Every finding on record at Texas County Memorial Hospital

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 04/09/2025. 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 04/09/2025. The provider had 20 current 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, record review, home visit observation, and interview, the provider failed to ensure the patient's plan of care (POC) was individualized with appropriate parameters and treatments in, but not limited to, two of six records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect the care for all the patients served by the provider. Findings included: Review of the provider's policy titled, "Care Planning," dated February 2018, showed in part the following: -An individualized plan of care is developed for each patient; and -The plan of care "covers" all patient care orders, and all pertinent diagnoses. RECORD/PATIENT#1: Review of the clinical record showed the patient was admitted to home health services on 07/22/2024, and was recertified on 03/13/2025 with a primary diagnosis of non-pressure chronic ulcer of other part of right foot (wounds to the toes that were not caused by pressure), and had additional diagnoses including peripheral vascular disease (PVD) (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), essential (primary) hypertension (abnormally high blood pressure that is not the result of a medical condition), and type 2 diabetes mellitus (DM) (a chronic disease that affects how the body uses sugar for energy). The patient lived at home with a spouse. Review of the POC, dated 03/19/2025 - 05/17/2025, showed in part the following: -SN-Notify MD: * "ACC (acceptable) PAIN LVL (level) 5(five)/10 (on a numeric pain scale where zero (0) equals no pain and 10 is the worst possible pain) . PAIN GOAL: 0/10." -SN-Notify MD: Parameters: * WT (weight) gain > (greater than) 3 (three) LB (pounds) in 3 days; * Pain > 8 (eight)/10; and * FBG (fasting blood glucose) 400, RAND (random blood glucose) 400. Review of the skilled nurse visit notes dated 03/19/25, 03/21/25, 03/24/25, 03/26/25, 03/31/25, 04/02/25, 04/06/2025, and 04/08/2025 failed to include an assessment of a blood glucose measurement or measurement of an actual weight. The documentation showed the patient's weight was "198" at every visit and was a "reported" weight. The documentation failed to include an assessment of the patient's weight for the days prior to the skilled nurse visits to assess for weight gain per parameter order. Per interview conducted during observation on 04/08/2025 at 1:30 PM, registered nurse (RN) D stated that the patient was a diet controlled diabetic, took no medications for diabetes, and did not check his/her blood sugar levels. During an interview on 04/09/2025 at 8:45 AM, the home health administrator stated that parameter orders could vary from patient to patient and should be patient specific. The nurse should remove information that did not apply to the patient. Pain parameter orders should match patient's expectation. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/18/2025 with a diagnosis of closed (surgery was not required) displaced bicondylar fracture of the right tibia (bumps at the top right and left of the shin bone are broken), and had additional diagnoses of age related osteoporosis (abnormal loss of bone density), lumbar radiculopathy (inflammation of a nerve root in the low back), muscle weakness, and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home with their spouse. Review of the POC, dated 03/18/2025 - 05/16/2025, showed in part the following: -Under the durable medical equipment section (DME); a leg brace/immobilizer was documented; -Under the activities permitted section; non weight bearing RLE (right lower extremity) was documented; -The POC failed to contain an order related to whether the leg brace/immobilizer could be removed or should remain in place; -SN Notify MD: * "Pain intensity > (greater than) 8/10"; * "Pain acceptable pain level: 5/10, Patient pain Goal 0-5/10"; and * These were conflicting notification orders on the POC. Observation and interview on 04/08/2025 at 10:50 AM showed the patient wore a leg brace. The patient stated that the leg brace had been in place since he/she left the nursing facility and he/she was looking forward to the physician appointment next week in hopes the brace would be removed. During an interview on 04/09/2025 at 8:45 AM, the home health administrator stated that parameter orders could vary from patient to patient and should be patient specific. Pain parameter orders should match the patient's expectation.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on home visit observation and interview, the home health provider failed to ensure that a written visit schedule for all personnel providing visits was given to the patient in three of three home visits conducted (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect the care of all the patients served by the provider. Findings included: RECORDS/PATIENTS #1, #2, and #3: Observation on 04/08/2025 at 1:30 PM (for Patient #1), on 0408/2025 at 10:50 AM (for Patient #2) and on 04/08/2025 at 10:00 AM (for Patient #3) showed the provider's admission folder, given to the patients at the time of admission, failed to include a written visit schedule for any personnel that provided visits. Per interview conducted during a home visit observation on 04/08/2025 at 1:20 PM, for patient #1, the registered nurse stated that the staff did not leave a schedule of visits in the patient's home. During an interview on 04/09/2025 at 9:10 AM, the administrator stated that they did not leave a written schedule of visits with the patient as they were not aware of the requirement.

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 policy review, home visit observation, and interview, the staff failed to follow accepted infection control standards of practice while providing care to patient's in two of three home visit observations (Records/Patients #1 and #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, "Nursing Bag Techniques," dated February 2018, showed in part the following: Procedure: -The bag shall not be placed on the floor; -Skin cleanser and paper towels shall be kept in an outside pocket for available access; -Prior to care, skin cleanser and paper towels shall be removed, the bag shall be opened (indicating the bag would be closed) and hands shall be cleansed; -After hand cleansing, all clean supplies and equipment needed for the visit shall be removed from the bag; -When the visit is complete, cleanse reusable supplies with alcohol, antiseptic spray/wipes and/or soap and water as appropriate; and -Hands shall be cleansed prior to returning clean equipment and supplies to the bag. Review of the provider's undated policy titled, "Indications for Hand Hygiene," showed in part the following: -Hand hygiene should be performed after having contact with inanimate objects in the patient's environment; and -After removing gloves. RECORD/PATIENT #1: Observation on 04/08/2025 at 1:00 PM, showed registered nurse (RN) D had his/her nursing bag on the floor of his/her vehicle without a barrier underneath prior to the patient visit. The bag was brought into the patient's home and placed on a barrier on the couch. The nursing bag was left open, and the patient had several dogs in the home. RN-D cleansed his/her hands and removed the pulse oximeter, thermometer, and stethoscope from the nursing bag. RN-D assessed the patient's pulse oximetry and temperature then went to the open nursing bag, entered the nursing bag and took out one glove (left the bag of gloves open), put the glove on, entered the nursing bag and pulled out one sanitizing wipe, wiped the pulse oximeter and thermometer, laid them on a clean barrier, entered the nursing bag, pulled out the blood pressure cuff , removed the blood pressure cuff from the black bag and took the patient's blood pressure, removed the glove from his/her hand, entered the nursing bag took out one new glove and applied it to the right hand, entered the nursing bag and took a sanitizing wipe out, wiped the blood pressure cuff and black bag off, put the blood pressure cuff back into the black blood pressure bag and put it back into the nursing bag, wiped the stethoscope off and put it into the nursing bag, put the pulse oximeter and thermometer into the nursing bag, removed the glove, and sanitized his/her hands with hand gel. Observation of the patient's wound care during the same home visit showed; the nurse applied hand gel, applied gloves, opened a cabinet (nurse contaminated his/her gloves with this step), took out gauze and soap for wound treatment then went to the kitchen for water(faucet is an inanimate object), removed bandages from patient's feet, then removed gloves, applied hand gel, applied new gloves and continued with wound treatment. RECORD/PATIENT #2: Observation on 04/08/2025 at 11:30 AM, the certified nursing assistant ( CNA) washed his/her hands and applied gloves prior to checking the patient's vital signs. The CNA assembled the pulse oximeter, thermometer, and blood pressure cuff on his/her plastic notebook. The vital signs were assessed then the CNA cleaned the pulse oximeter, thermometer, and blood pressure cuff with a sanitizing wipe and put the thermometer, and pulse oximeter back on the plastic notebook, laid the blood pressure cuff in the black bag on the patient's couch, then picked the blood pressure cuff up and moved it up to the plastic notebook with the other supplies. During an interview on 04/08/2025 at 2:30 PM, the administrator stated that (the vital sign assessment process) did not sound right. When asked if it was usual for the staff to wear gloves during vital sign assessments, the administrator stated that was not normal, they usually wore them during the bathing process. When asked about the nursing bag being on the floor, the administrator stated that the nursing bag should not be on the floor.

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, record review, and interview, the home health provider failed to ensure professional staff followed the provider's policies and procedures regarding discharges/transfers in one of two discharge records reviewed (Record/Patient #6). This deficient practice has the potential to affect the post-discharge care of all the patients served by the provider. Findings included: Review of the provider's policy titled, "Discharge and Transfer Summary," dated February 2018, showed in part: Purpose: -To ensure a standardized process for discharging patients from the Home Health Agency (HHA); -To uphold the patient's right to receive information about his/her care, treatment and/or services and to be involved in the decision-making process when appropriate; and -To ensure that appropriate information related to the care, treatment and/or services provided is exchanged with other service members when patients are transferred or discharged from the HHA. Policy: -Discharge/Transfer summary information shall include, but shall not be limited to: -Patient identifying information, including patient's emergency contact; -Summary of the patient's diagnoses as well as physical, mental, and emotional status at the time of transfer or discharge; -The date, initiation and reason for transfer or discharge; -The extent to which goals were met and any referrals made; and -Documentation of notification of all physicians issuing orders for the HHA Plan of Care, patient, patient's legal representative (if any) and family regarding the termination of service. RECORD/ PATIENT #6: Review of the clinical record showed: -The patient was admitted to the provider on 05/09/2024; -The admission diagnoses included a pleural effusion in the right lung (a buildup of excessive fluid in the space between the lung and chest wall which may cause breathing difficulty and chest pain), hypertension (elevated blood pressure), and excessive alcohol intake/ abuse; and -The patient was discharged from the provider 07/07/2024. Review of the patient discharge summary note showed: -The patient went to the hospital with shortness of breath on 06/17/224, and was admitted to the hospital; - The patient was discharged from home health services 07/07/2024; and -The discharge summary failed to include the patient's physical, mental, and emotional status at the time of transfer/discharge, the extent to which goals were met, and any referrals made by the provider as required by the discharge and transfer policy. During an interview on 04/08/2025 at 11:30 AM, the clinical manager stated that: -The discharge summary's last page was missing, and could not be located; -The last page contained multiple discharge summary components, as listed in the policy; and -Due to the missing last page, patient #6's discharge summary was incomplete.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to ensure the aide assignment sheet included all instructions needed for the aide to provide safe care to the patient in, but not limited to, two of four aide assignment sheets reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all the patients receiving aide services. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/11/2025 with a primary diagnosis of aftercare of an above the knee amputation of the right leg. The patient lived at home. Review of the patient's Plan of Care (POC) dated 02/11/2025 to 04/11/2025 showed the following intervention: -Skilled Nurse (SN) to notify Physician for out-of-range patient vital signs which included an SpO2 level (peripheral oxygen saturation, which measures the percentage of oxygen in the blood), below 89%. -Review of the Home Health Aide (HHA) Visit dated 03/17/2025 showed the HHA (home health aide) staff documented a SpO2 reading of 82%. -Review of the HHA Visit dated 03/20/2025 showed the HHA staff documented a SpO2 reading of 87%. -Review of the HHA Visit dated 03/25/2025 showed the HHA staff documented a SpO2 reading of 88%. -Review of the HHA Visit dated 03/28/2025 showed the HHA staff documented a SpO2 reading of 88% -Review of the HHA Visit sheet showed the SN signed each HHA visit but failed to provide SpO2 parameter reference for when the HHA was to notify the SN. During an interview on 04/09/2025 at 10:30 AM, the clinical manager stated that vital sign parameters of SpO2 should be listed on the HHA visit assignment sheet as the other parameters vital signs listed on the POC. The nurse assigned to the patient should review each HHA visit for abnormal findings. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/18/2025 with a diagnosis of closed (surgery was not required) displaced bicondylar fracture of the right tibia (bumps at the top right and left of the shin bone are broken), and had additional diagnoses of age related osteoporosis (abnormal loss of bone density), lumbar radiculopathy (inflammation of a nerve root in the low back) , muscle weakness, and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home with their spouse. Review of the patient's plan of care showed the patient had a leg brace/immobilizer listed under the durable medical equipment (DME) section. Review of the Home Health Aide Assignment Sheet showed a section for "dressing care or other specific assignments" with documentation of; non-weight bearing RLE (right lower extremity). The aide assignment sheet failed to include the leg brace/immobilizer. During the home visit observation on 04/08/2025 at 11:40 AM, the aide covered the patient's brace with a plastic bag and secured the top with tape to ensure water would not seep into the bag and get the brace wet. When asked how he/she knew what to do with the brace on the patient's right lower extremity, he/she said that patients usually will tell him/her what to do with the brace/cast if the instructions are not on the aide assignment sheet.

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 policy review, record review, and interview, the provider failed to ensure that home health aide (HHA) services were provided as ordered by the physician or allowed practitioner in two of four records that received aide services (Records/Patients #1 and #2) This deficient practice has the potential to affect all the patients that receive aide services. Findings included: Review of the provider's policy titled, "Home Health Aide Assignments and Duties," dated February 2018, showed in part the aide must: -Follow written patient care instructions as prepared by the registered nurse (RN); and -Report changes in the patient's condition to a registered nurse. RECORD/PATIENT #1: Review of the home health aide assignment sheet, dated 11/13/2024, showed the aide was assigned to assess bladder elimination every visit. Review of the home health aide visit notes dated 03/20/25, 03/24/25, 03/28/25, 03/31/25, and 04/04/25 showed the aide failed to document bladder elimination assessment. RECORD/PATIENT #2: Review of the home health aide assignment sheet, dated 03/18/2025, showed in part the aide was assigned to: -Clean the bathroom every visit; -Assess bladder elimination every visit; -Vital sign parameters to report to nurse if outside listed ranges: * Systolic blood pressure (greater than) 170; * Diastolic blood pressure 90; * Pulse 120; * Respirations 24; and * Temperature 100.4. Review of the home health aide visit note, dated 03/21/2025, showed the aide failed to document cleaning the bathroom or a bladder elimination assessment. The vital sign assessments showed the temperature (90.1), and diastolic blood pressure (92) were out of range and the aide failed to notify the registered nurse (RN). The visit note was cosigned by the case managing RN, but was not dated by the RN. Review of the home health aide visit note, dated 03/25/2025, showed the aide failed to document bladder elimination assessment. The visit note was cosigned by the case managing RN, but was not dated by the RN. Review of the home health aide visit note, dated 03/28/2025, showed the aide failed to document bladder elimination assessment. The temperature (95.5) was out of range and the aide failed to notify the RN. The visit note was cosigned by the case managing RN, but was not dated by the RN. Review of the home health aide visit note, dated 04/01/2025, showed the temperature (92.4) was out of range and the aide failed to notify the RN. The visit note was cosigned by the case managing RN, but was not dated by the RN. Review of the home health aide visit note, dated 04/04/2025, showed the aide failed to document bladder elimination assessment, the temperature (91.2) was out of range and the aide failed to notify the RN. The visit note was cosigned by the case managing RN, but was not dated by the RN. During an interview on 04/09/2025 at 8:45 AM, the administrator stated that, if the vital signs are out of parameter, the aide should have notified notify the nurse, checked the box that they notified, and made a note up in the comment section. During an interview 04/09/2025 at 9:17 AM, the administrator stated that, if the aide assignment sheet has bladder elimination marked, the aide should document under elimination bladder. If no problems, they would mark no. If problems, they would mark yes and document more under comments.

An extended survey for Medicare certification for Home Health of the Ozarks was completed on 03/23/2022. The agency had 18 current patients. Two condition level deficiencies were identified during this survey: - 484.50 Condition of Participation: Patient Rights; and - 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. The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 03/23/2022. Two (2) standard level deficiencies were identified.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on policy review, review of the agency’s emergency preparedness manual, and interview, the agency failed to comply with all federal, state, and local emergency preparedness (EP) requirements when the agency failed to review and update their EP policies and procedures at least every two years. This deficient practice has the potential to affect the health, safety, and well-being of all patients and staff of the agency. Findings included: Review of the agency’s emergency preparedness manual showed the policies and procedures for the agency’s EP plan showed a last reviewed date of November 2017. During an interview on 03/23/2022 at 10:30 AM, the administrator stated that the policies and procedures in the manual had not been updated but he/she would check with the previous administrator to see if there was an updated version in a different location. No further documentation was produced. .

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on policy review, review of the agency’s emergency preparedness manual, and interview, the agency failed to develop an emergency preparedness system of documentation that preserved patient information, protected confidentiality, and secured and maintained the availability of records. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Natural Disaster Management Plan,” dated 11/2017, showed; - Purpose: To outline a planned, coordinated strategy to promote the safety and continuation of care, treatment and/or services to Home Health of the Ozarks patients in the event of a natural disaster; and - Computer patient and staff data is backed up daily. The backed-up information is stored off-site. During an interview on 03/22/2022 at 2:00 PM, the administrator stated that all medical records are on paper and are kept in a file cabinet at the agency office. The administrator also stated that the file cabinet is not fire proof and, in the event of a disaster, they will rescue the medical records if they are able to get them. If it is not safe, they would not be able to save or access the records. The administrator stated that the medical records are not saved in any digital form and there are no duplicate hard copies stored off-site. .

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on policy review, review of current patient rights information, clinical record review, observation, and interview, the agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information. The agency failed to provide in writing, in advance of furnishing care, the following information: - Written notice of patient's rights and responsibilities under this rule, and the agency transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities (G412); - The patient has the right to be advised orally and in writing of financial liability and changes as soon as possible, in advance of the next home health visit (G440); - The patient has the right to be advised of the state toll free home health telephone hotline, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs (home health agency) (G444); - Be advised of the names, addresses, and telephone numbers of the federally-funded and state-funded entities that serve the area where the patient resides that include: the Quality Improvement Organization of Livanta LLC (446); - The patient and representative (if any), have a right to be informed of the home health agency’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if (G452): * The agency can no longer meet the patient's needs (G454); * The physician and agency agree that the outcomes and goals have been achieved and the patient no longer needs the agency services (G458); * The patient refuses services or elects to be transferred or discharged (G460); * The agency determines that the patient's or other persons in the home, behavior is disruptive, abusive or uncooperative to extent that the delivery of care to the patient or the ability of the agency to operate effectively is impaired (G462); * The agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered (G464); * The agency must make efforts to resolve the problem presented by the patient's behavior, the behavior of other persons in the home, or situation (G466); * Provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care (G468); * Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation in the clinical record (G470); and - Information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no cost to the patient (G490). The cumulative effect of these systemic practices resulted in the agency's inability to ensure that all patients and/or representatives were informed of their rights and responsibilities.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to include: - Rights and responsibilities that are understandable to persons who have limited English proficiency; and - Rights and responsibilities accessible to individuals with disabilities. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. The agency's administrator provided an admission packet for review on 03/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit contained no written information regarding written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to be advised, orally and writing, of financial liability changes as soon as possible, in advance of the next home health visit of charges for services that may not be covered by Medicare, Medicaid, or any other Federally-funded or Federal aid program known to the home health agency, and the charges the individual may have to pay before care is initiated. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. The administrator provided an admission packet for review on 03/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be advised, orally and writing, of financial liability changes as soon as possible, in advance of the next home health visit of charges for services that may not be covered by Medicare, Medicaid, or any other Federally-funded or Federal aid program known to the home health agency, and the charges the individual may have to pay before care is initiated. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

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 policy review, review of the agency's current patient rights information, admission packet review, and interview, the agency failed to ensure staff provided the written notice of patient rights to include that the Missouri state toll free home health telephone hotline hours of operation was 7:00 AM to 8:00 PM daily. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all patients/representatives served by the agency. Findings included: Review of the agency's policy titled, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. The administrator provided an admission packet for review on 03/21/2022. The agency notice of patient rights and other information given to a patient during the initial visit showed the Missouri state toll free home health telephone hours of operation was 7:00 AM to midnight. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to include that the patient and representative (if any) be advised of the name, addresses, and telephone number of the following Federally and state funded entities that serve the area where the patient resides: * Quality improvement organization; * Agency of Aging; * Center for Independent Living; * Protection and Advocacy Agency; and * Aging and Disability Resource Center. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. The administrator provided an admission packet for review on 03/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit showed no name, address and telephone number for the following Federally funded and state funded entities that serve the area where the patient resides: * Agency of Aging; * Center for Independent Living; * Protection and Advocacy Agency; * Aging and Disability Resource Center; and * Quality Improvement Organization. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same information as the above admission packet review. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on policy review, review of the agency's admission folder, and interview, the agency failed to update the written notice of patient rights to include that the agency must inform the patient and representative (if any) of the agency's policies for transfer and discharge. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. Review of the agency's admission folder provided to patients at the start of care showed it included the agency's discharge policy but no information related to the agency's transfer policy. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the agency can no longer meet the patient's needs. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. The agency's administrator provided an admission packet for review on 03/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit contained no written information regarding that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the agency can no longer meet the patient's needs. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

Outcomes/goals have been achieved CFR(s): 484.50(d)(3) The transfer or discharge is appropriate because the physician or allowed practitioner, who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency current patient rights information, and interview, the agency failed to update the written notice of patient rights to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the physician and agency agree that the outcomes and goals have been achieved and the patient no longer needs the agency services. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. The agency's administrator provided an admission packet for review on 03/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit, contained no written information regarding the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the physician and agency agree that the outcomes and goals have been achieved and the patient no longer needs the agency services. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the patient refuses services or elects to be transferred or discharged. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. The agency's administrator provided an admission packet for review on 03/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit contained no written information regarding that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the patient refuses services or elects to be transferred or discharged. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on policy review, review of the agency current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that the agency's policy for discharge for cause: - Determines that the patient's or other persons in the home, behavior is disruptive, abusive or uncooperative to extent that the delivery of care to the patient or the ability of the agency to operate effectively is impaired; and - Then the agency must follow the requirements of paragraphs (d) (5) (i) through (d) (5) (iii) of this section. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. The agency's administrator provided an admission packet for review on 03/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient rights when the agency determines that the patient's or other persons in the home, behavior is disruptive, abusive or uncooperative to extent that the delivery of care to the patient or the ability of the agency to operate effectively is impaired and the patient is being considered for discharge for cause. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. The agency's administrator provided an admission packet for review on 03/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit contained no written information regarding that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that if the patient is being considered for discharge for cause, the agency must make efforts to resolve the problem. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's titled policy, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. The administrator provided an admission packet for review on 03/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit contained no written information regarding that the agency must make efforts to resolve the problem, if the patient is being considered for discharge for cause. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on policy review, review of the agency current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that if the patient is being considered for discharge for cause, the agency must provide the patient or representative with contact information for other agencies or providers who may be able to provide care after discharge. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. The administrator provided an admission packet for review on 03/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be informed about the agency's policy to provide the patient or representative with contact information for other agencies or providers who may be able to provide care after discharge, if patient is being considered for discharge for cause. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that the agency must document the problem and efforts made to resolve the problem, if the patient is considered for discharge for cause. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's titled policy, "Notice of Rights," dated January 2018 showed in part, the purpose is to provide information to patients/families and/or the patient's legal representative (if any) regarding the patient's rights and responsibilities while care, treatment and/or services are provided, in accordance with applicable laws, regulations and standards. The administrator provided an admission packet for review on 03/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be informed that if the patient is considered for discharge for cause, the agency must document the problem and efforts made to resolve the problem. The above findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD is not met as evidenced by: Based on review of the agency's current patient rights information, and home visit observation, the agency failed to ensure the written patient rights information included; information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services, that are at no cost to the individual, and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations, in three (Record/Patient #1, #2, and #3) of three home visit observations conducted. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The administrator provided an admission packet for review on 03/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit failed to include; written information regarding the patient's right to be informed about information that must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no cost to the individual, and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations. Observations during Patient #1's home visit on 03/21/2022 at 12:15 PM, Patient #2's home visit on 03/21/2022 at 2:00 PM, and Patient #3's home visit on 03/22/2022 at 4:12 PM, showed the written patient rights in their home folders failed to include the information as shown above. The findings were reviewed with the administrator on 03/21/2022 at 11:00 AM. Per interview conducted during the review, the administrator stated that they thought the patient rights were current. No additional information was provided.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure the patient's current health status was assessed and documented in two (Patients/Records #2 and #5) of five records reviewed. This deficient practice has the potential to affect the identification of patient needs for all patients on service with the agency. Findings included: Review of the agency's policy titled, "Comprehensive Assessment," dated February 2018, showed in part, the following: - To provide the home health agency (HHA) patient, regardless of payment source, with a comprehensive assessment that accurately identifies the patient’s needs for care, treatment and/or services as outlined by federal regulatory requirements; - To determine the patient’s current needs for continuing care, treatment and/or services; - To identify information that may be utilized to demonstrate the patient’s progress toward the achievement of desired outcomes; - To ensure that the patient’s current needs and/or problems are continuously evaluated and the care, treatment and/or services provided are adjusted accordingly; and - The comprehensive assessment shall include the patient’s problems, including current health and pertinent diagnosis. RECORD/PATIENT #2: Review of the plan of care dated 3/09/2022 through 05/07/2022, based on the comprehensive assessment completed by the registered nurse (RN) on 03/09/2022, showed: - Diagnosis included cerebral infarction (stroke), atherosclerotic heart disease of native coronary artery (buildup of plaque in the walls of the arteries causing obstruction to blood flow), hypertension and weakness; and - Skilled nurse (SN) to monitor signs/symptoms of pain including type, frequency, location and relief measures. Review of the comprehensive assessment dated 03/09/2022 showed: - The patient had headaches and shoulder pain; - Pain was a level eight (a scale used to rate pain, zero representing no pain at all, to 10 representing the worst pain imaginable) prior to taking pain medication; - The RN did not assess/document the pain medication taken, effectiveness and how long the pain relief last; and - The RN did not assess/document pain history in last 24 hours. RECORD/PATIENT #5: Review of the plan of care dated 02/19/2022 through 04/19/2022, based on the comprehensive assessment for recertification completed by the RN on 02/19/2022, showed: - Diagnoses included displacement of internal fixation device of other bones and displaced subtrochanteric fracture of right femur (upper bone of the leg); - SN to notify physician of blood glucose fasting (a test to determine how much glucose is in a blood sample after an overnight fast) below 60 and above 300; - Novolog (fast acting insulin) 100 units (u)/milliliter (ml) varies, sliding scale before meals, subcutaneously; and - Lantus (long acting insulin) 100 u/ml 40 units daily and bedtime. Review of the comprehensive assessment, dated 02/19/2022 showed: - Comorbidities and co-existing conditions included diabetes mellitus (a chronic condition that affects the way the body processes blood sugar); - No assessment/documentation of fasting blood sugar; - No assessment/documentation to show if patient used or needed sliding scale insulin (progressive increase in pre-meal or nighttime insulin doses); - The patient and caregiver had moderate understanding of diabetes, management of blood sugars and insulin administration; - No assessment/documentation of the patient's ability to check blood sugars, administer insulin, or the patient's compliance; and - The patient has one observable surgical wound and there was no assessment/documentation of the surgical wound. The above information was reviewed with the administrator on 03/22/2022 at 11:25 AM. The administrator agreed there was incomplete documentation on the comprehensive assessment and there was no additional information provided.

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 an accurate medication reconciliation was performed in, but not limited to, two (Records/Patients #1 and #3) 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, “Patient Medication Information/Reconciliation,” dated/revised 05/2019, showed: - The agency shall implement a patient medication information/reconciliation process to obtain and document a complete list of a patient’s current medications upon admission; - The patient’s medications are reviewed and assessed during each skilled visit; and - At each skilled nurse visit, the nurse must look at all medication bottles. Review of the agency’s policy titled, “Drug Regimen Review,” dated/revised 05/2016, showed: - Purpose: The nurse reviews all medications including prescriptions drugs and over the counter medications during the comprehensive assessment. This will help to identify ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance with drug therapy; - A complete medication list is obtained with prescription drugs and over the counter medications; and - New, changed and discontinued medication should be updated on the medication profile in a timely manner. RECORD/PATIENT #1: Review of the medication profile, dated 03/10/2022, showed the patient was taking acetaminophen 325 milligrams (MG) one tablet every six hours as needed for pain. Review of the plan of care, dated 03/10/2022, showed the patient was taking acetaminophen 325 MG two tablets every six hours as needed for pain. Review of the patient’s medications during a home visit on 03/21/2022 at 12:15 PM, showed: - The patient was taking acetaminophen 500 MG two tablets every six hours as needed for pain; - The patient was also taking sodium chloride tablets, 1 gram (GM) three times a day; - The sodium chloride tablets showed a prescription label with a fill date of 03/11/2022; - The patient was also taking Equate Severe Congestion Relief with acetaminophen 325 MG, guaifenesin 200 MG, and phenylephrine hydrochloride 5 MG; and - The registered nurse failed to look at the patient’s medication bottles during the home visit observation. The agency failed to reconcile the patient’s medications to include the correct dosage of acetaminophen or to include the sodium chloride and the Equate Severe Congestion Relief on the patient’s plan of care and medication profile. During an interview on 03/22/2022 at 11:35 AM, the administrator stated that he/she would expect the patient’s home medications to be reconciled at every visit and any discrepancies to be called to the physician. RECORD/PATIENT #3: Review of the patient’s medications during a home visit on 03/22/2022 at 4:15 PM, showed the patient was taking fish oil capsules 950 MG one daily. Review of the medical record showed the agency failed to include the fish oil capsules on the medication profile and the plan of care. Findings were reviewed with the administrator on 3/23/2022 at 11:15 AM. The administrator stated that he/she would expect the medications to be reconciled at every visit and any discrepancies to be called to the physician. .

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, observation, and interview, the agency failed to provide an individualized, written plan of care specifying the 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: - Provide an individualized plan of care that included all required elements (G574); -Ensure drugs, services and treatments are administered only as ordered by a physician (G580); and - Ensure the home health agency (HHA) staff promptly alerted the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggested outcomes are not being achieved and/or that the POC 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, record review, home visit observation, and interview, the agency failed to include all the elements of an individualized plan of care in five (Records/Patients #1, #2, #3, #4 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 policy titled, “Medication Orders and Administration,” dated 10/2017, showed medication orders must include specific indications for use along with the maximum dose allowed within a specific time period. Review of the agency’s policy titled, “Care Planning,” dated 02/2018, showed: - The plan of care must be established based on an evaluation of the patient’s immediate and long term needs; - An individualized plan of care is developed for each patient and is documented by the registered nurse or physical therapist if a physical therapy-only admission; - The plan of care includes, at least, the following information: * A list of dates of onset of problems/needs based upon assessment data and physician orders; * Interventions to address the identified patient needs, including teaching and training guidelines, as appropriate to the scope of practice of the individual developing and/or updating the plan of care; * All pertinent diagnoses; * Mental status; * Psychosocial status; * Cognitive status; * Functional limitations; * Orders for therapy services, which should specify specific procedures and modalities to be used; and * Patient-specific interventions and education. Review of the agency’s policy titled, “Patient/Family Education,” dated 02/2018, showed the skilled nurse or therapist shall provide instructions to the patient/family that effectively address how and when to take medications in a safe and effective manner and any specific precautions related to their use. RECORD/PATIENT #1: Review of the medical record showed the patient was admitted to the agency with diagnoses of hyponatremia (a lower than normal level of sodium in the bloodstream), influenza (a highly contagious viral infection of the nose, throat and lungs with symptoms that can range from mild to severe), and weakness. Review of the hospital referral, dated 03/05/2022 to 03/09/2022, showed the following additional diagnoses: - Heart Failure (a chronic (long term) condition in which the heart doesn’t pump blood as well as it should; - Hypertension (high blood pressure); - Hypothyroidism (abnormally low activity of the thyroid gland in which the thyroid gland doesn’t produce enough thyroid hormone); - Arthritis (inflammation of the joints); - Invasive ductal cancer of the breast (a type of breast cancer that can spread to other tissues in the breast); - A hiatal hernia (a condition in which part of the stomach pushes up through the diaphragm muscle (the muscular partition that separates the chest cavity from the abdominal cavity); - Anxiety; - GERD (gastroesophageal reflux disease) (a digestive disease in which stomach acid or bile irritates the food pipe lining); and - Chronic pain following a left total hip replacement. Review of the plan of care, dated 03/10/2022, showed the agency failed to include all the pertinent diagnoses provided in the referral but showed the patient was taking the following medications: - Lisinopril 20 Milligrams (MG) daily (used to treat high blood pressure); - Omeprazole 40 MG daily (used to treat conditions where there is too much acid in the stomach); - Anastozole 1 MG daily for 90 days (used to treat certain breast cancers); - Pregabalin 75 MG daily (used to treat pain caused by nerve damage); - Levothyroxine 88 micrograms (MCG) (used to treat an underactive thyroid gland); - Sotalol Hydrochloride 80 MG (used to treat heart rhythm problems); - Naproxen 220 MG two tabs daily (used to treat inflammation and pain caused by arthritis); - Alprazolam 0.25 MG daily (a narcotic used to treat anxiety); - Buspirone 5 MG every twelve hours as needed (used to treat anxiety); - Norco 5-325 MG every four hours as needed (a narcotic pain medication); During a home visit observation on 3/22/2022 at 12:15 PM, the patient’s home medications included; - Acetaminophen 500 MG two tablets every six hours for pain - Norco 5-325 MG (a combination pain medication containing hydrocodone 5 MG and acetaminophen 325 MG) every four hours as needed for pain; and - Equate Severe Congestion Relief which contains acetaminophen 325 MG. - The agency failed to include any education on the plan of care that warned the patient not to exceed the Food and Drug Administration’s (FDA) maximum acetaminophen daily dose of 4000 MG in a twenty-four hour time period. During an interview on 3/22/2022 at 11:35 AM, the administrator stated that he/she would expect all pertinent diagnoses to be listed on the plan of care. He/she stated that, if the patient was taking a medication to treat a medical condition, the diagnosis should be included on the plan of care. The administrator also stated he/she would expect the care plan to contain education that warned the patient not to exceed 4000 MG of acetaminophen in twenty-four hours. RECORD/PATIENT #3: Review of the medical record showed the patient was admitted to the agency with diagnoses of cerebral infarction (a stroke that occurs as a result of disrupted blood flow to the brain) and COVID-19 (an acute respiratory illness caused by a coronavirus, capable of producing severe symptoms and, in some cases, death). Review of the comprehensive assessment, dated 03/14/2022, showed: - The patient has edema (swelling) in both legs; - The patient is confused in new or complex situations; - The patient has anxiety less often than daily; - The patient feels little interest or pleasure in doing things several (two to six) days a week; - The patient feels down, depressed or hopeless several (two to six) days a week; and - The patient’s speech is difficult to understand. Review of the skilled nurse notes, dated 03/17/2022, showed edema to both legs and that the patient’s speech is hard to understand. Review of the physical therapy plan of care, dated 03/17/2022, showed the patient demonstrated signs of expressive aphasia (decreased ability to speak effectively) and receptive aphasia (decreased ability to understand what is being said). Review of the physical therapist note, dated 03/18/2022, showed the therapy assistant noted, due to the patient’s aphasia, he/she cannot express himself/herself very well. Review of the occupational therapy plan of care, dated 03/16/2022, showed the patient has dysphasia (difficulty forming coherent speech). Review of the plan of care, dated 03/14/2022, showed the agency failed to include interventions for managing the patient’s edema, the agency does not address the patient’s confusion in new situations, the agency failed to include interventions to address the patient’s anxiety or feelings of depression and the agency failed to include interventions relating to the patient’s aphasia. During an interview on 03/23/2022 at 10:50 AM, the administrator stated that he/she would expect the patient’s aphasia to be addressed on the plan of care. He/she stated that interventions for the patient’s edema should be on the care plan. The administrator also stated that any psychosocial issues and interventions for the patient’s feelings of anxiety and depression should be on the plan of care. RECORD/PATIENT #4: Review of referral information, dated 01/31/2022, showed diagnoses of coronary artery disease (damage or disease in the heart’s major blood vessels), cerebrovascular accident (CVA) (a loss of blood flow to part of the brain, which damages brain tissue; a stroke), Hypertension (high blood pressure), elevated neutrophils (an increase in a type of white blood cells that can be a sign your body has an infection), a surgical history of cardiac stents (small tubes that are implanted into the arteries of the heart to help blood flow get to the heart), a surgical history of an implanted loop recorder (a device that records the heart’s rate and rhythm), a surgical history of a carotid artery stent (a small tube in one of the main arteries in the neck to help supply adequate blood flow to the brain) and depression. Review of the plan of care, dated 02/01/2022, showed: - The patient was taking sulfamethoxazole/trimethoprim 800/160 milligrams (MG) (a combination of two antibiotics used to treat a wide variety of bacterial infections); - The patient was taking citalopram 40 MG (a drug used to treat depression); - The plan of care did not contain a diagnosis or an explanation for why the patient is taking antibiotics; and - The plan of care did not contain a diagnosis or an explanation for why the patient is taking an anti-depressant; - The agency failed to include all pertinent diagnoses on the plan of care. During an interview on 03/22/2022 at 11:33 AM, the administrator stated that he/she would expect the reason the patient is taking antibiotics to be on the plan of care and he/she would expect the diagnosis for the anti-depressant and all other pertinent diagnoses to be on the plan of care. RECORD/PATIENT #2: Review of the comprehensive assessment dated 03/09/2022 showed: - Diagnoses cerebral infarction (stroke); - The patient had headaches and shoulder pain; and - Pain was a level eight (a scale used to rate pain, zero representing no pain at all to 10, representing the worst pain imaginable) prior to taking pain medication; - Location of pain: Headaches and shoulders; - Position changes makes pain worse; - Lying still and medication makes pain better; and - Dizziness and headache, left side (cheekbone/ear). Review of the patient's plan of care dated 03/09/2022 to 05/07/2022, showed, in part: - Skilled nurse to monitor signs and symptoms of pain including type, frequency, location and relief measures; and - Report to physician pain intensity greater than eight. The plan of care failed to include where the pain was located, patient specific interventions, education and goals for pain control and dizziness. RECORD/PATIENT #5: Review of the comprehensive assessment, dated 02/19/2022 showed: - Diagnoses included displacement of internal fixation device of other bones and displaced subtrochanteric fracture of right femur (upper bone of the leg); - Comorbidities and co-existing conditions included diabetes mellitus (too much sugar in the blood); - The patient and caregiver had moderate understanding of diabetes, management of blood sugars and insulin administration; - The patient had pain to legs and knees; - Pain was a level seven prior to taking any medications and the patient was comfortable with a pain level of six; - Walking made pain worst; - Relaxation and medications made pain better; - Sleep disruption was an associated symptom/side effect of pain; and - The patient has one observable surgical wound and there was no assessment/documentation of the surgical wound. Review of the plan of care dated 02/19/2022 through 04/19/2022 showed: - Skilled nurse to monitor signs and symptoms of pain including type, frequency, location and relief measures; - Novolog (fast acting insulin) 100 units (u)/milliliter (ml) varies, sliding scale before meals, subcutaneously (there was no sliding scale based on blood sugar levels); and - Skilled nurse to notify physician of blood glucose fasting (a test to determine how much glucose is in a blood sample after an overnight fast) below 60 and above 300. The plan of care failed to include where the pain was located, patient specific interventions, education and goals for pain control. The plan of care failed to include a diagnosis for diabetes mellitus, sliding scale, patient specific interventions, education and goals for diabetes mellitus. During an interview on 03/22/2022 at 11:13 AM, the administrator stated the office administrator enters the OASIS information and the plan of care is generated. The nurse does the plan of care through OASIS

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 staff obtained a physician order for treatment and services which affected two (Records/Patients #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 policy titled "Care Planning", dated February 2018, showed in part, the following: - All clinical services shall be implemented only in accordance with a plan of care established by a physician’s written orders; and - Clinical services are implemented in accordance with a plan of care that is established by a physician’s written orders, in accordance with the home health agency’s policy. RECORD/PATIENT #2: Review of the plan of care (POC) dated 03/09/2022 to 05/07/2022, showed, in part: - The patient was admitted to home health services on 03/09/2022; - Diagnoses included cerebral infarction (stroke) and weakness; and - Physical therapy to evaluate and treat. Review of the physical therapy evaluation/plan of care dated 03/10/2022, showed: - Status post cerebral vascular accident and hospitalization; - The patient would benefit from physical therapy to address decreased strength, gait, transfers, balance and functional mobility/ability; and - The visit frequency and times per week was blank. Review of the physical therapy visit reports dated 03/14/2022 and 03/16/2022, showed the physical therapy assistant provided service. There were no physician orders for physical therapy visits. During an interview on 03/22/2022 at 11:13 AM, the administrator stated that physical therapy usually adds visit frequency on the plan of care and sends it to the physician. No further information was provided. During an interview on 03/23/2022 at 10:50 AM, the physical therapist stated that he/she was unable to find physician orders for physical therapy visits. No further information was provided. RECORD/PATIENT #5: Review of the POC dated 02/19/2022 to 04/19/2022, showed, in part: - The patient was admitted to home health services on 02/19/2022; - Diagnoses included displacement of internal fixation device of other bones and displaced subtrochanteric fracture of the right femur (thigh bone); and - Skilled nurse to monitor signs/symptoms of pain including type, frequency, location and relief measures (there was no relief measures listed). Review of the physical therapy’s evaluation/plan of care dated 02/22/2022, showed: - The patient’s main concern is right knee; - It was swollen last night and popping and are worried about the knee giving away; - The patient said he/she rarely has hip/knee pain but most of the pain is in the right knee (the physician was not notified); - The patient fell on the right knee with the initial fall and was unsure if it was x-rayed; - Bruising was still present to the right knee; and - Instructed patient to try icing the right knee three to five times a day for 10 to 20 minutes with towel to help with irritation and inflammation. There were no physician orders to apply ice to the right knee. During an interview on 03/23/20022 at 10:50 AM, the physical therapist stated that: - Therapy does not have modalities (represents the administration of thermal, mechanical, electromagnetic, and light energies applied to produce therapeutic changes to biological tissues); - Physician orders were not needed, since therapy does not provide modalities; and - He/she left the patient instructions for the use of ice.

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, record review, and interview, the agency failed to ensure prompt notification of the physician(s) of 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 in, but not limited to, three (Records/Patients #2, #4, 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 policy titled, “Change in Patient’s Condition- Reporting to the Physician,” dated 02/2018, showed: - The purpose is to ensure that appropriate treatment is started as soon as possible whenever a significant change in the patient’s status occurs; - A significant change that should be reported to a physician include, but are not limited to: * Deviations in a patient’s normal baseline pulse rate, rhythm and regularity; * Deviations in a patient’s normal blood pressure; * Deviations in a patient’s normal respiratory rate; and * Temperature higher than 100 degrees Fahrenheit. Review of the agency’s policy titled, “Drug Regimen Review,” dated/revised 05/2016, showed: - A complete medication list is obtained with prescription drugs and over the counter medications; - New, changed, and discontinued medication should be updated on the medication profile in a timely manner; - The registered nurse will assess if the patient is experiencing any medication problems, significant side effects and/or reactions, ineffective drug therapy, duplicate drug therapy, or patient non-compliance upon initial assessment; - If such problems are found, the registered nurse will notify the physician of the problems and document in the clinical record; and - A form included in the policy titled, “Medication Reconciliation,” dated 07/2015, showed a section where the clinician records any medications on the discharge medication list which patient is not taking at home. RECORD/PATIENT #4: Review of the nursing home discharge medication list, dated 01/31/2022, showed the patient took the following medications: - Clopidogrel Bisulfate 75 milligrams (MG) daily (used to prevent blood clots from forming); - Coreg 3.125 MG daily (used to treat high blood pressure and heart failure); - Lantus insulin 24 units in a subcutaneous (under the skin) injection at bedtime (used to control high blood sugar in people with diabetes); - nitroglycerine sublingual (under the tongue) spray as needed for chest pain; and - polyethylene glycol 17 grams as needed for constipation. Review of plan of care, dated 02/01/2022, showed: - Orders to notify the physician if the systolic blood pressure (top number) is less than 95 or greater than 170 and a diastolic blood pressure (blood pressure) is less than 50 or greater than 90; - The agency failed to include clopidogrel, coreg, lantus, nitroglycerine spray or polyethylene glycol on the medication list. Review of skilled nurse note, dated 02/18/2022, showed the patient’s blood pressure was 94/56. The agency failed to notify the physician that the blood pressure was below the ordered parameters. Review of the physical therapy visit note, dated 02/22/2022, showed the patient’s blood pressure was 92/52. The agency failed to notify the physician that the blood pressure was below the ordered parameters. Review of the skilled nurses notes, dated 02/01/2022 through 03/16/2022, showed the agency failed to notify the physician that the patient did not have clopidogrel, coreg, lantus, nitroglycerine spray, or polyethylene glycol in the home. During an interview on 03/22/2022 at 11:33 AM, the administrator stated that the agency’s registered nurse takes the discharge instructions and compares it to medications the patient is taking in the home on admission. The nurse sends the patient’s home list to the physician for a signature. The administrator stated that the doctor can make changes to the list but the agency does not notify the doctor of any discrepancies noted between the discharge medication list and the actual medications in the home. The administrator also stated that he/she would expect the physician to be notified if a patient’s vital signs are outside of the physician ordered parameters. During an interview on 03/23/2022 at 10:50 AM, the physical therapist stated that the therapy team communicates with nursing regarding patient needs or concerns. He/she stated that he/she has a “sticky note” with the ordered vital signs parameters written on it. The physical therapist stated that the therapists know to notify the nurse if something is outside of the parameters and document a narrative note that they notified nursing of any changes or concerns. RECORD/PATIENT #2: Review of the plan of care (POC) dated 03/09/2022 through 05/07/2022, showed: - The patient was admitted to home health services on 03/09/2022; - Diagnoses included cerebral infarction (stroke), atherosclerotic heart disease of native coronary artery (plaque buildup in arteries), and hypertension; and (high blood pressure); and - Skilled nurse to notify physician of systolic blood pressure (pressure exerted when the heart beats and blood is ejected into the arteries) lower than 95 and greater than 170 and diastolic blood pressure (pressure in the arteries when the heart rest between beats) lower than 50 and greater than 90; Review of the physical therapy assistant (PTA) visit note dated 03/14/2022 at 2:20 PM showed the patient’s blood pressure was 142/92. The physician was not notified of elevated diastolic blood pressure. Review of the PTA visit note dated 03/16/2022 at 2:00 PM showed the patient’s blood pressure was 198/72. The physician was not notified of elevated systolic blood pressure. Review of a skilled nursing visit dated 03/16/2022 at 2:50 PM showed the patient's blood pressure was 174/82. The skilled nurse documented the physical therapy assistant (PTA) reported the patient was not taking his/her medications. The physician was not notified of the elevated systolic blood pressure and the patient not taking medications. During an interview on 03/22/2022 at 11:13 AM, the administrator stated that he/she would have expected staff to notify the physician of blood pressures out of parameters. RECORD/PATIENT #5 Review of the referral information that included a medication list faxed to the agency on 02/17/2022 showed the following: - Docusate sodium (stool softener) 100 milligram (mg) two times daily (the medication had a line marked through it and not included on the agency’s medication list); - Lovenox (anticoagulant) syringe 40 mg every 12 hours subcutaneous (under the skin) (the medication had a line marked through it and not included on the agency’s medication list); - Famotidine (antihistamine and antacid) 20 mg two times daily (crossed out); - Glucagon injection (used for very low blood sugar) one mg intramuscular once as needed for low blood sugar (the medication had a line marked through it and not included on the agency’s medication list); - Tizanidine (muscle relaxant) two mg every six hours as needed for muscle spasms (the medication had a line marked through it and not included on the agency’s medication list); - Hydrocodone-acetaminophen (relieves moderate to severe pain) 5-325 mg, one tablet two times daily (not included on the agency medication list); - Insulin glargine (Lantus, long acting insulin) 100 units (u)/milliliter (ml) 24 u subcutaneous nightly; - Insulin glargine100 u/ml injection 36 u subcutaneous every morning; and - Insulin lispro (Humalog, fast acting insulin) injection zero to 12 u four times daily before meals and nightly. - The agency failed to notify the physician of the medications on the patient's discharge medication list. Review of the POC dated 02/19/2022 through 04/19/2022 showed: - The patient was admitted to home health services 02/19/2022; - Lantus 100 u/ml 40 u subcutaneous daily and bedtime (referral medication list showed Lantus 24 u nightly and 36 u every morning); and - Novolog subcutaneous varies liking scale before meals (no sliding scale). During interview on 03/22/2022 at 11:25 AM, the administrator stated that he/she was not sure why the medications on the faxed medication list was crossed off. He/she agreed medications and dosage could change from a recent hospital admission and the admitting physician may not be aware of the changes and should be notified. There was no further information provided.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on policy review, Quality Assessment and Performance Improvement (QAPI) program documentation, and interview, the agency failed to provide evidence that collection of quality data was on going during 2021 to: -Identify opportunities for improvement; and -Included OASIS (Outcome and Assessment Information Set) outcome measures and other relevant agency data. This deficient practice has the potential to affect the quality of care and safety of all agency patients. Findings included: Review of the agency's policy titled, "Role of Home Health Agency Leadership in QAPI", dated 02/2018, showed in part, the following: - To formulate and implement formulate and implement an effective, efficient, collaborative interdisciplinary QAPI plan that identifies, monitors and evaluates key areas of improvement for care, treatment and services throughout the organization; - The administration and governing body shall be committed to improving organizational performance and sustaining quality performance in the organizations’ governance, management and clinical processes; - Inherent in the agency’s leadership commitment to develop and implement a continuous effective QAPI program is a commitment to plan, budget for and allocate resources to sustain the QAPI program; - The effectiveness of the home health agency’s administration and governing body in implementing and sustaining an effective organizational QAPI program shall be evaluated at least annually and as needed; - The administration of this agency and the governing body shall participate in a variety of educational activities on a regular basis to learn about and maintain currency of knowledge relative to QAPI principles and methodologies; - The home health agency administration, upon approval of the governing body, shall provide the following resources for assessing the organization’s governance, managerial and clinical processes: * Sufficient information systems and processes to support timely and effect data collection, management and analysis; - The activities that are inherent in this agency’s approach to QAPI shall include the following: * Planning the improvement process; * Identifying and setting improvement priorities for those process and activities that most significantly impact patient outcomes; and * Implementing improvement activities based on assessment data. Observation of the QAPI program documentation for 2021, showed the agency monitored the same data each quarter. The agency failed to have documentation of on-going monitoring of data relevant to OASIS outcomes and other areas of the agency program. During an interview on 03/22/2022 at 1:30 PM, the administrator stated that he/she used the same QAPI focused areas that were in place since the previous administrator. He/she was unclear where to get the data to identify opportunities for improvement and how to initiate the process.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on policy review, agency documents, and interview, the agency failed to provide evidence that the governing body was responsible for ensuring the agency had an ongoing program for quality improvement and patient safety. This deficient practice has the potential to affect the quality of care and safety of all patients served by the agency. Findings included: Review of the agency's policy titled, "Role of Home Health Agency Leadership in QAPI", dated 02/2018, showed in part, the following: - The administration and governing body shall be committed to improving organizational performance and sustaining quality performance in the organizations’ governance, management and clinical processes; - The effectiveness of the home health agency’s administration and governing body in implementing and sustaining an effective organizational Quality Assurance and Performance Improvement (QAPI) program shall be evaluated at least annually and as needed; - The administration of this home health agency and the governing body shall participate in a variety of educational activities on a regular basis to learn about and maintain currency of knowledge relative to QAPI principles and methodologies; - The home health agency administration, upon approval of the governing body, shall provide the following resources for assessing the organization’s governance, managerial and clinical processes: * Sufficient, appropriate staff, including management staff, to participate in QAPI activities; * Adequate time for staff to participate in QAPI activities; * Sufficient information systems and processes to support timely and effect data collection, management and analysis; and * Staff training in QAPI approaches and methodologies. Review of the board of trustees meeting dated 07/27/2021 and 10/26/2021, provided by the administrator, showed the board of trustees failed to discuss/document sufficient information to show governing body responsibility for oversight of a QAPI program. The documented minutes failed to show: - A QAPI program that is defined, implemented and maintained; - Approval of a QAPI program that addressed priorities based on agency-wide quality indicators; - A QAPI program that included improvement actions and an evaluation for effectiveness; - Clear expectations for patient safety; and - A consideration regarding fraud or waste and actions taken, if needed. The governing body minutes for 10/26/2021 contained only the following limited information about the QAPI program: - The third quarter QAPI was discussed; - There are good reports noted; - One example is dietary and the plans they are working on; and - Only two departments were missing from the reporting, one was patient care and one was non-patient care. During an interview on 03/21/2022 at 1:17 PM, the administrator stated that the advisory board of trustees discusses QAPI. He/she give his/her information to the QAPI director monthly and quarterly. The QAPI director discusses this information with the board. There was no further information provided.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on policy review, review of the agency’s infection prevention and control program, and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance of infectious and communicable diseases as an integral part of the agency’s quality assurance and performance improvement (QAPI) program. This deficient practice has the ability to affect the health and wellness of all patients served by the agency. Review of the agency’s policy titled, “Infection Prevention and Control Plan,” dated 02/2018, showed: - Infection control management decisions shall be made using data regarding institutional experience/epidemiology, trends in community and institutional healthcare associated infection’s (HAI’s), local, regional and national epidemiology, and emerging infectious disease threats; - The home health agency shall use the Center for Disease Prevention and Control’s (CDC’s) National Healthcare Safety Network (NHSN) surveillance methodology; - The NHSN surveillance methodology includes monitoring patients for events, risk factors, and procedures and practices related to patient care; and - Objectives for surveillance are defined and focused on specific events, processes, organisms and/or patients/populations. Review of the agency’s policy titled, “Infection Prevention and Control Program,” dated 02/2018, showed: - The program shall incorporate current scientific methods and epidemiologic principles for infection surveillance and prevention of adverse outcomes; - Infection prevention and control activities shall include the following: * Continuously collecting and/or screening data to identify isolated incidents or potential infectious outbreaks; * Analyzing data for problems or undesirable trends; * Determining if infections are organization acquired or community acquired; * Examining data for common factors related to the agency’s processes, systems or functions that could have resulted in infection transmission; * Facilitating a multidisciplinary approach to the prevention and control of infections; * Utilizing sound epidemiologic principles and infection research from recognized authoritative sources; and * Integrating outcomes from surveillance and control activities to allow for internal comparison, for trend analysis and comparison with external databases for benchmarking purposes. Review of the agency’s infection prevention and control program showed the agency did not have a system in place to provide surveillance of infectious and communicable diseases. During an interview on 03/21/2022 at 2:15 PM, the administrator produced a form titled, “Patient Nosohusial Infection Report Form.” The administrator stated that the agency staff completed the form on patients that acquire an infection while on the agency’s services. The administrator stated that they only track infections that develop while the patient is on their services. The agency does not track or do surveillance on any patient admitted with an infection because they did not cause the infection. He/she stated that they do not have a method of surveillance of infections and communicable diseases for the agency’s entire patient population. .

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 agency failed to ensure that services ordered by the physician are provided as indicated in the plan of care, in two (Records/Patients #3 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Review of the agency’s policy titled, “Patient Plan of Treatment,” dated/reviewed 09/2016 showed: - The patient’s plan of treatment is established at the time of admission and must be approved by the patient’s attending physician before actual home health care is provided; - The plan of treatment is the primary working statement of service delivery and reflects current problems and interventions; and - The plan includes reasonable and measurable goals and the specific action needed to meet these goals. Review of the agency’s policy titled, “Conformance with Physician’s Orders,” dated/revised 03/2018, showed: - Patient care delivered shall be in conformance with physician’s orders as evidenced by documentation of visit reports; and - All drugs and treatments are administered by agency staff only as ordered by the physician. RECORD/PATIENT #3: Review of the medical record showed the patient was admitted to the agency on 03/14/2022 for treatment of a cerebral infarction (a stroke caused by disrupted blood supply and restricted oxygen supply to the brain) and COVID-19 (a respiratory illness caused by a coronavirus, capable of producing severe symptoms and, in some cases, death). Review of the occupational therapy plan of care, dated 03/16/2022, showed the frequency of occupational therapy visits is two times a week for six weeks. Review of the medical record showed the agency failed to perform two occupational therapy visits for the week of 03/14/2022 through 03/19/2022. RECORD/PATIENT #4: Review of the medical record showed the patient was admitted to the agency on 02/01/2022 for type 2 diabetes mellitus with hyperglycemia (a chronic or long term condition that affects the way the body processes blood sugar) and dehydration (a dangerous loss of body fluid caused by illness, sweating or inadequate fluid intake). Review of the comprehensive assessment, dated 02/01/2022, showed the patient had an unstageable pressure ulcer on the right foot dorsum (upper side) identified as wound #2. Review of the plan of care, dated 02/01/2022, showed: - The frequency of skilled nursing visits is two times a week for three weeks then one time a week for six weeks; - Orders for wound care of wound #2 included: * Cleanse the wound with normal saline and gauze; * Pat dry with gauze; * Apply Mepilex (a bordered foam dressing); and * Skilled nurse to do wound care at nursing visits. Review of skilled nursing notes, dated 02/01/2022 through 03/16/2022, showed the agency failed to perform two visits during the week of 02/01/2022 through 02/05/2022. Review of skilled nursing notes, dated 02/09/2022 through 03/02/2022, showed the nursing staff failed to follow physician’s orders for wound care by leaving the wound open to air. The agency failed to obtain a physician’s order for leaving the right foot wound open to air. During an interview on 03/22/2022 at 11:33 AM, the administrator stated that he/she would expect home visits to be conducted as ordered. He/she also stated that he/she would expect the wound care orders to be followed as written and would expect physician notification to be made if any changes to wound care were needed. .

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 noncompliance with two Conditions of Participation: Patient rights and 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 03/23/2024. .

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on document review, and interview, the agency failed to ensure a qualified, pre-designated person who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator when the administrator is not available. This deficient practice has the potential to affect the health and safety of all the patients served by the agency. Findings included: Review of an e-mail, dated 01/10/2022 at 11:13 AM (provided by the administrator during survey), showed: - The administrator e-mailed the Bureau of Home Care and Rehabilitative Standards; - Subject: Agency alternate administrator change; and -The new alternate administrator will be registered nurse (RN) A, The agency failed to provide documentation from the governing body regarding the appointment of the pre-designated, qualified person to act in the absence of the administrator. During an interview on 03/22/2022 at 2:00 PM, the administrator stated that the board had not approved the alternate administrator, and that the alternate administrator was scheduled to be approved this month (March 2022).

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of Section 192.2495 RSMo, 192.2495.6 RSMo, and 192.2495.7 RSMo, personnel file review, and interview, the agency failed to request and obtain results of findings of the Family Care Safety Registry (FCSR) prior to patient contact for three employees (Employees #1, #2, and #3) of four personnel files reviewed. This deficient practice has the potential to affect the safety of all patients served by the agency. Findings included: Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Safety Registry regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Safety Registry. Review of Section 192.2495.6, RSMo: "A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, 566 or 569, or any violation of subsection 3 of section 198.070 or section 568.020." Review of Section 192.2495.7, RSMo (effective August 28, 2018): "Any in-home services provider agency or home health agency shall be guilty of a class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the family care safety registry or if such person: (1) Has any of the disqualifying factors listed in subsection 6 of this section; (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under chapter 195 or 579; (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under section 568.045, 568.050, 568.060, 568.175, 570.023, 570.025, 570.030, 570.040 as it existed prior to January 1, 2017, 570.090, 570.145, 570.223, 575.230, or 576.080; (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of section 577.010 or 577.012 and who is alleged and found by the court to be an aggravated or chronic offender under section 577.023; (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under section 589.400; (6) Is listed on the department of health and senior services employee disqualification list under section 192.2490; (7) Is listed on the department of mental health employee disqualification registry under section 630.170; or (8) Has a finding on the child abuse and neglect registry under sections 210.109 to 210.183." EMPLOYEE #1 (E1): Review of E1's personnel file showed: - Date of hire 02/2019 and transferred to home health on 04/19/2021; and - The agency failed to request and obtain results of findings of the FCSR. EMPLOYEE #2 (E2): Review of E2's personnel file showed: - Date of hire 02/01/2019; and - The agency failed to request and obtain results of findings of the FCSR. EMPLOYEE #3 (E3): - Date of hire 11/29/2021; and - The agency failed to request and obtain results of findings of the FCSR. During an interview on 03/22/2022 at 10:34 AM, the administrator stated that the agency only checks the FCSR on nurse assistants. There was no further information provided.