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revised: 8/1/19 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: …Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission 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: a. When changes occur in the patient’s condition… b. When changes occur in caregiver’s support or the environment that affect patient treatment. Policy: Patient Discharge/Transfer Process Policy Number: 2.1.004 Revised: 4/1/21 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...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...is being considered, the agency will: a. Advise patient...physician ordering services, patient's primary care physician...responsible for care after discharge of possible discharge. b. Attempt to resolve problem(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; communication with the physician responsible for the POC; a plan to resolve issues and results of the plan implementation... * MR # 4 was admitted to the agency on 5/10/21 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer, and Non-Pressure Chronic Ulcer Other Part Left Foot with Fatty Layer Exposed. Review of the Home Health Certification and Plan of Care dated 5/10/21 to 7/8/21 revealed a SN frequency of once a week for one week, then two times a week for 8 weeks. Review of the SN VNR dated 5/24/21 revealed the SN documented the patient reported a pain level of “0” and in the narrative note documented, “…no S/S (signs or symptoms) CHF (Congestive Heart Failure) exacerbation, no edema noted…” Review of the SN VNR dated 5/28/21 revealed the SN documented a pain level of “6” and in the narrative note documented “…edema noted to BLE (bilateral lower extremities) and LUE (left upper extremity)… SOB (shortness of breath) noted upon exertion. There was no documentation the SN notified the doctor of the patient’s pain, edema and SOB. An interview was conducted on 6/10/21 at 9:29 AM with EI # 1, who confirmed the SN failed to notify the doctor of the patient’s pain, edema and SOB. * MR # 2 was admitted to the agency on 5/15/21 with diagnoses including Malignant Neoplasm of Larynx, Unspecified, Encounter for Attention to Tracheostomy and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/15/21 to 7/13/21 revealed a SN (Skilled Nurse) frequency of once a week for 9 weeks. Review of the RN (Registered Nurse) Admission Visit Note Report (VNR) dated 5/15/21 revealed no documentation the patient was experiencing edema to the bilateral lower extremities. Review of the SN VNR dated 5/19/21 revealed documentation of 2+ edema to the right and left lower extremities. There was no documentation the physician was notified of the edema. Review of the SN VNR dated 5/25/21 revealed documentation of the patient’s last bowel movement (BM) date was 5/20/21. There was no documentation the physician was notified of the patient not having a BM in 5 days. An interview was conducted on 6/10/21 at 10:08 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation the physician was notified of the patient’s edema and not having a BM in 5 days. * MR # 8 was admitted to the agency on 11/13/2020, and recertified for continued care from 1/12/21 to 3/12/21, with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris and Essential (Primary) Hypertension. Review of the SN VNR dated 1/22/21 revealed documentation of “…pt (patient) still has sutures in leg stating (she/he) has MD (Medical Doctor) appt (appointment) next week sometime.” Review of the SN VNR dated 1/28/21 revealed documentation of “…pt still has not been to MD office for removal of sutures at this point. SN called (daughter/son) and (she/he) stated that (she/he) has an appt on Tuesday. Pts meds (medications) are out of date…” There was no documentation of what patient medication was out of date and the SN notified the physician of the expired medications, the failure to remove sutures or to coordinate the possibility of the SN removing the sutures. Review of the SN VNR dated 2/6/21 revealed documentation of “…patient still has stitches to right lower extremity. Contacted patient’s cg (caregiver) and left message regarding importance of taking patient to get stitches removed to avoid infection…discharging patient at this time due to cg (caregiver) noncompliance with POC…” There was no documentation the SN notified the physician prior to or post discharge of the caregiver’s noncompliance with the POC and agency discharge due to noncompliance, the failure to remove sutures or to coordinate the possibility of the SN removing the sutures. An interview was conducted on 6/10/21 at 9:12 AM with EI # 1, who confirmed there was no documentation the physician was notified of the above information. EI # 1 also confirmed the agency SN was able to remove sutures if ordered by a physician and there was no documentation the physician was notified for the agency SN to attempt to obtain a physician’s order to remove the sutures. * HV # 6 was admitted to the agency on 11/14/2020, and recertified for continued care from 3/14/21 to 5/12/21, with diagnoses including Encounter for Attention to Cystostomy and Encounter for Attention to Colostomy. Review of the Physician Order dated 3/26/21 revealed documentation of MSW (Medical Social Worker) eval (evaluation) due to spouse confessing being verbally abused by the patient and patient excessive drinking of alcohol… Review of the MSW VNR dated 4/1/21 revealed documentation of: “Indicate Emotional Assessment Findings: Patient presents with moderate to severe depression Patient presents with anger issues Patient exhibits agitation/irritability …Indicate Behavioral Assessment Findings: …Jeopardizes safety through actions Yelling …Indicate Family/Social Support Findings: Open conflict with family members/friends Tension involved with family relationship Further review of the MSW VNR dated 4/1/21 revealed narrative documentation of the patient harboring anger over disability and injury that caused it and his/her drinking stems from this but maintain he/she does not have a problem. The caregiver verbalized she/he was “…open to talking to someone due to (her/his) coping with patient’s behavior…” and the caregiver harbored “…anger over coping with the patient’s behavior over years and wants out of…relationship but knows patient needs…help…appears to fear upsetting…” the patient. The “MSW recommendations…highly recommended counseling for both patient and caregiver. Their personal issues with their situation and with he incident that caused patient to be disabled have not been dealt with in a healthy manner…” There was no documentation the MSW notified the physician of the patient’s drinking, anger, depression, conflict with caregiver and need for counseling services. An interview was conducted on 6/10/21 at 9:52 AM with EI # 1, who confirmed there was no documentation the physician was notified of the MSW evaluation findings. * HV # 1 was admitted to the agency on 5/21/21 with diagnoses including Unspecified Dementia with Behavioral Disturbances, Anemia in Chronic Kidney Disease, and Hypertensive Chronic Kidney Disease with Stage 1- 4 Unspecified. Review of the 5/18/21 physician’s office referral revealed the following medications as current: Calcitrol 0.25 milligram (mg) capsule (cap) 1 every Monday, Wednesday and Friday. Diltiazem Extended Release (ER) 24 360 mg, take 1 capsule (cap) daily. Eliquis 2.5 mg tablet (tab), take 1 tab daily Ezetimbe 10 mg tab, take 1 tab once daily. Iron 325 mg tabs, take 1 tab daily. Levocetrizine 5 mg tabs, take 1 tab daily for allergies. Review of the 5/24/21 Client Coordination Note Report (CCNR) revealed a note to physician stating patient was only taking Eliquis. A home visit was conducted on 6/8/21 at 12:15 PM to observe care provided by the Home Health Aide (HHA). The surveyor requested to review medications and was provided a clear plastic box. The patient’s caregiver said, “He/she only takes 2 medicines Eliquis and Iron." Review of the current Client Medication Report (CMR) revealed Eliquis 2.5 milligram (mg) 1 tablet (tab) twice daily. The following medications were listed on the current CMR as “Discontinued by: Process, Readmission” and were in the plastic medication box: Calcitrol 0.25 mg capsule (cap) 1 every Monday, Wednesday and Friday. Diltiazem Extended Release (ER) 24 360 mg, take 1 cap daily. Ezetimbe 10 mg tabs, take 1 tablet once daily. Iron 325 mg tabs, take 1 tab daily. Levocetrizine 5 mg tabs, take 1 tab daily for allergies. Also, found in the medication box was a bottle of Centrum Silver multivitamins and 2 clear zip lock bags. The bags were labeled as: Tylenol 500 mg 2 every (Q) 6 hours (hrs). Benadryl 1 Q 4 – 6 hrs for itching, allergy. There was no strength labeled for the pink caplets. As the surveyor reviewed the medications with the patient’s caregiver, he/she asked, “Does he/she need to take this? I think he/she needs to take this.” The surveyor submitted the question to the agency, “Has there been any follow up to 5/24/21 CCNR regarding medications?” Employee Identifier (EI) # 1 stated, "No documentation has been found." In an interview conducted on 6/10/21 at 9:16 AM, EI # 1 confirmed the staff failed to ensure the physician was notified of patient's reluctance to take medications as ordered. * MR # 3 was admitted to the agency on 5/12/21 with diagnoses including Parkinson’s Disease, Essential Primary Hypertension, and Major Depressive Disorder Single Episode Unspecified. Review of the 5/6/21 physician referral included the following medications: Klonopin 1 mg tab (1/2 tab hs [hours of sleep]) Metoprolol Tartrate 25 mg tab (1/2 tab every day) Review of the Home Health Certification (HHC) and Plan of Care (POC) 5/12/21 to 7/10/21 revealed medication orders for Clonazepam (Klonopin) 1 mg tab twice a day. Metoprolol Tartrate 25 mg tab take 1/2 tab twice daily. Further review of the HHC and POC revealed Oxycodone-Acetaminophen (APAP) 10 mg tab take 1 tab three times daily with the start date of 4/30/21. The Oxycodone-APAP was not listed as ordered from the referring physician. Review of the Skilled Nurse 5/12/21 Start of Care note revealed no documentation the physician was alerted to the differences in medications from referral to admission to agency. In an interview conducted on 6/10/21 at 10:45 AM, EI # 1 confirmed there was no documentation the physician was alerted to the medication differences on admission to agency.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Medical Social Worker (MSW) job description, medical records (MR) and interviews with the staff it was determined the agency failed to: 1. Attempt to resolve the caregiver noncompliance with the Plan of Care (POC). 2. Provide MSW services, within the MSW scope of practice, and/or make a referral for counseling services. This affected for 1 of 1 patient discharged for cause reviewed, including MR # 8 and 1 of 1 record reviewed with MSW services, including Home Visit (HV # 6). This had the potential to negatively affect all patients served by the agency. Findings Include: Policy: Patient Discharge/Transfer Process Policy Number: 2.1.004 Revised: 4/1/21 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...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...is being considered, the agency will: a. Advise patient...physician ordering services, patient's primary care physician...responsible for care after discharge of possible discharge. b. Attempt to resolve problem(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; communication with the physician responsible for the POC; a plan to resolve issues and results of the plan implementation... MSW Job Description Job Summary: …The Social Worker will assess and treat patient’s mental and social conditions, counsel individuals and/or families… …Essential Functions Assists the patient, significant others, physician…to understand significant personal, emotional, environmental, and social factors and difficulties related to the patient’s health problems; which interfere with maximizing the benefit of medical services and the plan of care. …Assesses and treats social and emotional factors related to patient’s illness to determine ability to cope with daily living problems. Assists the patient and significant others to understand, accept, follow, and implement medical recommendations. Assists the patient and significant others in utilizing community resources which will help the patient to achieve and maintain optimal functioning. Identifies gaps in community resources and stimulates resource development and/or improvement… * MR # 8 was admitted to the agency on 11/13/2020, and recertified for continued care from 1/12/21 to 3/12/21, with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris and Essential (Primary) Hypertension. Review of the SN VNR dated 1/22/21 revealed documentation of “…pt still has sutures in leg stating (she/he) has MD (Medical Doctor) appt (appointment) next week sometime.” Review of the SN VNR dated 1/28/21 revealed documentation of “…pt still has not been to MD office for removal of sutures at this point. SN called (daughter/son) and (she/he) stated that (she/he) has an appt on Tuesday. Pts meds (medications) are out of date…” There was no documentation of what patient medication was out of date and the SN notified the physician of the expired medications, the failure to remove sutures or to coordinate the possibility of the SN removing the sutures. Review of the SN VNR dated 2/6/21 revealed documentation of “…patient still has stitches to right lower extremity. Contacted patient’s cg (caregiver) and left message regarding importance of taking patient to get stitches removed to avoid infection…discharging patient at this time due to cg (caregiver) noncompliance with POC…” There was no documentation the SN notified the physician prior to or post discharge of the caregiver’s noncompliance with the POC and agency discharge due to noncompliance, the failure to remove sutures or to coordinate the possibility of the SN removing the sutures. Review of the MR revealed no documentation the agency staff performed an assessment to determine the cause of the caregiver's noncompliance or attempted to obtain a physician order for Medical Social Worker evaluation due to caregiver's noncompliance. An interview was conducted on 6/10/21 at 9:12 AM with EI # 1, who confirmed the agency SN was able to remove sutures if ordered by a physician and there was no documentation the physician was notified for the agency SN to attempt to obtain a physician’s order to remove the sutures. EI # 1 also confirmed there was no documentation the agency staff performed an assessment to determine the cause of the caregiver's noncompliance or attempted to obtain a physician order for Medical Social Worker evaluation due to caregiver's noncompliance. * HV # 6 was admitted to the agency on 11/14/2020, and recertified for continued care from 3/14/21 to 5/12/21, with diagnoses including Encounter for Attention to Cystostomy and Encounter for Attention to Colostomy. Review of the Physician Order dated 3/26/21 revealed documentation of MSW eval (evaluation) due to spouse confessing being verbally abused by the patient and patient excessive drinking of alcohol… Review of the MSW VNR dated 4/1/21 revealed documentation of: “Indicate Emotional Assessment Findings: Patient presents with moderate to severe depression Patient presents with anger issues Patient exhibits agitation/irritability …Indicate Behavioral Assessment Findings: …Jeopardizes safety through actions Yelling …Indicate Family/Social Support Findings: Open conflict with family members/friends Tension involved with family relationship Further review of the MSW VNR dated 4/1/21 revealed narrative documentation of the patient harboring anger over disability and injury that caused it and his/her drinking stems from this but maintain he/she does not have a problem. The caregiver verbalized she/he was “…open to talking to someone due to (her/his) coping with patient’s behavior…” and the caregiver harbored “…anger over coping with the patient’s behavior over years and wants out of…relationship but knows patient needs…help…appears to fear upsetting…” the patient. The “MSW recommendations…highly recommended counseling for both patient and caregiver. Their personal issues with their situation and with he incident that caused patient to be disabled have not been delt with in a healthy manner…” Review of the MR revealed no documentation the MSW attempted to obtain an physician order for additional MSW visit for counseling services or made a referral for counseling services. An interview was conducted on 6/10/21 at 9:52 AM with EI # 1, who confirmed the MSW’s scope of practice would include the counseling services required for the patient and caregiver. EI # 1 also confirmed there was no documentation a physician order was attempted to be obtained for additional MSW visit for counseling or a referral was made for counseling services.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, agency policy, and interview it was determined the agency failed to ensure infection control practices were observed. This deficient practice affected 2 of 7 Home Visits (HV) including HV # 7 and HV # 4 and had the potential to affect all patients admitted to this agency. Findings include: Policy: Hand Hygiene Policy Number: 8.004 Revised Date: 5/1/19 ...Policy: Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact... Procedure: 1. Staff performs hand hygiene by handwashing with soap and water or using an alcohol based hand sanitizer: ...c. after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, wound dressings, or contaminated surfaces. ...f. before and after removal of personal protective equipment (PPE)... Policy: Cleaning of Re-Useable Equipment Policy Number: 8.006 Revised Date: 11/1/2020 ... Equipment used for more than one patient is cleaned between each patient use. Definitions: 1. Low-Level Disinfection destroys most bacteria, fungi and some viruses ... Examples include isopropyl alcohol/ethyl alcohol. 2. Intermediate Level Disinfection destroys vegetative bacteria, mycobacterium tuberculosis and most fungi...Examples include Sani Cloth Plus and bleach wipes. 3. Non-Critical Items. Equipment that is only meant to come in contact with intact skin and thus should be cleaned for use by undergoing low level disinfection... Non-critical items also include items which are brought into and out of patient's homes, but do not come in contact with the patient ( ... staff bags, laptop cases, hand held computers)... ... Procedure: 1. Non-critical items which will come in contact with intact patient skin will undergo a low level disinfection between each patient use... * HV # 4 was admitted to the agency on 5/12/21 with diagnoses including Other Specified Soft Tissue Disorders, Pain in Left Hand, and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. A HV was conducted on 6/8/21 at 3:40 PM with EI # 4, Occupational Therapy (OT), to observe care provided. Following the use of a blood pressure cuff and goniometer to provide care to the patient at the visit, EI # 4 removed Endust for Electronics wipes from agency bag and cleaned reusable equipment prior to replacing in agency bag. Upon observation by the surveyor of the container which contained the Endust for Electronics wipes there was documentation the wipes were to be used for dusting and no documentation the wipes were a disinfectant. An interview was conducted on 6/10/21 at 9:56 AM with Employee Identifier (EI) # 1 who verbalized the agency provides all staff with either Sani-cloth wipes and/or alcohol pads to disinfected patient reusable equipment and it was against the agency policy to use Endust for Electronics to disinfected patient reusable equipment. * HV # 7 was admitted on 6/13/19 and recertified for home care on 6/2/21 with diagnoses including Atherosclerotic Native Arteries of Left Leg with Ulceration, Chronic Ulcer of Left Foot, and Venous Insufficiency. A HV visit was conducted on 6/8/21 with Employee Identifier (EI) # 3, Registered Nurse (RN), to observe wound care. EI # 3 donned gloves, performed Blood Pressure (BP) check, cleaned the BP cuff and stethoscope with sanitizing wipes, removed gloves, and then donned new gloves. EI # 3 failed to perform hand hygiene after removing gloves. EI # 3 then assisted HV # 7 to stand to obtain weight, performed pulse check, medication review, and entered information on notepad. With the gloves still on, EI # 3 removed the sock from HV # 7 left foot and removed the dressing from left great toe. EI # 3 then removed the gloves and donned new gloves. EI # 3 failed to perform hygiene after removing gloves. EI # 3 sprayed the wound with wound cleanser then removed the right glove and donned new glove to right hand. EI # 3 did not perform hand hygiene after removing glove. An interview was conducted on 6/8/21 at 4:00 after the HV was completed with EI # 3 who confirmed he/she did not perform hand hygiene after each glove removal. An interview was conducted on 6/10/21 at 11:00 AM with EI # 1, Executive Director, who confirmed the hand hygiene policy was not followed during the HV.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of medical record (MR), policy and procedure, and interview it was determined the agency failed to ensure: 1. Wound measurements were obtained weekly. 2. Wound location and assessment was completed. 3. Occupational Therapist (OT) and Physical Therapist Assistant (PTA) assessed vital signs each visit. 4. Speech Therapy completed /documented patient discharge. This affected 4 of 12 active records reviewed including Home Visit (HV) # 3, MR # 8, MR # 3, HV # 2 and had the potential to affect all patients admitted to the agency. Findings include: Policy: Wound assessment, Documentation, and Photography. Policy Number: 2.2.001 Revised Date: 2/1/21 ...Policy: Upon initial visit and subsequently as indicated below all wounds will be assessed with appropriate documentation within the medical record. ... Unless otherwise ordered by the physician, the Registered Nurse or Physical Therapist will assess wounds at least: Weekly for patient receiving negative pressure wound therapy, receiving daily wound care performed by the agency, have an infected wound, or have stage IV pressure injury with evidence of infection or exposed bone, tendon, or muscle tissue.Every other week for patients receiving wound care by the agency at a frequency less than daily. ..Reassessments will be documented on the Wound Assessment Tool. The assessment includes measurement of the length, width and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage and the condition of the peri-wound. ... Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revised: 8/1/19 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: …Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission 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: a. When changes occur in the patient’s condition… 5. Coordination of care among disciplines: Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care admission to discharge... c. Appropriate, timely communication with the patient, caregiver, and staff involved in the patient's care regarding patient needs, goals and care as well as changes in these: i. All clinicians will report within 1 business day... Report will include: Significant changes in the patient's condition (i.e. new or worsening symptom, new of changed orders, or vital signs not within physician ordered parameters)... 7. Coordination of care with patient and caregiver:... Ongoing, the patient/ caregiver will be notified of: ... d. Transfer or discharge... * MR # 8 was admitted to the agency on 11/13/2020, and recertified for continued care from 1/12/21 to 3/12/21, with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris and Essential (Primary) Hypertension. Review of the Home Health Certification (HHC) and POC dated 1/12/21 to 3/12/21 revealed the following physician order, “skilled nurse (SN) to instruct (/) monitor closed incision site for s/s (signs and symptoms) of infection.” Further review of the HHC and POC dated 1/12/21 to 3/12/21 revealed no documentation of where the incision site was located on the body, incision wound care, how the incision site was closed and when and by whom the sutures to the right lower extremity would be removed. Review of the SN Visit Note Report (VNR) dated 1/22/21, which was the first SN visit in the recertification, revealed documentation of “…pt (patient) still has sutures in leg stating (she/he) has MD (Medical Doctor) appt (appointment) next week sometime…” There was no documentation of which leg was sutured, the number of sutures in the incision and the condition of the sutures. Review of the SN VNR dated 1/28/21 revealed documentation of “…pt still has not been to MD office for removal of sutures…wound care provided…” There was no documentation of where the sutures were and what wound care was provided. Review of the SN VNR dated 2/6/21, discharge visit, revealed documentation of “…stitches intact to right lower extremity…” There was no documentation of the number of sutures in the incision. An interview was conducted on 6/10/21 at 9:12 AM with Employee Identifier (EI) # 1, who confirmed there was no documentation of wound location, number of sutures, condition of sutures and wound assessments on the above dates. * MR # 3 was admitted to the agency on 5/12/21 with diagnoses including Parkinson’s Disease, Essential Primary Hypertension, and Major Depressive Disorder Single Episode Unspecified. Review of the Home Health Certification (HHC) and Plan of Care (POC) for 5/12/21 to 7/10/21 revealed orders for the licensed professional to report vital signs falling outside the following established parameters: Temp 100, Pulse 110, Resp24, Systolic BP (blood pressure) 170, Diastolic BP96, Pain>7. Review of the Occupational Therapy (OT) visit notes dated 5/18/21 and 5/27/21 revealed no documentation vital signs were obtained. In an interview conducted on 6/10/21 at 10:45 AM, Employee Identifier (EI) # 1, Executive Director, confirmed the OT failed to document vital signs as ordered. * HV # 2 was admitted to the agency on 2/11/21 and recertified for the dates of 4/12/21 to 6/10/21 with diagnoses including Hemiplegia Following Cerebral Infraction Affecting Left Nondominant Side, Dysphagia Following Cerebral Infarction, and Dysphagia Unspecified. Review of the HHC and POC for 4/12/21 to 6/10/21 revealed the frequency of the Speech Therapy (ST) as 2 times a week for 4 weeks. Review of the MR revealed ST completed 5 visit notes dated 4/12/21 to 4/26/21. There was no further documentation regarding ST. The surveyor submitted question if ST completed a discharge from services. EI # 1 stated in an interview conducted on 6/10/21 at 9:40 AM there was no documentation ST followed up with patient and no documentation HV # 2 was discharged from home health services. Review of the PTA (Physical Therapy Assistant) visit notes dated 4/16/21, 5/22/21 and 5/27/21 visit notes revealed no documentation vital signs were performed. Review of the 5/28/21 PTA missed visit note revealed documentation, "patient not feeling well." There was no documentation the PTA communicated the patient's complaints of not feeling well to SN or PT. In an interview conducted on 6/10/21 at 9:40 AM, EI # 1 confirmed the above findings ST failed to document a discharge from agency, PTA failed to document vitals signs and report patient's condition to SN or PT. * HV # 3 was admitted to the agency on 4/23/21 with diagnoses including Critical Illness Myopathy, Pressure Ulcer of Sacral Region, Stage 4, and Hypertensive Chronic Kidney Disease. Review of the Plan of Care dated 4/23/21 revealed orders including; Skilled nurse to cleanse wound to sacrum with wound cleanser, pat dry, prepare peri-wound area with skin prep and drape. Fill entire cavity with black foam, cover with transparent drape and apply tubing. Apply negative pressure device at - 125 mm/hg (millimeters of mercury) continuous/intermittent. Dressing to be changed today then 3 times weekly... Review of the Visit Note Reports for week 2 including 4/25/21, 4/27/21, and 4/29/21 revealed no documentation of wound measurements. An interview was conducted on 6/10/21 at 10:00 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed the wound measurements were not obtained per policy.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, medical records (MR) and interviews with the staff it was determined the agency failed to ensure the staff provided education to the patient and/or caregiver and obtained a return demonstration to ensure competency for: 1. Tracheostomy (Trach) care, suctioning, safety and emergency procedures related to the tracheostomy. 2. Blood sugar monitoring using a glucometer 3. Insulin administration. This affected for 1 of 1 patients review with a Tracheostomy, including MR # 2 and 1 of 5 MR’s review with Diabetes, including MR # 4 and had the potential to negatively affect all patients served by the agency. Findings Include: Policy: Patient Education Policy Number: 3.001 Revised: 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.... Procedure: ...3. The patient and caregiver receive ongoing information specific to the identified needs, at a level appropriate to their learning abilities, including: ...b. Patient/caregiver plan of care responsibilities... ...7. Using the progress/visit note, the clinician documents the level of patient/caregiver comprehension, patient/caregiver return demonstration of skill(s) taught... * MR # 2 was admitted to the agency on 5/15/21 with diagnoses including Malignant Neoplasm of Larynx, Unspecified, Encounter for Attention to Tracheostomy and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/15/21 to 7/13/21 revealed a SN (Skilled Nurse) frequency of once a week for 9 weeks. Review of the RN Admission Visit Note Report (VNR) dated 5/15/21 revealed documentation the patient had a "new trach" which used a "humidification machine..." There was no documentation the patient and/or caregiver was provided education or performed a return demonstration on trach care, suctioning, safety and emergency procedures related to the trach, or humidification machine. Review of the 3 SN VNR's from 5/16/21 through 6/9/21 revealed no documentation the patient and/or caregiver was provided education on safety and emergency procedures related to the trach and the humidification machine in use with the trach. An interview was conducted on 6/10/21 at 10:08 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation the patient and/caregiver were provided education and performed a return demonstration of the above trach related interventions. * HV # 4 was admitted to the agency on 5/12/21 with diagnoses including Other Specified Soft Tissue Disorders, Pain in Left Hand, and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. Review of the Client Medication Report (CMR) printed by the agency on 6/8/21 revealed documentation of “Accu-Chek Aviva Plus Test Strips…check blood sugar 3 times a day…Accu-Chek Fastclix Lancet Drum…test 3 times a day…Lantus Solostar U-100 Insulin… 11 Units daily…Novolog U-100 Insulin Aspart…4 Units 3 times daily…” Review of the HHC and POC dated 5/12/21 to 7/10/21 revealed a SN (Skilled Nurse) frequency of once a week for 1 week and Occupational Therapy (OT) frequency of once a week for 5 weeks. Review of the SN Admission VNR dated 5/12/21 revealed documentation the patient obtains blood sugar and administers insulin to self. There was no documentation the patient provided a return demonstration of monitoring blood sugar using a glucometer nor the administration of insulin at the visit. Review of the OT Evaluation VNR dated 5/12/21 revealed documentation of “…Therapist noted ulnar deviation in all four fingers of left hand, with index being the worse (worst). This is making patient need assistance to draw insulin for injections, (daughter/son) is assisting…” There was no documentation the patient and/or caregiver provided a return demonstration of the administration of insulin. Review 2 of 2 OT VNRs from 5/13/21 through discharge date of 6/8/21 revealed no documentation the patient and/or caregiver provided a return demonstration of monitoring blood sugar using a glucometer nor the administration of insulin. A HV was conducted on 6/8/21 at 3:40 PM with EI # 4, OT, to observe care provided. During the HV the surveyor asked the patient and caregiver if the agency had observed the patient and/or caregiver monitor blood sugar using the glucometer and administer insulin. Both the patient and the caregiver verbalized the agency had not observed the use of the glucometer nor the administration of insulin. The patient did show the surveyor a device at the visit used to assist her/him in the administration of insulin since per the patient she/he still has difficulty administering insulin. An interview was conducted on 6/10/21 at 9:56 AM with EI # 1 who confirmed there was no documentation of a return demonstration by the patient and/or caregiver of monitoring the patient’s blood sugar with the use of a glucometer nor administration of insulin.

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), policy and procedure, and interview with staff, it was determined the HHA (Home Health Aide) failed to follow the Aide Plan of Care and notify the RN (Registered Nurse) of tasks not completed. This affected 1 of 3 MR’s reviewed with HHA services, and did affect HV (Home Visit) # 5, and had the potential to affect all patients receiving HHA services. Findings include: Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revised Date: 8/1/19 Purpose: To establish the processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: Identifying patient needs through assessment and communication… Procedure: …5. Coordination of care among disciplines: …c. Appropriate, timely communication with the patient, caregivers, and staff… regarding patient needs, goals, and care as well as changes in these. * HV # 5 was admitted to the agency on 3/4/21 with diagnoses including Displaced Pilon Fracture Right Tibia, Subsequent for Closure of Fracture with Routine Healing, and Other Fracture Upper and Lower End Right Fibula, Subsequent for Closure of Fracture with Routine Healing. Review of the Physician's Order, dated 5/12/21, revealed a HHA frequency of 3 WK 4 (3 times a week for 4 weeks). Review of the Aide Care Plan Report dated 5/3/21 revealed tasks for the HHA including Shampoo every visit. Review of 5 Aide Visit Notes, dated 5/7/21, 5/12/21, 5/17/21, 5/24/21, and 5/31/21, revealed the HHA documented "N" (No) to service completed for Shampoo, with a note, "Client refused." There was no documentation on the 5 visits that the HHA notified the RN of the tasks not completed. An interview was conducted on 6/10/21 at 9:47 AM with Employee Identifier # 1, Executive Director, who confirmed the HHA failed to notify the RN of tasks not completed.