Every finding on record at Trinity Home Health Services

As directed by the Centers for Medicare and Medicaid Services (CMS) Kansas City Location, the Department of Inspections, Appeals and Licensing conducted an unannounced complaint survey for complaint #113576-C from 3/10/25 to 3/12/25. The complaint survey identified the following: 1.Condition of Participation 42 CFR 484.105 Organization and Administration of Services, was investigated and one condition level deficiency was identified and 2.Condition of Participation 42 CFR 484.55 Comprehensive Assessment of Patient, was investigated and no condition level or standard level deficiencies were identified. The agency reported a current census of 322 patients, including 293 patients at the parent office in Des Moines, and 29 patients at the proposed branch location in Mason City.

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 staff interview, surveyor observation, policy review and record review the home health agency failed to: ensure the parent home health agency notified the state agency of the proposed intent to add a branch office and obtain approval for the branch office prior to providing services out of the branch office. (G972) The cumulative effects of these systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of the agency's patients.

Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA's request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This ELEMENT is not met as evidenced by: Based on staff interview, home visit observation, surveyor observation, policy review and agency documents review, the agency failed to notify the State agency (SA) of their intent to add a branch location, provide the necessary documentation and obtain approval for a branch location prior to providing services to agency patients from that branch location. Failure to obtain approval for a branch office prior to providing services, placed agency patients at risk for inadequate and unsafe care. Findings include: On 3/10/25 at 11:45 AM, the surveyor entered the office located at 910 N Eisenhower Ave, Mason City, IA 50401. The surveyor observed the office to be staffed and operational. According to agency policy, titled Trinity Health at Home – Governance: Home Health Board of Directors, dated 4/14/24, the Continuing Care Board of Directors is the Governing Body with full responsibility for Trinity Health at Home agencies and is responsible overseeing compliance with the Trinity Health Integrity and Compliance Program and facilitating and recommending actions within the community healthcare system. During an interview on 3/10/25 at 3:05 PM, Administrator reported all patients from the Home Care office located in Mason City had been discharged and readmitted under the Des Moines parent office CCN (CMS Certification Number) starting 2/1/25. " All current patients in the Mason City branch office would be listed on the Des Moines parent office census. All Mason City branch office patients were notified of the need to discharge and readmit under the Des Moines parent office." On 3/10/25 at 1:58 PM, the surveyor received an email from the Administrator identifying an attachment. The attachment, dated 3/5/25, on Celerian Group Company (CGS) letter head, identified; this letter updates you on the status of your change of information enrollment application. Your application is required to go through a multi-step review process. CGS Administrators is a CMS Medicare Administrative Contractor (MAC) charged with enrolling providers and suppliers in the Medicare program. We have assessed your enrollment application and forwarded it to the Iowa State Agency for the next step in the process. The State Agency will conduct a review for further compliance with the applicable Federal, State, and local requirements. Once the State Agency’s review is complete, CMS will conduct a final review and issue a decision. We will contact you when your application has completed all stages of review and a decision has been made. Requested changes: Added practice location effective 2/24/25: 910 N Eisenhower Ave, Mason City, IA 50401. Notification of approval must be submitted to the MAC before the changes noted above can be approved. On 3/10/25 at 2:37 PM, the State Agency Program Coordinator received an email from Staff C, VP of Home Care Operations. The email included an attachment, with the completed branch questionnaire and supporting documents for the proposed branch office located at 910 N Eisenhower Ave, Mason City, IA 50401. The attachment, titled Home Health Agency Branch Request Questionnaire, dated 3/5/25, signed by Staff C, VP of Home Care Operations. The Questionnaire identified no services can be provided from this proposed location without prior CMS approval. On 3/11/25 at 11:00 AM, the surveyor completed a home visit observation with Staff D, RN (registered nurse) and Clinical Manager for Patient #1. During an interview at the time of the home visit observation, Patient #1 reported receiving a letter in the mail from the agency informing them of the change in the agency name. On 3/11/25 at 4:00 PM, the Clinical Manager provided the surveyor with a copy of a name change letter, she reported all current Mason City patients on services in February received the letter in February. During an interview on 3/12/25 at 10:20 AM, Administrator reported "Mason City branch office is staffed with Clinical Manager, Document Specialist and Scheduler. Administrator is on site at least 2 times a month if not more frequently." On 3/12/25 at 10:30 AM, the surveyor was provided a printout of staff schedules for the Mason City office for Tuesday 3/11/25 and Wednesday 3/12/25. Observations on 3/10, 3/11 and 3/12/2025 showed staff were present at the proposed branch location. The agency failed to obtain approval for a branch office prior to providing services to agency patients from the branch office. The above findings were reviewed with the Administrator.

The Department of Inspections and Appeals conducted a complaint survey, complaint #94491-C, dated 12/19/22 to 12/20/22. The complaint survey identified the following: 1) 42 CFR 484.55 Comprehensive assessment of Patients, was not substantiated and the hospice was operating in substantial compliance with this Condition of Participation; 2) 42 CFR 484.60 Care Planning, Coordination and Quality of Care, was substantiated with related standard level deficiency (see G0574). The home health agency reported a census of 335 patients at the time of the complaint survey.

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 clinical record review, agency policy review and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 3 of 4 sampled patients (Patients #2, #3 and #4). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive treatments according to assessed needs and physician orders. Review of the agency policy, titled Care Management and Plan of Care (POC), dated 12/9/22, identified the registered nurse (RN) case manager and other ordered disciplines develop the patient's POC in conjunction with the patient's attending physician. Agency staff provide services to the patient according to the POC and the POC includes all treatments. 1. Patient #2 had a start of care date of 12/5/22. Review of the clinical record revealed the following: a. The POC, dated 12/5/22 to 2/2/23, identified the patient had diabetes mellitus with a foot ulcer and included an order for skilled nursing services one time per week. The POC included orders for treatment to a wound on the patient's right lateral foot. The POC also included the following: patient had to have an incision and drainage done to the patient's abdominal wound 2 weeks ago and patient is now requiring Monday, Wednesday and Friday wound care for the abdominal wound. The POC did not include any specific wound treatment for the identified abdominal wound. b. The comprehensive assessment completed by Staff F, RN, at the start of care, dated 12/5/22, identified the patient had a right lateral foot wound. The assessment did not identify the patient had an abdominal wound. On 12/20/22 at 10:48 AM, during an interview, Staff F, RN, reported the only wound the patient currently has is a right foot wound. The patient did not have an abdominal wound and did not know where this information came from. She confirmed it should not be on the POC. 2. Patient #3 had a start of care date of 11/9/22 and discharged from agency services on 12/6/22. Review of the clinical record revealed the following: a. The POC, dated 11/9/22 to 1/7/23, identified the patient had a diagnosis of disruption of a surgical wound to the abdomen and included an order for skilled nursing services. The POC identified the patient had a left ankle fracture and deep tissue wound on the left hand. b. The comprehensive assessment completed at the start of care by Staff G, RN, dated 11/9/22, identified the patient had a wound on the patient's posterior right hand. c. The skilled nursing visit, dated 11/11/22, included documentation of an assessment of a posterior right hand wound and identified the patient had a right ankle fracture. On 12/20/22 at 11:16 AM, during an interview, Staff G, RN, reported the patient had a right ankle fracture and right hand deep tissue injury. She confirmed the POC had identified the ankle fracture and deep tissue hand wound on the left side. 3. Patient #4 had a start of care date of 10/19/22 and transferred from agency services to a higher level of care on 11/15/22. Review of the clinical record revealed the following: a. The POC, dated 10/19/22 to 12/17/22, identified the patient had diagnoses of a left hip fracture and an unstageable pressure ulcer of the sacral region. The POC included an order skilled nursing services and an order to provide wound care treatment by cleansing a wound in the coccyx region and applying a Mepilex (type of foam dressing) sacral border dressing every 3 days and or as needed. b. The comprehensive assessment completed at the start of care by a physical therapist, dated 10/19/22, identified the patient had a pressure ulcer on the coccyx. The assessment did not include an assessment of the wound. c. The initial skilled nursing visit note, completed by Staff H, RN, dated 10/20/22, included documentation the nurse assessed the patient had an unstageable pressure ulcer on the coccyx and a left posterior, proximal upper leg wound. She documented she cleansed both wounds with Normal Saline and covered the wounds with a foam adhesive border dressing. She documented in a separate communication note that she noted the patient had a wound on the back of the left leg and a coccyx wound. She removed a sacral dressing covering the sacral wound. She documented she had no wound care supplies and no orders for wound care in the patient's hospital discharge paperwork. She contacted the patient's attending healthcare practitioner for wound care orders. She documented, "ok to keep coccyx wound and area on left leg covered with foam adhesive border until seen by wound center." The POC included the wound care order for the coccyx wound, but failed to include any treatment orders or identification of the posterior left leg wound. On 12/20/22 at 11:26 AM, during an interview, Staff H, RN, explained the patient's significant other reported a dressing was put on the coccyx wound by the hospital staff prior to sending the patient home. She was unaware of and unsure of why the left posterior upper leg wound treatment did not make it to the plan of care when the coccyx wound care orders did make it. She confirmed she discovered both wounds and received the wound care orders for both together. 12/20/22 at 2:14 PM, during an interview, the Administrator, Regional Director of Home Care and Staff D, Clinical Manager, reported an inability to find any information to refute the above findings for the patients.

The recertification survey, conducted 11/8/21 through 11/17/21, identified the following deficient practices:

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on review of agency's emergency preparedness plan/policies, review of the agency's admission packet, clinical record review, home visit observation and agency staff interview, the home health agency failed to provide the patient with a copy of their individualized emergency preparedness plan and/or failed to maintain documentation of the patient's individualized emergency preparedness plan in the patient's chart, for 12 of 18 sampled patients (Patients #2, #3, #4, #7, #9, #10, #12, #13, #14, #15, #17 and #18). The agency reported a current census of 359 patients at the time of the survey. Failure to ensure the agency maintained documentation of the patients' individualized emergency plans in the patient's chart placed patients at risk for staff being unaware and unprepared to respond in a timely and effective manner to potential health and safety hazards the patient may encounter. Findings include: 9. Patient #10 had a start of care date of 10/13/21. Clinical record review revealed the following: a. The initial comprehensive assessment completed at start of care, dated 10/13/2021, included documentation of assessment of emergency preparedness to determine the individualized needs of the patient during a disaster or emergency. b. The clinical record lacked documentation or a copy of an individualized emergency preparedness plan. 10. Patient #14 had a start of care date of 5/21/21 and a discharge date of 6/3/21. a. The initial comprehensive assessment completed at start of care, dated 5/21/2021, included documentation of assessment of emergency preparedness to determine the individualized needs of the patient during a disaster or emergency. b. The clinical record lacked documentation or a copy of an individualized emergency preparedness plan. 11. Patient #15 had a start of care date of 4/12/21 and a discharge date of 6/29/21. Clinical record review revealed the following: a. The initial comprehensive assessment completed at start of care, dated 4/12/21, included documentation of assessment of emergency preparedness to determine the individualized needs of the patient during a disaster or emergency. b. The Recertification of Care comprehensive assessment, dated 6/9/21, lacked documentation the therapist completed an individualized emergency preparedness plan with the patient. c. The clinical record lacked documentation or a copy of an individualized emergency preparedness plan. 12. Patient #17 had a start of care date of 7/28/21 and a discharge date of 9/17/21. Clinical record review revealed the following: a. The initial comprehensive assessment completed at start of care, dated 7/28/21, included documentation of assessment of emergency preparedness to determine the individualized needs of the patient during a disaster or emergency. b. The clinical record lacked documentation or a copy of an individualized emergency preparedness plan. The surveyor reviewed the above stated findings with the Administrator, the Clinical Manager, and the Corporate Regional Director of Clinical Services. The agency provided no additional information prior to the end of the survey. 5. Patient #4 had a start of care date of 10/16/2021. Clinical record review and associated surveyor observation revealed the following: a. The Plan of Care, dated 10/16/2021 to 12/14/2021, included the diagnoses of hypertensive heart disease with heart failure, Alzheimer's disease and repeated falls. The initial comprehensive assessment completed at start of care, dated 10/16/2021, included documentation of assessment of emergency preparedness to determine the individualized needs of the patient during a disaster or emergency. On 11/9/2021 at 1:00 PM , the surveyor accompanied Staff J, Physical Therapist (PT), to the patient's home. During the home visit, the surveyor observed a copy of an individualized emergency preparedness plan in the patient's home health agency folder. Patient #4's electronic clinical record lacked inclusion of a copy of the patient's individualized emergency preparedness plan. 6. Patient #9 had a start of care date of 8/4/2021. Clinical record review revealed the following: a. The Plans of Care, dated 8/4/2021 to 10/2/2021 and 10/3/2021 to 12/1/2021, included the diagnoses of hypertensive heart disease with heart failure and dementia. The initial comprehensive assessment completed at start of care, dated 8/4/2021, and the update to the comprehensive assessment at the time of recertification, dated 10/1/2021, included documentation of assessment of emergency preparedness to determine the individualized needs of the patient during a disaster or emergency. Patient #9's electronic clinical record lacked inclusion of a copy of an individualized emergency preparedness plan. 7. Patient #12 had a start of care date of 9/15/2021. Clinical record review revealed the following: a. The Plan of Care, dated 9/15/2021 to 11/13/2021, included the diagnoses of stroke, aphasia (difficulty expressing speech or understanding conversation); dysphagia (difficulty with swallowing); and apraxia (inability to perform purposive actions as a result of brain damage). The initial comprehensive assessment completed at start of care, dated 9/15/2021, included documentation of assessment of emergency preparedness to determine the individualized needs of the patient during a disaster or emergency. Patient #12's electronic clinical record lacked inclusion of a copy of an individualized emergency preparedness plan. 8. Patient #18 had a start of care date of 9/28/2021. Clinical record review revealed the following: a. The Plan of Care, dated 9/28/2021 to 11/26/2021, documented Patient #18 had a tracheostomy and received tube feedings through a tube inserted into the stomach through the abdomen. The Plan of Care included medications administered via a nebulizer (a portable machine used to change liquid medication into a mist for inhalation). The initial comprehensive assessment at the time of start of care, dated 9/28/2021, included documentation of assessment of emergency preparedness to determine the individualized needs of the patient during a disaster or emergency. Patient #18's electronic clinical record lacked inclusion of a copy of an individualized emergency preparedness plan. According to the agency policy, dated 2/4/2020 and titled Comprehensive Patient Assessment, each comprehensive assessment includes an assessment of emergency preparedness individualized to the patient. Review of the agency's admission booklet included a form titled Patient Emergency Preparedness Plan. The Plan included instructions to complete, remove and place in a prominent place for quick reference and including the patient's plan in the event of power outage, what the patient would do in the event of need for evacuation from the home, tornado shelter area, escape route from fire and alternate route, back up plan if agency staff, family or caregivers are unable to reach the patient and important phone numbers including agency's 24 hour number, ambulance/fire/police, doctor, non emergency transportation, pharmacy, poison control, home medical equipment, electric company, phone company, water company, gas company and family. Agency staff interview on 11/16/21 at 3:28 PM with the Clinical Manager revealed clinicians have been requested to photograph patient's emergency plans in the home and send to the office so they would have copies of the plans in the patient's records. 1. Patient # 2 had a start of care date of 8/31/2009. Clinical record review revealed the following: a. The Plans of Care, dated 6/29/21 to 8/272021, 8/28/21 to 10/26/21 and 10/27/21 to 12/25/21, included the diagnosis of gastroparesis. b. The updates to the comprehensive assessment completed at recertification, dated 6/28/21, 8/23/21 and 10/25/21, included documentation of assessment of emergency preparedness information to determine the individualized needs of the patient during a disaster or emergency. During agency staff interview on 11/9/21 at 10:15 AM, the surveyor informed the Clinical Manager of inability to locate a copy of Patient # 2's individualized emergency plan in the patient's chart. The Clinical Manager revealed Patient #2 was admitted prior to the agency providing a plan to agency patients. Home visit surveyor observation revealed the following: On 11/10/2021 at 11:15 AM , the surveyor accompanied Staff D, Registered Nurse (RN), to the patient's home. During the home visit, the patient was unable to locate the agency's admission information, including the individualized emergency preparedness plan. Review of the clinical record revealed the record lacked documentation of the patient's individualized emergency preparedness plan. 2. Patient # 3 had a start of care date of 7/17/21. Clinical record review revealed the following: a. The Plans of Care, dated 7/17/21 to 9/14/21 and 9/15/21 to 11/13/21, included the diagnosis of hemiplegia to right dominant side following a cerebral infarction. b. The initial comprehensive assessment completed at start of care, dated 7/17/21, included documentation of assessment of emergency preparedness information to determine the individualized needs of the patient during a disaster or emergency. c. The update to the comprehensive assessment completed at recertification, dated 9/13/21, included documentation of assessment of emergency preparedness information to determine the individualized needs of the patient during a disaster or emergency. During agency staff interview on 11/9/21 at 10:15 AM, the surveyor informed the Clinical Manager of inability to locate a copy of the Patient# 3's individualized emergency plans in the patient's chart. The Clinical Manager revealed plans to follow up with clinical staff to determine why no copy was provided to the office. Review of the patient's clinical record revealed the record lacked documentation of the patient's individualized emergency preparedness plan. 3. Patient # 7 had a start of care date of 9/11/2020. Clinical record review revealed the following: a. The Plans of Care, dated 9/11/2020 to 11/9/2020, 7/8/21 to 9/5/21, 9/6/21 to 11/4/21/21, and 11/5/21 to 1/3/22, included the diagnosis of a cutaneous abscess of the buttock. b. The initial comprehensive assessment completed at start of care, dated 9/11/2020, included documentation of assessment of emergency preparedness information to determine the individualized needs of the patient during a disaster or emergency. c. The updates to the comprehensive assessment completed at recertification, dated 7/6/21, 9/3/21 and 11/3/21, included documentation of assessment of emergency preparedness information to determine the individualized needs of the patient during a disaster or emergency. Home visit surveyor observation revealed the following: On 11/10/2021 at 8:30 AM , the surveyor accompanied Staff E, RN, to the patient's home. During the home visit, the patient 's admission booklet was reviewed and included a copy of the patient's individualized emergency preparedness plan. Review of the clinical record revealed the record lacked documentation of the patient's individualized emergency preparedness plan. 4. Patient #13 had a start of care date of 7/23/21 and a discharge date of 9/17/21. Clinical record review revealed the following: a. The Plan of Care, dated 7/23/21 to 9/17/21, included the diagnosis of cerebral palsy. b. The initial comprehensive assessment completed at start of care, dated 7/23/21, included documentation of assessment of emergency preparedness information to determine the individualized needs of the patient during a disaster or emergency including the patient was chair bound. Review of the patient's clinical record revealed the record lacked documentation of the patient's individualized emergency preparedness plan.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with with the recertification survey from 11/8/21 through 11/17/21. The recertification survey found the following: The survey found the agency was operating out of compliance with the following Conditions of Participation: 1) Condition of Participation 42 CFR 484.60 Care Planning, Coordination and Quality of Care (G570, G572, G574, G576, G580, G590, and G608) and 2) Condition of Participation 42 CFR 484.100 Compliance with Federal, State and Local Law (G848).The survey also found the agency operating out of compliance with multiple other standard level regulatory requirements. The agency was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. As a result of the agency's noncompliance with the Medicare Conditions of Participation for home health agencies, the home health agency and its registered nurses are prohibited from providing basic skills competency training, and prohibited from providing evaluation of home health aide written basic skills testing and evaluation of demonstrated competency of the hands on basic skills for the agency's home health aides for 2 years, beginning on 11/17/21 and ending on 11/17/23.

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 agency policy review, clinical record review and agency staff interview, the agency failed to complete a drug regimen review within the required time frames as part of the comprehensive assessments for 13 of 18 sampled patients (Patients #1, #2, #5 #6, #7, #8, #9, #12, #13, #15, #16, #17 and #18). The agency reported a current patient census of 359 patients. Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings Include: 10. Patient #1 had a start of care date of 9/24/21. Clinical record review revealed the following: a. Start of Care (SOC) comprehensive assessment, dated 9/24/21, included documentation no duplicate drug therapy. b. Plan of Care (POC), dated 9/24/21 to 11/22/21, included physician orders for acetaminophen 500 milligrams (mg) for pain, oxycodone 5 mg for pain, amlodipine 5 mg for heart, aspirin 81 mg for heart, fosinopril 20 mg for heart, and metoprolol succinate extended release 25 mg for heart. The drug regimen review (DRR) failed to identify the duplicate pain and heart medications. 11. Patient #6 had a start of care date of 7/12/21. Clinical record review revealed the following: a. Resumption of Care (ROC) comprehensive assessment, dated 7/27/21, included documentation of a DRR, noncompliance with drug therapy, significant side effects, ineffective drug therapy, and duplicate drug therapy; but lacked documentation of significant drug interactions. b. On 11/17/21 at 10:32 AM, the Clinical Manager provided copies of the client medication report, this included documentation DRR including significant drug interactions had been completed at the time points required. The client medication report failed to identify a DRR had been completed on 7/27/21 with the ROC comprehensive assessment. 12. Patient #15 had a start of care date of 4/12/21 and a discharge date of 6/29/21. Clinical record review revealed the following: a. POC, dated 4/12/21 to 6/10/21, included physician orders for acetaminophen 500 mg for mild pain, hydrocodone 5mg/acetaminophen 325 mg for pain, pregabalin 150 mg for nerve pain; alprazolam 0.5 mg for anxiety, venlafaxine extended release 150 mg for mood, quetiapine 200 mg for mood/sleep, trazodone 100 mg for sleep; amlodipine 5 mg for blood pressure, losartan 50 mg for blood pressure; docusate sodium 100 mg for constipation, milk of magnesia 400 mg/5 milliliters (ml) for constipation; finasteride 5 mg for prostate, tamsulosin 0.4 mg for prostate; and montelukast 10 mg for breathing, proair inhaler for breathing, symbicort inhaler for breathing. b. ROC comprehensive assessment, dated 5/7/21, included documentation of a DRR, noncompliance with drug therapy, significant side effects, and ineffective drug therapy; included documentation no duplicate drug therapy, and lacked documentation of significant drug interactions. c. ROC comprehensive assessment, dated 5/18/21, included documentation of a DRR, noncompliance with drug therapy, significant side effects, and ineffective drug therapy; included documentation no duplicate drug therapy, and lacked documentation of significant drug interactions. d. Recertification comprehensive assessment, dated 6/9/21, included documentation of a DRR, noncompliance with drug therapy, significant side effects, and ineffective drug therapy; included documentation no duplicate drug therapy, and lacked documentation of significant drug interactions. e. POC, dated 6/11/21 to 8/9/21, included physician orders for acetaminophen 500 mg for mild pain, pregabalin 150 mg for nerve pain; alprazolam 0.5 mg for anxiety, venlafaxine extended release 150 mg for mood, quetiapine 200 mg for mood/sleep, trazodone 100 mg for sleep; amlodipine 5 mg for blood pressure, losartan 50 mg for blood pressure; docusate sodium 100 mg for constipation, milk of magnesia 400 mg/5 milliliters (ml) for constipation; finasteride 5 mg for prostate, tamsulosin 0.4 mg for prostate; and montelukast 10 mg for breathing, proair inhaler for breathing, symbicort inhaler for breathing. f. Discharge comprehensive assessment, dated 6/29/21, included documentation of a DRR, noncompliance with drug therapy, significant side effects, and ineffective drug therapy; included documentation no duplicate drug therapy, and lacked documentation of significant drug interactions. g. On 11/17/21 at 10:32 AM, the Clinical Manager provided copies of the client medication report, this included documentation DRR including significant drug interactions had been completed at the time points required. The client medication report failed to identify a DRR had been completed on 6/29/21 with the discharge comprehensive assessment h. The comprehensive assessments failed to identify the duplicate pain, mood/sleep, blood pressure, bowel, prostate, and breathing medications the patient was using. 13. Patient #17 had a start of care date of 7/28/21 and a discharge date of 9/17/21. Clinical record review revealed the following: a. POC dated 7/28/21 to 9/25/21, included physician orders for amlodipine 10 mg for blood pressure, diltiazem 120 mg for blood pressure; duloxetine 60 mg for mood/depression, sertraline 100 mg for mood; gabapentin 300 mg for neuropathic pain, ibuprofen 800 mg for pain; mycophenolate mofetil 500 mg for multiple sclerosis/lupus, vumerity 231 mg for multiple sclerosis; omeprazole 40 mg for stomach, ondansetron 8 mg for nausea and vomiting; and triple omega supplement, vitamin C supplement. b. SOC comprehensive assessment, dated 7/28/21, included documentation of a DRR, noncompliance with drug therapy, significant side effects, and ineffective drug therapy; included documentation no duplicate drug therapy, and lacked documentation of significant drug interactions. The above stated findings were reviewed with the Administrator, the Clinical Manager, and the Corporate Regional Director of Clinical Services. The agency provided no additional information prior to the end of the survey. 5. Patient #5 had a start of care date of 12/17/2020. Clinical record review revealed the following: a. The Plan of Care, dated 12/17/2020 to 2/14/2021, included physician orders for Acetaminophen 1000 milligrams (mg) every 6 hours as needed for pain and Tylenol PM Extra Strength (25 mg diphenhydramine and 500 mg Acetaminophen) 2 tablets at bedtime for sleep. Both medications included acetaminophen. The initial comprehensive assessment at start of care, dated 12/17/2020, documented the clinician identified no duplicate drug therapies. The clinical record lacked documentation of an accurate drug regimen review to include the duplicate medications containing Acetaminophen used by the patient at the time of start of care. b. The Plans of Care, dated 4/15/2021 to 6/14/2021, 6/15/2021 to 8/13/2021, 8/14/2021 to 10/12/2021 and 10/13/2021 to 12/11/2021, included physician orders for Acetaminophen 1000 mg every 6 hours as needed for pain and Tylenol PM Extra Strength (25 mg diphenhydramine and 500 mg Acetaminophen) 2 tablets at bedtime for sleep. Both medications included acetaminophen. The updates to the comprehensive assessment at the time of recertification, dated 6/10/2021, 8/12/2021 and 10/12/2021, documented the clinician identified no duplicate drug therapies. The clinical record lacked documentation of an accurate drug regimen review to include the duplicate medications containing Acetaminophen used by the patient at the time of recertification. 6. Patient #8 had a start of care date of 1/23/2021. Clinical record review and associated agency staff interviews revealed the following: The Plans of Care, dated 5/23/2021 to 7/21/2021, 7/22/2021 to 9/19/2021 and 9/20/2021 to 11/18/2021, documented the patient's diagnoses as hypertensive heart disease with heart failure, severe chronic kidney failure and polyosteoarthritis. The Plans included physician orders for Amlodipine and Metoprolol, both medications used to treat hypertension; Allopurinol and Colchicine, both medications taken for gout; Bisacodyl tablets, Senna with Docusate Sodium and Miralax, all three containing a laxative; and Senna with Docusate Sodium and Miralax, both containing docusate sodium (a stool softener). The updates to the comprehensive assessment at the time of recertification, dated 5/18/2021, 7/21/2021 and 9/16/2021, documented the clinician identified no duplicate drug therapies and failed to document an assessment of the medications for actual or potential medication interactions. All three assessments were completed by a physical therapist and included no documentation indicating a registered nurse completed the drug regimen reviews. The Client Medication Reports, dated 5/19/2021, 7/22/2021 and 9/16/2021 and completed by a physical therapist, documented "the patient's medications were reviewed for any potential adverse effects including, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy." The documentation did not identify any actual or potential medication interactions. The clinical record lacked communication notes documenting identification of the potential for hypotension when combining antihypertensive medications. The Medication Reports lacked documentation of a drug regimen review by a registered nurse (RN) in the last five days of each certification period for the above stated Plans of Care. During agency staff interview on 11/17/2021 at 10:50 AM, the Clinical Manager reported agency RNs complete the drug regimen reviews for therapy only cases and document the reviews in the communication notes. Clinical record review revealed no documentation of drug regimen reviews completed by an RN in the communication notes to accompany the recertification comprehensive assessments dated 5/18/2021, 7/21/2021 and 9/16/2021. During agency staff interview on 11/17/2021 at 11:45 AM, the Clinical Manager reported she reviewed Patient #8's electronic clinical record and was unable to find documentation of any drug regimen review completed by a registered nurse within the last five days of the above stated Plan of Care certification periods. The clinical record lacked documentation of an accurate drug regimen review to include identification of the patient's use of duplicate medications containing laxatives and stool softeners; identification of the use of duplicate medications used to treat gout; and/or identification of the duplicate blood pressure medications and the potential for hypotension when combining the duplicate antihypertensive medications. The drug regimen reviews were completed by a physical therapist and not by an RN as required by regulation and the agency's own policies. 7. Patient #9 had a start of care date of 8/4/2021. Clinical record review revealed the following: a. The Plan of Care, dated 8/4/2021 to 10/2/2021, documented the patient's diagnoses as atrial fibrillation and hypertensive heart disease with heart failure. The Plan included physician orders for Amlodipine and Lasix, both medications used to treat the heart condition and lower the blood pressure. The initial comprehensive assessment at start of care, dated 8/4/2021, documented the clinician identified no duplicate drug therapies and failed to assess the patient's medications for actual or potential medication interactions. The Client Medication Report, dated 8/4/2021, documented "the patient's medications were reviewed for any potential adverse effects including, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy." The Report lacked documentation identifying the potential for hypotension when combining the antihypertensive medications. The communication notes lacked documentation of identification of the potential for hypotension when combining the antihypertensive medications. The clinical record lacked documentation of an accurate drug regimen review to include the duplicate anti-hypertensives and the potential for medication interactions when combined at the time of start of care. b. The Plan of Care, dated 10/3/2021 to 12/1/2021, documented the patient's diagnoses as atrial fibrillation and hypertensive heart disease with heart failure. The Plan included physician orders for Amlodipine, Digoxin, Sotalol and Lasix, all medications used to treat the heart condition and/or lower the blood pressure. The update to the comprehensive assessment at the time of recertification, dated 10/1/2021, documented the clinician identified no duplicate drug therapies and failed to assess the patient's medications for actual or potential medication interactions. The Client Medication Report, dated 10/1/2021, documented "the patient's medications were reviewed for any potential adverse effects including, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy." The Report lacked documentation identifying the potential for hypotension when combining the antihypertensive medications. The communication notes lacked documentation of identification of the potential for hypotension when combining the antihypertensive medications. The clinical record lacked documentation of an accurate drug regimen review to include the duplicate anti-hypertensives and the potential for medication interactions when combined at the time of recertification. 8. Patient #12 had a start of care date of 9/15/2021 and was discharged from agency services on 11/11/2021. Clinical record review revealed the following: a. The Plan of Care, dated 9/15/2021 to 11/13/2021, documented the patient's diagnoses as cerebral vascular accident (stroke) with aphasia (difficulty expressing or understanding speech), dysphagia (difficulty swallowing) and apraxia (difficulty with movement). The Plan included physician orders for low dose Aspirin and Eloquis, both blood thinners; and Baclofen, Gabapentin and Tramadol, all medications taken for pain. The initial comprehensive assessment at start of care, dated 9/15/2021, documented the clinician identified no duplicate drug therapies and failed to assess the patient's medications for actual or potential medication interactions. The Client Medication Report, dated 9/16/2021, documented "the patient's medications were reviewed for any potential adverse effects including, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy." The Report lacked documentation identifying the potential for abnormal bleeding when combining the blood thinners. The communication notes lacked documentation of identification of the potential for abnormal bleeding when combining the blood thinners. The clinical record lacked documentation of an accurate drug regimen review to include the duplicate blood thinners and pain medications or the potential for medication interactions when combined at the time of start of care. b. The update to the comprehensive assessment at the time of discharge, dated 11/11/2021, failed to assess the patient's medications for actual or potential medication interactions. The Client Medication Report lacked documentation of the statement "the patient's medications were reviewed for any potential adverse effects including, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy" on or around the time of discharge. The communication notes lacked documentation of identification of the potential for abnormal bleeding when combining the blood thinners. The clinical record lacked documentation of an assessment of the patient's medications at the time of discharge to identify any actual or potential medication interactions. 9. Patient #18 had a start of care date of 9/28/2021. Clinical record review revealed the following: The Plan of Care, dated 9/28/2021 to 11/26/2021, included physician orders for Tramadol and Acetaminophen, both taken for pain. The initial comprehensive assessment at start of care, dated 9/28/2021, documented the clinician identified no duplicate drug therapies. The clinical record lacked documentation of an accurate drug regimen review to include the duplicate pain medications at the time of start of care. According to the agency policy, titled Comprehensive Drug Regimen Review, Adverse Drug Reactions and Medication Error Response, and dated 12/6/18, a registered nurse, physical therapist, occupational therapist or speech language pathologist reviews all medications the patient is currently using in order to identify any potential adverse effects, drug reactions and are accountable for evaluation of the following, which includes but is not limited to: ineffective drug therapy, effectiveness of drug therapy, significant drug side effects, immediate desired effects, significant drug interactions, duplicative drug therapy, non-compliance with drug therapy, drug therapy currently associated with laboratory monitoring, allergic reactions, and changes in the patient's condition that contraindicates continued administration of the medication. The procedure for drug regimen review is the clinician will complete a comprehensive drug regimen review at start of care, resumption of care, recertification, and discharge and ongoing, as patient need dictates. The review will identify discrepancies, adverse drug interactions, duplicate dosage therapy and noncompliance with drug therapy. In therapy only cases, the therapist submits a list of medications, which the therapist collects during the comprehensive assessment to the home health agency nurse for review. The home health agency will communicate any potential or actual adverse interaction to the physician and document all interactions and follow up in the patient medical record. During agency staff interview on 11/8/2021 at 3:57 PM, the Clinical Manager revealed Registered nurses (RNs) and physical therapists (PTs) completed the drug regimen review. The medications are entered into the electronic health care system and the system will alert of any potential drug interactions and the clinician will notify the physician of any concerns by phone or fax. For therapy only cases the PT will do the initial and enter the medications into the the electronic health care system and the Managers of Clinical Services (MCS), will verify as well. Interview with the Clinical Manager on 11/17/21 at 9:43 AM revealed the interactions were documented in care coordination notes and provided surveyors the notes. The Clinical Manager explained that if the software system does not identify any drug interactions a note is not completed. The Clinical Manager further reported the Client Medication Reports for each certification period contains a statement that all required components were reviewed and include documentation of the dates reviewed. The Clinical Manager reported she would provide the reports for all patients for all episodes to the surveyors. 1. Patient #2 had a start of care date of 8/31/09. Clinical record review revealed the following: a. The Plans of Care, dated 6/29/21 to 8/27/21, 8/28/21 to 10/26/21, and 10/27/21 to 12/25/21, included physician orders for Bisoprolol Fumarate, Fludrocortisone, and Lisinopril (for blood pressure regulation), Butorphanol nasal spray, Hydrocodone/Acetaminophen, Oxycodone and Tramadol (for pain), Compazine, Prochlorperazine, Promethazine, Tigan, and Zofran (for nausea), Carafate and Nexium (for GERD (gastroesphageal reflux disease), Baclofen and Cyclobenzaprine (for muscles), and Denavir and Famciclovir (cold sores). b. The updates to the comprehensive assessment for recertification, dated 6/28/21, lacked identification of any duplicate drug therapies. c. The updates to the comprehensive assessment for recertification, dated 8/23/21 and 10/25/21, documented assessment of duplicate drug therapies with a response documented of "no". d. The Client Medication Reports, dated 8/23/2021, and 10/25/2021 and completed by a nurse, documented "the patient's medications were reviewed for any potential adverse effects including, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy." The documentation did not identify any actual or potential medication interactions. The clinical record lacked documentation of an accurate drug regimen review to include the duplicate medications used by the patient and any actual or potential medication interactions.. 2. Patient #7 had a start of care date of 9/11/2020. Clinical record review revealed the following: a. The Plan of Care, dated 9/11/2020 to 11/9/2020, included physician orders for Aleve and Oxycodone (for pain). b. The initial comprehensive assessment for recertification, dated 9/11/2020, documented assessment of duplicate drug therapies with a response documented of "no". The assessment documented the clinician identified no duplicate drug therapies and failed to document an assessment of the medications for actual or potential medication interactions. c. The updates to the comprehensive assessment at the time of recertification, dated 5/18/2021, 7/21/2021 and 9/16/2021, documented assessment of duplicate drug therapies with a response documented of "no". d. The Client Medication Reports, dated 7/6/2021, and 9/3/2021 and completed by a nurse, documented "the patient's medications were reviewed for any potential adverse effects including, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy." The documentation did not identify any actual or potential medication interactions. The clinical record lacked documentation of an accurate drug regimen review to include the duplicate medications used by the patient and any actual or potential medication interactions.. 3. Patient #13 had a start of care date of 7/23/21 and a discharge date of 9/17/21. Clinical record review revealed the following: a. The Plan of Care, dated 7/23/21 to 9/17/21, included physician orders for several medications. b. The update to the comprehensive assessment for discharge, dated 9/17/21, lacked documentation of assessment of a drug regimen review. 4. Patient #16 had a start of care date of 3/12/21 and a discharge date of 5/10/21. Clinical record review revealed the following: a. The Plan of Care, dated 3/12/21 to 5/10/21, included physician orders for baby aspirin and furosemide (both prescribed for heart). b. The initial comprehensive assessment for recertification, dated 3/12/21, documented assessment of duplicate drug therapies with a response documented of "no". The clinical record lacked documentation of an accurate drug regimen review to include the duplicate medications used by the patient.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 2 of 8 sampled patients requiring a recertification assessment (Patients #2 and #6). The agency reported a census of 359 patients at the time of the survey. Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: 2. Patient #6 had a start of care date of 7/12/21. Clinical record review revealed the following: a. Plans of Care dated, 7/12/21 to 9/9/21, 9/10/21 to 11/8/21, and 11/9/21 to 1/7/21, included physician orders for skilled nursing services. b. Recertification Comprehensive Assessment, dated as initiated on 9/7/21 (day 58 of the certification period) but was not signed as completed until 9/10/21, the first day of the new certification period, making the assessment 1 day late. c. Recertification Comprehensive Assessment, dated as initiated on 11/8/21 (day 60 of the certification period) but was not signed as completed until 11/9/21, the first day of the new certification period, making the assessment 1 day late. The assessments were not completed by day 60 of the certification period as required by regulation. The above stated findings were reviewed with the Administrator, the Clinical Manager, and the Corporate Regional Director of Clinical Services. The agency provided no additional information prior to the end of the survey. According to agency policy, titled Comprehensive Patient Assessment and dated 2/4/2020, a comprehensive assessment for recertification will be completed every 60 days for Medicare and Medicaid OASIS patients, and must be performed during days 56-60 (a 5 day window. 1. Patient #2 had a start of care date of 8/31/09. Clinical record revealed: a. An update to the comprehensive assessment for recertification, dated as initiated on 6/28/21, day 5 of the recertification period, but was not electronically signed as completed until 6/29/21, day 1 into the new certification period. The assessment was not completed by day 60 as required by regulation and agency policy, which was 1 day late.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 2 of 4 sampled patients requiring a resumption of care assessment (Patients #1 and #17). The agency provided services to 359 patients at the time of the survey and performed 130 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: 1.Patient #1 had a start of care date of 9/24/21. Clinical record review revealed a Resumption of Care Comprehensive Assessment, dated as initiated on 10/5/21 and signed as completed on 10/8/21, included documentation the resumption of care was physician ordered for 10/5/21. The assessment was completed 3 days after it was initiated, making the assessment 1 day late per regulations. 2. Patient #17 had a start of care date of 7/28/21 and a discharge date of 9/17/21. Clinical record review revealed a Resumption of Care Comprehensive Assessment, dated as initiated on 8/25/21 and signed as completed on 8/26/21, included documentation the patient was discharged from the hospital on 8/23/21. The assessment was completed 3 days after the hospital discharge, making the assessment 1 day late per regulations. The above stated findings were reviewed with the Administrator, the Clinical Manager, and the Corporate Regional Director of Clinical Services. The agency provided no additional information prior to the end of the survey. According to the agency policy, titled Comprehensive Patient Assessment, dated 2/4/2020, an update to the comprehensive assessment for resumption of care should be completed after discharge from the hospital.

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: 570 CONDITION Based on clinical record review, agency policy review, patient and patient caregiver interview, agency staff interview and home visit observation, the agency: 1) failed to ensure each patient received services that were established by a doctor of medicine, osteopathy or podiatry (G572); 2) failed to ensure all supplies/equipment/medications/treatments required by the patient to meet his/her needs were included on each patient's Plan of Care (G574); 3) failed to ensure all patient care orders, including verbal orders, must be recorded in the plan of care (G576); 4) failed to provide medications, treatments and services only as ordered by a physician (G580); 5) failed to promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or the plan of care should be altered (G590); and 6) failed to coordinate care delivery to meet the patients needs (G608). The cumulative systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 359 patients.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 4 of 7 sampled patients (Patients #2, #3, #16 and #17). The agency reported a census of 359 patients at the time of the survey. Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: 4. Patient #17 had a start of care date of 7/28/21 and a discharge date of 9/17/21. Clinical record review revealed the following: a. Interim physician order, dated 8/27/21, included documentation for physical therapy services, one time a week for one week and two times a week for four weeks. b. Physical therapy visit notes, dated 8/30/21 and 9/17/21, included documentation physical therapy services were provided. c. The week 8/29/21 to 9/4/21, lacked documentation of missed physical therapy visit and physician notification of the missed physical therapy visit. d. A coordination note, dated 9/14/21, included documentation the physical therapist had stopped at the patient’s home with no answer to the door, phone call to patient revealed the patient had been in the hospital for 3 days. The coordination note lacked documentation of a missed physical therapy visit and the physician had been notified of the missed physical therapy visit. The clinical record lacked any documentation of physician notification for the missed physical therapy visits. The above stated findings were reviewed with the Administrator, the Clinical Manager, and the Corporate Regional Director of Clinical Services. The agency provided no additional information prior to the end of the survey. According to the agency policy, titled Plan of Care and Physician Orders and dated 3/8/21, all care and services provided is according to current physician orders. Clinicians are responsible for alerting the physician to any changes in patient care or condition that suggest a need to alter the Plan of Care (POC). During agency staff interview on 11/8/2021 at 9:45 PM, the Clinical Manager reported if the frequency of visits if varied from the Plan of Care, the clinician will send a missed visit note to the physician. If an extra visit needs to be made, the clinician will obtain an order. 1. Patient #2 had a start of care date of 8/31/09. Clinical record review revealed the following: a. The Plan of Care, dated 6/29/21 to 8/27/21 and 8/28/21 to 10/26/21, included physician orders for skilled nursing visits 1-3 times per week and included to report pulse oximeter readings less than 88. b. The update to the comprehensive assessment for recertification, dated 8/23/21, lacked documentation of assessment of the patient's pulse oximeter reading. c. The skilled nurse visit notes, dated 9/6, 9/10, 9/17, 9/20, 9/24,and 10/6/21, lacked assessment of the patient's patient's pulse oximeter reading. The clinical record lacked any documentation of physician notification for the variance in the task ordered on the Plan of Care. 2. Patient #3 had a start of care date of 7/17/21. Clinical record review revealed the following: a. The Plan of Care, dated 7/17/21 to 9/14/21, included physician orders for a physical therapy visit 1 times per week for one week beginning on 7/18/2021. b. The initial physical therapy visit note, dated 7/30/21, documented 7/30/21 as the patient's initial evaluation visit. c. A client coordination note, dated 7/23/21 and completed by the physical therapist, documented the patient was too tired and requested to wait until 7/30/21 for the initial visit. The clinical record lacked documentation of communication with the physician to discuss the inability to follow the Plan of Care. 3. Patient #16 had a start of care date of 3/12/21 and a discharge date of 5/10/21. Clinical record review revealed the following: a. The Plan of Care, dated 3/12/21 to 5/10/21, included physician orders for an occupational therapy visit 1 times per week for three week beginning on 3/14/2021. b. The initial occupational therapy visit note, dated 3/22/21, documented 3/22/21 as the patient's initial evaluation visit. The clinical record lacked documentation of why an occupational therapy visit did not occur the week of 3/14/21. The clinical record lacked documentation of communication with the physician to discuss the inability to follow the Plan of Care. c. A physician's order, dated 4/9/21, documented to continue physical therapy visits starting 4/11/21 weekly for four weeks. d. A client coordination note, dated 4/16/21 and completed by the therapist, documented the patient did not answer phone calls so a physical therapy visit did not occur. The clinical record lacked documentation of communication with the physician to discuss the inability to follow the Plan of Care.

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 agency policy review, clinical record review, home visit observation and patient, patient caregiver and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 12 of 17 sampled patients (Patients #1, #2, #3, #4, #5, #7, #8, #9, #11, #12, #13, and #16). The agency reported a total current census of 359 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: 12.Patient #1 had a start of care date of 9/24/21. Clinical record review revealed the Plan of Care, dated 9/24/21 to 11/22/21, included shower/tub equipment and personal care as medical equipment and supplies used by the patient. During a home visit observation, on 11/15/21 at 3:05 PM, with Staff L, registered nurse, the patient reported using a shower bench for bathing. Staff L and the patient did not know what personal care meant regarding medical equipment and supplies. The Plan of Care failed to identify specific equipment used by the patient. The surveyor reviewed the above stated findings with the Administrator, the Clinical Manager, and the Corporate Regional Director of Clinical Services. The agency provided no additional information prior to the end of the survey. 7. Patient #4 had a start of care date of 10/16/2021. Clinical record review, surveyor observations and associated patient/caregiver/staff interview revealed the following: a. The initial comprehensive assessment completed at the time of start of care, dated 10/16/2021, documented Patient #4 was incontinent of urine. b. On 11/9/2021 at 1:00 PM during a home visit while accompanied by Staff J, Physical Therapist (PT), the surveyor observed Patient #4 wore incontinence briefs, used a bed rail and used a toilet riser with hand rails. c. During patient caregiver interview on 11/9/2021 while in the patient's home, the caregiver reported the bedrail and toilet riser with hand rails were used solely by the patient. The caregiver confirmed the patient wore incontinence briefs due to episodes of occasional urinary incontinence. d. The Plan of Care, dated 10/16/2021 to 12/14/2021, lacked identification of the incontinent briefs, bedrail and toilet riser with rails as equipment or supplies used by the patient to meet his/her needs. During the same home visit, the surveyor noted the following medication discrepancies: e. The surveyor observed the patient took Ditiazem 180 milligrams (mg) two tablets twice daily. The Client Medication Report, printed 11/8/2021, lacked inclusion of Ditiazem as taken by the patient. The Plan of Care, dated 10/16/2021 to 12/14/2021, did not include Ditiazem as a medication taken by the patient. f. The surveyor observed the patient took Omeprazole 40 mg daily. The Client Medication Report, printed 11/8/2021, lacked inclusion of Omeprazole as taken by the patient. The Plan of Care, dated 10/16/2021 to 12/14/2021, did not include Omeprazole as a medication taken by the patient. g. The surveyor observed the patient took Potassium Chloride 10 mEq twice daily. The Client Medication Report, printed 11/8/2021, lacked inclusion of Potassium Chloride as taken by the patient. The Plan of Care, dated 10/16/2021 to 12/14/2021, did not include Potassium Chloride as taken by the patient. h. The surveyor observed the patient took Sertraline 50 mg daily. The Client Medication Report, printed 11/8/2021, lacked inclusion of Sertraline as taken by the patient. The Plan of Care, dated 10/16/2021 to 12/14/2021, did not include Sertraline as taken by the patient. i. The surveyor observed the patient took Vitamin B12 1000 micrograms (mcg) daily. The Client Medication Report, printed 11/8/2021, lacked inclusion of Vitamin B12 as taken by the patient. The Plan of Care, dated 10/16/2021 to 12/14/2021, did not include Vitamin B12 as taken by the patient. j. The surveyor observed the patient took Metoprolol 25 mg daily. The Client Medication Report, printed 11/8/2021, lacked inclusion of Metoprolol as taken by the patient. The Plan of Care, dated 10/16/2021 to 12/14/2021, did not include Metoprolol as taken by the patient. 8. Patient #5 had a start of care date of 12/17/2020. Clinical record review, surveyor observation during home visit and associated patient/caregiver/staff interview revealed the following: On 11/9/2021 at 10:00 AM, the surveyor accompanied Staff I, Registered Nurse, to Patient #5's home. During the home visit, the surveyor observed the following: a. The Plan of Care, dated 10/13/2021 to 12/11/2021, documented the patient took Vitamin D3 25 micrograms 3 times weekly. The surveyor observed a bottle of Vitamin D3 125 micrograms in the home. The 90 tablet bottle contained only 11 tablets left. b. The surveyor observed the patient took Migraine Relief Tablets which contained 250 mg Acetaminophen, 250 mg Aspirin and 65 mg Caffeine. During patient interview on 11/9/2021 during the home visit, Patient #5 reported taking the Migraine Relief tablets one daily as needed. The Plan of Care, dated 10/13/2021 to 12/11/2021, lacked inclusion of Migraine Relief Tablets as medication taken by the patient. c. The surveyor observed pharmacy identification of Pioglitazone 30 mg included once daily in the medication strips filled by the pharmacy. The medication strips were filled on 10/12/2021. The Plan of Care, dated 10/13/2021 to 12/11/2021, lacked inclusion of Pioglitazone as medication taken by the patient. d. Staff interview during the home visit on 11/9/2021 revealed Staff I, RN, reported the patient was using a medicated cream on skin biopsy sites on both lower legs. Patient #5 presented a tube of Clobetasol Propionate 0.05%. Patient interview on 11/9/2021 during the home visit revealed Patient #5 reported using the cream twice daily since biopsy. The Plan of Care, dated 10/13/2021 to 12/11/2021, lacked inclusion of the Clobetasol cream despite the RN's knowledge of the patient's use. 9. Patient #8 had a start of care date of 1/23/2021. Clinical record review and associated patient/caregiver/staff interview revealed the following: a. The updates to the comprehensive assessment at the time of recertification, dated 5/18/21 and 7/21/2021, documented Patient #8 used a bedside commode, slept in a hospital bed and used a gait belt when ambulating with therapy staff. The same assessment documented the patient was incontinent of urine at times. The Plans of Care, dated 5/23/2021 to 7/21/2021 and 7/22/2021 to 9/19/2021, did not include bedside commode, hospital bed, gait belt or incontinence brief/pad as equipment or supplies used by the patient to meet his/her needs. b. The update to the comprehensive assessment at the time of recertification, dated 9/16/2021, documented Patient #8 used a bedside commode, slept in a hospital bed, used a lift chair and used a gait belt when ambulating with therapy staff. The same assessment documented the patient was incontinent of urine at times. The Plan of Care, dated 9/20/2021 to 11/18/2021, did not include bedside commode, hospital bed, lift chair, gait belt or incontinence brief/pad as equipment or supplies used by the patient to meet his/her needs. c. During agency staff interview on 11/10/2021 at 9:15 AM, Staff F, Physical Therapist (PT), reported Patient #8 had a hospital bed, lift chair, bedside commode, used incontinence briefs and ambulated using a gait belt. d. During patient caregiver interview on 11/11/2021 at 3:30 PM, Patient #8's adult child reported the patient wears incontinence briefs, has a hospital bed, has a lift recliner and uses a bedside commode. 10. Patient #9 had a start of care date of 8/4/2021. Clinical record review revealed the following: a. The initial comprehensive assessment completed at start of care, dated 8/4/2021, documented Patient #9 was incontinent of urine. The update to the comprehensive assessment completed at the time of recertification, dated 10/1/2021, documented Patient #9 was incontinent of urine. The Plans of Care, dated 8/4/2021 to 10/2/2021 and 10/3/2021 to 12/1/2021, lacked identification of incontinence products as supplies used by the patient to meet his/her needs. The hospital visit summary, dated 9/27/2021, included the following medication orders: b. Acetaminophen 325 mg twice daily. The Plan of Care, dated 10/3/2021 to 12/1/2021, did not include Acetaminophen as medication taken by the patient. c. Vitamin D3 50 mcg one twice daily. The Plan of Care, dated 10/3/2021 to 12/1/2021, included Vitamin D3; however, documented the dosage as 25 mcg one daily. d. Magnesium Oxide 400 mg. daily. The Plan of Care, dated 10/3/2021 to 12/1/2021, did not include Magnesium Oxide as medication taken by the patient. e. Omeprazole 20 mg daily. The Plan of Care, dated 10/3/2021 to 12/1/2021, did not include Omeprazole. 11. Patient #12 had a start of care date of 9/15/2021. Clinical record review revealed the following: The initial comprehensive assessment completed at start of care, dated 9/15/2021, documented Patient #12 was incontinent of urine and bowel movements. The Plan of Care, dated 9/15/2021 to 11/13/2021, lacked documentation of incontinence products as used by the patient to meet his/her needs. According to agency policy, titled Plan of Care and Physician Orders, dated 3/8/21, the individualized plan of care must include types of supplies, types of equipment and all medications. 1. Patient #2 had a start of care date of 3/26/21. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 6/29/21 to 8/27/21, 8/28/21 to 10/26/21, and 10/27/21 to 12/25/21, included orders for Ambien 5 milligrams (mg) at bedtime. b. The Client Medication Report, dated 11/8/21, included orders for Ambien 5 milligrams (mg) at bedtime. During a home visit observation on 11/10/21 at 11:15 AM, with Staff D, Registered Nurse (RN), the surveyor reviewed the patient's medications with patient and RN. The medication bottle instructed 10 mg at bedtime. The patient reported the dose changed about a year ago. The bottle had a fill date of 10/11/21. During phone interview with the pharmacy on 11/15/21 at 9:19 AM, pharmacy staff revealed use of Ambien 10 mg since 3/10/2020. The Plans of Care lacked the correct dosage of Ambien used by the patient. c. The Plans of Care, dated 6/29/21 to 8/27/21, 8/28/21 to 10/26/21, and 10/27/21 to 12/25/21, included orders for Famciclovir 500 mg twice daily as needed for cold sores. d. The Client Medication Report, dated 11/8/21, included orders for Famciclovir 500 mg twice daily as needed for cold sores. During the same home visit the patient revealed no longer taking Famciclovir since starting Valacyclovir 500 mg as needed for cold sores on 11/17/2020. During phone interview with the pharmacy on 11/15/21 at 9:19 AM, pharmacy staff revealed use of Valacyclovir 500mg since 12/12/19. The Plans of Care lacked discontinuation of the Famciclovir and initiation of the Valacyclovir on 11/17/2020. e. The Plans of Care, dated 6/29/21 to 8/27/21, 8/28/21 to 10/26/21, and 10/27/21 to 12/25/21, included orders for Nexium 40 mg two times daily. f. The Client Medication Report, dated 11/8/21, included orders for Nexium 40 mg two times daily. During the same home visit, the patient and the current medication bottle revealed instructions to take Nexium one time daily. The bottle had a refill date of 10/11/21. During phone interview with the pharmacy on 11/15/21 at 9:19 AM, pharmacy staff revealed use of Nexium 40 mg daily since 11/2/17. The Plans of Care lacked identification of the correct dosage of Nexium used by the patient. g. The Plans of Care, dated 6/29/21 to 8/27/21, 8/28/21 to 10/26/21, and 10/27/21 to 12/25/21, included orders for Orphenadrine Citrate Extended Release 100 mg daily for stomach. h. The Client Medication Report, dated 11/8/21, included orders for Orphenadrine Citrate Extended Release 100 mg daily for stomach. During the same home visit, the patient revealed use of Orphenadrine Citrae only as needed for headaches and last used one week ago. The Plans of Care lacked identification of the correct use of Orphenadrine used by the patient.. i. The Plans of Care, dated 6/29/21 to 8/27/21, 8/28/21 to 10/26/21, and 10/27/21 to 12/25/21, included orders for Pilocarpine 4% eye drops 1 drop to both eyes daily to prevent pupil constriction. j. The Client Medication Report, dated 11/8/21, included orders for Pilocarpine 4% eye drops 1 drop to both eyes daily to prevent pupil constriction. During the same home visit the patient and the current eye drop bottle revealed a dosage Pilocarpine 1% eye drops and apply1 drop to both eyes daily to prevent pupil constriction. Interview with Staff D, RN, revealed sometimes the electronic health record does not have the correct option of prescribed dose and so the clinician selects what is offered in the electronic health record. During phone interview with the pharmacy on 11/15/21 at 9:19 Am, pharmacy staff revealed use of Pilocarpine 1% since 8/28/18. The Plans of Care lacked identification of the correct dosage of Pilocarpine used by the patient. k. The Plans of Care, dated 6/29/21 to 8/27/21, 8/28/21 to 10/26/21, and 10/27/21 to 12/25/21, included orders for Tizanidine 4 mg and instructed to take 2 capsules at breakfast. l. The Client Medication Report, dated 11/8/21, included orders for Tizanidine 4 mg and instructed to take 2 capsules at breakfast. During the same home visit the patient reported a current dosage 1 capsule daily. During phone interview with the pharmacy on 11/15/21 at 9:19 Am, pharmacy staff revealed use of Tizanidine 4 mg since 11/2/17. The Plans of Care lacked identification of the correct dosage of Tizanidine used by the patient. During the same home visit the patient reported use of Propulosid 10 mg four times per day. m. The Plans of Care dated 6/29/21 to 8/27/21, 8/28/21 to 10/26/21, and 10/27/21 to 12/25/21, lacked identification of Propulosid as a medication used by the patient. n. The Plans of Care, dated 6/29/21 to 8/27/21, 8/28/21 to 10/26/21, and 10/27/21 to 12/25/21, identified the following as medical equipment and supplies used by the patient: respiratory supplies, lab/intravenous infusion supplies. During the same home visit the patient reported independently setting up medications in pill boxes. The patient revealed use of the pill boxes for 20 years since diagnosed with gastroparesis. The Plan of Care lacked identification of the pill boxes as medical equipment/supplies used by the patient. 2. Patient #3 had a start of care date of 7/17/21. Clinical record review revealed the following: a. The Plans of Care dated 7/17/21 to 9/14/21 and 9/15/21 to 11/13/21,identified the following as medical equipment and supplies used by the patient: glucometer and test supplies, rails/grab bars, shower/tub equipment, walker, and wheelchair. b. The update to the comprehensive assessment, dated 9/13/21 and completed by the physical therapist, documented the patient's use of a bedpan for most toileting. c. The Plans of Care lacked identification of the bed pan as medical equipment/supplies used by the patient. 3. Patient #7 had a start of care date of 9/11/2020. Clinical record review revealed the following: a. The Plans of Care dated 9/6/21 to 11/4/21 and11/5/21 to 1/3/22,identified the following as medical equipment and supplies used by the patient: oxygen supplies, ostomy supplies and wound care supplies. During a home visit observation on 11/10/21 at 8:30 AM, with Staff E, RN, the surveyor noted a CPAP (continuous positive airway pressure device) located on a bedside stand next to the patient's bed. The patient reported use of the CPAP for the past 4-5 years. The Plans of Care lacked identification of the CPAP as medical equipment/supplies used by the patient. During the same home visit the surveyor reviewed the medications currently in use by the patient. The patient had a bottle of Amoxicillin-Clavulanate 815mg-125mg filled on 10/28/21 to be taken for 14 days. b. The Plan of Care, dated 11/5/21 to 1/3/22, lacked identification of Amoxicillin-Clavulanate 815mg-125mg used by the patient. 4. Patient #11 had a start of care date of 10/10/21. Clinical record review revealed the following: a. The Plan of Care dated 11/10/21 to 1/8/22, identified the patient's use of the following medications: Atorvastatin, Diltiazem, Glipizide, Lisinopril, Miralax, and extra strength Tylenol. During a home visit observation on 11/15/21 at 1:10 PM, with Staff K, Occupational Therapist (OT), the surveyor reviewed with the patient current medications used. The surveyor observed a bottle of Eliquis 5 mg with instructions to take twice daily. The patient reported use of the medication since returned home from the skilled nursing facility. The Plan of Care lacked identification of Eliquis as medication used by the patient. b. The Plan of Care dated 11/10/21 to 1/8/22, identified the patient's use of the following equipment/supplies: commode, glucometer and test supplies, incentive spirometer, rails/grab bars, shower/tub equipment, transfer bench, and hemi walker. During the same home visit the surveyor observed the patient's use of a front wheeled walker. The patient denied having a hemi walker ever, but does also have a rollator walker, but is not using that. The patient also reported use of poise pads for urinary incontinence at night and last used the pads 2 nights ago. The Plan of Care lacked identification of the poise pads as equipment/supplies used by the patient and incorrectly identified the type of walker used by the patient. 5. Patient #13 had a start of care date of 7/23/21 and a discharge date of 9/17/21. Clinical record review revealed the following: a. The Plan of Care dated 7/23/21 to 9/17/21, identified the following as medical equipment and supplies used by the patient: glucometer and test supplies, rails/grab bars, shower/tub equipment, walker, and powered wheelchair. b. The occupational therapy visit note, dated 7/26/21, identified the patient lived in a mobile home with a ramp entrance. The Plan of Care lacked identification of the ramp as medical equipment/supplies used by the patient. c. The skilled nurse visit note, dated 9/3/21, identified the patient fell while standing with a walker for the home health aide to cleanse the backside. The patient fell to the floor and denied injuries and was assisted back to the wheelchair by wife and hoyer lift (mechanical lift). The Plan of Care lacked identification of the hoyer lift as medical equipment/supplies used by the patient. 6. Patient #16 had a start of care date of 3/12/21 and a discharge date of 5/10/21. Clinical record review revealed the following: a. The Plan of Care dated 3/12/21 to 5/10/21, identified the following as medical equipment and supplies used by the patient: hospital bed, rails/grab bars, shower/tub equipment, walker, gloves, and wound care supplies. b. The initial comprehensive assessment completed at start of care, dated 3/12/21, documented a gel or foam mattress was required and already in place. The Plans of Care lacked identification of the gel or foam mattress as medical equipment/supplies used by the patient.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, and staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 16 of 16 sampled patients with new verbal/interim orders (Patients #1, #2, #3, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17 and #18). The agency reported a total current census of 359 patients at the time of the survey. Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: 11. Patient #1 had a start of care date of 9/24/21. Clinical record review revealed the following: a. The Plan of Care, dated 9/24/21 to 11/22/21, included orders for skilled nursing, physical therapy and occupational therapy services. b. Interim physician order to apply negative pressure system, dated 9/29/21; c. Interim physician order for resumption of care, dated 10/5/21; d. Interim physician order for physical therapy services, dated 10/11/21; e. Interim physician order for occupational therapy services, dated 10/12/21; f. Interim physician order for negative pressure wound care to left lower leg, dated 10/21/21; g. Interim physician order for wound care to left lateral heel, dated 10/27/21; h. Interim physician order to discontinue occupational therapy services, dated 11/1/21; i. Interim physician order for wound care to left lateral heel with betadine, dated 11/4/21; j. Interim physician order to discontinue physical therapy services, dated 11/5/21; k. Interim physician order for infusion catheter care to continue daily saline flushes, dated 11/5/21; l. Interim physician order for wound care to left lower leg, hold wound vac (negative pressure therapy), apply wet to dry dressing twice a day until 11/8/21, dated 11/5/21; m. Interim physician order for wound care to left lower leg, pack with silver alginate and decrease skilled nursing visits, dated 11/8/21; and n. Interim physician order for wound care to left lower leg, use silver alginate and wrap with ace wrap, dated 11/9/21. The clinical record failed to include Plan of Care updates that included interim physician orders. 12. Patient #6 had a start of care date of 7/12/21. Clinical record review revealed the following: a. The Plans of Care, dated 7/12/21 to 9/9/21, 9/10/21 to 11/8/21 and 11/9/21 to 1/7/22, included orders for skilled nursing services. b. Interim physician order for weekly lab draws for CBC and CMP, dated 7/19/21; c. Interim physician order for resumption of care, dated 7/27/21; d. Interim physician order for physical therapy services, dated 8/2/21; e. Interim physician order for physical therapy services discharge, dated 8/16/21; f. Interim physician order to decrease skilled nursing services to every other week, dated 10/4/21; and g. Interim physician order to draw labs on 10/25/21 and then every other week, dated 10/11/21. The clinical record failed to include Plan of Care updates that included interim physician orders. 13. Patient #10 had a start of care date of 10/13/21. Clinical record review revealed the following: a. The Plan of Care, dated 10/13/21 to 12/11/21, included orders for skilled nursing and physical therapy services. b. Interim physician order to monitor daily vital signs, dated 10/15/21; c. Interim physician order for as needed skilled nursing visit for occluded wound vac line, dated 10/29/21; d. Interim physician order for as needed skilled nursing visit for clogged wound vac, dated 10/30/21; and e. Interim physician order for additional physical therapy services, dated 11/4/21. The clinical record failed to include Plan of Care updates that included interim physician orders. 14. Patient #14 had a start of care date of 5/21/21 and a discharge date of 6/3/21. Clinical record review revealed the following: a. The Plan of Care, dated 5/21/21 to 7/19/21, included orders for skilled nursing, physical therapy and occupational therapy services. b. Interim physician order for pravastatin and discontinue simvastatin, dated 5/24/21; and c. Interim physician order for physical therapy services discharge, dated 6/3/21. The clinical record failed to include Plan of Care updates that included interim physician orders. 15. Patient #15 had a start of care date of 4/12/21 and a discharge date of 6/29/21. Clinical record review revealed the following: a. The Plan of Care, dated 4/12/21 to 6/10/21, included orders for physical therapy, occupational therapy and speech language therapy services. b. Interim physician order to hold services due to hospitalization, dated 4/26/21; c. Interim physician order for resumption of care, dated 5/7/21; d. Interim physician order to cancel occupational therapy evaluation, dated 5/11/21; and e. Interim physician order for resumption of care, dated 5/18/21. The clinical record failed to include Plan of Care updates that included interim physician orders. 16. Patient #17 had a start of care date of 7/28/21 and a discharge date of 9/17/21. Clinical record review revealed the following: a. The Plan of Care, dated 7/28/21 to 9/25/21, included orders for physical therapy and occupational therapy services. b. Interim physician order for skilled nursing services to evaluate, dated 7/30/21; c. Interim physician order for potassium medication, dated 8/2/21; d. Interim physician order for skilled nursing services weekly, dated 8/9/21; e. Interim physician order to hold services due to hospitalization, dated 8/23/21; f. Interim physician order for resumption of care, dated 8/25/21; g. Interim physician order for occupational therapy services, dated 8/26/21; h. Interim physician order for physical therapy services, dated 8/27/21; i. Interim physician order to cancel physical therapy visit due to patient being in emergency room, dated 9/3/21; j. Interim physician order to draw BMP (basic metobolic panel), dated 9/8/21; k. Interim physician order to cancel physical therapy services due to hospitalization, dated 9/23/21; and l. Interim physician order to hold all services due to hospitalization, dated 9/25/21. The clinical record failed to include Plan of Care updates that included interim physician orders. The above stated findings were reviewed with the Administrator, the Clinical Manager, and the Corporate Regional Director of Clinical Services. The agency provided no additional information prior to the end of the survey. 6. Patient #5 had a start of care date of 12/17/2020. Clinical record review revealed the following: a. The Plan of Care, dated 12/17/2020 to 2/14/2021, lacked inclusion of the medication Trazadone. The interim physician order, dated 2/10/2021, documented identification of a medication bottle in the patient's home. The bottle added Trazadone 50 milligrams (mg) at bedtime to the patient's medication regimen. The Client Medication Report included documentation of the noted addition of Trazadone. The newly ordered Trazadone was not added to a Plan of Care Update. The nurse did not add the Trazadone to a Plan of Care until the next certification period of 2/15/2021 to 4/15/2021. b. The Plan of Care, dated 2/15/2021 to 4/15/2021, lacked inclusion of Hydrochlorithiazide (HCTZ) as a medication used by the patient. The interim physician order, dated 3/29/2021, documented identification of a medication bottle in the patient's home. The bottle added HCTZ 25 mg daily to the patient's medication regimen. The Client Medication Report included documentation of the noted addition of HCTZ. The newly ordered HCTZ was not added to a Plan of Care Update. The nurse did not add the HCTZ to a Plan of Care until the next certification period of 4/16/2021 to 6/14/2021. c. The Plan of Care, dated 4/16/2021 to 6/14/2021, included physician orders for only skilled nursing services. The physician's interim order, dated 5/10/2021, added a physical therapy evaluation. A second physician's interim order, dated 5/10/2021, approved a frequency of physical therapy visits twice weekly for 3 weeks. The newly ordered therapy services were never added to a Plan of Care Update. The therapy services discontinued on 5/28/2021. 7. Patient #8 had a start of care date of 1/23/2021. Clinical record review revealed the following: a. The Plan of Care, dated 5/23/2021 to 7/21/2021, included orders for home health aide services once weekly for 4 weeks. The physician's interim order, dated 6/13/2021, added home health aide services once weekly for an additional 4 weeks. The additional home health aide visit frequency and duration were never added to a Plan of Care Update. The physician's interim order, dated 7/18/2021, added home health aide visits once weekly for one additional week. The change in frequency was never added to a Plan of Care Update. b. The Plan of Care, dated 5/23/2021 to 7/21/2021, included orders for physical therapy services twice weekly for 2 weeks then once weekly for 2 weeks. The physician's interim order, dated 6/15/2021, added physical therapy services twice weekly for an additional 3 weeks then once weekly for an additional 2 weeks. The additional physical therapy visit frequency and duration were never added to a Plan of Care Update. The physician's interim order, dated 7/11/2021, increased the frequency of physical therapy visits to twice weekly for the remaining 2 weeks. The change in frequency was never added to a Plan of Care Update. c. The Plan of Care, dated 7/22/2021 to 9/19/2021, included orders for home health aide services once weekly for 4 weeks. The physician's interim order, dated 8/23/2021, added home health aide services once weekly for an additional 4 weeks. The additional home health aide visit frequency and duration were never added to a Plan of Care Update. d. The Plan of Care, dated 7/22/2021 to 9/19/2021, included orders for physical therapy services twice weekly for 2 weeks; once weekly for 1 week; then twice weekly for 1 week. The physician's interim order, dated 8/19/2021, changed the frequency of physical therapy services to twice weekly for 4 weeks. The change in frequency was never added to a Plan of Care Update. e. The Plan of Care, dated 9/20/2021 to 11/18/2021, included orders for home health aide services once weekly for 4 weeks. The physician's interim order, dated 10/15/2021, added home health aide services once weekly for an additional 5 weeks. The additional home health aide visit frequency and duration were never added to a Plan of Care Update. f. The Plan of Care, dated 9/20/2021 to 11/18/2021, included orders for physical therapy services twice weekly for 4 weeks. The physician's interim order, dated 10/15/2021, added physical therapy services twice weekly for an additional 4 weeks. The additional physical therapy visit frequency and duration were never added to a Plan of Care Update. g. The Plan of Care, dated 9/20/2021 to 11/18/2021, lacked inclusion of skilled nursing services. The interim physician's order, dated 11/2/2021, added a skilled nursing evaluation visit. The interim physician's order, dated 11/6/2021, added skilled nursing services for wound care/education once weekly for one week; twice weekly for 2 weeks; then once weekly for 1 week with 3 as needed (PRN) visits for wound issues, pain or falls. The additional skilled nurse visits were not added to a Plan of Care Update. h. The physician's interim order, dated 11/9/2021, added Lasix 20 mg daily to the patient's medication regimen. The same order added Unnaboot dressing to the patient's right leg -change every 2-3 days and compression stocking to the left leg. The Lasix, Unnaboot and compression stocking were not added to a Plan of Care Update. 8. Patient #9 had a start of care date of 8/4/2021. Clinical record review revealed the following: The Plan of Care, dated 10/3/2021 to 12/1/2021, did not include home health aide services. The physician's interim order, dated 10/26/2021, added home health aide visits once weekly for 6 weeks. The additional aide services were not added to a Plan of Care Update. 9. Patient #12 had a start of care date of 9/15/2021. Clinical record review revealed the following: a. The Plan of Care, dated 9/15/2021 to 11/13/2021, included orders for physical therapy visits once weekly for 1 week; twice weekly for 4 weeks; once weekly for 1 week; twice weekly for 2 weeks; and once weekly for 1 weeks. The interim physician's order, dated 10/6/2021, changed the planned frequency and duration of physical therapy visits to once weekly for 4 weeks. The changed frequency was never added to a Plan of Care Update. b. The Plan of Care, dated 9/15/2021 to 11/13/2021, included orders for occupational therapy visits once weekly for 4 weeks. The interim physician's order, dated 10/7/2021, added occupation therapy visits once weekly for an additional 3 weeks. The additional visits were not added to a Plan of Care Update. c. The Plan of Care, dated 9/15/2021 to 11/13/2021, included orders for speech therapy visits twice weekly for 3 weeks; then once weekly for 2 weeks. The interim physician's order, dated 10/18/2021, added speech therapy visits once weekly for an additional 4 weeks. The additional visits were not added to a Plan of Care Update. 10. Patient #18 had a start of care date of 9/28/2021. Clinical record review revealed the following: The Plan of Care, dated 9/28/2021 to 11/26/2021, did not include Cefpodoxime as a medication taken by the patient. The interim physician order, dated 10/3/2021, added the medication to the patient's regimen but failed to include a dosage or frequency noted on the bottle in the patient's home. The nurse failed to add the medication to the Client Medication Report. The medication was never added to a Plan of Care Update. According to agency policy, titled Plan of Care and Physician Orders, dated 3/8/21, all care and services are provided according to current physician orders. Clinicians are responsible for alerting the physician to any changes in patient care or condition that suggest a need to alter the Plan of Care (POC). All verbal orders written by clinicians are transmitted into the Electronic Medical Record. On 11/8/21 at 3:44 PM, interview with the Clinical Manager reported she was sure they were updating the Plan Of Care and the agency had a process, but would need to look into it. On 11/9/21 at 9:14 AM, interview with the Clinical Manager reported the only thing she discovered is the clinician writes a verbal order and she does not believe they are updating the Plan of Care to include the new verbal orders. On 11/15/21 at 3:10 PM, the Administrator reported the agency found the updated Plan of Care, but the bad news is none of the nurses know how to use it. The Administrator commented to the surveyor and the Clinical Manager the updated Plan of Care will be easier for the nurses to track current orders. 1. Patient #2 had a start of care date of 8/31/09. Clinical record review revealed: a. The Plan of Care, dated 8/28/21 to 10/26/21, included physician orders for skilled nursing to obtain peripheral intravenous access for infusions. b. An interim physician's order, dated 8/30/21, ordered new medications for heart failure, lisinopril 2.5 milligrams (mg) daily and Fludrocortisone 0.1 mg daily for hypotension. c. An interim physician's order, dated 9/7/21, ordered to discontinue current dose of lisinopril 2.5 mg and change to lisinopril 2.5 mg 2 tablets (for dose of 5 mg) daily. The Plan of Care lacked updates to include the interim physician's orders. 2. Patient #3 had a start of care date of 7/17/21. Clinical record review revealed: a. The Plan of Care, dated 7/17/21 to 9/14/21, included orders for skilled nursing, physical therapy and occupational therapy. b. An interim physician's order, dated 7/23/21, ordered the following new medications aspirin low dose 81 mg daily, lantus solostar insulin pen 100 units per 1 milliliter and ordered 5 units at lunch, lisinopril 10 mg daily, and simvastatin 40 mg at bedtime. c. An interim physician's order, dated 9/2/21, discontinued aspirin low dose 81 mg daily, famotidine 20 mg daily, ferrous sulfate 325 mg twice daily, lantus solostar insulin pen 100 units per 1 milliliter 5 units daily, and ondansetron HcCl 4 mg as needed for nausea and added ferrous sulfate 325 mg every other day and lantus solostar insulin pen 100 units per 1 milliliter and ordered 5 units daily as needed for blood sugars over 250. d. The Plan of Care, dated 7/17/21 to 9/14/21, included orders for skilled nursing, physical therapy and occupational therapy. e. An interim physician's order, dated 9/7/21, to decrease the frequency of occupational therapy visits to 1 time per week for the week of 9/7/21 per patient request. The Plan of Care lacked updates to include the interim physician's orders. f. The Plan of Care, dated 9/15/21 to 11/13/21, included orders for physical therapy and occupational therapy. g. An interim physician's order, dated 9/30/21, to continue physical therapy visits beginning 10/3/21 to 2 times per week for one week. h. An interim physician's order, dated 10/7/21, to continue occupational therapy visits starting 10/10/21 1 time per week for 5 weeks. i. An interim physician's order, dated 10/11/21, to decrease the frequency of physical therapy visits starting 10/3/21 to 1 time per week. j. An interim physician's order, dated 10/11/21, to continue physical therapy visits to 1 time per week for 4 weeks starting 10/17/21. The Plan of Care lacked updates to include the interim physician's orders. 3. Patient #7 had a start of care date of 9/11/2020. Clinical record review revealed: a. The Plan of Care, 9/6/21 to 11/4/21, included orders for skilled nursing to perform dressing change as follows: cleanse around the wound with soap disposable cloth in water, rinse well. Apply skin prep to intact skin around wound bed prior to adhesive to protect skin. Use adhesive remover while removing the dressing. Hold KCI Wound Vac this week. Primary dressing: right buttocks wound: keep mepitel with steri strips in place. Grafix #1 applied 8/30/21 followed by collagen roping. Change plain aquacel/calcium alginate over the mepitel daily along with the ABD gauze pad. Do not use aquacel AG/Calcium Alginate with silver. Change dressing daily and as needed for one week. b. A faxed physician's order, dated 9/7/21, cleanse around the wound with soap disposable cloth in water, rinse well. Cleanse the wound with normal saline solution moistened gauze. Apply skin prep to intact skin around wound bed prior to adhesive to protect skin. Use adhesive remover while removing the dressing. Negative Pressure Wound therapy to right buttock and sacral wound- Place Prisma AG (collagen with silver) to wound base, then fill with black foam, black granufoam spiral cut layer to lightly fill wound, one continuous piece offset foam and tubing away from points of pressure to prevent injury. Negative pressure setting 125 MMHG continuous. Dressing to be changed Tuesday and Friday this week, then Monday, Wednesday, Friday and as needed. Change canister weekly. c. A faxed physician's order, dated 9/22/21, no tub baths or soaking. May shower with protection: Covered dressings with plastic or saran wrap to keep dressings dry. cleanse around the wound with soapy disposable cloth and water, rinse well. Cleanse the wound with normal saline solution moistened gauze on Friday. Dressing change pat dry with gauze. Apply skin prep to intact skin around wound bed prior to adhesive to protect skin. Use adhesive remover while removing the dressing. Negative Pressure Wound therapy to right buttock to sacral open surgical wound- Grafix #2 applied to wound bed today then placed Prisma AG (collagen with silver) to wound base, then fill with black foam with the end half wrapped in Mepitel, black granufoam spiral cut layer to lightly fill wound, one continuous piece offset foam and tubing away from points of pressure to prevent injury. Negative pressure setting 125 MMHG continuous. Dressing to be changed Monday, Wednesday, Friday and as needed. Do not irrigate wound bed with saline on Wednesday. d. An interim physician's order, dated 9/29/21, to decrease the frequency of skilled nursing visits to 2 times per week for two weeks, 3 times per week for 4 weeks and 2 times per week for one week beginning 9/19/21. e. A faxed physician's order, dated 9/30/21, Negative Pressure Wound therapy to right buttock and sacral wound- Place Prisma AG (collagen with silver) to wound base, then fill with black foam, black granufoam spiral cut layer to lightly fill wound, one continuous piece offset foam and tubing away from points of pressure to prevent injury. Negative pressure setting 125 MMHG continuous. Dressing to be changed every Monday, Wednesday, Friday and as needed. Do not irrigate wound bed with saline on Wednesday. f. An interim physician's order, dated 10/11/21, to decrease the frequency of skilled nursing visits to 2 times per week for one week, 3 times per week for 2 weeks and 2 times per week for one week beginning 10/10/21. g. A faxed physician order, dated 10/12/21 as follows: no tub baths or soaking. May shower with protection. Cleanse around the wound with soapy disposable cloth and water, rinse well. Irrigate the wound with saline each dressing change. Pat dry with gauze. Apply skin prep to intact skin around wound bed prior to adhesive to protect skin. Use adhesive remover while removing the dressing. Negative Pressure Wound therapy to right buttock to sacral open surgical wound- Prisma AG (collagen with silver) to wound base, then fill with black foam, black granufoam spiral cut layer to lightly fill wound, one continuous piece offset foam and tubing away from points of pressure to prevent injury. Negative pressure setting 125 MMHG continuous. Dressing to be changed Monday, Wednesday, Friday and as needed. Do not irrigate wound bed with saline on Wednesday. Change canister weekly and as needed. h. An interim physician's order, dated 10/18/21, to decrease the frequency of skilled nursing visits to 2 times per week for one week, 3 times per week for 1 week and 2 times per week for one week beginning 10/17/21. i. A faxed physician order, dated 10/25/21 as follows: Apply skin prep to intact skin around wound bed prior to adhesive to protect skin. Use adhesive remover while removing the dressing. Primary dressing-Hold wound vac for one week. Right buttocks ulcer apply 1 inch Nugauze moistened with 0.125% Dakin's solution wicked into wound bed. Use one continuous piece and leave a one inch tail for easy removal. Please order Hydrofera blue roping to place into wound bed instead of Dakin's solution and then change three times per week. Secondary dressing cover with ABD gauze pad or Opsite and secure with Medipore or VAC draping. Dressing to be changed daily and as needed until Hydrofera blue roping is available then 3 times weekly. j. An interim physician's order, dated 10/28/21, to decrease the frequency of skilled nursing visits to 1 time per week for one week, beginning 10/31/21. k. An interim physician's order, dated 10/30/21, to increase the frequency of skilled nursing visits to 5 times per week for one week, and 2 times per week for 1 week beginning 10/24/21. l. A faxed physician order, dated 11/3/21 as follows: Cleanse around the wound with soapy disposable cloth and water, rinse well. Irrigate the wound with saline each dressing change. Pat dry with gauze. Apply skin prep to intact skin around wound bed prior to adhesive to protect skin. Use adhesive remover while removing the dressing. Hold wound VAC one more week. Right buttock ulcer apply 1 inch Nugauze moistened with 0.125% Dakin's solution wicked in wound bed. Use 1 continuous piece and leave a one inch tail for easy removal. Please order than change to Hydrofera blue roping to place into wound bed instead of Dakin's solution and then change three times per week. Secondary dressing cover with ABD gauze pad or Opsite and secure with Medipore Tape or VAC draping. Change dressing daily and as needed until Hydrofera blue roping is available then 3 times weekly. m. The Plan of Care, 11/5/21 to 1/3/22, included orders for skilled nursing to perform dressing change as follows: right buttocks wound cleanse with saline. Place Hydrofera blue roping into wound bed. Cover with ABD gauze or opsite and secure with Medipore or VAC draping. Change three times per week. n. An interim physician's order, dated 11/5/21, to decrease the frequency of skilled nursing visits to 2 times per week for one week, 3 times per week for 7 weeks and 1 time per week for one week, beginning 11/7/21. The Plan of Care lacked updates to include the faxed and interim physician's orders. 4. Patient #13 had a start of care date of 7/23/21 and a discharge date of 9/17/21. Clinical record review revealed: a. The Plan of Care, dated 7/23/21 to 9/20/21, included physician orders for skilled nursing, home health aide, physical therapy, and occupational therapy. b. An interim physician's order, dated 8/12/21, ordered a social worker evaluation. c. An interim physician's order, dated 8/13/21, ordered to discontinue current dose of allopurinol 100 mg daily and change to allopurinol 300 mg daily, discontinue metformin 500mg twice daily and change to 500 mg 2 tablets (1000mg) twice daily. d. An interim physician's order, dated 8/13/21, included frequency of 1 time per week for one week and 2 times per week for two weeks social worker visits, along with goals. e. An interim physician's order, dated 8/19/21, ordered to discontinue current dose of allopurinol 100 mg daily and change to allopurinol 300 mg daily, discontinue metformin 500mg twice daily and change to 500 mg 2 tablets (1000mg) twice daily. f. An interim physician's order, dated 8/19/21, discharged occupational therapy services with goals met. g. An interim physician's order, dated 8/20/21, ordered to discontinue current dose of furosemide 40 mg daily and change to furosemide 20 mg daily, and add fenofibrate 54 mg daily. h. An interim physician's order, dated 8/24/21, ordered to continue physical therapy services 2 times per week for two weeks and 1 time per week for two weeks effective 8/22/21 i. An interim physician's order, dated 9/8/21, discharged physical therapy services with goals met. The Plan of Care lacked updates to include the interim physician's orders. 5. Patient #16 had a start of care date of 3/12/21 and a discharge date of 5/10/21. Clinical record review revealed: a. The Plan of Care, dated 3/12/21 to 5/10/21, included physician orders for skilled nursing, home health aide, physical therapy, and occupational therapy. b. A faxed physician's order, dated 3/17/21, ordered monthly standing labs starting 4/14/21 to include complete blood count with differential, complete metabolic panel, folate, vitamin B12, and iron panel. c. An interim physician's order, dated 4/1/21, ordered to decrease physical therapy visits effective 3/28/21 to 1 time per week for one week, and every 2 weeks for two weeks. d. An interim physician's order, dated 4/9/21, ordered to continue physical therapy visits effective 4/11/21 to 1 time every other week for four weeks. e. An interim physician's order, dated 4/15/21 ordered to decrease occupational therapy visits effective 4/11/21 to 1 time every other week for two weeks. f. An interim physician's order, dated 4/22/21, discharged occupational therapy services with goals met. g. An interim physician's order, dated 4/30/21, ordered to discharge from physical therapy services due to lack of compliance. h. An interim physician's order, dated 5/6/21, ordered to discontinue current dose of hydroxyurea 500mg 2 capsules twice daily and changed to hydroxyurea 500 mg 2 capsules daily with breakfast and hydroxyurea 500 mg at bedtime. The Plan of Care lacked updates to include the interim physician's orders.

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 agency policy review, clinical record review, physician interview and agency staff interview, the agency failed to provide medications, treatments or services only as ordered by the physician for 2 of 17 sampled patients (Patients #8 and #16). The agency reported a current patient census of 359 patients at the time of the survey. Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: 2. Patient #16 had a start of care date of 3/12/21 and a discharge date of 5/10/21. Clinical record review revealed: a. The Plan of Care, dated 3/12/21 to 5/10/21, included orders for skilled nursing visit to perform/teach wound care to bilateral feet stasis ulcers as follows: cleanse with saline, apply iodasorb nickel thick to wound bed, cover/secure with Mepilex foam, Kerlix, ang tubagrip. Wound care to be performed two times per week. Caregiver to assist on non skilled nursing visit days. b. Skilled nursing visit note, dated 4/19/21, documented wound care was completed per orders and the patient tolerated well. c. Skilled nursing visit note, dated 4/26/21, documented wound care was completed per orders and the patient tolerated well. The nurse advised patient need to likely return to wound center as current treatment is probably not appropriate as wounds are closed. d. Skilled nursing visit note, dated 5/6/21, documented wound care was not completed as wound was healed and closed. e. The update to the comprehensive assessment at discharge, dated 5/10/21, documented the patient's feet are calloused and patient educated on need to still clean and monitor areas. The nurse washed the feet with soap and water and covered areas with foam for protection. The nurse lacked documentation of completing wound cares as ordered on the Plan of Care. The above findings were reviewed with the Administrator, Clinical Manager, and Corporate Regional Director of Services. Agency staff provided no further information prior to the end of the survey. According to the agency policy, titled Plan of Care and Physician Orders and dated 3/8/2021, all care and services provided must be in accordance with current physician orders. Clinicians are responsible for alerting the physician to changes in patient care or condition that suggest a need to alter the Plan of Care. 1. Patient #8 had a start of care date of 1/23/2021. Review of the clinical record and associated agency staff interviews revealed the following: a. The Plan of Care, dated 9/20/2021 to 11/18/2021, included physician orders for physical therapy (PT) and home health aide services. The Plan of Care documented diagnoses of hypertensive heart disease with chronic congestive heart failure and chronic severe kidney disease. b. The physical therapy visit note, dated 11/2/2021 and completed by Staff F, PT, documented the patient stated "I'm in bad shape". The therapist noted the patient's adult daughter who previously resided with the patient had moved out of state and was no longer in the home. The therapist noted the patient did not have reliable help. During the visit, the physical therapist documented 2+ edema to both lower extremities and identified a new, open wound on the patient's right shin. The physical therapist documented an estimated size of the wound as "approximately 2.5 inches by 2.5 inches". The physical therapist dressed the wound with an ABD pad, wrapped with gauze roll and taped to secure. The physical therapist then "notified MCS (manager of clinical services), will obtain order for nursing, MCS to order supplies." The clinical record included an interim physician order, dated 11/2/2021, ordering "RN to eval and treat for shin blister that has opened." The clinical record lacked any interim orders directing the physical therapist to treat the patient's wound on the right shin in any way. b. The RN evaluation occurred on 11/6/2021. The clinical record included an interim physician's order, dated 11/6/2021, directing the skilled nurse to cleanse the right shin open area with soap and water. Apply Prisma to the wound bed, cover with an ABD pad and secure with tape- change daily and as needed for loose or soiled dressing. Caregiver may perform wound care on days skilled nurse does not visit. c. The clinical record included an interim physician's order, dated 11/9/2021, changing the wound care to the right lower leg venous stasis ulcer to: cleanse with saline, pat dry; apply unna boot from toes to knees every 2-3 days and as needed for loose or soiled dressing. Apply compression stocking to the left lower extremity on in the morning and off at night. Add Lasix 20 milligrams daily to the patient's medication regimen. The skilled nursing visit, dated 11/12/2021, documented the nurse applied the unna boot to the patient's right leg and wrapped ace wraps on the left leg. The physician order was to apply compression stockings. The clinical record lacked documentation of communication with the physician or orders to apply ace wraps to the left leg as a substitution for compression stockings. d. During physician interview on 11/9/2021 at 4:45 PM, the patient's primary Physician's Assistant reported she had been out ill for 2 weeks but upon return, noted the home health agency staff contacted the on-call physician on 11/6/2021 to report a new wound on the patient's right shin. The physician gave an order for Prisma in the wound bed with ABD covering and secure with tape. Change daily. Ok to teach son to perform dressing change. The Physician's Assistant reported she gave a verbal order on 11/9/2021, to apply an unnaboot to the right leg and compression stocking to the left leg. e. During agency staff interview on 11/10/2021, Staff F, PT, reported she had just recently taken over care of Patient #8 on 10/27/2021 due to another therapists medical leave. The PT reported the patient's primary caregiver, an adult daughter, was no longer in the home residing with and caring for the patient. Upon arrival on 10/27/2021, the PT noted 2+ pitting edema in both lower extremities due to the patient dangling legs from the side of the hospital bed as the patient was afraid to use the lift chair without someone in the home. "She was afraid she wouldn't get out. The therapist gave direction to avoid dangling feet as this will increase edema. "I don't thinks she did it" because next visit on 11/2/2021 identified a new open blistered area on the right shin. Staff F, PT, reported she did place an ABD over the wound, wrap with gauze roll and tape in place as the patient had placed an ABD over the wound before the visit and taped in place with scotch tape on the skin. Staff F, PT, reported she did contact Staff H, Manager of Clinical Services, to report the wound and she directed the therapist get an order for skilled nurse evaluation. Staff F, PT, reported she did call the physician's office but was unsure who she spoke with. She asked for an ok to have a skilled nurse evaluation due to a new wound and whoever it was said that would be ok. She did not speak with a physician.

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 agency policy review, clinical record review, and agency staff interview, the agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 2 of 17 sampled patients (Patients #13 and #16). The agency provided services to 359 patients at the time of the survey. Failure to communicate the patient's status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: According to the agency policy, titled Plan of Care and Physician Orders and dated 3/8/21, all care and services provided is according to current physician orders. Clinicians are responsible for alerting the physician to any changes in patient care or condition that suggests a need to alter the Plan of Care (POC). Interview with Clinical Manager on 11/8/21 at 3:44 PM revealed staff document communication with the physician in the narrative note of the visit or a care coordination note. 1. Patient #13 had a start of care date of 7/23/21 and a discharge date of 9/17/21. Clinical record review revealed the following: a. The Plan of Care, dated 7/23/21 to 9/20/2021, included diagnoses of idiopathic gout and cerebral palsy. b. The occupational therapy assistant note, dated 8/2/21, documented the patient had 2 falls over the weekend while transferring, including an emergency room visit on Friday. The occupational therapist did document care coordination with the occupational therapist. c. The initial comprehensive assessment at the time of start of care, dated 7/23/2021, documented the patient's integumentary status was assessed and no problems were identified. d. The occupational therapy visit note, dated 8/9/21, documented the patient had two falls over the weekend and required EMT (emergency medical technician) assistance to get back to chair. The patient was incontinent of bowel and the occupational therapy assistant (OTA) provided assistance with cleanup while patient stood with walker, needing 2 rest breaks. An open sore was noted on the patient's left buttock and patient reported sore was painful due to sleeping in recliner. The OTA documented will discuss with supervising Occupational Therapy (OT) and care team at weekly case conference. e. The skilled nursing visit note, dated 8/13/21, documented integumentary was assessed and no problems were identified. Phone interview on 11/6/21 at 9:42 AM, with Staff O, OTA, revealed the OTA believed the patient was going to the MD on the 9th, therefor fall not reported to the physician. The falls documented on 8/2/21 resulted in emergency room visits, and the occupational therapist believed since in the emergency room the physician would have been aware already. Phone interview with Patient #13 revealed the patient frequently has sores that open up on the patient's bottom due to sleeping in recliner chair. The clinical record lacked documentation of physician notification of the open sore noted by the OTA and reported falls. 2. Patient #16 had a start of care date of 3/12/21 and a discharge date of 5/10/21. Clinical record review revealed: a. The Plan of Care, dated 3/12/21 to 5/10/21, included orders for skilled nursing visit to perform/teach wound care to bilateral feet stasis ulcers as follows: cleanse with saline, apply iodasorb nickel thick to wound bed, cover/secure with Mepilex foam, Kerlix, ang tubagrip. Wound care to be performed two times per week. Caregiver to assist on non skilled nursing visit days. b. Skilled nursing visit note, dated 4/26/21, documented wound care was completed per orders and the patient tolerated well. The nurse advised patient need to likely return to wound center as current treatment is probably not appropriate as wounds are closed. The note lacked documentation of the nurse contacting the physician to discuss possible need for change of wound care. c. Skilled nursing visit note, dated 5/6/21, documented wound care was not completed as wound was healed and closed. The note lacked documentation of the nurse contacting the physician to discontinue wound care. d. The update to the comprehensive assessment at discharge, dated 5/10/21, documented the patient's feet are calloused and patient educated on need to still clean and monitor areas. The nurse washed the feet with soap and water and covered areas with foam for protection. The nurse lacked documentation of completing wound cares as ordered on the Plan of Care and did not contact the physician to discuss patient's need for continued orders for cleaning the area and need for foam dressing for protection. The above findings were reviewed with the Administrator, Clinical Manager, and Corporate Regional Director of Services. Agency staff provided no further information prior to the end of the survey.

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 clinical record review, review of agency patient lists, physician interview and agency staff interview, the agency failed to ensure agency staff coordinated the delivery of care in a way to meet patient individualized needs for 1 of 17 sampled patients (Patient #8). The agency reported a current census of 359 patients at the time of the survey. Failure to ensure agency staff effectively coordinated the delivery of care resulted in the patients not receiving care to meet individualized patient needs. Findings include: Patient #8 had a start of care date of 1/23/2021. Review of the clinical record and associated agency staff interviews revealed the following: a. The Plan of Care, dated 9/20/2021 to 11/18/2021, included physician orders for physical therapy (PT) and home health aide services. The Plan of Care documented diagnoses of hypertensive heart disease with chronic congestive heart failure and chronic severe kidney disease. b. The update to the comprehensive assessment, dated 9/16/2021, documented the patient experienced a gait deficit, had limited ambulation ability and was deemed a fall risk. The patient resided in the home with an adult daughter who was the primary caregiver of the patient. The patient experienced 2+ pitting edema in both lower extremities; walked occasionally for very short distances but spent the majority of time in bed or chair; was incontinent of urine and used a bedside commode; someone must help the patient dress the lower and upper body; requires another person present for safe ambulation; and was able to transfer from bed to chair independently. c. The physical therapy visit note, dated 10/27/2021 and completed by Staff F, PT, documented finding the patient sitting on the side of the hospital bed with feet dangling upon the therapist's arrival. The patient's adult daughter who had been residing in the patient's home and caring for the patient was no longer living in the home due to personal/medical issues. The daughter had moved out of state and was no longer able to care for the patient. The patient reported feeling afraid to get into the lift chair without someone in the home in case she was unable to stand up from the chair and be stuck. The PT educated the patient on the need to have legs elevated as much as possible to decrease edema and the risk for venous stasis ulcers. d. The physical therapy visit note, dated 11/2/2021 and completed by Staff F, PT, documented the patient stated "I'm in bad shape". The therapist noted the patient's adult daughter who previously resided with the patient had moved out of state and was no longer in the home. The therapist noted the patient did not have reliable help. During the visit, the physical therapist documented 2+ edema to both lower extremities and identified a new, open wound on the patient's right shin. The physical therapist documented an estimated size of the wound as "approximately 2.5 inches by 2.5 inches" with clear drainage noted. The physical therapist dressed the wound with an ABD pad, wrapped with gauze roll and taped to secure. The physical therapist then "notified MCS (manager of clinical services), will obtain order for nursing, MCS to order supplies." The clinical record included an interim physician order, dated 11/2/2021, ordering "RN to evaluate and treat for shin blister that has opened." The clinical record lacked any interim orders directing the physical therapist to treat the patient's wound on the right shin in any way. e. The next visit was made by physical therapy. The physical therapy visit note, dated 11/4/2021, documented 2+ pitting edema in both lower extremities. The open blistered area on the right shin remained and continued to drain; weeping noted on the left lower extremity as well but no blistering noted; "RN ordered." The therapist documented notifying the MCS (Staff H. Manager of Clinical Services). "Nurse to assess wound." f. During agency staff interview on 11/10/2021, Staff F, PT, reported she had just recently taken over care of Patient #8 on 10/27/2021 due to another therapists medical leave. The PT reported the patient's primary caregiver, an adult daughter, was no longer in the home residing with and caring for the patient. The therapist reported, after the adult daughter left, the patient's adult son began staying with the patient. The therapist reported a concern that the son was not interested or willing to care for the patient. Staff F, PT, reported the son was not present during the 10/27 or 11/2/2021 visits. The therapist reported the son was present during the 11/4/2021 visit but when the therapist was attempting to educate the son, he turned and walked away, leaving the room. Upon arrival on 10/27/2021, the PT noted 2+ pitting edema in both lower extremities due to the patient dangling legs from the side of the hospital bed as the patient was afraid to use the lift chair without someone in the home. "She was afraid she wouldn't get out. The therapist gave direction to avoid dangling feet as this will increase edema. "I don't thinks she did it" because next visit on 11/2/2021 identified a new open blistered area on the right shin. Staff F, PT, reported she did place an ABD over the wound, wrap with gauze roll and tape in place as the patient had placed an ABD over the wound before the visit and taped in place with scotch tape on the skin. Staff F, PT, reported she did contact Staff H, Manager of Clinical Services, to report the wound and she directed the therapist get an order for skilled nurse evaluation. Staff F, PT, reported she did call the physician's office but was unsure who she spoke with. She asked for an ok to have a skilled nurse evaluation due to a new wound and whoever it was said that would be ok. She did not speak with a physician. g. The RN evaluation did not occur until 11/6/2021, 4 days after identification of the wound. The RN documented only trace edema bilaterally; noted an open wound on the patient's right shin; documented an inability to measure the wound; documented the wound was irregular in shape and had a moderate amount of serous drainage. The team coordination note, dated 11/6/2021, documented the RN called the physician to report the wound and obtain orders to treat. The interim physician's order, dated 11/6/2021, approved skilled nursing visits once weekly for 1 week- twice weekly for 1 week and then once weekly for 1 week. The order directed the skilled nurse to cleanse the right shin open area with soap and water. Apply Prisma to the wound bed, cover with an ABD pad and secure with tape- change daily and as needed for loose or soiled dressing. Caregiver may perform wound care on days skilled nurse does not visit. h. The skilled nursing visit, dated 11/9/2021, documented 3+ pitting edema in both lower extremities; some slight breathlessness; the right shin wound was measured for the first time- 5.24 centimeters (cm) long by 3.32 cm wide by 0.2 cm deep with a large amount of serosanguineous drainage. The interim physician's order, dated 11/9/2021, changing the wound care to the right lower leg venous stasis ulcer to: cleanse with saline, pat dry; apply Unna boot from toes to knees every 2-3 days and as needed for loose or soiled dressing. Apply compression stocking to the left lower extremity on in the morning and off at night. Add Lasix 20 milligrams daily to the patient's medication regimen. i. The skilled nursing visit, dated 11/12/2021, documented the nurse applied the Unna boot to the patient's right leg and wrapped ace wraps on the left leg. The physician order was to apply compression stockings. The clinical record lacked documentation of communication with the physician or orders to apply ace wraps to the left leg as a substitution for compression stockings. j. During physician interview on 11/9/2021 at 4:45 PM, the patient's primary Physician's Assistant reported she had been out ill for 2 weeks but upon return, noted the home health agency staff contacted the on-call physician on 11/6/2021 to report a new wound on the patient's right shin. The physician gave an order for Prisma in the wound bed with ABD covering and secure with tape. Change daily. Ok to teach son to perform dressing change. The Physician's Assistant reported she gave a verbal order on 11/9/2021 to apply an Unnaboot to the right leg and compression stocking to the left leg. k. During agency staff interview on 11/15/2021 at 9:50 AM, Staff H, MCS Manager of Clinical Services, verified Staff F, PT, notified her of Patient #8's new wound on 11/2/2021. "I told her to get an order for an RN evaluation." When asked why the RN did not go evaluate the wound before 11/6/2021, 4 days after the identification of the wound, Staff H, MCS, replied "we didn't have a nurse available to go" "We only have 10 nurses for almost 400 patients. "Finally I said let's just have the on-call nurse go and she went on Saturday 11/6/2021". l. Review of the agency's patient lists revealed the agency admitted 35 new patients with orders for skilled nursing services between 11/2/2021 and 11/6/2021. m. During agency staff interview on 11/17/2021 at 1:40 PM, the Clinical Manager reported the agency "had an overabundance of referrals". There was a delay in skilled nurse visit for Patient #8 because "we had to just prioritize I guess." Patient #8's needs changed when the adult daughter was no longer able to care for the patient. The therapist noted edema and a new venous stasis ulcer present on 11/2/2021. The therapist reported the new wound to the agency nurse staff but did not measure the wound or report the assessment of the wound to the physician. The RN evaluation of the wound was delayed for 4 days due to staff unavailability even though the agency admitted 35 patients with skilled nursing need during those 4 days. The above stated findings were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on review of criminal background checks, child abuse and dependent adult abuse record checks, the agency allowed 1 of 10 sampled employees hired or contracted after 11/29/2018 (the date of the last survey conducted by the Department of Inspections and Appeals) without completing the required criminal history, dependent adult abuse and child abuse background checks within 30 days prior to hire (Staff M). The agency hired 41 new employees since 11/29/2018. The systemic practice resulted in the failure to ensure the organizational framework of the agency promoted and supported the adherence to state regulations and coordination of safe and effective delivery of care to the agency's 359 patients. 481 IAC (Iowa Administrative Code) rule 50.9 requires Home Health Agencies complete a criminal background history check, a dependent adult abuse background history check and a child abuse background history check on each prospective employee who will have direct patient contact. The home health agency must complete these record checks prior to the date of hire of a prospective employee. If a positive criminal history, dependent adult abuse history or child abuse history is identified, the agency must seek approval to hire from the Department of Human Services. 481 IAC rule 50.9(4) limits the validity of criminal history, dependent adult abuse history, and child abuse history record checks to a period of 30 days from the date the results of the background checks were received by the agency. Should a potential employee have a delayed hire date exceeding the allowed 30 days, the agency is required to run the background checks again to search for changes that may have occurred since the last background checks. Failure to complete the required backgrounds checks according to the State of Iowa requirements placed agency patients at risk for potential harm. Findings include: Staff M, Registered Nurse, had a hire date of 12/30/19. Staff D's personnel file included an initial criminal history check, dependent adult abuse history check and child abuse history check, completed on 11/13/19. The Single Contact License and Background Check were completed 41 days prior to the nurse's hire date, exceeding the 30 day requirement by 14 days. Staff M's personnel file lacked documentation of any additional background checks for criminal history, dependent adult abuse history or child abuse history completed within 30 days of the RN's hire date. The findings were reviewed with the Administrator and Clinical Manager. No further information was provided by the agency prior to the end of the survey.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on agency policy review and review of the agency's governing body meeting minutes, the agency failed to involve the governing body in the overall management and operation of the organization resulting in the governing body not being aware the agency was operating out of compliance with condition level regulations at Care Planning, Coordination and Quality of Care and condition level regulations at Compliance with Federal, State and local laws and regulations related to health and safety of patients. The agency reported a census of 359 patients at the time of the survey. Failure to include the governing body in the overall management and operation of the agency, placed agency patients at risk for inadequate and unsafe care. Findings include: According to the agency policy, titled Administrative Control and dated 5/25/2021, policies and procedures are approved and modified by the Governing Body of each agency. The Governing Body assumes full legal authority and responsibility for operation of the agency. The Governing Body will meet twice annually. The Governing Body is responsible for but not limited to overseeing Corporate Responsibility; adopting and periodically reviewing written bylaws and policies; oversees the management and fiscal affairs of the agency; reviews annual budget and program evaluation; decision making for the agency; QAPI review. The Governing Body is responsible for the overall operation of the agency and services provided by the home health agency. Review of the agency's governing body meeting minutes, dated 3/18/2019; 7/22/2019; 10/23/2019; 3/10/2020; 6/22/2020; 9/8/2020; 3/18/2021and 6/15/2021, demonstrated the meeting minutes did not reflect discussion of the home health agency's operations/concerns/struggles, focusing mostly on special projects and QAPI project approval. The above findings were reviewed with the Administrator/Clinical Manager. The agency provided no further information prior to the end of the survey.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure the patients clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 4 of 7 sampled patients (Patients #1, #7, #10 and #16). The agency reported a census of 359 patients at the time of the survey. Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patients at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. Findings include: Review of the agency's undated policy, titled Skin and Wound Care, identified wound measurements, length, width, depth; completed weekly and at the start of care, resumption of care, recertification, and discharge. When using negative pressure therapy always count the total number of pieces of sponge/foam used in the wound. Document the quantity and color and the date of dressing change on the wound drape and in the patients chart. When dressing is removed, always count the number of sponge/foam pieces removed, correlate the count and the color with the number of pieces previously placed in the wound and verify the complete removal of all pieces. Document number and color removed in the patient chart. On 11/16/21 at 8:29 AM, Clinical Manager reported the wound documentation should be in the skilled nursing visit note narrative note and should include what cares are done, such as if wound was cleansed, packed, and covered. 3. Patient# 1 had a start of care date of 9/24/21. Clinical record review revealed the following: a. Resumption of care interim physician orders, dated 10/5/21, included the following wound care orders: perform wound care to left lower leg. Utilizing clean technique, cleanse wound and periwound area with saline or water. Apply skin prep as needed to protect periwound skin. Frame periwound area with drape. Apply dressing to wound cavity and adhere with drape. Change 3 times a week and as needed for negative pressure complications and troubleshooting. Negative pressure setting 120 mmHg (millimeters of mercury) continuous, dressing to wound bed (black foam). b. Resumption of care comprehensive assessment visit note, dated 10/5/21, included documentation wound care provided: apply negative pressure system 3 times per week, tolerated well. The visit note failed to identify if the wound and periwound was cleansed and what it was cleansed with, the number and color of foam removed/placed in the wound, and the suction on the negative pressure system. c. The skilled nursing visit notes, dated 10/11, 10/13 and 10/15/21, included documentation wound care provided: apply negative pressure system 3 time per week, one black foam removed from wound bed and one black foam placed in wound bed. Suction obtained at 120 mmHg continuous pressure. The visit notes failed to identify if the wound and periwound was cleansed and what it was cleansed with. d. The skilled nursing visit notes, dated 10/18/21, included documentation wound care provided: apply negative pressure system 3 times per week, one black foam removed from wound bed and two black foam placed in wound bed. Suction obtained at 120 mmHg continuous pressure. The visit note failed to identify if the wound and periwound was cleansed and what it was cleansed with. e. Interim physician order, dated 10/21/21, included the following wound care orders to left lower leg: apply triad to upper portion of the wound bed where depth noted/sample provided till gone. Utilizing clean technique, cleanse wound and periwound area with saline or water. Apply skin prep as needed to protect periwound skin. Frame periwound area with drape. Apply spiraled black foam dressing to wound cavity and adhere with drape. Change 3 times a week and as needed for negative pressure complication and troubleshooting. Negative pressure setting 120 mmHg continuous, dressing to wound bed (black foam). f. The skilled nursing visit notes, dated 10/25, 10/27 and 10/29/21, included documentation wound care provided: apply triad to upper portion of the wound bed where depth noted/sample provided till gone. Utilizing clean technique, cleanse wound and periwound area with saline or water. Apply skin prep as needed to protect periwound skin. Frame periwound area with drape. Apply spiraled black foam dressing to wound cavity and adhere with drape. Change 3 times a week and as needed for negative pressure complication and troubleshooting. Negative pressure setting 120 mmHg continuous, dressing to wound bed (black foam). One black foam removed from wound bed and one black foam placed in wound bed. The visit notes failed to identify what the wound was cleansed with, saline or water. g. The skilled nursing visit notes, dated 11/1/21 and 11/3/21, included documentation wound care provided: apply triad to upper portion of the wound bed where depth noted/sample provided till gone. Utilizing clean technique, cleanse wound and periwound area with saline or water. Apply skin prep as needed to protect periwound skin. Frame periwound area with drape. Apply spiraled black foam dressing to wound cavity and adhere with drape. Change 3 times a week and as needed for negative pressure complication and troubleshooting. Negative pressure setting 120 mmHg continuous, dressing to wound bed (black foam). One black foam removed from wound bed and one black foam placed in wound bed. The visit notes failed to identify what the wound was cleansed with, saline or water. h. The skilled nursing visit notes, dated 11/1, 11/3, and 11/5/21, included documentation no wound measurements taken. The skilled nurse failed to document wound measurements for the week of 10/31/21 through 11/6/21. 4. Patient# 10 had a start of care date of 10/13/21. Clinical record review revealed the following: a. Plan of Care, dated 10/13/21 to 12/11/21, included physician orders for skilled nursing services 3 times a week for wound care to right toe amputation site. b. The skilled nursing visit notes, dated 10/25, 10/27, and 10/29/21, included documentation no wound measurements taken. The visit notes failed to include wound measurements for the week of 10/24/21 to 10/30/21. The above stated findings were reviewed with the Administrator, the Clinical Manager, and the Corporate Regional Director of Clinical Services. The agency provided no additional information prior to the end of the survey. 1. Patient #7 had a start of care date of 9/11/2020. The Plans of Care, dated 7/8/21 to 9/5/21 and 9/6/21 to 11/4/21, included orders for skilled nursing services 3 times per week and ordered the nurse to perform wound care 3 times per week and as needed for wound VAC complications. The clinical record review revealed: a. Skilled nursing visit notes, dated 9/5/21, 9/6/21, 9/8/21 and 9/10/21, included documentation that wound care was performed as ordered and documented wound measurements were not completed as they were "not due". The clinical record lacked documentation of weekly wound measurements per agency policy for the week of 9/5/21. 2. Patient #16 had a start of care date of 3/12/21 and a discharge date of 3/12/21. The Plan of Care, dated 3/12/21 to 5/10/21, included orders for skilled nursing services 1 time per week for one week, 2 times per week for two weeks and then 1 time per week for seven weeks. and ordered the nurse to perform/teach wound care to bilateral feet venous stasis ulcers as follows: cleanse with saline, apply iodosorb nickel thick to wound bed, cover/secure with Mepilex foam, Kerlix, and tubigrip. Wound care to be perfomed 2 days per week and patient's caregiver to assist on non skilled nursing visit days. Clinical record review revealed: a. Skilled nursing visit note, dated 3/17/21, included documentation that wound care was performed as ordered and documented wound measurements were not completed as they were "not due". b. Skilled nursing visit note, dated 3/19/21, included documentation that wound care was not performed as ordered as the caregiver completed wound care. The narrative note further documented the patient would have the caregiver perfom wound care over the weekend since wound care was just done on 3/17/21. The clinical record lacked documentation of weekly wound measurements per agency policy for the week of 3/14/21. c. Skilled nursing visit note, dated 3/23/21 and completed by a licensed practical nurse (LPN), included documentation that wound care was performed as ordered and documented wound measurements were not completed as they were "not due". b. Skilled nursing visit notes, dated 3/25/21, included documentation that wound care was not performed as ordered as the caregiver completed wound care. The narrative note further documented the patient would have the caregiver perform wound care next day or Saturday since wound care was just done on 3/23/21. The clinical record lacked documentation of weekly wound measurements per agency policy for the week of 3/21/21.