Every finding on record at Thomas Home Health, LLC

A recertification survey was conducted on 1/14/25 to 1/16/25, at Thomas Home Health. The agency was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted from 1/14/25 to 1/16/25 at Thomas Home Health. Standard level deficiencies were cited and will require a plan of correction.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on review of medical records (MRs), observations, agency policy and interviews with staff, it was determined the agency failed to ensure medications were reconciled in five of seven Home Visits (HV) conducted. This affected HV # 7, HV # 6, HV # 3, HV # 4, HV # 5, and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Medication Management Policy Number: 10.008 Date Revised: 07/01/24 Purpose: To Provide a process to ensure continuous monitoring of medications in the patient's home. Policy: A drug regimen will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. Procedure: 1.The discipline responsible for the drug regimen review will: a. Compare medication list obtained...to actual medications patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins, herbs... creams and topical ointments... 2. ...During the patient's episode of care the following will occur: a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies. 3. HV # 3 was admitted on 10/4/24 and recertified for continued care from 12/3/24 to 1/31/25 with diagnoses including Hypertensive Chronic Kidney Disease, Bronchitis, and Iron Deficiency Anemia. Review of the HHC and POC dated 12/3/24 revealed physician's orders for SN one visit per week for two weeks, one visit every two weeks for two weeks, one visit for one week, one visit every two weeks for two weeks, then one visit for one week. A HV was conducted on 1/14/25 at 12:10 PM to observe care provided by EI # 5, LPN. EI # 8, Clinical Director, Coastal Home Health Branch, accompanied the surveyor on the visit. A review of the medications was conducted with EI # 5 and HV # 3. The following is a list of the discrepancies identified from the ML dated 1/14/25 provided by the agency prior to the HV and the medications HV # 3 was currently taking at home: a. Diltiazem CD 240 mg take one capsule daily was listed on the ML. In the home the surveyor observed prescriptions bottles of Cardizem 240 mg, take one daily, prescription dated 10/16/23, and Tiazac 240 mg take one daily, prescription dated 9/1/24. EI # 5 confirmed that both Cardizem and Tiazac were brand names of the generic medication Diltiazem. HV # 3 stated he/she had been taking both the medications since the prescriptions were filled. b. Gemtesa 75 mg take one daily and Gemtesa 75 mg take one every other day were listed separately on the ML. HV # 3 stated he/she had been taking only one Gemtesa every day. c. Celebrex 200 mg take one every day was on the ML. HV # 3 stated he/she had not been taking the medication for two to three months. d. Aspirin 81 mg take two tablets as needed for pain was on the ML. HV # 3 stated he/she was not taking the Aspirin and did not remember when the the last dose was taken. There was no Aspirin medication bottle with the patient's medications. e. Esomeprazole Magnesium 40 mg take one daily and Nexium 40 mg take one daily was on the medication list. EI # 5 confirmed that Esomeprazole and Nexium were different names for the same medication. HV # 3 stated he/she was currently only taking the Esomeprazole daily. f. Mybetriq 50 mg take one daily was on the ML. HV # 3 stated he/she had not been taking the medication for two to three months. The following over the counter medications were in the home but not listed on the ML: a. Centrum Men's Silver 50 Plus. HV # 3 stated he/she had been taking daily every day "forever." b. Iron Slow Release 45 mg. HV # 3 stated he/she had been taking the medication daily for over a year. c. Vitamin C 500 mg. HV # 3 stated he/she had been taking the medication daily every day forever. d. Glucosamine Chondroitin 1500 mg. HV # 3 stated he/she had been taking the medication daily taking for over a year. e. L-Arginine 500 mg. HV # 3 stated he/she had been taking the medication daily for over a year. f. CO-Q 10 200 mg. HV # 3 stated he/she had been taking the medication daily for over a year. g. Meta Fiber Gummies 5 grams. HV # 3 stated he/she had been taking the medication three times a day for two weeks. An interview was conducted on 1/16/25 at 1:05 PM with EI # 1 who confirmed the agency failed to ensure the staff reconciled the medications per agency policy and included all current medications on the ML. 4. HV # 4 was admitted on 1/7/25 with diagnoses including Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, and Unspecified Atrial Fibrillation. Review of the HHC and POC dated 1/7/25 revealed physician's orders for SN one visit per week for nine weeks. A HV was conducted on 1/14/25 at 2:45 PM to observe care provided by EI # 6, RN. EI # 8 accompanied the surveyor on the visit. A review of the medications was conducted by EI # 6 and HV # 4 and compared to the current ML dated 1/14/25. The following discrepancies were identified: a. Metoprolol 50 mg take one daily was on the ML. Metoprolol 100 mg take one daily, filled 11/19/24, was in the home. HV # 4 stated he/she had been taking the 100 mg tablets since the prescription was filled. b. Chlorthalidone 25 mg take one daily, filled 10/7/24, was in the home but not on the ML. HV # 4 stated he/she had been taking the medication since the prescription was filled. c. Paricalcitol 2 micrograms (mcg) take one two times a week, filled 11/25/24, was in the home. Zemplar (brand name for Paricalcitol) 2 mcg take one daily was on the ML. HV # 4 stated he/she had been taking the Paricalcitol two times a week since the prescription was filled. d. Levothyroxine 150 mg take one daily, filled 11/26/24, was in the home. Levothyroxine 175 mg take one daily was listed on the ML. HV # 4 stated he/she had been taking the 150 mg tablets since the prescription was filled. e. Farxiga 10 mg take one daily, filled 11/26/24, was in the home but not on the ML. HV # 4 stated he/she had been taking the medication since the prescription was filled two months ago. f. Carbazepine 200 mg take one daily, filled 11/26/24, was in the home but not listed on the ML. HV # 4 stated he/she had been taking the medication daily since the prescription was filled. g. Jantovan (brand name for Warfarin) 1 mg, filled 8/14/23, and Jantovan 5 mg, filled 10/3/24, was in the home. Warfarin 5 mg take one daily was on the ML. HV # 4 stated he/she sometimes took 6 mg daily and sometimes he/she would take 5 mg. An interview was conducted on 1/16/25 at 1:40 PM with EI # 1 who confirmed the agency failed to ensure the staff reconciled the medications per agency policy and included all current medications on the ML. 5. HV # 5 was admitted on 1/1/25 with diagnoses including Aftercare following Joint Replacement Surgery, Presence of Left Artificial Hip Joint, and Anemia, Unspecified. A HV was conducted on 1/15/25 at 8:45 AM to observe care provided by EI # 7, Physical Therapy Assistant. A review of the home medications was conducted with EI # 7 and HV # 5 and compared to the current ML dated 1/14/25. The following is a list of the discrepancies: a. Omeprazole 40 mg take one daily as needed, filled 10/7/24, was in the home but not on the ML. HV # 5 stated he/she is currently taking the medication as needed. b. Sucralfate 1 gram take daily as needed, filled 10/7/24, was in the home but not on the ML. HV # 5 stated he/she is currently taking the medication as needed. An interview was conducted on 1/16/25 at 1:40 PM with EI # 1 who confirmed the agency failed to ensure the staff reconciled the medications per agency policy and included all current medications on the ML. 1. HV # 7 was admitted to the agency on 11/6/2024 and recertified for continued care from 1/5/25 to 3/5/25 with the diagnosis of Cyst of Pancreas. Review of the Home Health Certification (HHC) and Plan of Care (POC) for the dates of 1/5/25 to 3/5/25 revealed physician’s orders for the Skilled Nurse (SN) to visit one time a week for nine weeks. A home visit was conducted on 1/14/25 at 11:05 AM to observe care provided by Employee Identifier (EI) # 4, Licensed Practical Nurse (LPN). EI # 2, Area Director was also present during the HV. A comparison was made between medications observed in the home and the Medication List (ML) dated 1/14/25 provided by the agency prior to the HV. The following medications were listed, but not in the patient’s home: a. Morphine 30 mg (milligram) Immediate Release Tablet Oral, take one tablet two times daily. HV #7 reported he/she stopped taking the medication two months ago. b. Seroquel 50 mg tablet, take one tablet at bedtime. HV # 7 reported he/she stopped taking the medication about one month ago. An interview conducted on 1/16/25 at 1:52 PM with EI # 1, Director, confirmed the agency staff failed to ensure medications were reconciled and all current medications were included on the ML. 2. HV # 6 was admitted to the agency on 2/6/24 and recertified for continued care from 12/22/24 to 2/19/25 with the diagnosis of Pressure Ulcer of Sacral Region Stage Three. Review of the HHC and POC for the dates of 12/22/24 to 2/19/25 revealed physician’s orders for the SN to visit one time a week for eight weeks. A home visit was conducted on 1/14/25 at 12:44 PM to observe care provided by EI # 3, Register Nurse (RN). EI # 2 was also present during the HV. A comparison was made between medications observed in the home and the ML dated 1/14/25 provided from the agency prior to the HV. The following medications were in the home, but were not listed on the ML: a. Aspirin 81mg take one daily. The Caregiver (CG) reported HV # 6 started taking the medication on 12/4/24. b. Plavix 75 mg take one daily. The CG reported HV # 6 started taking the medication on 12/4/24. An interview conducted on 1/16/25 at 1:52 PM with EI # 1, confirmed the agency staff failed to ensure medications were reconciled and all current medications were included on the ML.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interview it was determined the agency failed to ensure a comprehensive assessment was completed within the last five days of the re-certification. This deficient practice did affect one of six MR reviewed with recertifications including Home Visit (HV) # 3 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Patient Assessment, Initial and Reassessment Policy Number: 2.1.002 Revised: 9/1/24 Purpose: To describe the process of patient assessments... Procedure: ...5. A qualified clinician performs a comprehensive assessment or reassessment visit in the following situations: ...c. Periodic reassessment during the last 5 (five) days of the re-certification, or at least every 60 days... 8. Patients are assessed for continued need and response to care and services... HV # 3 was admitted on 10/4/24 and recertified for home care from 12/3/24 to 1/31/25 with diagnoses including Hypertensive Chronic Kidney Disease, Bronchitis, and Iron Deficiency Anemia. Review of the Visit Note Report, RN (Registered Nurse) Recert with Skill note dated 12/4/24 revealed the comprehensive assessment was not completed prior to the end of the prior certification period. An interview was conducted on 1/16/25 at 1:05 PM with Employee Identifier # 1, Director, who confirmed the comprehensive assessment had not been completed within the last five days of the prior certification.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy and procedures, and interviews with staff it was determined the agency failed to ensure the physician was notified of significant changes in the patient condition. This deficient practice affected one of 17 MR reviewed including MR # 4 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revised: 9/1/24 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. ...Procedure: ...4. Coordination of care with physician/authorized practitioner: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician. a. When changes occur in the patient's condition or response to treatment. ...e. When there is a need to change the patient's plan of care. MR # 4 was admitted on 12/22/24 with diagnoses including Type 2 Diabetes Mellitus with Ketoacidosis without Coma, Atherosclerotic Heart Disease, Hypertensive Heart Disease, and Heart Failure. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 12/22/24 revealed physician's orders for Skilled Nurse (SN) two visits per week for one week then one visit per week for seven weeks, and SN may perform up to two PRN (as needed) visit. Review of the SN Visit Note Report (VNR) dated 1/1/25 revealed the SN documented "...SN arrived to patient home to find patient severley intoxicated and soiled. Patient urinated on (self) in the bed...Patient had cigarette butts and ashes in bed that almost burned hole in bed...Caregiver...in Louisiana...unaware of condition...Patient unable to get up alone. Patient is a severe fall risk. Patient barely eats and drinks anything but alcohol". There was no documentation the SN notified the physician of the patient changes. An interview was conducted on 1/16/25 at 2:05 PM with Employee Identifier # 1, Director, who confirmed the physician was not notified of the changes in the patient condition.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interview with staff it was determined the agency failed to ensure care was coordinated to meet the patient's needs. This deficient practice affected one of 17 MR reviewed includint MR # 4 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2/1/017 Revised: 9/1/24 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: Identifying patient needs through assessment and communication with other health care providers. ...Coordinating patient care among various disciplines ... to ensure that services are continuous and coordinated... Procedure: ...5. Coordination of care among disciplines...This includes... c. Appropriate, timely communication with the patient, caregivers, and staff involved in the patient's care...as well as changes in these... 6. Coordination of services with other organizations and community... b. Communication with other health care providers when there are significant changes in patient care and/or condition... MR # 4 was admitted on 12/22/24 with diagnoses including Type 2 Diabetes Mellitus with Ketoacidosis without Coma, Atherosclerotic Heart Disease, Hypertensive Heart Disease, and Heart Failure. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 12/22/24 revealed physician's orders for Skilled Nurse (SN) two visits per week for one week then one visit per week for seven weeks, and SN may perform up to two PRN (as needed) visit. Review of the SN Visit Note Report (VNR) dated 1/1/25 revealed the SN documented "...SN arrived to patient home to find patient severely intoxicated and soiled. Patient urinated on (self) in the bed...Patient had cigarette butts and ashes in bed that almost burned hole in bed...Caregiver...in Louisiana...unaware of condition...Patient unable to get up alone. Patient is a severe fall risk. Patient barely eats and drinks anything but alcohol." There was no documentation care was coordinated among other disciplines or outside agencies to meet the patient's changing needs including safety concerns, caregiver support, and nutritional needs. An interview was conducted on 1/16/25 at 2:05 PM with Employee Identifier # 1, Director, who confirmed there was no documentation of coordination of care among disciplines to meet MR # 4's needs. EI # 1 provided a copy of a report to the the Department of Human Resources dated 1/16/25 outlining allegations of substance abuse, physical neglect, and poor physical condition.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure the staff observed hand hygiene and bag technique policy. This deficient practice affected three of seven home visit (HV) patients including HV # 3, HV # 4, HV # 5, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Hand Hygiene Policy Number: 8.004 Revised: 5/1/19 Purpose: To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines. Policy: Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact... Procedure: Staff performs hand hygiene... b. before performing an aseptic task (...wound care). c. after contact with ... wound dressings, or contaminated surfaces... e. after contact with inanimate objects (including medical equipment...) in the immediate vicinity of the patient... Agency Policy: Home Care Bag Protocol Job Aid Policy Number: None Listed Revised: 5.10.21 ...4. Hand washing supplies (...waterless hand-washing gel...) shall be kept in the outermost pocket of the home care bag for easy accessibility. This pocket is referred to as the "dirty" section of the bag... 14. Never return soiled equipment to the bag. Items such as stethoscopes shall be cleaned per policy/procedure and allowed to dry prior to returning them to the bag... Agency Policy: Cleaning of Re-Useable Equipment Policy Number: 8.006 Revised: 6/1/22 Purpose: To assure equipment required for patient care is clean and sanitized to prevent the spread of infections. ...Definitions: Low-Level Disinfection - destroys most bacteria...Examples include at least 70 % isopropyl alcohol/ethyl alcohol. Intermediate - Level Disinfection - destroys vegetative bacteria...Dwell time and dry time must be allowed when cleaning with an intermediate levey disinfectant. Examples include Sani Cloth and Micro Kill. Non-Critical Items - Equipment that is only meant to come in contact with intact patient skin...(...stethoscopes, blood pressure cuffs, pulse oximeters...) ...An intermediate level disinfection may be used...as long as appropriate dwell time and dry time...is observed. Semi-Critical Items - Equipment that comes in contact with mucous membranes or non-intact skin...All other semi-critical items will undergo intermediate level disinfection... 1. HV # 3 was admitted on 10/4/24 and recertified for home care from 12/3/24 to 1/31/25 with diagnoses including Hypertensive Chronic Kidney Disease, Bronchitis, and Iron Deficiency Anemia, Unspecified. A HV was conducted on 1/14/25 at 12:10 PM to observe care provided by Employee Identifier (EI) # 5, Licensed Practical Nurse (LPN). After obtaining the vital signs, EI # 5 removed hand sanitizer from the left pocket of the scrub top, performed hand hygiene and replaced the hand sanitizer back in the pocket. EI # 5 then removed gloves from the right scrub top pocket and donned. EI # 5 then retrieved the scissors from the clean barrier and cut the soiled dressing from HV # 3's left arm. EI # 5 then placed the contaminated scissors back on the clean barrier. EI # 5 failed to clean the scissors before returning them to the clean area and contaminated the barrier. EI # 5 then removed gloves, removed the hand sanitizer from his/her pocket, performed hand hygiene, and returned the hand sanitizer to the pocket. EI # 5 then removed gloves from the pocket and donned. EI # 5 then wiped the scissors with sanitizing wipes and placed the scissors back on the now contaminated barrier. EI # 5 then removed gloves, performed hand hygiene with hand sanitizer in the pocket and donned gloves which were removed from the pocket. EI # 5 cleaned the open wound with wound cleanser and patted dry with gauze. EI # 5 then removed gloves and donned gloves from the right pocket. EI # 5 failed to perform hand hygiene after removing gloves. EI # 5 then used the scissors from the contaminated barrier to cut the Xeroform dressing and applied the Xeroform dressing and 4 x 4 gauze to the wound site. An interview was conducted on 1/16/25 at 1:20 PM with EI # 1, Director, who confirmed the agency failed to ensure the staff performed hand hygiene and cleaned re-useable equipment per agency policy. 2. HV # 4 was admitted on 1/7/25 with a diagnosis of Chronic Obstructive Pulmonary Disease. A HV was conducted on 1/14/25 at 2:45 PM to observe care provided by EI # 6, Registered Nurse. After care was provided, EI # 6 performed hand hygiene, donned gloves and wiped the re-useable items including the blood pressure cuff, stethoscope, and pulse oximeter with disinfecting wipes and dropped each into the bag immediately after wiping. EI # 6 failed to allow the items to air dry prior to placing back in the bag. An interview was conducted on 1/16/25 at 1:20 PM with EI # 1 who confirmed the agency failed to ensure the staff followed the agency policy for bag technique. 3. HV # 5 was admitted on 1/1/25 with diagnoses including Aftercare following Joint Replacement Surgery and Presence of Left Artificial Hip Joint. A HV was conducted on 1/15/25 at 8:45 AM to observe care provided by EI # 7, Physical Therapist Assistant. After setting up clean and dirty barriers on the counter top, EI # 7 removed items including the Pulse Oximeter from the bag. EI # 7 dropped the Pulse Oximeter onto the floor, picked the item up, replaced the batteries, then placed the contaminated item onto the clean barrier with the other clean items. EI # 7 failed to disinfect the Pulse Oximeter after contact with the floor. An interview was conducted on 1/16/25 at 1:20 PM with EI # 1 who confirmed the agency failed to ensure the staff followed agency policy for cleaning of equipment.

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 review of medical record (MR), agency policy and procedure, and interviews it was determined the agency failed to ensure the staff followed physician's orders for patient care. This deficient practice affected two of 17 MR reviewed including Home Visit (HV) # 3, HV # 2, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Plan of Care (POC) Policy Number: 2.1.007 Revised: 9/1/24 Purpose: ...To ensure that physician/authorized practioner's orders are followed... Procedure: ...2. The POC includes: ...i. Patient specific interventions and education; measurable outcomes and goals identified by the agency... 13. Staff reviews the patient's chart periodically to ensure compliance with physician/authorized practioner's orders... 2. HV # 2 was admitted on 1/2/25 with a diagnosis of Age Related Osteoporosis with a Pathological Fracture of the Right Femur. Review of the HHC and POC dated 1/2/25 revealed orders including: SN one time a week for five weeks, two times a week for two weeks for two weeks, one time a week for two weeks, and two PRN (as needed) wound issues. Skilled Nurse to provide/instruct to client/caregiver wound care to right upper leg closed incision/suture line. Instruct patient/caregiver signs/symptoms of infection and proper disposal of dressings. Skilled Nurse may perform two PRN visits for surgical wound complications such as increase and/or change in wound drainage color, foul odor to wound/wound drainage, increased pain to wound site, elevated temperature, signs and symptoms of infection, increase in wound size and/or staging. EI # 1, Director, reported when questioned regarding if there were specific wound care orders, the order was on the referral and had not been transcribed to the POC. An order was entered as late on 1/15/25: Per referral late entry effective 1/2/25 Right Hip Surgical Incision: Clean with wound cleanser, skin prep to peri wound and apply Optifoam Gentle Post Op. (Brand Name).Change twice weekly and PRN. Review of the start of care nursing documentation dated 1/2/25 revealed # 1 Lateral- Proximal Thigh. Right, Surgical Incision onset date 12/19/24 wound assessment not performed due to covered by a non-removeable dressing or device. Review of the SN Visit Note Report (VNR) dated 1/7/25 revealed # 1 Lateral- Proximal Thigh. Right, Surgical Incision onset date 12/19/24 wound assessment not performed due to caregiver completed the care. An interview was conducted on 1/16/25 at 1:23 PM with Employee Identifier # 1, Director, who confirmed the SN did not perform the wound care as ordered on the referral. HV # 3 was admitted on 10/4/24 and recertified for home care from 12/3/24 to 1/31/25 with diagnoses including Hypertensive Chronic Kidney Disease, Bronchitis, and Iron Deficiency Anemia, Unspecified. Review of the Home Health Certification (HHC) and POC dated 12/3/25 revealed orders including Skilled Nurse (SN) one visit per week for two weeks, one visit every two weeks for two weeks, one visit per week for one week, one visit every two weeks for two weeks, then one visit per week for one week. SN to obtain body measurement of ankles every visit. Review of the SN Visit Note Report (VNR) dated 12/4/24 revealed the SN documented the ankle circumference of the left leg only. Review of the SN VNR dated 12/31/24 revealed no documentation of the ankle measurements. Review of the SN VNR dated 1/14/25 revealed no documentation of the ankle measurements. An interview was conducted on 1/16/25 at 1:05 PM with Employee Identifier (EI) # 1, Director, who stated the ankle measurements should have been obtained from both ankles and the agency failed to ensure the staff followed the physician's orders for ankle measurements.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on observations, medical record review, agency policy and procedure, and interviews with staff it was determined the agency failed to provide medication education to prevent duplication of medications. This deficient practice affected one of seven home visit (HV) patients including HV # 3 and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Patient Education Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety... Procedure: ...2. Education provided is coordinated among the interdisciplanary team, in accordance with the plan of care... 6. Per assessed knowledge deficit, patients and caregivers receive oral and/or written information on medication education to include: a. Dosage, route, duration b. Description, purpose, expected actions... d. Potential drug-food interactions... 1. HV # 3 was admitted on 10/4/24 and recertified for home care from 12/3/24 to 1/31/25 with diagnoses including Hypertensive Chronic Kidney Disease, Chronic Kidney Disease, Bronchitis, and Iron Deficiency Anemia, Unspecified. Review of the Home Health Certification and Plan of Care dated 12/3/24 revealed physician's orders for Skilled Nurse (SN) one visit per week for two weeks, one visit every two weeks for two weeks, one visit per week for one week, one visit every two weeks, then one visit per week for one week. SN to instruct on new and changed medications, those with assessed knowledge deficit, high risk medications, and any applicable drug interactions. A HV was conducted on 1/14/25 at 12:10 PM with Employee Identifier (EI) # 5, Licensed Practical Nurse. A review of the medications in the home revealed the following duplicate prescriptions of the same medications: a. Cardizem 240 milligram (mg) and Tiazac (brand name for Cardizem) 240 mg was observed in the home. A review of the Medication List (ML) dated 1/14/25 revealed orders for Diltiazem (generic name for Cardizem and Tiazac) 240 mg take one daily for heart rate. HV # 3 stated he/she was currently taking both the Cardizem and the Tiazac and was not aware both medications were the same. A review of the SN Visit Notes from 12/4/24 through1/9/25 revealed no documentation of patient education for Diltiazem, Cardizem, or Tiazac. An interview was conducted on 1/16/25 at 1:05 PM with EI # 1, Director, who confirmed there was no documentation of patient teaching for Diltiazem, Cardizem, or Tiazac prior to the 1/14/25 SN visit and further stated he/she would have expected the medications to have been caught as being the same during medication reconciliation.

Based on review of the agency Emergency Preparedness Plan and interview it was determined Thomas Home Health was in substantial compliance with 484.102 Conditions of Participation: Emergency Preparedness.

An on site recertification survey was conducted on 1/25/22 to 1/26/22 with standard level deficiencies cited.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), policies and procedures, and interview, it was determined the agency failed to meet the needs of a patient requiring administration of Intravenous (IV) antibiotics through a Vascular Access Device (VAD). This affected 1 of 2 MR's reviewed with a VAD, including MR # 10, and had the potential to negatively affect all patient's receiving IV antibiotics through a VAD. Findings include: Agency Policy: Admission Process Policy Number: 2.1.001 Revised Date: 1/1/21 Policy: Patients admitted to home care services must be under the care of a physician, meet admission criteria, and have reasonable expectations that needs can be met safely in the home. Procedure: 1. Patient admission criteria: ...c. The agency: ...Must be able to meet the patient's needs. Agency Policy: On-Call Process (To Include During and After Hours Care) Policy Number: 5.008 Revised Date: 3/1/19 Policy: The agency ensures that patients... have access to a staff clinician 24 hours -a-day by means of providing an on-call nurse during and after office hours... Procedure: 1. The agency will provide each client, upon admission to services, a designated on-call telephone number and will instruct each client to call this number to access care from the agency after regular business hours. ...5. Clinicians will document responses and outcomes of appropriate calls on the On-Call Event Coordination note. Agency Policy: Operations For Patient Care Delivery Policy Number: 5.004 Revised Date: 1/1/18 Policy: Leadership, ...provides organization direction and staffing for patient care services according to the scope of care or services offered... Procedure: ...2. Services are provided in a timely manner to meet patient's needs. 1. MR # 10 was admitted to the agency on 1/11/2022 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System, Encounter for Adjustment and Management of VAD. and Long Term (Current) Use of Antibiotics. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 1/11/22 to 3/11/22 revealed a Skilled Nurse (SN) frequency of 1 week (wk) 9. SN... instruct patient/caregiver on administering the following medication Meropenem 1 gram every 8 hours till 1/16/22. Patient/ Caregiver to flush IV site with 10 ml (milliliters) of Normal Saline before infusion and 10 ml of Normal Saline and Heparin 10 units/5 ml after infusion. Followed by Heparin 10 units/ml with 10 ml of Normal Saline before and 10 ml of Normal Saline after infusion. SN instruct patient/caregiver regarding infusion procedure, care and use of infusion equipment and signs and symptoms of complications of IV therapy. Review of the SN admission visit dated 1/11/22 at 7: 53 AM revealed, "Pt (patient) neighbor who is a retired nurse showed competency of IV antibiotic treatment and IV midline flushed with mock demonstration". Review of the SN Coordination Notes dated 1/11/22 revealed, "Received call after hours from pt on SN personal cell. Pt states the planned friend for antibiotic administration won't be able for night time dose. Request nurse to come administer. Nurse informed this was not an option. Pt able to administer to self, but refuses. SN attempted to teach how to self administer medication during admission visit this morning. Pt refused. Pt states she will try and find someone to help." There was no documentation the patient was educated on or refused to be educated on self administration of the IV antibiotics during the admission visit on 1/11/22. There was no documentation of the time the SN received the after hours call. There was no documentation the SN met the needs of the patient and conducted an after hours on- call visit to assist he/she in administering the IV antibiotics as requested. Further review of the MR revealed there was no documentation the SN followed up with MR # 10 to ensure the pt/cg was able to self administer IV antibiotics as ordered from 1/11/22 to 1/17/22. An interview was conducted on 1/26/22 at 4:58 PM with Employee Identifier (EI) # 2, Performance Improvement Coordinator, who verified the staff failed to meet the needs of the patient with a VAD in the administration of IV antibiotics per agency policy.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, review of medical records (MR), agency policy and procedure, and interviews, it was determined the agency failed to ensure staff reconciled medications in 4 of 17 MRs reviewed, including Home Visits (HV) # 1, HV # 4, MR # 5, MR # 3, and had the potential to negatively affect all patients receiving services by this agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised Date: 5/1/19 Purpose: To provide process to ensure continuous monitoring of medications in the patient's home. Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. ...The physician is contacted immediately if any discrepancies between agency information and patient medications are found. Procedure: 1. The discipline responsible for the drug regimen will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins... to identify such issues such as: ...viii. Noncompliance with drug therapy; x. Drug omissions. e. Notify the physician of any of the above identified issues / discrepancies. Collaborate with the Patient Care Manager and ensure that supportive documentation is evident in the medical record. 2. All clinicians participating in the patient's care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. During the patient's episode of care the following will occur: a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies... b. The Physician will be notified of discrepancies and documentation of notification must be evident in the medical record. 3. MR # 5 was admitted to the agency on 9/24/21 to 11/22/21 with diagnoses including, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Kidney Disease, Stage 3 Unspecified, and Urinary Tract Infection (UTI), Site Not Specified. Review of the physician's order dated 9/29/21 revealed an order for "SN to obtain a urine specimen via I&O catheter for UA (Urinalysis) with C&S (culture and Sensitivity) due to possible UTI..." Review of the SN Visit Note Report dated 9/29/21 revealed documentation a UA with C&S was obtained via I&O catheter. Review of the Client Coordination Note dated 10/1/21 revealed documentation the patient was prescribed a "...new antibiotic for UTI." Review of the MR revealed no documentation of the antibiotic the patient was prescribed. An interview was conducted on 1/26/22 at 3:17 PM with EI # 1, who confirmed there was no documentation of the antibiotic the patient was prescribed. 4. MR # 3 was admitted to the agency on 10/28/2020, recertified for continued care from 4/26/21 to 6/24/21, with diagnoses including Pressure Ulcer of Right Buttock, Stage 4 and Paraplegia, Unspecified. Review of the Physician order dated 5/12/21 revealed and order for "SN to perform/instruct/reinforce patient/caregiver procedure of wound care to Stage 4 Rt (Right) Buttock...Cleanse with Normal Saline, pat dry, pack with Dakin's Moistened gauze, cover with dry gauze dressing, secure with tape or mepilex daily...patient/caregiver to perform when SN not visiting..." Review of the SN Visit Note Report dated 5/12/21 revealed documentation of "...receiving IV (intravenous) infusion at infusion center twice a day..." There was no documentation of the IV infusion the patient was receiving. Review of the Client Medication Report (CMR) revealed no documentation of a current IV infusion the patient was receiving. Further review of the CMR revealed documentation of two IV infusions, Daptomycin 350 mg daily IV and Levofloxacin 500 mg IV daily, which the patient was receiving at the infusion center with a discontinued date of 11/4/2020. An interview was conducted on 1/26/22 at 3:19 PM with EI # 2, who was asked if the agency had documentation of the IV infusion(s) the patient was receiving at the infusion center. EI # 2 provided the surveyor with a SN Visit Note Report dated 10/28/2020 which revealed documentation of "...patient went to (Hospital Identified) infusion center today for IV Daptomycin and Levofloxacin antibiotic infusions...will be going to infusion center daily..." EI # 2 was asked if the agency had documentation of Daptomycin and Levofloxacin current dosage and frequency. EI # 2 confirmed the agency did not have documentation of an IV infusion dose and frequency for the patient. 2. HV # 4 was admitted to the agency on 1/23/22 with diagnoses including Secondary Osteoarthritis, Other Specified Site, and Primary Osteoarthritis, Right Ankle and Foot. A HV was conducted on 1/25/22 at 11:50 AM to observe care provided by EI # 5, RN (Registered Nurse). EI # 1, Executive Director, was also present during the HV. Prior to the HV, the surveyor received a current Medicine List dated 1/25/22. The list was compared to the medications in the home, and the following discrepancies were observed: Buspirone 15 mg tablet, 1 tablet daily as needed for anxiety was on the Medicine List. The bottle in the home, date filled 1/21/21, read 1/2 tablet twice a day as needed for anxiety, and confirmed by the patient's caregiver (cg). Simvastatin 75 mg tablet, 1 tablet daily for cholesterol, was reported by the cg as a current medication, but needs refilled. Cg states has taken for over one year. Simvastatin was not listed on the Medicine List. EI # 1, Executive Director, who was present on the HV, confirmed staff failed to reconcile the patient's medications. 1. HV # 1 was admitted to the agency on 1/19/22 with diagnosis including Lobar Pneumonia, Unspecified Organism and Chronic Obstructive Pulmonary Disease with (Acute) Lower Respiratory Infection. A HV was conducted on 1/25/22 at 10: 35 AM with Employee Identifier (EI) # 3, Physical Therapy Assistant, to observe care provided. Prior to the HV, the surveyor received a current Medicine List (ML) dated 1/25/22. The list was compared to the medications in the home with EI # 3, and the following discrepancies were observed: Magnesium 400 mg (milligrams) 1 capsule daily was on the agency ML and the prescription bottle dated 1/18/22 read 1 capsule 2 times daily. HV # 3 stated he/she started taking it 2 times daily on 1/18/22. Review of the MR revealed a Skilled Nurse conducted a visit on 1/21/22 and failed to reconcile the patient's medications. Melatonin 1 mg tablet 1 tablet at bedtime was on the agency ML and there was none found in the home. HV # 3 stated he/she has not taken it for over a year. Trazodone 100 mg 1 tablet at bedtime was on the agency ML and there was none found in the home. HV # 3 stated he/she has not taken it for over 6 months. Hydrocodone 5-325 mg 1 tablet by mouth q (every) 8 hours prn (as needed) for pain was in the home but not listed on the agency ML. HV # 3 stated he/she takes it as needed for about 6 months. Centrum Silver Men 50 + (Plus) MVI (Multivitamin) Supplement 1 tablet daily was in the home but not listed on the agency ML. HV # 3 stated he/she has taken it for years. An interview as conducted on 1/26/22 at 4:57 PM with EI # 2, Performance Improvement Coordinator (PIC), who verified the staff failed to reconcile medications on HV # 3 per agency policy.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, and interviews with agency staff, it was determined the agency failed to ensure: 1. The physician was notified of a change in the patient's increased wound measurements. 2. The physician was notified of patient reported diarrhea. This affected 2 of 12 current records reviewed including MR # 11, MR # 9 and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revised Date: 8/1/19 Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: ...Identifying patient needs through assessment and communication with other healthcare providers. Procedure: ....4. Coordination of care with physician: At admission, throughout care, ...coordination of services is promoted through routine communication with the patient's physician: a. When changes occur in the patient's condition or response to treatment. 2. MR # 9 was admitted to the agency on 1/10/22 to 3/10/22 with diagnoses including COVID -19 and Pneumonia Due to Coronavirus Disease 2019. Review of the Physical Therapy Visit Note Report (VNR) dated 1/10/22 and SN VNR dated 1/14/22 revealed documentation the patient reported diarrhea. There was no documentation the physician was notified of the patient's report of diarrhea. An interview was conducted on 1/26/22 at 3:16 PM with EI # 1, Executive Director, who confirmed there was no documentation the physician was notified of the patient reported diarrhea. 1. MR # 11 was admitted to the agency on 1/7/21 and recertified from 11/3/21 to 1/1/22 and 1/2/22 to 3/2/22 with diagnoses including Infection/Inflammatory Reaction Due to Internal Left Hip Prosthesis, Subsequent Encounter and Essential Hypertension. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 11/3/21 to 1/1/22 and 1/2/22 to 3/2/22 revealed a SN (Skilled Nurse) frequency of 1 wk (week) 9. SN to perform/instruct/reinforce patient/caregiver procedure of wound care to surgical wound to left hip: patient/cg (caregiver)/SN to cleanse wound daily...with normal saline or wound cleanser...apply collagen to wound bed. Cover with Mepilex using clean technique... Patient needs further instructions/care related to wound care to wound that is not healing. Review of the1/6/22 SN visit note revealed a left hip wound measurement of 1.2 x 0.8 x 0.1. Review of the 1/13/22 SN visit note revealed a left hip wound measurement of 6 x 1.5 x 0.1. Review of the 1/16/22 SN visit note revealed a left hip wound measurement of 6 x 1.5 x 0.3. There was no documentation the SN notified the physician on 1/13/22 or 1/16/22 of MR # 11's increase in wound measurements. An interview was conducted on 1/26/22 at 4:53 PM with Employee Identifier (EI) # 2, Performance Improvement Coordinator (PIC), who verified the staff failed to notify the physician of the patient's increase in wound measurements.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on review of Medical Record (MR), agency policy and procedure and interviews it was determined the agency failed to ensure care was coordinated throughout the agency disciplines and with the physician for patient requested services. This deficient practice did affect 2 of 17 MR's reviewed, including MR # 9 and MR # 2, and had the potential to negatively impact all patients served by the agency. Finding include: Agency Policy: Coordination of Care, From Admit through Discharge Policy Number: 2.1.017 Revised Date: 8/1/19 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by...coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge. Procedure: ...4. Coordination of care with physician...At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician: ...b. When changes occur in caregiver support or the environment that affect patient treatment. ...e. When there is a need to change the patient's plan of care. ...5. Coordination of care among disciplines...Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge. This includes: ...c. Appropriate, timely communication with the patient, caregivers, and staff involved in the patient's care regarding patient needs, goals, and care as well as changes in these. 1. MR # 9 was admitted to the agency on 1/10/22 to 3/10/22 with diagnoses including COVID -19 and Pneumonia Due to Coronavirus Disease 2019. Review of the Physical Therapy (PT) Visit Note Report (VNR) dated 1/14/22 revealed documentation the patient requested a Social Work consult for information on resources to assist with caregiving and the PT "informed incoming nurse...stated...will put in an order for a consult..." Review of the SKilled Nurse (SN) VNR dated 1/14/22 revealed no documentation of the PT notification the patient requested a consult for Social Work and the physician was notified about the patient request. Review of the MR revealed no documentation the physician was notified of the patient request for a social work consult, no physician's order for a social work consult or a social work consult had been completed. An interview was conducted on 1/26/22 at 3:16 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation the physician was notified of the patient request for a social work consult, no physician's order for a social work consult or a social work consult had been completed. 2. MR # 2 was admitted to the agency on 2/2/21 to 4/2/21 with diagonses including Lymphedema, Not Elsewhere Classified and Essential (Primary) Hypertension. Review of the PT VNR dated 2/22/21 revealed documentation the PT reported the patient "...could use bath aide" to the agency supervisor. There was no documentation the PT notified the physician of the need for a bath aide. Review of the PT VNR dated 2/25/21 revealed documentation the patient reported, "I need a bath, I need to urine vaccume (vacuum) purewic (Purewick -urinary system for incontinence)..." There was no documentation the PT notified the physician of the need for bath services and patient request for Purewick system. Review of the MR revealed no documentation the patient received bath aide services from the agency. An interview was conducted on 1/26/22 at 3:29 PM with EI # 1, who confirmed there was no documentation the physician was notified of the patient's need for bath aide services and request for Purewick system. EI # 1 also confirmed there was no documentation the patient received bath aide services from the agency.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, policies and procedures, and interviews, it was determined the agency failed to ensure staff: 1. Performed hand hygiene as directed per policy. 2. Disposed of medical waste per policy. This affected 2 of 6 Home Visits (HV), including HV # 4, HV # 6, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene Policy number: 8.004 Date revised: 5/1/19 Purpose: To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines. Policy: Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact... Procedure: 1. Staff performs hand hygiene ... f. before and after removal of personal protective equipment (PPE). Agency Policy: Agency Waste Handling and Disposal Policy number: 9.009 Date revised: 3/1/09 Purpose: To delineate the appropriate measures for general and biohazardous waste disposal by... safe handling and appropriate disposal of such waste... Policy: Based on type of waste generated, employees will dispose of identified waste materials consistent with safe patient care and infection prevention and control practices... Definitions: ...Medical Waste: ...Includes: ...dressing materials for wounds, IV (Intravenous) sites... which are heavily contaminated by blood and/ or infectious materials. Procedure: ...Medical Waste: 1. Items considered medical waste as defined above will be placed in a leak-proof, heavy duty plastic bag and securely fastened. Small amounts may be discarded in the patient's regular waste container once securely fastened. 1. HV # 4 was admitted to the agency on 1/23/22 with diagnoses including Secondary Osteoarthritis, Other Specified Site, and Primary Osteoarthritis, Right Ankle and Foot. A HV was conducted on 1/25/22 at 11:50 AM to observe PICC (Peripherally Inserted Central Catheter) care provided by Employee Identifier (EI) # 5, RN (Registered Nurse). EI # 1, Executive Director, was also present during the HV. EI # 5 donned gloves, removed the PICC line dressing, and placed the contaminated dressing on the bare carpet. EI # 5 removed her/his gloves and dropped them on the carpet. EI # 5 performed hand hygiene, donned sterile gloves, and cleaned the site with a chlorahexadine swab. The RN then removed gloves, dropped them on the carpet, and failed to perform hand hygiene prior to donning new gloves. EI # 5 donned gloves and performed an assessment of HV # 4's left foot. EI # 5 doffed gloves and failed to perform hand hygiene prior to gathering the patient's IV dressing supplies and documenting on the electronic tablet. An interview was conducted on 1/26/22 at 4:50 PM with EI # 1, who was also present during the HV, and confirmed EI # 5 failed to perform hand hygiene per policy, and failed to discard medical waste per policy. 2. HV # 6 was admitted to the agency on 9/10/19, recertified for continued care on 12/28/21 to 2/25/22, with diagnoses including Pressure Ulcer of Right Ankle, Stage 2, and Pressure Ulcer of Left Buttock, Stage 2, and Paraplegia, Unspecified. A HV was conducted on 1/26/22 at 3:15 PM to observe care provided by EI # 6, RN. EI # 1 was also present during the HV. EI # 6 performed hand hygiene, donned clean gloves, and examined HV # 6's right ankle wound. EI # 6 then doffed gloves and failed to perform hand hygiene prior to gathering supplies for dressing the wound. Following wound care, EI # 6 doffed gloves and failed to perform hand hygiene prior to opening patient's bedside drawer and retrieving scissors. An interview was conducted on 1/26/22 at 5:10 PM with EI # 1, who was also present during the HV, and confirmed staff failed to perform hand hygiene per policy.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, agency Elsevier Urinary Catheter protocol and interview, it was determined the agency staff failed to ensure 1. Wound assessments and measurements were conducted at least every 2 weeks per agency policy. 2. In and out (I&O) catherization was documented per agency protocol. This affected 1 of 3 records reviewed with surgical wounds, including MR # 11, and 1 of 1 MR reviewed with an in and out catherization, including MR # 5, and had the potential to negatively affect all patients with wounds at this agency. Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revised Date: 12/01/21 Purpose: To ensure the accurate and consistent assessment and documentation of wounds. Policy: Upon initial and subsequently as indicated below, all wounds will be assessed with appropriate documentation within the medical record. Wound location and description documentation is completed on all patients with wounds at the time of admit or upon development of a wound. ...During routine visits, wounds will be documented in the Wound Assessment Tool. ...Unless otherwise ordered by the physician, the Registered Nurse or Physical Therapist will assess wounds at least: Weekly for patient ... have an infected wound. Surgical incisions requiring wound care will be assessed every 2 weeks at a minimum unless the incision is exhibiting signs of infection... In this case the supervision clinician will assess the incision weekly, at minimum. Procedure: ...2. Perform wound care according to... physician orders. 3. Document the following in the medical record: a. Wound type... i. For surgical wounds, include any descriptions of complications... b. Location... c. Wound size: Length, Width and Depth... Agency Protocol: Elsevier: Urinary Catheter: Straight and Indwelling (Foley) Catheter Insertion... Date: Not documented ...Documentation Type, size, and length of catheter inserted ...Amount of urine drained. Characteristics of Urine (color, odor, sediment). ...Patient's response to the procedure... 2. MR # 5 was admitted to the agency on 9/24/21 to 11/22/21 with diagnoses including, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Kidney Disease, Stage 3 Unspecified, and Urinary Tract Infection (UTI), Site Not Specified. Review of the physician's order dated 9/29/21 revealed an order for "SN to obtain a urine specimen via I&O catheter for UA (Urinalysis) with C&S (culture and Sensitivity) due to possible UTI..." Review of the SN Visit Note Report dated 9/29/21 revealed documentation a UA with C&S was obtained via I&O catheter. There was no documentation of the type, size, and length of the catheter inserted, amount of urine drained, characteristics of the urine, and patient's response to the catherization. An interview was conducted on 1/26/22 at 3:17 PM with EI # 1, Executive Director, who confirmed there was no documentation of the type, size, and length of the catheter inserted, amount of urine drained, characteristics of the urine, and patient's response to the catherization per the agency protocol. 1. MR # 11 was admitted to the agency on 1/7/21 and recertified from 11/3/21 to 1/1/22 and 1/2/22 to 3/2/22 with diagnoses including Infection/Inflammatory Reaction Due to Internal Left Hip Prosthesis, Subsequent Encounter and Essential Hypertension. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 11/3/21 to 1/1/22 and 1/2/22 to 3/2/22 revealed a SN (Skilled Nurse) frequency of 1 wk (week) 9. SN to perform/instruct/reinforce patient/caregiver procedure of wound care to surgical wound to left hip: patient/cg (caregiver)/SN to cleanse wound daily...with normal saline or wound cleanser...apply collagen to wound bed. Cover with Mepilex using clean technique. Review of the SN weekly visit note dated 12/16/21 revealed there was no documentation the SN assessed or measured MR # 11's surgical wound per agency policy. Review of the SN weekly visit note dated 12/30/21 revealed there was no documentation the SN assessed or measured MR # 11's surgical wound per agency policy. The staff failed to assess and measure MR # 11's surgical wound every 2 weeks per agency policy. An interview was conducted on 1/26/22 at 4:53 PM with Employee Identifier (EI) # 2, Performance Improvement Coordinator (PIC), who verified the staff failed to ensure wounds were assessed and measured per agency policy.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, Fundamentals of Nursing by Potter-Perry, agency Elsevier Urinary Catheter protocol and interview with staff it was determined the agency failed to ensure: 1. The pt (patient)/cg (caregiver) provided a return demonstration for administration of Intravenous (IV) antibiotics through a Vascular Access Device (VAD) to ensure competency. 2. The pt/cg were provided Jackson Pratt (JP) drain and wound site care education/instruction per physician orders. 3. The pt/cg were provided education on Urinary Tract Infection (UTI). 4. The pt/cg were provided education on new antibiotic for UTI. This affected 1 of 2 patient's reviewed with a VAD, including MR # 10, and 2 of 3 of MR's reviewed for development of UTI, including MR # 4 and MR # 5, and had the potential to negatively affect all patients receiving IV antibiotics at this agency. Findings include: Agency Policy: Patient Education Policy Number: 3.001 Revised Date; 11/1/17 Policy: The agency plans, supports, and coordinates patient and caregiver educations designed to promotes optimal patient health and safety. Patients receive oral and/or written information for this purpose on an ongoing basis while being cared for by the agency. Procedure: ...5. Medical equipment: i. Purpose, operating instructions, troubleshooting, and correct use of supplies/accessories. ii. Precautions and warning for use. iii. Cleaning and infection-control precautions... 6. Per assessed knowledge deficit, patients and caregivers receive oral and/or written information on medication education to include: a. Dosage, route, duration ...f. Self administration and monitoring techniques g. Any special precautions or directions for preparation. Fundamentals of Nursing by Potter-Perry 6th Edition Chapter 24 Client Education Page 473 Key Concepts-....A nurse evaluates a client's learning by observing performance of expected learning behaviors under desired conditions.... Agency Protocol: Elsevier: Urinary Catheter: Straight and Indwelling (Foley) Catheter Insertion... Date: Not documented ...Documentation ...Education 2. MR # 4 was admitted to the agency on 9/18/21 with diagnoses including Aftercare Following Joint Replacement Surgery and Essential (Primary) Hypertension. Review of the HHC and POC dated 9/18/21 to 11/16/21 revealed documentation of "...the following co-morbidities that are new or have exacerbated within the last month...UTI symptoms..." Review of the SN VNR dated 9/19/21 revealed documentation the patient complained of urinary urgency and frequency and a urinalyses was obtained. There was no documentation the pt/cg was provided education on UTI. Review of the Client Medication Report revealed documentation the patient was prescribed Nitrofurantoin Macrocrystal 100 mg (milligram) every 12 hrs for 7 days and Phenazopyridine 200 mg three times daily for 5 days, with both medication documented for a UTI. An interview was conducted on 1/26/22 at 3:18 PM with EI # 1, Executive Director, who confirmed there was no documentation the pt/cg had been provided education on UTI. 3. MR # 5 was admitted to the agency on 9/24/21 to 11/22/21 with diagnoses including, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Kidney Disease, Stage 3 Unspecified, and Urinary Tract Infection (UTI), Site Not Specified. Review of the physician's order dated 9/29/21 revealed an order for "SN to obtain a urine specimen via I&O catheter for UA (Urinalysis) with C&S (culture and Sensitivity) due to possible UTI..." Review of the SN Visit Note Report dated 9/29/21 revealed documentation a UA with C&S was obtained via I&O catheter. There was no documentation the pt/cg was provided education on UTI. Review of the Client Coordination Note dated 10/1/21 revealed documentation the patient was prescribed a "...new antibiotic for UTI." Review of the MR revealed no documentation of the antibiotic the patient was prescribed, the pt/cg was provided education on the new antibiotic and UTI . An interview was conducted on 1/26/22 at 3:17 PM with EI # 1, Executive Director, who confirmed there was no documentation of the antibiotic the patient was prescribed, the pt/cg was provided education on the new antibiotic and UTI . 1. MR # 10 was admitted to the agency on 1/11/2022 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System, Encounter for Adjustment and Management of Vascular Access Device (VAD). and Long Term (Current) Use of Antibiotics. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 1/11/22 to 3/11/22 revealed a Skilled Nurse (SN) frequency of 1 week (wk) 9. SN... instruct patient/caregiver on administering the following medication Meropenem 1 gram every 8 hours till 1/16/22. Patient/ Caregiver to flush IV site with 10 ml (milliliters) of Normal Saline before infusion and 10 ml of Normal Saline and Heparin 10 units/5 ml after infusion. Followed by Heparin 10 units/ml with 10 ml of Normal Saline before and 10 ml of Normal Saline after infusion. SN instruct patient/caregiver regarding infusion procedure, care and use of infusion equipment and signs and symptoms of complications of IV therapy. Review of the SN admission visit dated 1/11/22 at 7: 53 AM revealed, "Pt neighbor who is a retired nurse showed competency of IV antibiotic treatment and IV midline flushed with mock demonstration". Review of the MR Coordination Notes by the SN dated 1/11/22 revealed, "Received call after hours from pt on SN personal cell. Pt states the planned friend for antibiotic administration won't be able for night time dose. Request nurse to come administer. Nurse informed this was not an option. Pt able to administer to self, but refuses. SN attempted to teach how to self administer medication during admission visit this morning. Pt refused. Pt states she will try and find someone to help." There was no documentation of the time the SN received the after hours call. There was no documentation the patient was educated on or refused to be educated on self administration of the IV antibiotics during the admission visit on 1/11/22. Review of the MR revealed a Physician's Order dated 1/17/22 at 2:50 PM which read, "...SN to provide/instruct/reinforce to client/caregiver wound care... Empty JP drain daily. Change dressing around the drain: cleanse with wound cleanser and cover with gauze, cover with tegaderm..." Review of the next SN visit note dated 1/17/22 at 2:50 PM revealed there was no documentation the patient was educated on or competent to administer the IV antibiotics per agency policy. There was no documentation the pt/cg was educated on the new wound care to the JP drain site as ordered. An interview was conducted on 1/26/22 at 4:58 PM with Employee Identifier (EI) # 2, Performance Improvement Coordinator (PIC), who verified the staff failed to educate the patient in the administration of IV antibiotics and JP drain and site care per agency policy.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, medical records (MR) and interviews, it was determined the agency failed to ensure medical record documentation was complete and accurate with all events, treatments, and medications administered which included: 1. Care and maintenance of a Vascular Access Device (VAD) as ordered. 2. Specific and accurate wound care provided. This affected 4 of of 17 MR's reviewed including MR # 10, Home Visit (HV) # 6, MR # 8, MR # 3 and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Home Care Record Policy Number: 7.003 Revised Date: 11/1/21 Purpose: To define the contents and requirements of the clinical home care record. Policy: A medical record is maintained for all patients receiving services and care from the agency. All entries in the patient care record will also reflect date and time care performed. Procedure: ...2. The patient home care record shall contain the following clinical information: ...e. Interventions, including medication administration, treatments, and services, and responses to those interventions. ...j. Education needs including ability, motivation, and readiness to learn. 3. MR # 8 was admitted to the agency on 7/14/21 and recertified for continued care 1/10/22 to 3/10/22, with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side and Dysarthria Following Cerebral Infarction. Review of the HHC and POC dated 1/10/22 to 3/10/22 revealed a physician order for SN once weekly to "...perform/instruct/reinforce patient/caregiver procedure of wound care as follows: for Left arm (# 6) and Right Shoulder (# 7) - Cleanse with wound cleanser/Normal Saline. Apply Xeroform to wound. Cover with adhesive bandage. For Left Groin (# 5) - Cleanse with wound cleanser/Normal Saline. Apply Xeroform to wound...Change all dressings daily...Patient/Caregiver to provide care in absence of SN..." Review of the SN Visit Note Report dated 1/14/22 revealed the following documentation under wound # 5 wound care provided: "for Left arm (# 6) and Right Shoulder (# 7) - Cleanse with wound cleanser/Normal Saline. Apply Xeroform to wound. Cover with adhesive bandage. For Left Groin (# 5) - Cleanse with wound cleanser/Normal Saline. Apply Xeroform to wound...Change all dressings daily...Patient/Caregiver to provide care in absence of SN..." There was no documentation of what was used to clean the wound, wound cleanser or Normal Saline. Further review of the SN Visit Note Report dated 1/14/22 revealed the following documentation under wound # 6 and wound # 7: "wound care not provided: client completed care." There was no documentation to clarify if the SN had completed the wound care to wounds # 6 and # 7 or if the caregiver had completed the wound care. An interview was conducted on 1/26/22 at 3:26 PM with EI # 2, who confirmed there was no documentation of what was used to clean the wounds. EI # 2 further confirmed there was no documentation to clarify who had performed the wound care to wounds # 6 and # 7 but felt the documented wound care to those wounds were under wound # 5 due to the association of the computer system. 4. MR # 3 was admitted to the agency on 10/28/2020, recertified for continued care from 4/26/21 to 6/24/21, with diagnoses including Pressure Ulcer of Right Buttock, Stage 4 and Paraplegia, Unspecified. Review of the Physician order dated 5/12/21 revealed and order for "SN to perform/instruct/reinforce patient/caregiver procedure of wound care to Stage 4 Rt (Right) Buttock...Cleanse with Normal Saline, pat dry, pack with Dakins Moistened gauze, cover with dry gauze dressing, secure with tape or mepilex daily...patient/caregiver to perform when SN not visiting..." Review of the SN Visit Note Reports dated 5/12/21, 5/21/21, 5/28/21 and 6/21/21 revealed documentation wound care was provided to wound # 1 Upper Right Buttock, Pressure Ulcer Stage 4 as follows: "Cleansed with Normal Saline, patted dry, packed with Dankins moistened gauze, covered with dry dressing, secured with tape or mepilex..." There was no documentation to clarify if the wound dressing was secured with tape or mepilex. An interview was conducted on 1/26/22 at 3:19 PM with EI # 2, who confirmed there was no documentation to clarify what was used to secure the wound dressing for wound # 1. 2. HV # 6 was admitted to the agency on 9/10/19, recertified for continued care on 12/28/21 to 2/25/22, with diagnoses including Pressure Ulcer of Right Ankle, Stage 2, and Pressure Ulcer of Left Buttock, Stage 2, and Paraplegia, Unspecified. A HV was conducted on 1/25/22 at 3:15 PM to observe care provided by EI # 6, RN (Registered Nurse). EI # 1, Executive Director, was also present during the HV. Review of the SN (Skilled Nurse) Visit Note Report, dated 1/25/22, revealed the following documentation by the SN, EI # 6, "...Wound # 6 - Low Buttock, LT (left), PU (Pressure Ulcer) Stage 1, Onset date: 01/25/22... discarded old dressing using biohazardous protocol..." This was a new wound that the patient requested the SN to examine. There was no dressing observed by the surveyor. Further review of the SN Visit Note Report, dated 1/25/22, revealed the following Narrative note by the SN, "... Patient was received in living room of clean and well-kept house... " On arrival, and during the entire home visit, the patient was lying in the bed in his/her bedroom. The house was cluttered and unclean with trash around on floor, counters, and table tops. An interview was conducted on 1/26/22 at 5:10 PM with EI # 1, who was also present during the HV, confirmed the inaccurate documentation by the SN, including there was no dressing on the left buttock, and the patient was in the bedroom during the HV. 1. MR # 10 was admitted to the agency on 1/11/2022 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System, Encounter for Adjustment and Management of Venous Access Device (VAD) and Long Term (Current) Use of Antibiotics. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 1/11/22 to 3/11/22 revealed a Skilled Nurse (SN) frequency of 1 week (wk) 9. SN to provide/instruct/reinforce to client/caregiver wound care to # 1 suprapubic closed incision suture line daily... Empty JP (Jackson Pratt) drain daily... SN for observation and access of IV (Intravenous) access site. Instruct patient/caregiver on administering the following medication Meropenem 1 gram every 8 hours till 1/16/22. Patient/ Caregiver to flush IV site with 10 ml (milliliters) of Normal Saline before infusion and 10 ml of Normal Saline and Heparin 10 units/5 ml after infusion. Followed by Heparin 10 units/ml with 10 ml of Normal Saline before and 10 ml of Normal Saline after infusion. SN instruct patient/caregiver regarding infusion procedure, care and use of infusion equipment and signs and symptoms of complications of IV therapy. SN to perform site care for infusion access device... with clear occlusive dressing changes weekly... cleanse with chlorhexidine,... cover with transparent dressing, injection cap change weekly. Review of the SN 1/11/22 admission note revealed, "Wound Care Provided: Pt (Patient) tolerated well with no complaints... Midline (VAD) dressing assessed, dressing changed... Pt neighbor who is a retired nurse showed competency of IV antibiotic treatment and IV midline flushed with mock demonstration... Mock demonstration of wound care and JP drain care. The SN failed to document the type of cleansing agent or dressing used to perform site care to the VAD and the type of wound care provided to the surgical incision (# 1 suprapubic closed incision). Review of the MR revealed a Physician's Order dated 1/17/22 which read, "SN to provide/instruct/reinforce to client/caregiver wound care... Empty JP drain daily. Change dressing around the drain: cleanse with wound cleanse and cover with gauze, cover with tegaderm." Review of the SN visit note dated 1/17/22 revealed, "Wound Care Provided: Pt (Patient) tolerated well with no complaints... Wound care provided per MD (Medical Doctor) orders." The SN failed to document the type of wound care provided to the surgical incision and the JP drain site. An interview was conducted on 1/26/22 at 4:58 PM with Employee Identifier (EI) # 2, Performance Improvement Coordinator (PIC), who verified the staff failed to ensure the MR documentation was complete for VAD and wound care per agency policy.