Every finding on record at Traditions Health Care of Independence

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 02/10/2022. During the survey it was determined Healthback Home Health of Missouri, Inc.- Independence is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

An extended survey for Medicare certification for Healthback Home Health of Missouri, Inc. – Independence was completed 02/10/2022. The agency had 25 current patients. Two condition-level deficiencies were identified during this survey: - 484.55 Condition of Participation: Comprehensive assessment of patients; and -484.105 Condition of Participation: Organization and administration of services. An additional condition-level deficiency was identified at an immediate jeopardy level as follows: - 484.60 Condition of Participation: Care Planning, coordination of services, and quality of care. An immediate jeopardy level for the likelihood of harm to two patients (Patient #3 and #5) and the likelihood of future harm to all current and future patients was identified during the survey. The findings were confirmed as immediate jeopardy by the Centers for Medicare and Medicaid Services (CMS). On 02/08/2022, the administrator was informed verbally and in writing via the IJ Template, of the findings identified at an immediate jeopardy level. A formal written removal plan was submitted by the agency on 02/10/2022. This removal plan was reviewed by the state agency (SA) in conjunction with CMS and it was determined at the time of the survey exit on 02/10/2022, that a satisfactory removal plan had been initiated related to the immediate jeopardy findings. The condition level deficiency identified above remains as cited. 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. A Covid 19 Focused Infection Control Survey was completed in conjunction with the survey with no deficiencies identified related to the Focused Infection Control Survey.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, and interview, the agency failed to ensure the patient received proper written notice, in advance of the home health agency (HHA) reducing or terminating on-going care in, but not limited to, one (Record/Patient #3) of three home visit observation. This deficient practice has the potential to adversely affect the patient's ability to pay for services for all the agency's patients. Findings included: Review of the agency's policy titled, “Client Discharge/Transfer Process,” revised 12/27/17, showed, in part: - The agency will coordinate with clients, caregivers, and physicians involved with client regarding discharge; - Client to receive written notice, in advance of a specific service being furnished, if the agency believes that the service may be non-covered care; or in advance of the agency reducing or terminating on-going care; and - Medicare and Medicare HMO patients are issued a notice of Medicare Non-Coverage (NOMNC) at least 48 hours prior of termination of home health services which explains the client’s right to an immediate independent review of the proposed discontinuation of services. RECORD/PATIENT #3: Observation on 02/01/2022 at 10:50 AM, during the patient's home visit showed the following: - The patient’s home folder contained visit frequency for PT (physical therapy) of 2wk2, 1wk6 (2 times a week for 2 weeks, and 1 time a week for 6 weeks) effective 12/12/2021; - Patient's instruction report in home folder was dated for 12/11/2021 to 02/08/2022, with patient receiving PT until week of 01/30/2022; - No written notice for reducing or terminating therapy services; - Spouse reported, they did not receive notice in advance for physical therapy being terminated; and - No discharge planning provided to the patient prior to termination of therapy services. During an interview on 02/01/2022 at 11:35 AM, the administrator stated: - The patient's insurance company denied insurance authorization for further physical therapy visits; - The patient’s insurance mails a letter to the patient regarding reason for denial; - The agency did not provide notice to the patient due to the insurance company sending notices to patient; - Therapy unable to make a discharge visit due to insurance not authorizing anymore visits; and - The patient’s daughter was informed via telephone that therapy services ended due to insurance authorization being denied.

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, and interview, the agency failed to ensure staff provided the written notice of the updated state toll free home health telephone hotline hours of operation (7:00 AM to 8:00 PM, seven days a week) in the admission booklet. This deficient practice has the potential to adversely affect the patient's knowledge and comprehension of the rights and responsibilities of all the agency's patients. Findings included: Review of the agency's policy titled, “CLIENT RIGHTS AND RESPONSIBILITES” dated revised 2017, showed in part: - Complaint procedure, you have the right to: ** Register a complaint; and ** The Missouri State Hotline Number 1-800-392-0210, open 365 days 7AM to 12AM midnight. Review of the agency’s current patient rights information showed, in part: - A care information form dated revised 2014 with the hotline hours listed as operating 365 days per year from 7 a.m. to 12 a.m.; and - A client rights and responsibilities complaint procedure dated revised 2017, with the hotline hours listed as open 365 days 7AM to 12AM midnight. During a review of the findings and interview conducted with the administrator on 01-31-2022 at 1:45 PM, the administrator stated that: - He/she was unaware of the change in the hotline hours; and - He/she would contact corporate.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on policy review, record review, observation, and interview, the agency failed to meet the requirements for the Condition of Participation: Comprehensive assessment of Patients, when the agency failed to ensure: -The initial assessment visit must be held within 48 hours of referral, or within 48 hours of the patients return home, or on the physician or allowed practitioner ordered start of care date (G514); -The comprehensive assessment accurately reflected the patient’s status (G526); -The comprehensive assessment must accurately reflect the patient’s status, and must include at a minimum, the patient’s medical, nursing, rehabilitative, social and discharge planning needs (G534); -The comprehensive assessment had a complete review of all mediations the patient was currently taking including potential adverse effects and drug reactions, ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy (G536); and -An accurate update of the comprehensive assessment at discharge (G550). The cumulative effect of these systemic practices resulted in the agency’s inability to ensure that the patient’s healthcare needs would be met by the home health agency.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in three (Records/Patients #2, #3, and #5) 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, “Comprehensive Client Assessment,” revised 12/27/17, showed, in part: - The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered start of care date; and - A comprehensive assessment is completed in a timely manner, consistent with the patient’s immediate needs, but no later than five calendar days after the start of care. RECORD/PATIENT #2: Review of the referral information, dated, 07/01/2021, showed, in part: - Order start of care date of 07/01/2021 for home health services; and - Skilled nursing services for medication education and management, including pill box set up bi-weekly. Review of the clinical record showed, in part: - SOC (start of care) was dated 07/06/2021; - Oasis question M0102 (Physician ordered start of care date), was answered with 07/06/2021; and - No order received for start of care to be on 07/06/2021. RECORD/PATIENT #3: Review of the referral records showed, in part: - Referral to home health service after hospitalization on 10/06/2021 for cellulitis (bacterial infection of the skin and deeper underlying tissue), metabolic encephalopathy (happens when another health condition such as kidney failure, makes it hard for the brain to work), and acute kidney injury (kidneys suddenly can’t filter waste from the blood); - Disciplines ordered: Skilled nursing for medication management and wound care, physical therapy for evaluation and treatment, occupational therapy for evaluation and treatment, home health aide for self-care, and social work services for community resources; - Patient discharged from hospital on 10/08/2021; and - Referral for home health services fax cover sheet with a date of 10/08/2021. Review of the clinical record showed, in part: - Skilled nurse SOC visit was dated 10/12/2021; - Oasis question M0102 (Physician ordered start of care date), was answered with 10/12/2021; and - No orders received for physician ordered start of care date. RECORD/PATIENT #5: Review of the referral records showed, in part: - Referral on 12/31/2021 for home health services after hospitalization for right total knee arthroplasty revision (surgery to replace nickel containing implant with a non-nickel implant due to having a metal allergy); and - Disciplines ordered: Skilled nursing for initial management of pain medication, anticoagulation, and surgical wound care, physical therapy to restore ROM (range of motion) with strength and home exercise training, occupational therapy for a safety assessment of the home. Review of the clinical record showed, in part: - Skilled nurse SOC visit was dated 01/06/2022; - Oasis is question M0102 (Physician ordered start of care date), was answered with 01/06/2022; and - No orders received for physician ordered start of care date. During an interview on 02/07/2022 at 5:10 PM, the administrator reported the referrals were received, but they were waiting on insurance authorization for patient #2 and patient #5. No orders provided for late start of care dates.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to accurately reflect the patient's status and include relevant patient data in the comprehensive assessment in one (Record/Patient #3) of three home visit observations. This deficient practice has the potential to affect the comprehensive assessments for all agency patients. Findings included: Review of the agency's policy titled, "Client Reassessment/Update of Comprehensive Assessment," dated, 12/27/2017, showed, in part, the following: - Each client is to receive a client-specific comprehensive assessment that accurately reflects the client’s current health status and demonstrates the client’s progress toward desired outcomes; - The comprehensive assessment must: ** Identify the client’s continuing need for home care; ** Meet the client’s medical, nursing, rehabilitative, social, and discharge planning needs; ** For Medicare client’s, identify eligibility for the home health benefit, including the client’s homebound status; - The comprehensive assessment will be updated and revised at the following time points: ** Recertification; ** Significant change in condition; ** Transfer of care; ** Resumption of care; and ** Discharge. Review of the agency's policy, titled, "Comprehensive Client Assessment," dated, 12/27/2017, showed, in part, the following: - Each client is to receive a client-specific, comprehensive assessment that accurately reflects the client’s current health; psychosocial, functional, and cognitive status; and reflects the client’s strengths, goals, and care preferences; - The assessment includes information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA (home health agency); - The comprehensive assessment will include a review of all medications the client is currently using; - The comprehensive assessment includes, but not limited to: ** Head to toe assessment; ** Identification of additional health problems or pertinent history; ** Integumentary status; and ** Other needed information that could impact the level of services required to meet the patient and family needs. RECORD/PATIENT #3: Review of the referral records showed, in part: - Referral to home health service after hospitalization on 10/06/2021 for cellulitis (bacterial infection of the skin and deeper underlying tissue), metabolic encephalopathy (happens when another health condition such as kidney failure, makes it hard for the brain to work), and acute kidney injury (kidneys suddenly can’t filter waste from the blood); - Disciplines ordered: Skilled nursing for medication management and wound care, physical therapy for evaluation and treatment, occupational therapy for evaluation and treatment, home health aide for self-care, and social work services for community resources; - Past medical history included, hypertension (the force of the blood against the artery walls is too high), hyperlipidemia (high levels of fat particles in the blood), hypothyroidism (thyroid gland doesn’t produce enough thyroid hormone), osteoarthritis (the wearing down of the protective tissue at the ends of bones) and Alzheimer’s disease (progressive disease that destroys memory and other important mental functions); - Patient discharged from hospital on 10/08/2021; and - Referral for home health services fax cover sheet with a date of 10/08/2021. Review of the discharge comprehensive assessment, dated, 02/01/2022 showed, in part: - The integumentary assessment findings had “no problems identified” documented; - The cardiovascular system assessment had “hypertension and hyperlipidemia” documented; - “Yes,” was documented for medication review being performed with, “No problems identified. Patient compliant with drug therapy,” noted. Observation on 02/01/2022 at 10:50 AM, during the patient's home visit, showed: - Patient with edema to BLE [bilateral lower extremities]. SN [skilled nurse] educated on elevating BLE; - Spouse reported skin under patients breasts “getting really bad again” with foul smell; - SN failed to perform a complete comprehensive assessment of patient during discharge visit; - SN failed to perform medication reconciliation; - After SN confirmed completion of discharge visit, surveyor reviewed patient medications and discrepancies were found; - Surveyor asked to see patient skin issues that spouse was concerned about. Patient had red irritation under bilateral breasts, right breast with open wound in the crease of breast, and strong foul odor; - SN observed skin issues, failed to assess wound, and no measurements obtained; - Discharge comprehensive assessment documentation does not accurately reflect the patient’s health status on discharge, observed by the surveyor; and - SN completed discharge visit with medication discrepancies, edema, and open wound with foul odor under breasts. During an interview on 02/07/2022 at 12:35 PM, the administrator reported the following: - When asked about discharge visit note on 02/01/2022 having documentation that medications were reviewed and no issues identified, the administrator reported, “you reviewed them” and “I didn’t write down the meds [medications] so I didn’t get orders;” - Medications not added to the MAR (medication administration record); - When asked about discharge visit note on 02/01/2022 having documentation that skin was assessed and no issues were found, the administrator reported, no issues were found was a “mistake” on the documentation and that he/she was in a hurry when documenting; - When asked why skin assessment was not performed during the discharge visit, the administrator reported, “I guess I forgot;” - Normally “I would do an assessment and notify the physician that it was back open and red;” - “I followed up with the [spouse] and it’s getting better now; and - Physician not contacted regarding patient’s impaired skin integrity, open wound, edema to BLE, and medication discrepancies identified by the surveyor during the discharge observation visit.

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 policy review, clinical record review, home visit observation, and interview, the agency failed to ensure patient’s medical, nursing, rehabilitative, social, and discharge planning needs, were met in two (Records/Patients #3 and #5) of five 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, "Client Reassessment/Update of Comprehensive Assessment," dated, 12/27/2017, showed, in part, the following: - Each client is to receive a client-specific, comprehensive assessment that accurately reflects the client’s current health status and demonstrates the client’s progress toward desired outcomes; - The comprehensive assessment must: ** Identify the client’s continuing need for home care; ** Meet the client’s medical, nursing, rehabilitative, social, and discharge planning needs; ** For Medicare client’s, identify eligibility for the home health benefit, including the client’s homebound status; - The comprehensive assessment will be updated and revised at the following time points: ** Recertification; ** Significant change in condition; ** Transfer of care; ** Resumption of care; and ** Discharge. Review of the agency's policy titled, "Comprehensive Client Assessment," dated 12/27/2017, showed, in part, the following: - The purpose is to accurately reflect the current health status of the client and need for home care services; - Each client is to receive a client-specific, comprehensive assessment that accurately reflects the client’s current health; psychosocial, functional, and cognitive status; and reflects the client’s strengths, goals, and care preferences; - The assessment includes information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA (home health agency); - The comprehensive assessment will include a review of all medications the client is currently using; - The comprehensive assessment includes, but not limited to: ** Head to toe assessment; ** Identification of additional health problems or pertinent history; ** Integumentary status; and ** Other needed information that could impact the level of services required to meet the patient and family needs. RECORD/PATIENT #3: Review of the referral records showed, in part: - Referral to home health service after hospitalization on 10/06/2021 for cellulitis (bacterial infection of the skin and deeper underlying tissue), metabolic encephalopathy (happens when another health condition such as kidney failure, makes it hard for the brain to work), and acute kidney injury (kidneys suddenly can’t filter waste from the blood); - Disciplines ordered: Skilled nursing for medication management and wound care, physical therapy for evaluation and treatment, occupational therapy for evaluation and treatment, home health aide for self-care, and social work services for community resources; - Past medical history of hypertension (the force of the blood against the artery walls is too high), hyperlipidemia (high levels of fat particles in the blood), hypothyroidism (thyroid gland doesn’t produce enough thyroid hormone), osteoarthritis (the wearing down of the protective tissue at the ends of bones) and Alzheimer’s disease (progressive disease that destroys memory and other important mental functions); - Patient discharged from hospital on 10/08/2021; and - Referral for home health services fax cover sheet with a date of 10/08/2021. Review of the POC (plan of care), dated 10/12/2021 to 12/10/2021 showed, in part: - Primary diagnosis of cellulitis of chest wall; - Other diagnosis included, Alzheimer’s disease, Dementia, Hypertension, Polyosteoarthritis, hyperlipidemia, hypothyroidism, and history of falling; - Skilled nurse (SN) to perform multisystem assessment every visit with emphasis on cardiovascular, musculoskeletal, and integumentary. Skilled nurse to provide instructions/reinforcement for management of disease process PRN (as needed); - SN to provide instructions/reinforcement for management of hypertension to include diet, medication, therapy, disease process, and activities permitted; - SN to instruct regarding chronic renal failure to include disease process, signs and symptoms, complications and management of disease process. No diagnosis on POC for chronic renal failure; - SN to instruct patient/caregiver on prevention of pressure ulcers. No diagnosis or history of pressure ulcers; - SN to review home safety each visit and instruct patient/caregiver in methods to prevent falls and improve home safety; - SN may instruct/reinforce new, change, and current medications regimen; - SN to provide discharge planning with patient/caregiver every visit; - SN to instruct client/caregiver regarding infection control measures R/T (related to) cellulitis; and - The plan of care (POC) failed to show diagnosis, interventions, and treatment for yeast infection under patient’s breast. Review of the clinical record showed, in part: - SN SOC (start of care) visit, dated 10/12/2021, showed, skin assessment completed and rash under breasts; - The comprehensive assessment failed to show: ** Detailed skin assessment under breasts with details of rash; ** Interventions and/or treatment plan for impaired skin integrity related to diagnosis of cellulitis; ** No education provided to patient/caregiver for cellulitis, yeast, or rash under breasts; - SN visit note on 11/09/2021 showed, vital sign alert for blood pressure of 152/94 (high limit 160/90) with comment of “Patient in pain [rated] 4 out of 10. Patient denies chest pain, headache, vision is clear and no ringing in ears. Patient reports sinus pressure and takes Clarinex-D every 12 hours. Follow-up comment entered by [screen watcher] on 01/09/2021 faxed to provider;” and - Clinical record failed to show documentation for call to physician regarding blood pressure. Review of the POC, dated, 12/11/2021 to 02/08/2022 showed, in part: - Primary diagnosis of cellulitis of chest wall; - Other diagnosis included, Alzheimer’s disease, Dementia, Hypertension, Polyosteoarthritis, hyperlipidemia, hypothyroidism, and history of falling; - SN to perform multisystem assessment every visit with emphasis on cardiovascular, musculoskeletal, and integumentary. Skilled nurse to provide instructions/reinforcement for management of disease process PRN (as needed); - SN to provide instructions/reinforcement for management of hypertension to include diet, medication, therapy, disease process, and activities permitted; - SN to instruct patient/caregiver on prevention of pressure ulcers. No diagnosis or history of pressure ulcers; - SN to review home safety each visit and instruct patient/caregiver in methods to prevent falls and improve home safety; - SN may instruct/reinforce new, change, and current medications regimen; - SN to provide discharge planning with patient/caregiver every visit; - The POC failed to show diagnosis, interventions, and treatment for yeast infection under patient’s breast; - The POC failed to show interventions, treatment, or wound care to abrasions from fall; and - The POC failed to show diagnosis, interventions, and treatment for edema. Review of the clinical record showed, in part: - SN visit note on 12/13/2021 showed, patient with 3+ pitting edema, patient educated to reduce sodium in diet and elevate lower extremities; - SN visit note on 12/27/2021 showed, skin assessment completed, abrasion to left knee, patient fell on Christmas day after tripping on uneven concrete and landing on left knee, left forearm, small scrape to right wrist, and all areas covered with band aids (No wound record report with measurements or detailed assessment, and no documentation of physician being contacted); - SN visit note on 01/03/2022 showed, patient with abrasion on left knee, 4+ edema to BLE (bilateral lower extremities) with 1+ diminished pedal pulses, capillary refill greater than 3 seconds, patient unsteady, held onto wall when ambulating, left knee healing per CG (caregiver), dressing dry and intact, left forearm and right wrist healed; - SN visit note on 01/12/2022 showed, 4+ edema to BLE; - SN visit note on 01/17/2022 showed, 4+ edema to BLE with 1+ diminished pedal pulses; - SN visit note on 01/24/2022 showed, discharge planning for end of episode as max potential will be met; and - SN discharge visit note on 02/01/2022 showed, medications reviewed with no issues identified, patient compliant with drug therapy, and integumentary assessment with no problems identified (SN failed to document edema present during visit, medication discrepancies, and open wound). Observation on 02/01/2022 at 10:50 AM, during the patient's home visit showed: - Patient with edema to BLE. SN educated on elevating BLE; - Spouse reported skin under patients breasts “getting really bad again” with foul smell; - SN failed to perform a complete comprehensive assessment of patient during discharge visit; - SN failed to perform a medication reconciliation; - After SN confirmed completion of discharge visit, surveyor reviewed patient medications and discrepancies found; - Surveyor asked to see patient skin issues that spouse was concerned about. Patient had red irritation under bilateral breasts, right breast with open wound in the crease of breast, and strong foul odor; - SN observed skin issues, failed to assess wound, and no measurements obtained; - Discharge comprehensive assessment documentation does not accurately reflect the patient’s health status on discharge, observed by the surveyor; and - SN completed discharge visit with medication discrepancies, edema, and open wound with foul odor under breasts. During an interview on 02/07/2022 at 12:35 PM, the administrator, stated the following: - The patient didn’t have any open wounds on admission, “just red,” and “if it’s just red” and “not open,” it doesn’t go on a wound record because it requires a “WAT” (wound assessment tool) score; - When asked about discharge visit note on 02/01/2022 having documentation that medications were reviewed and no issues identified, the administrator reported, “you reviewed them” and “I didn’t write down the meds [medications] so I didn’t get orders;” - Medications not added to the MAR (medication administration record); - When asked about discharge visit note on 02/01/2022 having documentation that skin was assessed and no issues were found, the administrator reported, no issues were found was a “mistake” on the documentation and that he/she was in a hurry when documenting; - When asked why skin assessment was not performed during the discharge visit, the administrator reported, “I guess I forgot;” - Normally “I would do an assessment and notify the physician that it was back open and red,” the physician was not contacted, and “I followed up with the [spouse] and it’s getting better now; - The physician was sent a fax on 11/09/2021 regarding blood pressure of 152/94 (No documentation provided of physician being called for confirmation and/or follow up on blood pressure); - No documentation provided for skin assessment of abrasions from fall, physician being notified of fall with injuries and/or wound care orders for abrasions from fall; and - No documentation provided for physician being contacted regarding edema. During a telephone interview on 02/08/2022 at 10:22 AM, spouse/caregiver, reported the following: - The patient has an appointment with physician scheduled for 02/09/2022 due to the patient having “more swelling” to bilateral lower extremities, skin under breasts being “worse” with odorous wounds being open “under both breasts,” and Spouse is "afraid” because he/she is “not good;” - When asked about services being offered for HHA (home health aide), OT (occupational therapy), and MSW (medical social worker), the spouse reported that no services were ever offered by the agency, caregiver did not refuse those services, and that the patient would benefit from any assistance possible; and - When asked if the administrator contacted the spouse to follow-up on the patient’s condition, the spouse reported, “I have not talked to [administrator] since last week.” RECORD/PATIENT #5: Review of the referral records showed: - Referral on 12/31/2021 for home health services after hospitalization for right total knee arthroplasty [TKA] revision (surgery to replace nickel containing implant with a non-nickel implant due to having a metal allergy); - Disciplines ordered: Skilled nursing for initial management of pain medication, anticoagulation, and surgical wound care, physical therapy to restore ROM (range of motion) with strength and home exercise training, occupational therapy for a safety assessment of the home; and - Past medical history of osteoarthritis (the wearing down of the protective tissue at the ends of bones), LBP (lower back pain) with sciatica (pain that radiates along the path of the sciatic nerve), pneumonitis (inflammation of the lung tissue), migraines (a headache of varying intensity), and thyroid nodule (lump in the thyroid). Review of the clinical records showed: - The plan of care, dated 01/06/2022 to 03/06/2022 showed, licensed professional to report vital signs falling outside the established parameters for temperature less than 95 or greater than 101, pulse less than 50 or greater than 100, respirations less than 14 or greater than 26, systolic blood pressure less than 90 or greater than 160, diastolic blood pressure less than 50 or greater than 90, fasting blood sugar less than 65 or greater than 150, random blood sugar less than 65 or greater than 250, oxygen saturation less than 90, and pain rated greater than 6; - Skilled nurse start of care visit, dated 01/06/2022, showed vital sign alert for sitting blood pressure of 168/87 (upper limit of 160/90), standing blood pressure of 170/88, and pain rated 9 (0 being no pain and 10 being the worst pain), comments report “pain meds taken” and “provider aware” (No documentation to clarify and/or confirm how the provider was aware); - PTA (physical therapy assistant) visit note on 01/07/2022 showed, pain rated 8, comment of “patient hasn’t taken medication since 4:00 AM follow up comment entered by [screen watcher] on 01/09/2022 faxed to provider,” no physician contacted by PTA, patient’s pain interfering with activity or movement all the time, areas of pain are back, hip, and knee, quality of pain is aching, pressure, radiating, tender, and throbbing, onset of patient’s pain s/p (status post) TKR (total knee revision), and non-verbal signs of pain demonstrated by patient included grimacing, moaning, guarding, tense, and restlessness, disciplines communicated with were supervisor, PT (physical therapist), and RN (registered nurse); - PTA visit note on 01/11/2022 showed, pain rated 7, comment of “patient states [he’s/she’s] having a lot of pain in low back, right hip, and knee. Taking pain meds every 4-5 hours. Follow up comment entered by [screen watcher] on 01/11/2022 faxed to provider,” no physician contacted by PTA, patient’s pain interfering with activity or movement all the time, areas of pain are back, hip, and knee, quality of pain is aching, burning, cramping, radiating, shooting, stabbing, and throbbing, onset of patient’s pain s/p TKR from 2 weeks ago, and non-verbal signs of pain demonstrated by patient included grimacing, moaning, guarding, and restlessness, disciplines communicated with were supervisor and RN, and communication details regarding laxatives patient can take due to lack of bowel movement since surgery; - PTA visit note on 01/13/2022 showed, pain rated 7, comment of “Pain with activity but especially at rest after activity. Follow up comment entered by [screen watcher] on 01/14/2022 faxed to provider,” no physician contacted by PTA, patient’s pain interfering with activity or movement all the time, areas of pain are back, hip, and knee, quality of pain is aching, cramping, radiating, sore, stabbing, tender, and throbbing, onset of patient’s pain s/p TKR, and non-verbal signs of pain demonstrated by patient included grimacing, moaning, guarding, tense, and restlessness, disciplines communicated with were supervisor and RN, and communication details noted that SN was present to remove staples from incision prior to PT visit; - SN visit note on 01/13/2022 showed, pain rated 7, comment of “MD (medical doctor) aware chronic pain. Follow up comment entered by [administrator] on 01/13/2022 provider aware,” pain areas were back and knee, quality of aching, dull, sore, and throbbing, onset of pain several months ago R/T (related to) OA and failed R (right) TKA, non-verbal signs of pain included grimacing and restlessness, integumentary issues included incision staples removed, steri-strips placed, and patient tolerated well, and communication with other disciplines involved in this case was answered no; and - PTA visit note on 01/19/2022 showed, pain rated 7, comment of “Patient hasn’t taken pain medication for 6 hours. Follow up comment entered by [administrator] on 01/19/2022 provider aware,” no physician contacted by PTA, patient’s pain interfering with activity or movement all the time, areas of pain are back, hip, and knee, quality of pain is aching, cramping, radiating, sore, stabbing, tender, and throbbing, onset of patient’s pain s/p TKR, and non-verbal signs of pain demonstrated by patient included grimacing, guarding, and restlessness, disciplines communicated with were PT regarding PT POC. During a telephone interview on 02/07/2022 at 11:12 AM, the patient reported the following: - The agency “didn’t do anything” that helped the pain; - During home visits the skilled nurse checked vital signs, “asked how I was doing,” and “told me to take my oxycodone and my Tizanidine at the same time” to help get pain under control; - The surgical incision at the bend of the knee “opened up about a day or so after” staples removed by SN, “it started bleeding,” SN “put a bandage on it,” and “it worried me so I put a call into the doctor’s office and the doctor told me to stop doing therapy for a couple days” to prevent incision from opening further; - When asked about issues having a bowel movement, noted on therapy visit note on 01/11/2022, the patient reported, “Before I left the hospital I hadn’t had a bowel movement. I still hadn’t had one after I got home, so the therapist called the nurse and the nurse told me to get senna and prune juice” and “I finally had a bowel movement the next day” (01/12/2022); and - The “only thing that really bothered me was they never called the doctor, I had to call them.” During an interview on 02/07/2022 at 1:15 PM, the administrator reported the following: - The PTA is expected to call the physician with vital signs or pain outside of parameters and then notify the supervisor; - The PTA “will be in-serviced” on calling the physician regarding vital sign alerts; - When asked about the patient having non-verbal signs of pain, the administrator reported, “This patient grimaces every time you do anything” with him/her, and the patient would “scream” when “I put a blood pressure cuff on” him/her; - When asked about an order to place steri-strips to the surgical incision after removing the staples, the administrator reported, “I didn’t have an order” but the “patient insisted” that steri-strips be placed on surgical incision and “I didn’t call the doctor for an order because I don’t view steri-strips as being invasive;” and - When asked about the PTA note regarding the administrator being contacted about laxatives due to lack of bowel movement since surgery, the administrator reported that he/she was not informed of patient not having a bowel movement since surgery, the patient was recommended prune juice by the administrator, the physician was never contacted about constipation because the patient “did not want to take another pill,” and the prune juice did help.

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, observation and interview the agency failed to perform 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 effect, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy in two (Records/Patients #1 and #3) of five full records reviewed. This deficient practice has the potential to adversely affect the medication management of all patients served by the agency. RECORD/PATIENT #3: Review of the plan of care, dated 12/11/2021 through 02/08/2022, showed, in part: - Aspirin 81mg (milligrams) tablet, delayed release, take 1 tablet by mouth daily for heart health; - Cholecalciferol (vitamin D3) 25mcg (micrograms) 1,000unit tablet, take 1 tablet by mouth daily for dietary supplement; and - Omeprazole 20mg capsule, delayed release, take 1 capsule by mouth daily for reflux. During a home visit on 02/01/2022 at 10:50 AM, the following medication discrepancies were identified: - Aspirin 81mg tablet, patient taking 1 tablet by mouth every other daily for heart health; - Patient is not taking Cholecalciferol dietary supplement; - Omeprazole 20mg capsule, delayed release, patient taking 1 capsule by mouth two times daily for reflux; - Patient is taking colon health probiotic 1.75 billion live bacteria/colony forming units (CFUs) 1 capsule by mouth daily (not on plan of care); - Nystatin topical powder 100,000 units per gram, apply topically to affected area two times daily for yeast infection (not on plan of care); and - Aripiprazole 5mg tablet, take 1 tablet by mouth every bedtime for moods (not on plan of care). During interview on 02/07/2022 at 12:35 PM, the administrator reported the following: - When asked about discharge visit note on 02/01/2022 having documentation that medications were reviewed and no issues identified, the administrator reported, “you reviewed them” and “I didn’t write down the meds so I didn’t get orders;” - Medications not added to the MAR (medication administration record); and - No further documentation provided for physician being notified and medication clarification being received. Findings included: Review of the policy titled, “Medication review process”, dated 2018, showed in part: - CMS (Centers for Medicare and Medicaid Services) requirements state that each patient will have a comprehensive drug regimen review; - This review is to include all medications, prescribed and over the counter, administered by any route (oral, topical, inhalant, pump, injection, IV- intravenous); - The patient’s home meds are to be reconciled with the physician’s and/or hospital discharge documentation to ensure patient safety and physician oversight of all medications; - Any discrepancies shall be reported to physician for guidance; - RN (registered nurse) case manager will review all medications found in the patient’s home; - The RN shall assess all other medication problems, including but not limited to, dosage errors, ineffective drug therapy (example: an analgesic that does not reduce pain), noncompliance, and medication reconciliation with physician as appropriate; - RN case manager/Clinical supervisor shall ensure medication review results and outcomes are documented; - This process to be followed with new/changed medication orders that are added within visit or in office and an alert appears; and - The POC (plan of care) will reflect the completed medication reconciliation with the physician and all medications will include dose/frequency/route/usage and pertinent instructions for all medications. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency 11/04/2021 with, but not limited to, diagnoses of spinal stenosis of the lumbar region with neurogenic claudication (narrowing of the spinal canal of the lower back resulting in pressure on the nerve roots, which causes symptoms of pain, fatigue, weakness or numbness in the legs that is made worse with activity such as walking). During a home visit observation on 01/31/2022 starting at 3:15 PM with the PTA (physical therapy assistant) the following issues were noted: - PTA failed to complete a comprehensive drug regimen review; - PTA asked if the doctor had changed or added any meds since the last visit and when the patient denied no, further review was completed by the PTA; - During surveyor review of the current medication regimen during the observation visit with the patient the following discrepancies were noted: - The VA discharge medication list dated 10/18/2021 showed cyclobenzaprine HCL 10 mg tablet take 1 tablet by mouth at bedtime. The current medication profile showed cyclobenzaprine HCL 10 mg tablet take 1 tablet three times daily. The clinical record failed to show clarification of the discrepancy; - The VA discharge medication list dated 10/18/2021 showed mometasone furoate 220mcg(microgram) oral inhalation 2 puffs at bedtime for breathing. The current medication profile failed to include the mometasone furoate and the clinical record failed to show clarification of the discrepancy; and - The VA discharge medication list dated 10/18/2021 showed omeprazole 20mg (miligrams) take one capsule by mouth every morning to lower stomach acid, take 30 minutes prior to food. The patient stated that he/she takes it 30 minutes before suppertime. During an interview with the administrator on 02/01/2022 at 12:05 PM the medication discrepancies were reviewed with no further information provided. RECORD/PATIENT #3:

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the comprehensive assessment was updated at discharge including a complete medication review, in one (Record/Patient #3) of six records reviewed. This deficient practice has the potential to affect the post discharge medication accuracy for all the agency's patients. Findings included: Review of the agency's policy, titled, "Client Reassessment/Update of Comprehensive Assessment," dated, 12/27/2017, showed, in part, the following: - Each client is to receive a client-specific comprehensive assessment that accurately reflects the client’s current health status and demonstrates the client’s progress toward desired outcomes; - The comprehensive assessment must: ** Identify the client’s continuing need for home care; ** Meet the client’s medical, nursing, rehabilitative, social, and discharge planning needs; ** For Medicare client’s, identify eligibility for the home health benefit, including the client’s homebound status; - The comprehensive assessment will be updated and revised at the following time points: ** Recertification; ** Significant change in condition; ** Transfer of care; ** Resumption of care; and ** Discharge. Review of the agency's policy, titled, "Comprehensive Client Assessment," dated, 12/27/2017, showed, in part, the following: - Each client is to receive a client-specific comprehensive assessment that accurately reflects the client’s current health; psychosocial, functional, and cognitive status; and reflects the client’s strengths, goals, and care preferences; - The assessment includes information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA (home health agency); - The comprehensive assessment will include a review of all medications the client is currently using; - The comprehensive assessment includes, but not limited to: ** Head to toe assessment; ** Identification of additional health problems or pertinent history; ** Integumentary status; and ** Other needed information that could impact the level of services required to meet the patient and family needs. RECORD/PATIENT #3: Review of the clinical record, showed, in part: - Referral to home health service after hospitalization on 10/06/2021 for cellulitis (bacterial infection of the skin and deeper underlying tissue), metabolic encephalopathy (happens when another health condition such as kidney failure, makes it hard for the brain to work), and acute kidney injury (kidneys suddenly can’t filter waste from the blood); - Review of the discharge comprehensive assessment, dated 02/01/2022 showed: ** Integumentary assessment findings had “no problems identified” documented; ** Cardiovascular system assessment had “hypertension and hyperlipidemia” documented; ** “Yes,” documented on medication review being performed with, “No problems identified. Patient compliant with drug therapy,” noted. Observation on 02/01/2022 at 10:50 AM, during the patient's home visit showed: - Patient with edema to BLE [bilateral lower extremities]. SN [skilled nurse] educated on elevating BLE; - Spouse reported skin under patients breasts “getting really bad again” with foul smell; - SN failed to perform a complete comprehensive assessment of patient during discharge visit; - SN failed to perform a medication reconciliation; - After SN confirmed completion of discharge visit, surveyor reviewed patient medications and discrepancies found; - Surveyor asked to see patient skin issues that spouse was concerned about. Patient had red irritation under bilateral breasts, right breast with open wound in the crease of breast, and strong foul odor; - SN observed skin issues, failed to assess wound, and no measurements obtained; - Discharge comprehensive assessment documentation does not accurately reflect the patient’s health status on discharge, observed by the surveyor; and - SN completed discharge visit with medication discrepancies, edema, and open wound with foul odor under breasts. During an interview on 02/07/2022 at 12:35 PM, the administrator stated the following: - When asked about discharge visit note on 02/01/2022 having documentation that medications were reviewed and no issues identified, the administrator reported, “you reviewed them” and “I didn’t write down the meds [medications] so I didn’t get orders;” - Medications not added to the MAR (medication administration record); - When asked about discharge visit note on 02/01/2022 having documentation that skin was assessed and no issues were found, the administrator reported, no issues were found was a “mistake” on the documentation and that he/she was in a hurry when documenting; - When asked why skin assessment was not performed during the discharge visit, the administrator reported, “I guess I forgot;” - Normally “I would do an assessment and notify the physician that it was back open and red;” - “I followed up with the [spouse] and it’s getting better now; - Physician not contacted regarding patient’s impaired skin integrity, open wound, edema to BLE, and medication discrepancies identified by the surveyor during the discharge observation visit.

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, record review, home visit observation and interview, the agency failed to meet the requirements for the Condition of Participation: Care Planning, coordination of services, and quality of care when the agency failed to ensure: -Each patient must receive an individualized written plan of care including, but not limited to, all medications and treatments (G574); -Services provided followed the plan of care as ordered by the physician (G580); -The home health agency must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest the outcomes are not being achieved and/or that the plan of care should be altered (G590) resulting in an immediate jeopardy; -Any revisions related to the patient’s discharge must be communicated to the patient, representative, caregiver, and all physicians or allowed practitioners issuing orders for the home health agency plan of care, and the patient’s primary care practitioner or other healthcare professional who will be providing care and services to the patient after discharge from the home health agency (if any) (G598); -Coordinate care delivery to meet the patient’s needs (G608); and -Provide written information of any treatments to be administered by home health agency personnel and personnel acting on behalf of the home health agency, including therapy services (G 618). The cumulative effect of these systemic deficient practices has the potential to adversely affect the quality of care for all the patients served by the home health agency.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, observation, and interview the agency failed to ensure an accurate and complete plan of care was developed in, but not limited to, three (Records/Patients #3, #4, and #5) of five full records reviewed. This deficient practice has the potential for unmet needs for all the agency’s patients. RECORD/PATIENT #3: Review of the referral records showed, in part: - Referral to home health service after hospitalization on 10/06/2021 for cellulitis (bacterial infection of the skin and deeper underlying tissue), metabolic encephalopathy (happens when another health condition such as kidney failure, makes it hard for the brain to work), and acute kidney injury (kidneys suddenly can’t filter waste from the blood); - Disciplines ordered: Skilled nursing for medication management and wound care, physical therapy for evaluation and treatment, occupational therapy for evaluation and treatment, home health aide for self-care, and social work services for community resources. No evaluation, treatment, or services were provided to patient for occupational therapy, home health aide, or social work services as ordered in referral; - Past medical history of hypertension (the force of the blood against the artery walls is too high), hyperlipidemia (high levels of fat particles in the blood), hypothyroidism (thyroid gland doesn’t produce enough thyroid hormone), osteoarthritis (the wearing down of the protective tissue at the ends of bones) and Alzheimer’s disease (progressive disease that destroys memory and other important mental functions); - Patient discharged from hospital on 10/08/2021; and - Referral for home health services fax cover sheet with a date of 10/08/2021. Review of the POC (plan of care), dated 10/12/2021 to 12/10/2021 showed, in part: - Primary diagnosis of cellulitis of chest wall; - Other diagnosis included Alzheimer’s disease, Dementia, Hypertension, Polyosteoarthritis, hyperlipidemia, hypothyroidism, and history of falling; - Skilled nurse to perform multisystem assessment every visit with emphasis on cardiovascular, musculoskeletal, and integumentary. Skilled nurse to provide instructions/reinforcement for management of disease process PRN (as needed); - Skilled nurse to provide instructions/reinforcement for management of hypertension to include diet, medication, therapy, disease process, and activities permitted; - Skilled nurse to instruct regarding chronic renal failure to include disease process, signs and symptoms, complications and management of disease process. No diagnosis on POC for chronic renal failure; - Skilled nurse to instruct patient/caregiver on prevention of pressure ulcers. No diagnosis or history of pressure ulcers; - Skilled nurse to review home safety each visit and instruct patient/caregiver in methods to prevent falls and improve home safety; - Skilled nurse may instruct/reinforce new, change, and current medications regimen; - SN (skilled nurse) to provide discharge planning with patient/caregiver every visit; - Skilled nurse to instruct client/caregiver regarding infection control measures R/T (related to) cellulitis; and - The POC failed to show diagnosis, interventions, and treatment for yeast infection under patient’s breast. Review of the POC, dated 12/11/2021 to 02/08/2022 showed, in part: - Primary diagnosis of cellulitis of chest wall; - Other diagnosis included Alzheimer’s disease, Dementia, Hypertension, Polyosteoarthritis, hyperlipidemia, hypothyroidism, and history of falling; - Skilled nurse to perform multisystem assessment every visit with emphasis on cardiovascular, musculoskeletal, and integumentary. Skilled nurse to provide instructions/reinforcement for management of disease process PRN (as needed); - Skilled nurse to provide instructions/reinforcement for management of hypertension to include diet, medication, therapy, disease process, and activities permitted; - Skilled nurse to instruct patient/caregiver on prevention of pressure ulcers. No diagnosis or history of pressure ulcers; - Skilled nurse to review home safety each visit and instruct patient/caregiver in methods to prevent falls and improve home safety; - Skilled nurse may instruct/reinforce new, change, and current medications regimen; - SN (skilled nurse) to provide discharge planning with patient/caregiver every visit; - The POC failed to show diagnosis, interventions, and treatment for yeast infection under patient’s breast; - The POC failed to show interventions, treatment, or wound care to abrasions from fall; and - The POC failed to show diagnosis, interventions, and treatment for edema. Review of the clinical records showed, in part: - Skilled nurse SOC (start of care) visit, dated 10/12/2021, showed, skin assessment completed and rash under breasts; - SN visit note on 12/13/2021 showed, patient with 3+ pitting edema, patient educated to reduce sodium in diet and elevate lower extremities; - SN visit note on 12/27/2021 showed, skin assessment completed, abrasion to left knee, patient fell on Christmas day after tripping on uneven concrete and landing on left knee, left forearm, small scrape to right wrist, and all areas covered with band aids; - SN visit note on 01/03/2022 showed, patient with abrasion on left knee, 4+ edema to BLE (bilateral lower extremities) with 1+ diminished pedal pulses, capillary refill greater than 3 seconds, patient unsteady, held onto wall when ambulating, left knee healing per CG (caregiver), dressing dry and intact, left forearm and right wrist healed. No documentation of physician being contacted; - SN visit note on 01/17/2022 showed, patient having 4+ edema to BLE with 1+ diminished pedal pulses; and - Clinical record failed to show physician notification, orders, and no updates to the POC to reflect patient’s change in condition. During interview on 02/07/2022 at 12:35 PM, the administrator acknowledged the findings. No further documentation provided. RECORD/PATIENT #5: Review of the referral records showed, in part: - Referral on 12/31/2021 for home health services after hospitalization for right total knee arthroplasty revision (surgery to replace nickel containing implant with a non-nickel implant due to having a metal allergy); - Disciplines ordered: Skilled nursing for initial management of pain medication, anticoagulation, and surgical wound care, physical therapy to restore ROM (range of motion) with strength and home exercise training, occupational therapy for a safety assessment of the home. No evaluation, treatment, or services were provided to patient for occupational therapy, as ordered in referral; - Past medical history of osteoarthritis (the wearing down of the protective tissue at the ends of bones), LBP (lower back pain) with sciatica (pain that radiates along the path of the sciatic nerve), pneumonitis (inflammation of the lung tissue), migraines (a headache of varying intensity), and thyroid nodule (lump in the thyroid); - Instructions on discharge: * Bear weight as tolerated on the affected knee; * Prevena (a therapy unit that reduces the incidence of surgical site infections by managing the environment of closed surgical incisions and remove fluid away from the surgical incision via the application of continuous negative pressure) dressing can be removed POD (post operation day) 7 by home health, PT or at the office if needed; * Staples to be removed POD 14; * Okay to shower with Prevena; * Okay to shower with staples as long as no drainage. If drainage, wait until it has stopped; * Keep incision clean and dry; * Continue anticoagulation therapy, as well as take pain medication as needed, as prescribed; - Special instructions: * Do exercises as instructed, working hard to get new knee out straight and bent 90 degrees or greater; * No pillow under knee; * White support hose to both legs for 3 weeks. Can remove hose at bedtime if patient wishes and put back on in the morning; * Can shower getting prevana dressing wet while keeping battery unit dry by putting it in a plastic bag; * Can shower getting staples wet if no drainage from knee incision. If any drainage, please let [surgeon] office know; * Cooling wrap to knee to help with swelling and pain; * Place light cloth between skin and wrap to protect skin; * If more pain pills needed, call [surgeon] office when there are about 10 pills left; and * Pain pills can cause constipation. Stool softeners and/or laxatives may be needed. Review of the POC, dated 01/06/2022 to 03/06/2022, showed, in part: - Primary diagnosis of aftercare following joint replacement surgery; - Other diagnosis of polyosteoarthritis (the wearing down of the protective tissue at the ends of bones), other chronic pain, LBP (lower back pain), migraines (a headache of varying intensity), Gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), hyperlipidemia (high levels of fat particles in the blood), presence of right artificial knee joint, long term (current) use of anticoagulants, and history of TIA (transient ischemic attack is a brief stroke-like attack caused by a temporary blockage of blood flow to the brain); - Skilled nurse to instruct/reinforce patient regarding pharmacologic, non-pharmacologic and other pain control measures; - SN to provide closed incision/suture line care to cleanse with sterile SNS (sterile normal saline), pat dry with 4x4 (gauze), remove staples week of 01/09/2022; - Skilled nurse to perform multisystem assessment every visit with emphasis on musculoskeletal and integumentary. Skilled nurse to provide instructions/reinforcement for management of disease process PRN (as needed); - Skilled nurse to review home safety each visit and instruct patient/caregiver in methods to prevent falls and improve home safety; - Skilled nurse may instruct/reinforce new, change, and current medications regimen; - The POC failed to include occupation therapy evaluation for safety of home, patient specific surgical incision instructions, patient specific surgical aftercare, and white support hose, ordered in the referral; and - No documentation provided to clarify and/or obtain new orders related to late start of care. During an interview on 02/07/2022 at 1:15 PM, the administrator acknowledged the findings. No further documentation provided. Findings included: Review of the policy titled, “Initial assessment/Plan of care- Policy 2-210” dated revised 12/27/17 showed, in part: -Home care services are furnished under the supervision and direction of the client’s physician; -The plan of care is based on current assessment by the registered nurse, therapists and other healthcare team members and is directed toward driving positive patient outcomes; -Serves as a measurable guideline to care given by all professional disciplines involved in client care; -Meets state/federal/guidelines and all applicable laws and regulations; -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 agency 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; -Physician orders are needed to provide any care requiring the administration of medication, treatment(s), on-going assessments or other activities; -The plan of care will delineate specific services and assessments to be delivered based on the evaluation; -All patient care orders, including verbal orders, must be recorded in the plan of care; -Personnel will promptly alert the physician(s) to any changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered; -Any revision to the plan of care due to a change in the patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians issuing orders for the agency plan of care; -Any revision related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians issuing orders for the agency 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 agency (if any); -The initial plan of care includes but is not limited to: ** Principle (primary) diagnosis and other pertinent diagnoses; ** Equipment and supply needs; and ** Treatments/orders; RECORD/PATIENT #4 Review of the clinical record showed the patient was admitted to home health services on 10/14/2021 with, but not limited to, diagnoses of encounter for attention to ileostomy (an opening in the belly to allow waste-stool to be removed from the body), diverticulitis (an inflammation or infection in one or more small pouches in the digestive tract) and primary hypertension (high blood pressure). Review of the plans of care dated 10/14/2021 to 12/12/2021 and 12/13/2021 to 02/10/2022 showed the agency failed to list ileostomy supplies under DME and supplies.

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, observation, and interview the agency failed to obtain orders to provide services and treatments only as ordered by a physician or allowed practitioner in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect physician driven care of all the agency's patients. Findings included: Review of the agency's policy titled, "Initial assessment/Plan of care- policy 2-210", dated revised 12/27/17 showed, in part, physician orders are needed to provide any care requiring the the administration of medication, treatment(s), on-going assessments or other activities. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency 11/04/2021 with, but not limited to, diagnoses of spinal stenosis of the lumbar region with neurogenic claudication (narrowing of the spinal canal of the lower back resulting in pressure on the nerve roots, which causes symptoms of pain, fatigue, weakness or numbness in the legs that is made worse with activity such as walking). Review of the plans of cares dated 11/04/2021 to 1/02/2022, and 1/03/2022 to 3/03/2022 showed: - Physical therapist to provide instruction regarding pain control methodologies including pharmacologic (utilizing medications) and non-pharmacologic methods; and - No specific orders for non-pharmacologic pain control methodologies. Further review of the clinical record showed no specific interim orders for non-pharmacologic pain control methodologies. Observation on 01/31/2022 starting at 3:15 PM, during the patient's home visit with the PTA, the following was noted: - The patient complained that his/her right upper arm was "achy" due to a recent injection administered there; - The PTA assessed the area and then stated that the patient had a knot where the recent injection had been given and instructed the patient to put some moist heat on it; and -The PTA provided no further directions to patient. During an interview with the administrator on 02/01/2022 at 12:05 PM, the PTA instructions to the patient (observed during the home visit) to utilize a warm moist compress without a physician order was reviewed, and no further information provided.

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, observation, and interview, the agency failed to promptly alert the physician to changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care (POC) should be altered, in two (Records/Patients #3 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, “Coordination of Client Services,” dated, 12/27/17, showed: - The agency coordinated care with clients and physicians by: ** Ensuring communication with all physicians involved in the plan of care; ** Coordinating 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; ** Ensure that each patient, and his or her caregiver(s) where applicable receives ongoing education and training provided by the agency, as appropriate, regarding the care and services identified in the plan of care. The agency must provide training, as necessary, to ensure a timely discharge; - Once the care plan has been discussed/developed after consultation with client, physician and agency staff, written instructions is given to the client of the following: ** Patient medication schedule/instructions, that include the medication name, dosage, and frequency; ** Any treatments to be administered by agency personnel and personnel acting on behalf of the agency, including therapy services; and ** Any other pertinent instructions related to the patient’s care and treatments that the agency will provide, specific to the patient’s care needs. Review of the agency's policy titled, “Medical Supervision,” dated, 12/27/17, showed: - The client’s primary physician shall be responsible for providing signed orders, and for establishing and reviewing the client’s plan of care throughout the time the client is receiving services from the agency; - To assure that all clients have adequate medical supervision while receiving home care services; - The physician will be contacted when any of the following occurs: ** Condition changes; ** Expected response to treatment or medication differs; and ** Any change in client condition or agency services. Review of the agency's policy titled, “Initial Assessment/Plan of Care,” dated, 12/27/17, showed: - Personnel will promptly alert the physician(s) to any changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered; - Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians issuing orders for the agency plan of care; and - Any revision related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians issuing orders for the agency 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 agency (if any). RECORD/PATIENT #3: Review of the referral records showed: - Referral to home health service after hospitalization on 10/06/2021 for cellulitis (bacterial infection of the skin and deeper underlying tissue), metabolic encephalopathy (happens when another health condition such as kidney failure, makes it hard for the brain to work), and acute kidney injury (kidneys suddenly can’t filter waste from the blood); - Disciplines ordered: Skilled nursing for medication management and wound care, physical therapy for evaluation and treatment, occupational therapy for evaluation and treatment, home health aide for self-care, and social work services for community resources; - Past medical history of hypertension (the force of the blood against the artery walls is too high), hyperlipidemia (high levels of fat particles in the blood), hypothyroidism (thyroid gland doesn’t produce enough thyroid hormone), osteoarthritis (the wearing down of the protective tissue at the ends of bones) and Alzheimer’s disease (progressive disease that destroys memory and other important mental functions); - Patient discharged from hospital on 10/08/2021; and - Referral for home health services fax cover sheet with a date of 10/08/2021. Review of the clinical records showed: - The plan of care (POC), dated 10/12/2021 to 12/10/2021 showed, licensed professional to report vital signs falling outside the established parameters for temperature less than 95 or greater than 101, pulse less than 50 or greater than 100, respirations less than 14 or greater than 26, systolic blood pressure less than 90 or greater than 160, diastolic blood pressure less than 50 or greater than 90, oxygen saturation less than 90, and pain rated greater than 6; - The POC failed to show interventions for cellulitis or yeast under breasts and edema; - Skilled nurse SOC (start of care) visit, dated 10/12/2021, showed skin assessment completed and rash under breasts; - SN (skilled nurse) visit note on 10/22/2021 showed, rash under bilateral breasts; - SN visit note on 11/09/2021 showed, vital sign alert for blood pressure of 152/94 (high limit 160/90) with comment of “Patient in pain 4 out of 10. Patient denies chest pain, headache, vision is clear and no ringing in ears. Patient reports sinus pressure and takes clarinex d every 12 hours. Follow-up comment entered by [screen watcher] on 01/09/2021 faxed to provider” (No documentation for call to physician regarding blood pressure); - SN visit note on 11/17/2021 showed, skin assessment completed, rash, and mild redness under breasts; - SN note on 11/30/2021 showed, skin assessment completed and no problems identified; - SN recertification visit note on 12/07/2021 showed skin assessment completed and no problems identified; - The POC, dated 12/11/2021 to 02/08/2022 showed, licensed professional to report vital signs falling outside the established parameters for temperature less than 95 or greater than 101, pulse less than 50 or greater than 100, respirations less than 14 or greater than 26, systolic blood pressure less than 90 or greater than 160, diastolic blood pressure less than 50 or greater than 90, oxygen saturation less than 90, and pain rated greater than 6; - SN visit note on 12/13/2021 showed, patient with 3+ pitting edema, patient educated to reduce sodium in diet and elevate lower extremities (No documentation of physician being notified); - SN visit note on 12/27/2021 showed skin assessment completed, abrasion to left knee, patient fell on Christmas day after tripping on uneven concrete and landing on left knee, left forearm, small scrape to right wrist, and all areas covered with band aids (No wound record report with measurements or detailed assessment, and no documentation of physician being contacted); - SN visit note on 01/03/2022 showed, patient with abrasion on left knee, 4+ edema to BLE (bilateral lower extremities) with 1+ diminished pedal pulses, capillary refill (time taken for a distal capillary bed to regain color after pressure has been applied to cause blanching) greater than 3 seconds, patient unsteady, held onto wall when ambulating, left knee healing per CG (caregiver), dressing dry and intact, left forearm and right wrist healed. No documentation of physician being notified; - SN visit note on 01/12/2022 showed, 4+ edema to BLE (No documentation for physician being notified); - SN visit note on 01/17/2022 showed, 4+ edema to BLE with 1+ diminished pedal pulses (No documentation of physician being notified); - SN visit note on 01/24/2022 showed discharge planning for end of episode as max potential will be met; and - SN discharge visit note on 02/01/2022 showed, medications reviewed with no issues identified, patient compliant with drug therapy, and integumentary assessment with no problems identified. Observation on 02/01/2022 at 10:50 AM, during the patient's home visit, showed: - Patient with edema to bilateral lower extremities (BLE) . SN educated on elevating BLE (SN failed to document edema on visit note); - Spouse reported skin under patients breasts “getting really bad again” with foul smell; - SN failed to perform a complete comprehensive assessment of patient during discharge visit; - SN failed to perform a medication reconciliation; - After SN confirmed completion of discharge visit, surveyor reviewed patient medications and discrepancies found; - Surveyor asked to see patient skin issues that spouse was concerned about. Patient had red irritation under bilateral breasts, right breast with open wound in the crease of breast, and strong foul odor; - SN observed skin issues, failed to assess wound, and no measurements obtained; and - SN completed discharge visit with medication discrepancies, edema, and open wound with foul odor under breasts. During an interview on 02/07/2022 at 12:35 PM, the administrator reported the following: - The patient didn’t have any open wounds on admission, “just red,” and “if it’s just red” and “not open,” it doesn’t go on a wound record because it requires a “WAT” (wound assessment tool) score; - The physician was sent a fax on 11/09/2021 regarding blood pressure of 152/94. (No documentation provided of physician being called for confirmation and/or follow up on blood pressure); - No documentation noted of physician being notified of patient having a fall with injuries resulting in abrasions on 12/25/2021 and was reported to SN on 12/27/2021; - No documentation noted of physician being contacted regarding edema; - When asked about discharge visit note on 02/01/2022 having documentation that medications were reviewed and no issues identified, the administrator reported, “you reviewed them” and “I didn’t write down the meds so I didn’t get orders;” - Medications not added to MAR (medication administration record); - When asked about discharge visit note on 02/01/2022 having documentation that skin was assessed and no issues were found, the administrator reported, no issues were found was a “mistake” on the documentation and that he/she was in a hurry when documenting; - When asked why skin assessment was not performed during the discharge visit, the administrator reported, “I guess I forgot;” - Normally “I would do an assessment and notify the physician that it was back open and red;” - “I followed up with the [spouse] and it’s getting better now; and - Physician was not notified of medication discrepancies, edema, and open wound with foul odor under breasts. During a telephone interview on 02/08/2022 at 10:22 AM, spouse/caregiver reported the following: - The patient has an appointment with physician scheduled for 02/09/2022 due to the patient having “more swelling” to bilateral lower extremities, skin under breasts being “worse” with odorous wounds being open “under both breasts,” and Spouse is “afraid” because he/she is “not good;” - When asked about services being offered for HHA (home health aide), OT (occupational therapy), and MSW (medical social worker), the spouse reported that no services were ever offered by the agency, caregiver did not refuse those services, and that the patient would benefit from any assistance possible; and - When asked if the administrator contacting the spouse to follow-up on the patient’s condition, the spouse reported, “I have not talked to [administrator] since last week.” RECORD/PATIENT #5: Review of the referral records showed, in part: - Referral on 12/31/2021 for home health services after hospitalization for right total knee arthroplasty revision (surgery to replace nickel containing implant with a non-nickel implant due to having a metal allergy); - Disciplines ordered: Skilled nursing for initial management of pain medication, anticoagulation, and surgical wound care, physical therapy to restore ROM (range of motion) with strength and home exercise training, occupational therapy for a safety assessment of the home; and - Past medical history of osteoarthritis (the wearing down of the protective tissue at the ends of bones), LBP (lower back pain) with sciatica (pain that radiates along the path of the sciatic nerve), pneumonitis (inflammation of the lung tissue), migraines (a headache of varying intensity), and thyroid nodule (lump in the thyroid). Review of the clinical records showed, in part: - The POC, dated 01/06/2022 to 03/06/2022 showed, licensed professional to report vital signs falling outside the established parameters for temperature less than 95 or greater than 101, pulse less than 50 or greater than 100, respirations less than 14 or greater than 26, systolic blood pressure less than 90 or greater than 160, diastolic blood pressure less than 50 or greater than 90, fasting blood sugar less than 65 or greater than 150, random blood sugar less than 65 or greater than 250, oxygen saturation less than 90, and pain rated greater than 6; - Skilled nurse SOC visit, dated 01/06/2022, showed vital sign alert for sitting blood pressure of 168/87 (upper limit of 160/90), standing blood pressure of 170/88, and pain rated 9 (0 being no pain and 10 being the worst pain), comments report “pain meds taken” and “provider aware” (No documentation to confirm and/or clarify how the provider was aware); - PTA (physical therapy assistant) visit note on 01/07/2022 showed, pain rated 8, comment of “patient hasn’t taken medication since 4:00 AM follow up comment entered by [screen watcher] on 01/09/2022 faxed to provider,” no physician contacted by PTA, patient’s pain interfering with activity or movement all the time, areas of pain are back, hip, and knee, quality of pain is aching, pressure, radiating, tender, and throbbing, onset of patient’s pain s/p (status post) TKR (total knee revision), and non-verbal signs of pain demonstrated by patient included grimacing, moaning, guarding, tense, and restlessness, disciplines communicated with were supervisor, PT (physical therapist), and RN (registered nurse); - PTA visit note on 01/11/2022 showed, pain rated 7, comment of “patient states [he’s/she’s] having a lot of pain in low back, right hip, and knee. Taking pain meds every 4-5 hours. Follow up comment entered by [screen watcher] on 01/11/2022 faxed to provider,” no physician contacted by PTA, patient’s pain interfering with activity or movement all the time, areas of pain are back, hip, and knee, quality of pain is aching, burning, cramping, radiating, shooting, stabbing, and throbbing, onset of patient’s pain s/p TKR from 2 weeks ago, and non-verbal signs of pain demonstrated by patient included grimacing, moaning, guarding, and restlessness, disciplines communicated with were supervisor and RN, and communication details regarding laxatives patient can take due to lack of bowel movement since surgery; - PTA visit note on 01/13/2022 showed, pain rated 7, comment of “Pain with activity but especially at rest after activity. Follow up comment entered by [screen watcher] on 01/14/2022 faxed to provider,” no physician contacted by PTA, patient’s pain interfering with activity or movement all the time, areas of pain are back, hip, and knee, quality of pain is aching, cramping, radiating, sore, stabbing, tender, and throbbing, onset of patient’s pain s/p TKR, and non-verbal signs of pain demonstrated by patient included grimacing, moaning, guarding, tense, and restlessness, disciplines communicated with were supervisor and RN, and communication details noted that SN was present to remove staples from incision prior to PT visit; - SN visit note on 01/13/2022 showed, pain rated 7, comment of “MD (medical doctor) aware chronic pain. Follow up comment entered by [administrator] on 01/13/2022 provider aware,” pain areas were back and knee, quality of aching, dull, sore, and throbbing, onset of pain several months ago R/T (related to) OA and failed R (right) TKA, non-verbal signs of pain included grimacing and restlessness, integumentary issues included incision staples removed, steri-strips placed, and patient tolerated well, and communication with other disciplines involved in this case was answered no (No documentation to confirm and/or clarify how the MD was aware); and - PTA visit note on 01/19/2022 showed, pain rated 7, comment of “Patient hasn’t taken pain medication for 6 hours. Follow up comment entered by [administrator] on 01/19/2022 provider aware,” no physician contacted by PTA, patient’s pain interfering with activity or movement all the time, areas of pain are back, hip, and knee, quality of pain is aching, cramping, radiating, sore, stabbing, tender, and throbbing, onset of patient’s pain s/p TKR, and non-verbal signs of pain demonstrated by patient included grimacing, guarding, and restlessness, disciplines communicated with were PT regarding PT POC. During a telephone interview on 02/07/2022 at 11:12 AM, the patient reported the following: - The agency “didn’t do anything” that helped the pain; - During home visits the skilled nurse checked vital signs, “asked how I was doing,” and “told me to take my oxycodone and my Tizanidine at the same time” to help get pain under control; - The surgical incision at the bend of the knee “opened up about a day or so after” staples removed by SN, “it started bleeding,” SN “put a bandage on it,” and “it worried me so I put a call into the doctor’s office and the doctor told me to stop doing therapy for a couple days” to prevent incision from opening further; - When asked about issues having a bowel movement, noted on therapy visit note on 01/11/2022, the patient reported, “Before I left the hospital I hadn’t had a bowel movement. I still hadn’t had one after I got home, so the therapist called the nurse and the nurse told me to get senna and prune juice” and “I finally had a bowel movement the next day” (01/12/2022); and - The “only thing that really bothered me was they never called the doctor, I had to call them.” During an interview on 02/07/2022 at 1:15 PM, the administrator reported the following: - The PTA is expected to call the physician with vital signs or pain outside of parameters and then notify the supervisor; - The PTA “will be in-serviced” on calling the physician regarding vital sign alerts; - When asked about the patient having non-verbal signs of pain, the administrator reported, “This patient grimaces every time you do anything” with him/her, and the patient would “scream” when “I put a blood pressure cuff on” him/her; - When asked about an order to place steri-strips to the surgical incision after removing the staples, the administrator reported, “I didn’t have an order” but the “patient insisted” that steri-strips be placed on surgical incision and “I didn’t call the doctor for an order because I don’t view steri-strips as being invasive;” and - When asked about the PTA note regarding the administrator being contacted about laxatives due to lack of bowel movement since surgery, the administrator reported that he/she was not informed of patient not having a bowel movement since surgery, the patient was recommended prune juice by the administrator, the physician was never contacted about constipation because the patient “did not want to take another pill,” and the prune juice did help.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA 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). This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to discuss/document notification to the patient of plans for discharge in one (Record/Patient #3) of six patients reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, “Client Discharge/Transfer Process,” dated, 12/27/17, showed: - The agency will coordinate with clients, caregivers, and physicians involved with client regarding discharge; - Client to receive written notice, in advance of a specific service being furnished, if the agency believes that the service may be non-covered care; or in advance of the agency reducing or terminating on-going care; and - Medicare and Medicare HMO patients are issued a notice of Medicare Non-Coverage (NOMNC) at least 48 hours prior of termination of home health services which explains the client’s right to an immediate independent review of the proposed discontinuation of services. RECORD/PATIENT #3: Review of the referral records showed, in part: - Referral to home health service after hospitalization on 10/06/2021 for cellulitis (bacterial infection of the skin and deeper underlying tissue), metabolic encephalopathy (happens when another health condition such as kidney failure, makes it hard for the brain to work), and acute kidney injury (kidneys suddenly can’t filter waste from the blood); and - Disciplines ordered: Skilled nursing (SN) for medication management and wound care, physical therapy for evaluation and treatment, occupational therapy for evaluation and treatment, home health aide for self-care, and social work services for community resources. Review of the POC (plan of care), dated 12/11/2021 to 02/08/2022 showed, in part: - Primary diagnosis of cellulitis of chest wall; - Other diagnosis included, Alzheimer’s disease, Dementia, Hypertension, Polyosteoarthritis, hyperlipidemia, hypothyroidism, and history of falling; - Skilled nurse to perform multisystem assessment every visit with emphasis on cardiovascular, musculoskeletal, and integumentary. Skilled nurse to provide instructions/reinforcement for management of disease process PRN (as needed); - Frequency and duration of visits: ** SN effective 12/12/2021 1wk8 (1 time weekly for 8weeks); ** PT effective 12/12/2021 2wk2, 1wk6 (2 times weekly for 2 weeks and 1 time weekly for 6 weeks); - Skilled nurse to provide instructions/reinforcement for management of hypertension to include diet, medication, therapy, disease process, and activities permitted; - Physical therapy to evaluate to determine condition, physical therapy plans and rehabilitation potential; - Physical therapy to establish/upgrade home exercise program and provide exercises designed to restore functional strength and ROM (range of motion); - Patient will demonstrate improved function ability as evidenced by patient/caregiver participation in established home exercise program by end of episode; and - Patient to demonstrate reduced fall risk and improved functional mobility as result of balance interventions and fall prevention education by end of episode. Observation on 02/01/2022 at 10:50 AM, during the patient's home visit, showed the following: - The patient’s home folder contained visit frequency for PT (physical therapy) of 2wk2, 1wk6 (2 times a week for 2 weeks and 1 time a week for 6 weeks) effective 12/12/2021; - Patient instruction report in home folder was dated for 12/11/2021 to 02/08/2022 with patient receiving PT until week of 01/30/2022; - No written notice for reducing or terminating therapy services; - Spouse reported, they did not receive notice in advance, for physical therapy being terminated; and - No discharge planning provided to the patient prior to termination of therapy services. During an interview on 02/01/2022 at 11:35 AM, the administrator stated that: - The patient's insurance company denied insurance authorization for further physical therapy visits; and - The patient’s insurance mails a letter to the patient regarding reason for denial; - The agency did not provide notice to the patient due to the insurance company sending notices to patient; - Therapy unable to make a discharge visit due to insurance not authorizing anymore visits; and - The patient’s daughter was informed via telephone that therapy services ended due to insurance authorization being denied.

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 policy review, clinical record review, and interview, the agency failed to ensure coordination of care delivery to meet the patient's needs in two (Records/Patients #3 and #5) of five records reviewed. This deficient practice has the potential to affect the coordination of care and services for all patients on service with the agency. Findings included: Review of the agency's policy titled, “Coordination of Client Services,” dated, 12/27/17, showed: - The agency coordinated care with clients and physicians by: ** Ensuring communication with all physicians involved in the plan of care; ** Coordinating 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; ** Ensure that each patient, and his or her caregiver(s) where applicable receives ongoing education and training provided by the agency, as appropriate, regarding the care and services identified in the plan of care. The agency must provide training, as necessary, to ensure a timely discharge; - Once the care plan has been discussed/developed after consultation with client, physician and agency staff, written instructions is given to the client of the following: ** Patient medication schedule/instructions, that include the medication name, dosage, and frequency; ** Any treatments to be administered by agency personnel and personnel acting on behalf of the agency, including therapy services; and ** Any other pertinent instructions related to the patient’s care and treatments that the agency will provide, specific to the patient’s care needs. Review of the agency's policy titled, “Initial Assessment/Plan of Care,” dated, 12/27/17, showed: - Personnel will promptly alert the physician(s) to any changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered; - Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians issuing orders for the agency plan of care; and - Any revision related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians issuing orders for the agency 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 agency (if any). RECORD/PATIENT #3: Review of the referral records showed, in part: - Referral to home health service after hospitalization on 10/06/2021 for cellulitis (bacterial infection of the skin and deeper underlying tissue), metabolic encephalopathy (happens when another health condition such as kidney failure, makes it hard for the brain to work), and acute kidney injury (kidneys suddenly can’t filter waste from the blood); - Disciplines ordered: Skilled nursing for medication management and wound care, physical therapy for evaluation and treatment, occupational therapy for evaluation and treatment, home health aide for self-care, and social work services for community resources; - Past medical history of hypertension (the force of the blood against the artery walls is too high), hyperlipidemia (high levels of fat particles in the blood), hypothyroidism (thyroid gland doesn’t produce enough thyroid hormone), osteoarthritis (the wearing down of the protective tissue at the ends of bones) and Alzheimer’s disease (progressive disease that destroys memory and other important mental functions); - Patient discharged from hospital on 10/08/2021; and - Referral for home health services fax cover sheet with a date of 10/08/2021. Review of the POC (plan of care), dated 10/12/2021 to 12/10/2021 showed, in part: - Primary diagnosis of cellulitis of chest wall; - Other diagnosis included, Alzheimer’s disease, Dementia, Hypertension, Polyosteoarthritis, hyperlipidemia, hypothyroidism, and history of falling; - SN (skilled nurse) 1wk9 (1 time weekly for 9 weeks); - PT (physical therapy) 1wk1, 2wk6, 1wk2 (1 time weekly for 1 week, 2 times weekly for 6 weeks and 1 time weekly for 2 weeks); and - Licensed professional to report vital signs falling outside the established parameters for temperature less than 95 or greater than 101, pulse less than 50 or greater than 100, respirations less than 14 or greater than 26, systolic blood pressure less than 90 or greater than 160, diastolic blood pressure less than 50 or greater than 90, oxygen saturation less than 90, and pain rated greater than 6. Review of the clinical records showed, in part: - Skilled nurse SOC (start of care) visit was dated 10/12/2021 and PT add on evaluation visit note was dated on 10/14/2021 (No documentation regarding physician communication for late SOC); - Referral orders received for OT (occupational therapy), HHA (home health aide), and MSW (medical social worker) (No documentation provided regarding physician communication for services ordered on referral but not offered by the agency); - SN visit note on 11/09/2021 showed, vital sign alert for blood pressure of 152/94 (high limit 160/90) with comment of “Patient in pain 4 out of 10. Patient denies chest pain, headache, vision is clear and no ringing in ears. Patient reports sinus pressure and takes clarinex d every 12 hours. Follow-up comment entered by [screen watcher] on 01/09/2021 faxed to provider” (No documentation for call to physician regarding blood pressure); and - PTA supervisory visit was completed on 11/09/2021 by a previously employed registered nurse (No documentation provided for supervisory visit being made by the supervising PT). Review of the POC, dated 12/11/2021 to 02/08/2022 showed, in part: - Primary diagnosis of cellulitis of chest wall; - Other diagnosis included, Alzheimer’s disease, Dementia, Hypertension, Polyosteoarthritis, hyperlipidemia, hypothyroidism, and history of falling; - SN effective 12/12/2021 1wk8 (1 time weekly for 8 weeks); - PT effective 12/12/2021 2wk2, 1wk6 (2 times weekly for 2 week, 1 time weekly for 6 weeks); and - Licensed professional to report vital signs falling outside the established parameters for temperature less than 95 or greater than 101, pulse less than 50 or greater than 100, respirations less than 14 or greater than 26, systolic blood pressure less than 90 or greater than 160, diastolic blood pressure less than 50 or greater than 90, oxygen saturation less than 90, and pain rated greater than 6. Review of the clinical records showed, in part: - PT recertification visit made on 12/09/2021; - PTA visit made on 12/14/2021; - No documentation of further therapy visits were found in the EMR (electronic medical record), made after 12/14/2021; - SN visit note on 12/13/2021 showed patient to have 3+ pitting edema, patient educated to reduce sodium in diet and elevate lower extremities. No documentation of physician being notified; - SN visit note on 12/27/2021 showed, skin assessment completed, abrasion to left knee, patient fell on Christmas day after tripping on uneven concrete and landing on left knee, left forearm, small scrape to right wrist, and all areas covered with band aids (No wound record report with measurements or detailed assessment, and no documentation of physician being contacted); - SN visit note on 01/03/2022 showed, patient with abrasion on left knee, 4+ edema to BLE (bilateral lower extremities) with 1+ diminished pedal pulses, capillary refill greater than 3 seconds, patient unsteady, held onto wall when ambulating, left knee healing per CG (caregiver), dressing dry and intact, left forearm and right wrist healed (No documentation of physician being notified for wound care orders); - SN visit note on 01/12/2022 showed, 4+ edema to BLE (No documentation for physician being notified); - SN visit note on 01/17/2022 showed, 4+ edema to BLE with 1+ diminished pedal pulses (No documentation of physician being notified); - SN visit note on 01/24/2022 showed, discharge planning for end of episode as max potential will be met; and - SN discharge visit note on 02/01/2022 showed, medications reviewed with no issues identified, patient compliant with drug therapy, and integumentary assessment with no problems identified (No documentation of edema, no documentation of medication discrepancies found by surveyor, and no documentation of physician being contacted regarding medication issues and open wound with odor). Observation on 02/01/2022 at 10:50 AM, during the patient's home visit, showed: - The patient's home folder was reviewed and no therapy discharge notice, reason for services abruptly ending, and/or instructions found; - SN reported that the last therapy visit was made on 12/14/2021 by the PTA due to agency not receiving insurance authorization for further therapy visits; - SN reports that patient was not provided with a notice for therapy visits ending due to the insurance company mailing letters to patients when visits are not authorized; - Patient with edema to BLE. SN educated on elevating BLE; - Spouse reported skin under patients breasts “getting really bad again” with foul smell; - SN failed to perform a complete comprehensive assessment of patient during discharge visit; - SN failed to perform a medication reconciliation; - After SN confirmed completion of discharge visit, surveyor reviewed patient medications and discrepancies found; - Surveyor asked to see patient skin issues that spouse was concerned about. Patient had red irritation under bilateral breasts, right breast with open wound in the crease of breast, and strong foul odor; - SN observed skin issues, failed to assess wound, and no measurements obtained; and - SN completed discharge visit with medication discrepancies, edema, and open wound with foul odor under breasts. During an interview on 02/07/2022 at 12:35 PM, the administrator reported the following: - The physician was sent a fax on 11/09/2021 regarding blood pressure of 152/94. (No documentation noted of physician being called for follow up on blood pressure); - No documentation noted for physician being notified of patient having a fall with injuries resulting in abrasions on 12/25/2021 and was reported to SN on 12/27/2021; - No documentation noted for physician being contacted regarding edema; - When asked about discharge visit note on 02/01/2022 having documentation that medications were reviewed and no issues identified, the administrator reported, “you reviewed them” and “I didn’t write down the meds so I didn’t get orders;” - Medications not added to the MAR (medication administration record); - When asked about discharge visit note on 02/01/2022 having documentation that skin was assessed and no issues were found, the administrator reported, no issues were found was a “mistake” on the documentation and that he/she was in a hurry when documenting; - When asked why skin assessment was not performed during the discharge visit, the administrator reported, “I guess I forgot;” - Normally “I would do an assessment and notify the physician that it was back open and red;” - “I followed up with the [spouse] and it’s getting better now; and - Physician was not notified of medication discrepancies, edema, and open wound with foul odor under breasts. During a telephone interview on 02/08/2022 at 10:22 AM, spouse/caregiver reported the following: - The patient has an appointment with physician scheduled for 02/09/2022 due to the patient having “more swelling” to bilateral lower extremities, skin under breasts being “worse” with odorous wounds being open “under both breasts,” and Spouse is “afraid” because he/she is “not good;” - When asked about services being offered for HHA (home health aide), OT (occupational therapy), and MSW (medical social worker), the spouse reported that no services were ever offered by the agency, caregiver did not refuse those services, and that the patient would benefit from any assistance possible; and - When asked if the administrator contacting the spouse to follow-up on the patient’s condition, the spouse reported, “I have not talked to [administrator] since last week.” RECORD/PATIENT #5: Review of the referral records showed, in part: - Referral on 12/31/2021 for home health services after hospitalization for right total knee arthroplasty revision (surgery to replace nickel containing implant with a non-nickel implant due to having a metal allergy); - Disciplines ordered: Skilled nursing for initial management of pain medication, anticoagulation, and surgical wound care, physical therapy to restore ROM (range of motion) with strength and home exercise training, occupational therapy for a safety assessment of the home; and - Past medical history of osteoarthritis (the wearing down of the protective tissue at the ends of bones), LBP (lower back pain) with sciatica (pain that radiates along the path of the sciatic nerve), pneumonitis (inflammation of the lung tissue), migraines (a headache of varying intensity), and thyroid nodule (lump in the thyroid). Review of the clinical records showed, in part: - The POC, dated 01/06/2022 to 03/06/2022 showed, licensed professional to report vital signs falling outside the established parameters for temperature less than 95 or greater than 101, pulse less than 50 or greater than 100, respirations less than 14 or greater than 26, systolic blood pressure less than 90 or greater than 160, diastolic blood pressure less than 50 or greater than 90, fasting blood sugar less than 65 or greater than 150, random blood sugar less than 65 or greater than 250, oxygen saturation less than 90, and pain rated greater than 6; - Skilled nurse SOC visit, dated 01/06/2022, showed vital sign alert for sitting blood pressure of 168/87 (upper limit of 160/90), standing blood pressure of 170/88, and pain rated 9 (0 being no pain and 10 being the worst pain), comments report “pain meds taken” and “provider aware” (No documentation to confirm or clarify how the provider was aware); - PTA (physical therapy assistant) visit note on 01/07/2022 showed, pain rated 8, comment of “patient hasn’t taken medication since 4:00 AM follow up comment entered by [screen watcher] on 01/09/2022 faxed to provider,” no physician contacted by PTA, patient’s pain interfering with activity or movement all the time, areas of pain are back, hip, and knee, quality of pain is aching, pressure, radiating, tender, and throbbing, onset of patient’s pain s/p (status post) TKR (total knee revision), and non-verbal signs of pain demonstrated by patient included grimacing, moaning, guarding, tense, and restlessness, disciplines communicated with were supervisor, PT (physical therapist), and RN (registered nurse); - PTA visit note on 01/11/2022 showed, pain rated 7, comment of “patient states [he’s/she’s] having a lot of pain in low back, right hip, and knee. Taking pain meds every 4-5 hours. Follow up comment entered by [screen watcher] on 01/11/2022 faxed to provider,” no physician contacted by PTA, patient’s pain interfering with activity or movement all the time, areas of pain are back, hip, and knee, quality of pain is aching, burning, cramping, radiating, shooting, stabbing, and throbbing, onset of patient’s pain s/p TKR from 2 weeks ago, and non-verbal signs of pain demonstrated by patient included grimacing, moaning, guarding, and restlessness, disciplines communicated with were supervisor and RN, and communication details regarding laxatives patient can take due to lack of bowel movement since surgery; - PTA visit note on 01/13/2022 showed, pain rated 7, comment of “Pain with activity but especially at rest after activity. Follow up comment entered by [screen watcher] on 01/14/2022 faxed to provider,” no physician contacted by PTA, patient’s pain interfering with activity or movement all the time, areas of pain are back, hip, and knee, quality of pain is aching, cramping, radiating, sore, stabbing, tender, and throbbing, onset of patient’s pain s/p TKR, and non-verbal signs of pain demonstrated by patient included grimacing, moaning, guarding, tense, and restlessness, disciplines communicated with were supervisor and RN, and communication details noted that SN was present to remove staples from incision prior to PT visit; - SN visit note on 01/13/2022 showed, pain rated 7, comment of “MD (medical doctor) aware chronic pain. Follow up comment entered by [administrator] on 01/13/2022 provider aware,” pain areas were back and knee, quality of aching, dull, sore, and throbbing, onset of pain several months ago R/T (related to) OA and failed R (right) TKA, non-verbal signs of pain included grimacing and restlessness, integumentary issues included incision staples removed, steri-strips placed, and patient tolerated well, and communication with other disciplines involved in this case was answered no (No documentation to confirm or clarify how the MD was aware); and - PTA visit note on 01/19/2022 showed, pain rated 7, comment of “Patient hasn’t taken pain medication for 6 hours. Follow up comment entered by [administrator] on 01/19/2022 provider aware,” no physician contacted by PTA, patient’s pain interfering with activity or movement all the time, areas of pain are back, hip, and knee, quality of pain is aching, cramping, radiating, sore, stabbing, tender, and throbbing, onset of patient’s pain s/p TKR, and non-verbal signs of pain demonstrated by patient included grimacing, guarding, and restlessness, disciplines communicated with were PT regarding PT POC. During a telephone interview on 02/07/2022 at 11:12 AM, the patient reported the following: - The agency “didn’t do anything” that helped the pain; - During home visits the skilled nurse checked vital signs, “asked how I was doing,” and “told me to take my oxycodone and my Tizanidine at the same time” to help get pain under control; - The surgical incision at the bend of the knee “opened up about a day or so after” staples removed by SN, “it started bleeding,” SN “put a bandage on it,” and “it worried me so I put a call into the doctor’s office and the doctor told me to stop doing therapy for a couple days” to prevent incision from opening further; - When asked issues not having a bowel movement that was noted on therapy visit note on 01/11/2022, the patient reported, “Before I left the hospital I hadn’t had a bowel movement. I still hadn’t had one after I got home, so the therapist called the nurse and the nurse told me to get senna and prune juice” and “I finally had a bowel movement the next day” (01/12/2022); and - The “only thing that really bothered me was they never called the doctor, I had to call them.” During an interview on 02/07/2022 at 1:15 PM, the administrator reported the following: - The PTA is expected to call the physician with vital signs or pain outside of parameters and then notify the supervisor; - The PTA “will be in-serviced” on calling the physician regarding vital sign alerts; - When asked about the patient having non-verbal signs of pain, the administrator reported, “This patient grimaces every time you do anything” with him/her, and the patient would “scream” when “I put a blood pressure cuff on” him/her; - When asked about an order to place steri-strips to the surgical incision after removing the staples, the administrator reported, “I didn’t have an order” but the “patient insisted” that steri-strips be placed on surgical incision and “I didn’t call the doctor for an order because I don’t view steri-strips as being invasive;” and - When asked about the PTA contacted the administrator regarding questions about laxatives due to lack of bowel movement since surgery, the administrator reported that he/she was not informed of patient not having a bowel movement since surgery, the patient was recommended prune juice by the administrator, the physician was never contacted about constipation because the patient “did not want to take another pill,” and the prune juice did help.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, and interview, the agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in one (Record/Patients #3) of three home visits. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, “Coordination of Client Services,” dated, 12/27/17, showed: - The agency coordinated care with clients and physicians by: ** Ensuring communication with all physicians involved in the plan of care; ** Coordinating 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; ** Ensure that each patient, and his or her caregiver(s) where applicable receives ongoing education and training provided by the agency, as appropriate, regarding the care and services identified in the plan of care. The agency must provide training, as necessary, to ensure a timely discharge; - Once the care plan has been discussed/developed after consultation with client, physician and agency staff, written instructions is given to the client of the following: ** Patient medication schedule/instructions, that include the medication name, dosage, and frequency; ** Any treatments to be administered by agency personnel and personnel acting on behalf of the agency, including therapy services; and ** Any other pertinent instructions related to the patient’s care and treatments that the agency will provide, specific to the patient’s care needs. RECORD/PATIENT #3: Observation on 02/01/2022 at 10:50 AM, during the patient's home visit, showed: - Patient with edema to bilateral lower extremities (BLE). Skilled nurse (SN) educated on elevating BLE; - Spouse reported skin under patients breasts “getting really bad again” with foul smell; - SN failed to perform a complete comprehensive assessment of patient during discharge visit; - SN failed to perform a medication reconciliation; - After SN confirmed completion of discharge visit, surveyor reviewed patient medications and discrepancies found; - Surveyor asked to see patient skin issues that spouse was concerned about. Patient had red irritation under bilateral breasts, right breast with open wound in the crease of breast, and strong foul odor; - SN observed skin issues, failed to assess wound, and no measurements obtained; - Spouse reported using Nystatin powder under patient’s breasts for yeast (No orders obtained and written instructions were not provided to caregiver for treatment); and - SN completed discharge visit with medication discrepancies, edema, and open wound with foul odor under breasts. During an interview on 02/07/2022 at 12:35 PM, the administrator reported the following: - When asked about discharge visit note on 02/01/2022 having documentation that medications were reviewed and no issues identified, the administrator reported, “you reviewed them” and “I didn’t write down the meds [medications] so I didn’t get orders;” - Medications not added to the MAR (medication administration record); - Patient/Caregiver not provided with an updated written medication list; - When asked about discharge visit note on 02/01/2022 having documentation that skin was assessed and no issues were found, the administrator reported, no issues were found was a “mistake” on the documentation and that he/she was in a hurry when documenting; - When asked why skin assessment was not performed during the discharge visit, the administrator reported, “I guess I forgot;” - Normally “I would do an assessment and notify the physician that it was back open and red;” - “I followed up with the [spouse] and it’s getting better now; and - Physician was not notified of medication discrepancies, edema, and open wound with foul odor under breasts.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure that physical therapy assistant (PTA) services were provided under the supervision of the physical therapist (PT) in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients receiving therapy services from the agency. Findings included: Review of the agency's policy titled, “Supervision of Staff,” dated, 12/27/17, showed: - All staff providing home care services will be supervised as outlined by Federal and State regulations; - When a Licensed Physical Therapy Assistant or Certified Occupational Therapy Assistant performs home therapy services, the Physical Therapist or Occupational Therapist will make a supervisory visit to the client at least every 30 days; - Qualified supervisory personnel will supervise staff; - Examples of qualified individuals to supervise staff and/or perform competency assessments may include: ** Physical Therapists: competency assessed by a peer PT or Director of Therapy; and ** Licensed Physical Therapy Assistant: competency assess by PT. RECORD/PATIENT #3: Review of the clinical record showed, in part: - Primary diagnosis of cellulitis of chest wall; - Other diagnosis included Alzheimer’s disease, Dementia, Hypertension, Polyosteoarthritis, hyperlipidemia, hypothyroidism, and history of falling; - Disciplines involved were SN (skilled nurse) and PT; - Frequency and duration of visits: ** SN effective 12/12/2021 1wk8 (1 time weekly for 8weeks); ** PT effective 12/12/2021 2wk2, 1wk6 (2 times weekly for 2 weeks and 1 time weekly for 6 weeks); - SN visit note on 11/09/2021 showed, RN (registered nurse) plus supervisory visit; - RN supervisory visit noted, “Therapist,” as the employee being supervised; and - No documentation of PTA supervisory visits being made by PT. During an interview on 02/07/2022 at 12:35 PM, the administrator reported the following: - The RN is not able to supervise PTA staff; - The PTA should have been supervised by the PT; and - No further documentation was provided for a supervisory visit completed by PT.

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 three Conditions of Participation: Comprehensive assessments of patients; Care Planning; Coordination of Services and Quality of Care; and Organization and administration of services, 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 02/10/2024.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on policy review, record review, observation and interview, the agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care, when the agency failed to show clinical manager oversight to patients resulting in an immediate jeopardy and three conditions of participation citations. The following standard level deficiencies were cited under this condition of participation: - Ensure the administrator must be responsible for all day to day operations of the home health agency (G948); - Clinical manager: Ensure one or more qualified individuals must provide oversight of all patient care services and personnel (G958); and - Clinical manager: Ensure oversight of all patient care services and personnel must include coordinating referrals (G964). The cumulative effect of these deficient practices resulted in the inability of the agency to provide effective ongoing management of all clinical services.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on administrator and clinical supervisor job descriptions review, observation, and interview, it cannot be assured the administrator has effectively assumed responsibilities for the overall administration, supervisory functions, and overall operations of the home health agency. The agency failed to ensure the administrator was available and/or responsible for all day to day operations of the agency. This deficient practice has the potential to affect all the patients receiving services from the agency. Findings included: Review of the job description: Home Health Administrator, RN (registered nurse), dated approved October 2013, showed the following responsibilities: -Directs administration of home healthcare branches within authority of governing board; -Directs and coordinates activities of medical, nursing, and administrative staff and services; -Participates in case management and quality assessment activities and analysis; -Develops, implements, and evaluates company policies, goals and objectives; -Interprets and enforces company policies; -Is responsible for the overall direction, coordination, and evaluation of each branch unit; -Directly supervisors up to five non-supervisory employees; -Carries out supervisory responsibilities in accordance with the organizations policies and applicable laws; and -Responsibilities include planning, assigning, and directing work. Review of the job description: Clinical Supervisor, RN, dated approved October 2013, showed the following responsibilities: -Manages, supervises, and coordinates the operations of a branch office; -Observes nursing care and visits patients to ensure that nursing care is carried out as directed and treatment is administered in accordance with physician instructions; -Confers with health team members, individually and in conference, to exchange, discuss and evaluate patient information for planning, modifying and coordinating treatment programs; -Interprets and enforces company policies; -Carries out supervisory responsibilities in accordance with the organizations policies and applicable laws; and -Responsibilities include planning, assigning, and directing work. Observation throughout the survey showed the home health administrator was also acting as the clinical supervisor, and the sole visiting nurse (for patient care) of the agency. On all days of the on-site survey (01/31/2022, 02/01/2022, 02/07/2022, 02/08/2022 and 02/10/2022) the administrator/clinical supervisor/RN, was busy in the field conducting patient visits, and unable during that time to assist surveyors. During an interview on 02/01/2022 at 2:15 PM the administrator stated that: - He/she currently served as the agency administrator, clinical supervisor, as well as the only skilled nurse making home visits for this agency; - He/she is also the administrator at two other corporate agencies with approximate census of 60 at each of those locations; - The pre-designated alternate administrator is filling in as the administrator at the other two corporate agencies until we get staff; - The predesignated alternate administrator also serves as the the clinical manager at one of the other two corporate locations as well as filling in as the clinical manager at the other corporate location; - They are unable to keep staff; - The agency has hired two nurses here recently: **One started having back pain shortly after starting here, was diagnosed with illness and quit; and **One worked a few weeks, wanted the sign on bonus already and then quit. -He/she has been up here [Independence, MO agency] filling in for about six months; and -A nurse has been hired and starts orientation on Monday (02/07/2022).

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on administrator and clinical supervisor job description review, organizational structure chart review, and interview, it cannot be assured the administrator/clinical supervisor has effectively assumed responsibility for oversight of all patient care services, coordination of patient care, and coordination of referrals of the home health agency. The agency failed to show that the clinical supervisor was responsible for assuring that the patient needs were continually assessed and the development, implementation and updates of the individualized plans of care were completed. This deficient practice has the potential to affect all the patients receiving services from the agency. Findings included: Review of the job description: Home Health Administrator, RN (registered nurse), dated approved October 2013, showed the following responsibilities: -Directs administration of home healthcare branches within authority of governing board; -Directs and coordinates activities of medical, nursing, and administrative staff and services; -Participates in case management and quality assessment activities and analysis; -Develops, implements, and evaluates company policies, goals and objectives; -Interprets and enforces company policies; -Is responsible for the overall direction, coordination, and evaluation of each branch unit; -Directly supervisors up to five non-supervisory employees; -Carries out supervisory responsibilities in accordance with the organizations policies and applicable laws; and -Responsibilities include planning, assigning, and directing work. Review of the job description: Clinical Supervisor, RN, dated approved October 2013, showed the following responsibilities: -Manages, supervises, and coordinates the operations of a branch office; -Observes nursing care and visits patients to ensure that nursing care is carried out as directed and treatment is administered in accordance with physician instructions; -Confers with health team members, individually and in conference, to exchange, discuss and evaluate patient information for planning, modifying and coordinating treatment programs; -Interprets and enforces company policies; -Carries out supervisory responsibilities in accordance with the organizations policies and applicable laws; and -Responsibilities include planning, assigning, and directing work. Review of the organizational chart showed below the parent agency: -The same nurse listed as the administrator, supervising nurse, clinical supervisor, and RN; and -No other nurses listed for the agency. During an interview on 02/01/2022 at 2:15 PM the administrator stated that: - He/she currently served as the agency administrator, clinical supervisor, as well as the only skilled nurse making home visits for this agency; - He/she is also the administrator at two other corporate agencies with approximate census of 60 at each of those locations; - The pre-designated alternate administrator is filling in as the administrator at the other two corporate agencies until we get staff; - The predesignated alternate administrator also serves as the the clinical manager at one of the other two corporate locations as well as filling in as the clinical manager at the other corporate location; - They are unable to keep staff; - The agency has hired two nurses here recently: **One started having back pain shortly after starting here, was diagnosed with illness and quit; and **One worked a few weeks, wanted the sign on bonus already and then quit. -He/she has been up here [Independence, MO agency], filling in for about six months; and -A nurse has been hired and starts orientation on Monday (02/07/2022).

Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the administrator (clinical manager and case manager) failed to provide oversight of patient care services that included, but not limited to, coordinating referrals in two (Records/Patients #3 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, “Admission Policy,” dated, 12/27/17, showed: - Clients are accepted for treatment in the home on the basis of reasonable criteria and under the expectation that the client’s medical, nursing, and social needs can be met adequately by the agency in the client’s place of residence; - Purpose: ** To provide guidelines for accepting client’s for home health care services to be provided in the client’s place of residence that are clear to the home care staff, the medical community, and the lay community and that abide by state/federal guidelines; ** To provide client-centered care that is safe, effective and well-organized to meet the needs of each client; ** To identify situations in which the agency will not provide services; and - The agency must have adequate and suitable personnel and resources to provide the services requested. RECORD/PATIENT #3: Review of the referral records showed, in part: - Referred to home health service on 10/08/2021 after hospitalization for cellulitis (bacterial infection of the skin and deeper underlying tissue); and - Disciplines ordered: Skilled nursing (SN) for medication management and wound care, PT (physical therapy) for evaluation and treatment, OT (occupational therapy) for evaluation and treatment, HHA (home health aide) for self-care, and MSW (medical social worker) services for community resources. Review of the POC (plan of care), dated 10/12/2021 to 12/10/2021 showed, in part: - Disciplines involved SN and PT; - Frequency and duration of visits: ** SN 1wk9 (1 time weekly for 8weeks); and ** PT 1wk1, 2wk6, 1wk2 (1 time weekly for 1 week, 2 times weekly for 6 weeks, and 1 time weekly for 2 weeks). Review of the POC, dated 12/11/2021 to 02/08/2022 showed, in part: - Disciplines involved SN and PT; - Frequency and duration of visits: ** SN effective 12/12/2021 1wk8 (1 time weekly for 8weeks); and ** PT effective 12/12/2021 2wk2, 1wk6 (2 times weekly for 2 weeks and 1 time weekly for 6 weeks). Review of the clinical records failed to showed: - Evaluation and/or treatment for OT, MSW, and HHA as ordered in referral; - Physician order to discontinue orders for OT, MSW, and HHA; - Patient being offered services and refusing; and - Physician being contacted regarding agency not offering services ordered in referral. During interview with the administrator on 02/07/2022 at 12:35 PM, the administrator reported the following: - The Patient’s caregiver refused services; - “There should be an order to discontinue those services;” and - No further documentation and/or orders, were provided. RECORD/PATIENT #5: Review of the referral records showed, in part: - Referred to home health service on 12/28/2021 after hospitalization on for right total knee arthroplasty revision (knee surgery to remove nickel containing implant and replace it with non-nickel containing implant) surgery; and - Disciplines ordered: Skilled nursing (SN) for pain medication management, anticoagulation, and wound care, PT (physical therapy) to restore ROM (range of motion) strength and home exercise training, OT (occupational therapy) for safety assessment of the home. Review of the POC, dated 01/06/2022 to 03/06/2022 showed, in part: - Disciplines involved were SN and PT; - Frequency and duration of visits: ** SN 1wk5, 1Q4wk4 (1 time weekly for 5 weeks and 1 time every 4 weeks for 4 weeks); and ** PT 2wk1, 3wk1, 2wk5, 1wk2 (2 times weekly for 1 week, 3 times weekly for 5 weeks, and 1 time weekly for 2 weeks). Review of the clinical records failed to showed: - OT evaluations for safety of home, as ordered in referral; - Physician order to discontinue orders for OT evaluation; - The Patient being offered OT services and refusing; and - Physician being contacted regarding agency not offering services ordered in referral. During an interview on 02/07/2022 at 1:15 PM, the administrator reported the following: - No OT services offered by the agency; - Will look for an order to discontinue OT; and - No further documentation was provided.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record review, home visit observation, and interview, the agency failed to ensure all documented entries included legible, clear, complete, and appropriate authentication, dated and timed in, but not limited to, one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #3: Review of the referral records showed: - The plan of care (POC), dated 12/11/2021 to 02/08/2022 showed disciplines involved were SN (skilled nurse) and PT (physical therapy); - Frequency and duration of visits: ** Skilled nurse (SN) effective 12/12/2021 1wk8 (1 time weekly for 8weeks); ** Physical therapy (PT) effective 12/12/2021 2wk2, 1wk6 (2 times weekly for 2 weeks and 1 time weekly for 6 weeks); and - Last home visit for therapy was made by the physical therapist assistant (PTA) on 12/14/2021. On 02/03/2022 at 1:32 PM, the administrative specialist provided the surveyor with a copy of the physical therapy discharge visit note that showed: - A paper with “Healthback Home Health Physical Therapy Visit Note” titled at the top; - “Discharge Note” handwritten next to the title; - The first line had written the name of patient #3, diagnosis of LE (lower extremity) weakness, and date of 12/15/2021; - The subject line had handwritten, “I will continue to do my home exercises you taught me;” - Pain had, “Generalized 0-2/10 intermittent,” noted; - Vital signs: BP (blood pressure) 128/72, HR (heart rate) 67, Resp (respirations) 18, Temp (temperature) 97.9, and O2 (oxygen saturation) 97%, noted; - Assessment portion with patient response to treatment had, “Improved and able to teach back HEP” (home exercise program); - Plan had, “Patient to be discontinued, due to being unable to receive additional visits from insurance,” noted; - At the bottom, was a signature from the physical therapist with a date of 12/15/2021; and - The line for the patient signature, visit time in, and visit time out were left blank. Observation on 02/01/2022 at 10:50 AM, during the patient's home visit, showed the following: - The patient’s home folder contained visit frequency for PT (physical therapy) of 2wk2, 1wk6 (2 times a week for 2 weeks and 1 time a week for 6 weeks) effective 12/12/2021; - Patient instruction report in home folder was dated for 12/11/2021 to 02/08/2022 with patient receiving PT until week of 01/30/2022; - No written notice for reducing or terminating therapy services; - Spouse reported, they did not receive notice in advance, for physical therapy being terminated; and - No discharge planning provided to the patient prior to termination of therapy services. During an interview on 02/01/2022 at 11:35 AM, the administrator reported: - The patients insurance company denied insurance authorization for further physical therapy visits; - Therapy unable to make a discharge visit due to insurance not authorizing anymore visits; and - The patient’s daughter was informed via telephone that therapy services ended due to insurance authorization being denied. During chart review conducted with the administrator on 02/07/2022 at 5:10 PM, the administrator stated that: - PT did not do a home visit for discharge; - The paper with “Health back Home Health Physical Therapy Visit Note,” that was provided to the surveyor from the administrative specialist, was a non-visit discharge note; and - Unsure how assessment findings and vital signs, that were documented on the discharge note, were determined, due to no visit being made.