Every finding on record at University of North Carolina Hospitals at Chapel Hill

An unannounced on-site recertification survey was conducted on 03/02/2026-03/05/2026. No deficiencies to the Medicare Conditions of Participation for Emergency Preparedness were identified.

An unannounced on-site recertification survey was conducted on 03/02/2026-03/05/2026. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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, observation, clinical record review, and staff interviews, the agency registered nurses failed to notify the physician of treatments that were not completed as ordered for 2 of 7 patients with orders for wound care (patients #12 & 16). Findings included: A policy, Home Health Monitoring Patient’s Response/Reporting to Physician or other Licensed Practitioner, received on 03/04/2026 at 1:26 PM from the administrator stated, “During each home visit, the clinician will assess the patient and communicate any change in the patient’s condition or established plan of care, including… Changes that have occurred regarding … treatment (including procedures…) When there is a problem implementing the plan of care.” 1. Patient #12 was admitted on 01/29/2026 with “No primary diagnosis documented.” The plan of care for 01/29/2026-03/29/2026 included orders for skilled nurse (SN) visits 1 time a week for 5 weeks with 5 PRN (as needed) and “SN to assess wound and measure weekly.” Review of the clinical record revealed that during the SN visits on 02/06/2026 and 02/13/2026 registered nurse (RN) #17 documented, “Dressing status Intact/not removed.” Further review revealed that there was no documentation of the physician not being notified that the wound was not assessed or measured as ordered. During an interview conducted on 03/05/2026 at 9:19 AM RN #17 stated, “I don’t believe that I did [notify the physician], normally yes [would notify the physician], it was just missed.” During an interview conducted on 03/05/2026 at 9:21 AM nurse supervisor #18 stated, “They [nurses] should notify the physician or provider.” 2. Patient #16 was admitted on 02/11/2026 with diagnoses of unspecified open wound, right lower leg and unspecified open wound, left lower leg. The plan of care for 02/11/2026-04/11/2026 included orders for skilled nurse (SN) visits 1 time a day for 1 day, 1 time a week for 1 week, 1 time a week for 8 weeks, with 3 PRN (as needed), “SN to perform wound care as follows: RLE [right lower extremity] Wash wound with soap and water… apply Dakin’s [topical antiseptic] moist to dry… Apply ABD [absorbent dressing] & Kerlix [rolled gauze], secure with _____ [brand name] tape, Change 1-2x/Day [1-2 times a day], Wear 1-2 layer tubigrip [compression bandage] 24/7 [continuously] size G… to be worn from just below the knee and down over the toes,” and “SN to perform wound care as follows: LLE [Left lower extremity] Wash wound with soap and water… apply Dakin’s [topical antiseptic] moist to dry… Apply ABD [absorbent dressing] & Kerlix [rolled gauze], secure with _____ [brand name] tape, Change 1-2x/Day [1-2 times a day], Wear 1-2 layer tubigrip [compression bandage] 24/7 [continuously] size G… to be worn from just below the knee and down over the toes.” During a home visit conducted on 03/03/2026 at 9:30 AM patient #16 requested that the tubigrip not be applied to his legs. RN #7 completed the wound care to both legs and did not apply the tubigrip as requested. A review of the clinical record revealed that there was no documentation of the physician being notified that the treatment was not provided as ordered. An interview conducted on 03/05/2026 at 8:47 AM with RN #8 revealed that they would normally notify the physician and document it. An interview conducted on 03/05/2026 at 9:00 AM with nurse manager #15 revealed that the nurse should have notified the physician and documented it.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency occupational therapist failed to include an order for a social worker (SW) visit in the plan of care for 1 of 3 patients with an order for SW visits (patient #15). Findings included: A policy, Home Health Monitoring Patient’s Response/Reporting to Physician or other Licensed Practitioner (revised 03/2026), received on 03/04/2026 at 1:26 PM from the administrator stated, “Based on communication with the physician or licensed practitioner, a verbal order will be obtained for any change in the plan of care and communicated to all appropriate team members to ensure that care is provided according to the revised plan of care.” Patient #15 was admitted on 02/02/2026 with a diagnosis of other sequelae of cerebral infarction (long term, post-acute, impairments following a stroke). The plan of care (POC) for 02/02/2026-04/02/2026 included orders for occupational therapy (OT) visits 1 time a week for 1 week, 2 times a week for 3 weeks and 2 times a week for 2 weeks. Review of the clinical record revealed that on 02/04/2026 OT #19 documented, “Disciplines ordered per referral and patient in agreement with the following evals [evaluations]: PT [physical therapy], OT, adding SW [social worker] …” OT #19 documented a communication with the physician requesting approval to the change in the POC including a request for the SW. The physician responded, “I agree with the POC.” Further review revealed that an order for a SW evaluation was not added to the POC. Patient #15 did not receive a SW visit. During an interview conducted on 03/05/2026 at 8:34 AM OT #19 stated, “I don’t think that was something that I was really attune too… What I would do would be to definitely let the care manager know that it was requested … for follow-up… the ball got dropped on this.” During an interview conducted on 03/05/2026 at 8:43 the therapy manager stated, “As soon as she received that communication from the doctor she should have put a one-time order in [the plan of care].”

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on agency policy, observation, and staff interviews the agency registered nurses failed to perform glove changes and hand hygiene during wound care for 2 of 2 patients with registered nurse (RN) home visits conducted (#’s 16 & 19), failed to disinfect equipment for 1 of 2 RN home visits conducted (#19), and failed to disinfect a wash basin, obtain clean water and washcloth during wound care for 1 of 2 RN (#19) with home visits conducted. Findings included: A policy, Home Health Standard Precautions (revised 03/2026) received on 03/04/2026 at 9:44 AM from the administrator stated, “Gloves are to be changed: Between task and procedures on the same patient… After removing an old dressing…” A policy, Wound Assessment, Home Care (revised 02/24/2024) received on 03/05/2026 at 9:45 AM from the administrator stated, “Remove the old dressing carefully… Discard the soiled dressing in the waterproof trash bag. Remove and discard your soiled gloves. Perform hand hygiene…” 1. Patient #16 was admitted on 02/11/2026 with diagnoses of unspecified open wound, right lower leg and unspecified open wound, left lower leg. The plan of care for 02/11/2026-04/11/2026 included orders for skilled nurse (SN) visits 1 time a day for 1 day, 1 time a week for 1 week, 1 time a week for 8 weeks, with 3 PRN (as needed), “SN to perform wound care as follows: RLE [right lower extremity] Wash wound with soap and water… apply Dakin’s [topical antiseptic] moist to dry… Apply ABD [absorbent dressing] & Kerlix [rolled gauze], secure with _____ [brand name] tape, Change 1-2x/Day [1-2 times a day], Wear 1-2 layer tubigrip [compression bandage] 24/7 [continuously] size G… to be worn from just below the knee and down over the toes,” and “SN to perform wound care as follows: LLE [Left lower extremity] Wash wound with soap and water… apply Dakin’s [topical antiseptic] moist to dry… Apply ABD [absorbent dressing] & Kerlix [rolled gauze], secure with _____ [brand name] tape, Change 1-2x/Day [1-2 times a day], Wear 1-2 layer tubigrip [compression bandage] 24/7 [continuously] size G… to be worn from just below the knee and down over the toes.” During a home visit conducted on 03/03/2026 at 9:30 AM while wearing clean gloves, registered nurse #7 removed supplies from the clinical bag, repositioned the patient’s personal bath towel on the floor and failed to remove the gloves and perform hand hygiene before removing the wound dressing from the right leg. RN #7 failed to remove the gloves after removing the soiled dressing and proceeded to begin the dressing change on the left leg. RN #7 used soap, water and a washcloth to cleanse the left leg and failed to remove the gloves, perform hand hygiene, disinfect the wash basin and obtain clean water before cleansing the right leg. RN #7 applied the Dakins soaked gauze to the right leg and failed to remove the gloves and perform hand hygiene before treating the left leg. An interview conducted on 03/05/2026 at 8:47 AM with RN #7 revealed that they were not aware that hand hygiene and new gloves were required after handling the patient’s personal bath towel and removing a wound dressing, was not aware that each wound should have been treated separately with glove changes and hand hygiene in-between each wound. During an interview conducted on 03/04/2026 at 12:05 PM the nurse educator stated, “They [nurses] should treat 1 wound at a time.” During an interview conducted on 03/05/2026 at 8:57 AM nurse manager #15 stated, “Hand hygiene should be performed every time you move from dirty to clean, every time you take off or put on your gloves, they should use individual cleanser for each wound and should done one wound at a time.” 2. Patient #19 was admitted on 11/24/2025 with a diagnosis of non-pressure chronic (long term) ulcer (wound) of right heel with fat layer exposed. The plan of care for 01/23/2026-03/23/2026 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 3 times a week for 2 weeks with 1 PRN visit and “SN to cleanse wound with Vashe [wound cleanser], apply collagen to the center of the wound, cover with bordered gauze/band-aid, and gentle 1-layer compression -8-15 [amount of compression] compression sock each visit.” During a home visit conducted on 03/02/2025 at 1:45 PM while wearing clean gloves RN #5 failed to remove the gloves and perform hand hygiene after removing bandage scissors from the patients personal supply box and failed to disinfect the scissors before cutting the collogen dressing and placing it on the wound. During an interview conducted on 03/05/2026 at 9:14 AM RN #5 stated, “Yes [would normally clean the scissor]” and agreed that she should have sanitized the scissors, removed gloves, performed hand hygiene and donned new gloves.” 9:18 AM 03/05, “Our expectation is that once she reached in the get the scissor, she should have removed the gloves, performed hand hygiene and put on clean gloves….”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the agency registered nurse documented inaccurate information in the clinical record for 1 of 2 patients with registered nurse home visits conducted. (#16) Findings included: Patient #16 was admitted on 02/11/2026 with diagnoses of unspecified open wound, right lower leg and unspecified open wound, left lower leg. The plan of care for 02/11/2026-04/11/2026 included orders for skilled nurse (SN) visits 1 time a day for 1 day, 1 time a week for 1 week, 1 time a week for 8 weeks, with 3 PRN (as needed), “SN to perform wound care as follows: RLE [right lower extremity] Wash wound with soap and water… apply Dakin’s [topical antiseptic] moist to dry… Apply ABD [absorbent dressing] & Kerlix [rolled gauze], secure with _____ [brand name] tape, Change 1-2x/Day [1-2 times a day], Wear 1-2 layer tubigrip [compression bandage] 24/7 [continuously] size G… to be worn from just below the knee and down over the toes,” and “SN to perform wound care as follows: LLE [Left lower extremity] Wash wound with soap and water… apply Dakin’s [topical antiseptic] moist to dry… Apply ABD [absorbent dressing] & Kerlix [rolled gauze], secure with _____ [brand name] tape, Change 1-2x/Day [1-2 times a day], Wear 1-2 layer tubigrip [compression bandage] 24/7 [continuously] size G… to be worn from just below the knee and down over the toes.” During a home visit conducted on 03/03/2026 at 9:30 AM patient #16 requested that the tubigrip not be applied to his legs. RN #7 completed the wound care to both legs and did not apply the tubigrip as requested. A review of the clinical record revealed that on 03/03/2026 RN #7 documented for the right and left lower extremity wounds that the wound care was provided as ordered. Further review revealed no documentation that the tubigrip was not applied. An interview conducted on 03/05/2026 at 8:47 AM with RN #7 revealed that because they had documented the patient’s refusal of the tubigrip at a prior visit they didn’t need to document it again. An interview conducted on 03/05/2026 at 9:00 AM with nurse manager #15 revealed that the expectation is for the nurses to document only the care that is provided, document any deviation from the physician’s order, and notify the physician.

An unannounced, onsite complaint investigation was conducted 6/3/24. The allegation was unsubstantiated, however, standard level deficiencies to the Medicare CoP were identified.

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, clinical record review, and staff interviews the agency failed to follow the physician's orders related to visit frequency for 1 of 2 patients with occupational therapy services orders [#3]. The findings included: On 6/3/24 at approximately 3:25 pm, the policy, Home Health Care Coordination, was provided by the Director of Home Health. The policy stated, "...integrate orders from all physicians involved in the plan of care so that all services and interventions are coordinated..." Patient #3 was admitted on 2/16/24 with diagnoses of pressure ulcer of sacral region (below the lumbar spine and above the tailbone, which is known as the coccyx), stage 4 (extending below the subcutaneous fat into deep tissues, including muscle, tendons, and ligaments) left heel pressure ulcer, infection and inflammatory reaction due to nephrostomy catheter (a tube that lets urine drain from the kidney through an opening in the skin on the back), Klebsiella pneumoniae (type of bacteria), malignant neoplasm of head of pancreas, secondary malignant neoplasm of other urinary organs, in addition to other comorbidities. The plan of care orders for the certification period 2/16/24 to 4/15/24 included orders for skilled nursing three times a week for wound care, physical therapy two times a week, and an occupational therapy [OT] evaluation. A supplemental order for OT was written on 2/20/24 for 2 times a week for 3 weeks. During the record review on 6/3/24, there were no occupational therapy visits done after the initial assessment on 2/20/24 and no documentation stating why the visits were not completed. During an interview with employee #1 on 6/3/24 at approximately 3:10 pm, employee #1 confirmed there was no evidence the patient received any OT visits after the initial evaluation on 2/20/24 and the agency failed to follow the physician’s orders related to visit frequencies.

An onsite recertification survey was conducted February 7, 2023-February 9, 2023. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted February 7, 2023-February 9, 2023. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on policy review, record review and staff interviews the agency failed to provide services as order for 5 of 17 patients. (Patients #10, 1, 4, 8 and 13) PolicyStat ID 9651479, titled Home Health Care Planning Process and last revised 04/2021, was received from the agency’s Assistant Director on 02/09/23 at 5:03 PM. This policy revealed, “…The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass equipment, supplies, and services required to meet the patient’s needs…Clinicians will inform the patient’s physician of any changes that suggest a need to alter the plan of care. Changes must be written, dated, and signed by the professional making the changes…” 4. Patient #8 was admitted to the agency on 01/18/23 with diagnoses including cellulitis (skin infection) of the groin, chronic respiratory failure, Type 2 diabetes, and heart failure (heart does not pump enough blood to meet the body’s demands). Plan of Care from 01/27/23 included order for skilled nursing 1 time per week for 1 week, 2 times per week for 4 weeks, and 1 time per week for 3 weeks; home health aide 2 times per week for 7 weeks; physical therapy 2 times per week for 6 weeks and 1 time per week for 1 week; and occupational therapy 1 time per week for 1 week. This plan of care also included skilled nursing interventions to instruct patient to monitor and record daily weights and to notify MD (medical doctor) for weight gain greater than 2 pounds in 24 hours or greater than 5 pounds in a week. Patient #8 received 5 skilled nursing visits between 01/19/23 and 02/07/23. There were no daily weights recorded in the clinical record during these visits and there was no evidence that the physician was notified that daily weights were not being monitored. In an interview on 02/09/23 at 3:18 PM, Employee #1, Assistant Director, stated, “She was not weighing herself…If she had orders to check it [daily weights]…” Employee #1 stated the expectation was “That they would notify the MD (medical doctor) that she was noncompliant. They should have notified the MD if she was supposed to weigh herself and was not doing it.” In an interview on 02/09/23 at 4:16 PM, Employee #5, RN (registered nurse) Case Manager, stated, “She would need a regulation, hospital sized one [scale]…she does not have a viable scale in the home…not one that would be correct anyway.” 5. Patient #13 was admitted to the agency on 01/24/23 with a primary diagnosis of Parkinson’s disease (a brain disorder leading to uncontrolled body movements and progressive difficulties with coordination and balance.) Plan of Care from 01/24/23 to 03/24/23 included orders for skilled nursing 3 times per week for 5 weeks, physical therapy 1 time per week for 1 week and 2 times per week for 4 weeks, speech therapy 1 time per week for 1 week (02/07/23-02/11/23) and medical social services 1 time per week for 1 week. A clinical record entry dated 01/27/23 at 2:45 AM and signed by Employee #7, Medical Social Worker, revealed, “…1/26/23 8:47 AM…1/26/23 2:46 PM [sic] patient does not want appointment”. There was no evidence that Employee #7 notified the physician regarding Patient #13 declining medical social services as ordered. In an interview on 02/09/23 at 3:23 PM, Employee #1, Assistant Director, stated, “There was not documentation [in the clinical record] that the doctor was notified. They should notify the doctor if the patient refuses.” Employee #7 was unavailable for interview at the time of survey. 2A. Patient #1 was admitted on 9/17/22 with diagnoses of type 2 diabetes mellitus with diabetic peripheral neuropathy (nerve damage due to diabetes) and hemiplegia and hemiparesis (paralysis on one side of the body) following cerebral infarction (stroke). The Plan of Care (POC) for 9/17/22-11/15/22 included orders for Occupational Therapy (OT) one time per week for one week beginning 9/18/22, one time for one week beginning 10/2/22, then one time weekly for four weeks. The OT evaluation was completed on 10/3/22. There was no evidence of an OT visit the week of 9/17/22. 2B. The referral included orders for skilled nursing. On 9/23/22, the patient refused the RN visit. No visit attempted until 10/13/22. 2C. The referral also included an order for Speech Therapy (ST). The ST conducted an evaluation on 10/29/22. There was no evidence of an attempt for ST to eval prior to 10/29/22. 2D. The referral also included a medical social work order. There was no evidence the MSW contacted the patient between 9/17/22-11/15/22. An interview with the assistant director on 2/8/22 at 2:42 p.m. confirmed the OT, SN, ST, and SW evaluations were not conducted within timeframes. 3. Patient #4 was admitted on 9/7/22 with a diagnosis of stage 2 pressure ulcer (a superficial wound caused by pressure) sacral region (area at the base of the spine). The Plan of Care (POC) for 9/7/22-11/5/22 included orders for skilled nursing (SN) two times per week for one week, three times per week for four weeks, two times per week for four weeks, and 2 as needed. The skilled nursing start of care note on 9/7/22 stated, “Home noted to have boards on the floor that are stable with wheelchair use during visit…Water turned on and off by spouse when requested…Agreed to OT [occupational therapy], MSW [medical social worker], and ST [speech therapy] and nursing with HHA [home health aide] to begin when isolation for COVID resolved.” The SN visit note from 9/14/22 stated, “Mold noted in several different patches/spots on wall of patient’s bedroom. Floors of home continue to be unsafe with holes, many covered with plywood and uneven.” On 9/26/22, the nurse visit documentation revealed, “An email has been sent to MSW with environmental and social concerns and uncertain of date MSW will be able make contact with son of patient. “Son states that son is ‘working on getting other housing options for patient but may not be able to get housing in ____ County due to expense.’ Home remains in disrepair with walks bowing, decaying, soft in areas on the outside, window broken, holes in floor in multiple places covered by large pieces of plywood. Son confirms that the home has been evaluated for repair and deemed unsafe to repair ‘due to pins beneath mobile home being broken.’ There is black mold around the edges of the walls all around near ceiling. There is no running warm water, any water has to be turned on outside then heated on stovetop. Patient is not able to have adequate personal hygiene met. At this time, it is not safe for home health aide service for ____ HH and it is not safe for PCS aide service…Nurse to provide care and instruction, and support for a few more weeks to allow time for MSW to provide resources and information.” On 10/4/22, the RN note stated, “Discussed with patient and spouse the seriousness and condition of their home and that winter is coming, it will be in the patient’s best interest for patient and spouse to seek alternative living arrangement. More siding on the exterior of the home peeled off in the tropical storm 9/30-10/1 and insulation is exposed and hanging out in multiple places. The flooring continues to soften and more plywood boards are being used. Patient verbalizes understanding and spouse is agreeable but patient/spouse and supportive son do not know how to go about proceeding with getting help. MSW has been given a report and patient has been discussed in team with supervisor.” The RN note on 10/7/22 stated, “Spoke with son and son is trying to arrange alternative living arrangement for himself and patient/spouse as soon as possible, son is very aware of the hazardous conditions of the patient’s current housing. Awaiting MSW. Plan to provide care and support until patient/son is in contact with MSW and/or moves from service area.” On 10/11/22, the RN stated, “Pt waiting to hear from social worker to discuss options for housing and care. Pt current living situation is not physically safe, trailer is in disrepair, loose missing floor boards, loose/missing external siding, insulation exposed.” On 10/14/22, the RN stated, “MSW has been contacted by nurse to inquire of status of MSW making contact with patient/son.” On 10/19/22, the RN noted, “No contact from MSW made as of today.” On 10/21/22, the patient was discharged with no MSW visit. An interview with the assistant director on 2/9/23 at 2:20 p.m. confirmed the order for medical social worker was present on the referral. The interview also confirmed there was no evidence the MSW contacted/visited the patient. 1. Patient #10 was admitted on 01/18/23 with a diagnosis of cellulitis (bacterial skin infection). The plan of care for 01/18/23-03/18/23 included orders for skilled nursing 3 times a week and medical social work (MSW) 1 time. On 01/26/23 MSW #7 stated, “patient requested that writer call her tomorrow afternoon”. There was no evidence that the MSW contacted the patient the following day and no evidence of physician notification of a missed visit. There was no evidence of a MSW visit between 01/18/23 and 02/09/23. MSW #7 was not available for an interview. An interview was conducted with the assistant director on 02/09/23 at approximately 11:30 A.M. The assistant director stated that there was no evidence that the MSW visits was completed.

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 record review and staff interview the agency failed to obtain a urinalysis as ordered by the physician for 1 of 1 patient with an order for a urinalysis. Findings included: Patient #16 was admitted 01/02/23 with a diagnosis of acute respiratory failure with hypoxia. The plan of care for 01/02/23-03/02/23 included orders for a urinalysis to be completed 01/13/23 related to increased agitation and confusion. The urine provided to the lab was a “poorly collected sample.” There was no evidence that the UA was completed. (Patient #16) An interview was conducted with the assistant director on 02/09/23 at approximately 11:00 A.M. The assistant director stated that there was no evidence that the UA was completed.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to notify the physician that medical social work visits were not conducted as ordered for 3 of 4 patients with medical social work orders (#1, 4, 10); and to notify the physician a patient had a high level of pain for 1 of 17 patients reviewed (#17); and to notify the physician of an incomplete urinalysis (UA) for 1 of 1 (#16) patient with an order for a UA. Findings included: A policy, Home Health Monitoring Patient’s Response/Reporting to Physician was provided by the assistant direct on 02/09/23 at approximately 4:45 P.M. The policy stated, “Communication with Physician… When a visit is missed for any reason… When results are received for relevant laboratory test ordered.” 4. Patient #10 was admitted on 01/18/23 with a diagnosis of cellulitis (bacterial skin infection). The plan of care for 01/18/23-03/18/23 included orders for skilled nursing 3 times a week and medical social work (MSW) 1 time. On 01/26/23, MSW #7 stated, “patient requested that writer call her tomorrow afternoon”. There was no evidence that the MSW contacted the patient the following day and no evidence of physician notification of a missed visit. MSW #7 was not available for an interview. 5. Patient #16 was admitted 01/02/23 with a diagnosis of acute respiratory failure with hypoxia (low levels of oxygen in body tissues). The plan of care for 01/02/23-03/02/23 included orders for a urinalysis (UA) to be completed 01/13/23 related to the patient experiencing increased agitation and confusion. The urine provided to the lab was a “poorly collected sample.” There was no evidence that the physician was notified or that the UA was completed. An interview with the agency director was conducted on 02/09/23 at approximately 3:00 P.M. The agency director stated that the physician should have been notified. A policy, Home Health Coordination (revised 4/2024), was provided by the agency director on 2/9/23 at 3:37 p.m. The policy stated, “Care coordination may include, but not be limited to…Coordinate communication with all physicians involved in the plan of care…Coordination of care deliver to meet the patient’s needs, and involve the patient, representative, and caregivers, as appropriate, in the coordination of care activities…Written evidence of care coordination may be found in the plan of care, case conference summary forms, or the clinical notes in the patient’s record.” A policy, Home Health Pain Management (revised 4/2021) was provided by the agency director on 2/9/23 at 3:36 p.m. The policy stated, “The patient’s right to pain management is respected and supported. Health Care clinicians plan, support, and coordinate activities and resources to ensure that the pain of all patients is recognized and addressed appropriately…Patients who report pain will receive further assessment and appropriate management.” 1. Patient #1 was admitted on 9/17/22 with diagnoses of type 2 diabetes mellitus with diabetic peripheral neuropathy (nerve damage due to diabetes) and hemiplegia and hemiparesis (paralysis on one side of the body) following cerebral infarction (stroke). The referral included an order for Medical Social Worker (MSW). There was no evidence the MSW contacted the patient between 9/17/22-11/15/22. An interview with the assistant director on 2/8/22 at 2:42 p.m. confirmed SW evaluation was not conducted, and there was no evidence the physician was notified. 2. Patient #4 was admitted on 9/7/22 with a diagnosis of stage 2 pressure ulcer sacral region. The Plan of Care (POC) for 9/7/22-11/5/22 included orders for skilled nursing. The skilled nursing start of care note stated, “Home noted to have boards on the floor that are stable with wheelchair use during visit…Water turned on and off by spouse when requested…Agreed to OT, MSW, and ST and nursing with HHA to begin when isolation for COVID resolved.” The SN visit note from 9/14/22 stated, “Mold noted in several different patches/spots on wall of patient’s bedroom. Floors of home continue to be unsafe with holes, many covered with plywood and uneven.” On 9/26/22, the nurse visit documentation revealed, “An email has been sent to MSW with environmental and social concerns and uncertain of date MSW will be able make contact with son of patient. “Son states that son is ‘working on getting other housing options for patient but may not be able to get housing in ____ County due to expense.’ Home remains in disrepair with walks bowing, decaying, soft in areas on the outside, window broken, holes in floor in multiple places covered by large pieces of plywood. Son confirms that the home has been evaluated for repair and deemed unsafe to repair ‘due to pins beneath mobile home being broken.’ There is black mold around the edges of the walls all around near ceiling. There is no running warm water, any water has to be turned on outside then heated on stovetop. Patient is not able to have adequate personal hygiene met. At this time, it is not safe for home health aide service for ____ HH and it is not safe for PCS aide service…Nurse to provide care and instruction, and support for a few more weeks to allow time for MSW to provide resources and information.” On 10/4/22, the RN note stated, “Discussed with patient and spouse the seriousness and condition of their home and that winter is coming, it will be in the patient’s best interest for patient and spouse to seek alternative living arrangement. More siding on the exterior of the home peeled off in the tropical storm 9/30-10/1 and insulation is exposed and hanging out in multiple places. The flooring continues to soften and more plywood boards are being used. Patient verbalizes understanding and spouse is agreeable but patient/spouse and supportive son do not know how to go about proceeding with getting help. MSW has been given a report and patient has been discussed in team with supervisor.” The RN note on 10/7/22 stated, “Spoke with son and son is trying to arrange alternative living arrangement for himself and patient/spouse as soon as possible, son is very aware of the hazardous conditions of the patient’s current housing. Awaiting MSW. Plan to provide care and support until patient/son is in contact with MSW and/or moves from service area.” On 10/11/22, the RN stated, “Pt waiting to hear from social worker to discuss options for housing and care. Pt current living situation is not physically safe, trailer is in disrepair, loose missing floor boards, loose/missing external siding, insulation exposed.” On 10/14/22, the RN stated, “MSW has been contacted by nurse to inquire of status of MSW making contact with patient/son.” On 10/19/22, the RN noted, “No contact from MSW made as of today.” On 10/21/22, the patient was discharged with no MSW visit. There was no evidence that the physician was notified the social worker did not assess the patient. 3. Patient #17 was admitted on 1/10/23 with a diagnosis of type 1 diabetes. The Plan of Care (POC) for 1/10/23-3/10/23 included orders for physical therapy (PT) two visits weekly for four weeks. The POC included orders for PT to assess location, intensity, duration, frequency, character, precipitating factors of pain and instruct patient/caregiver in non-pharmacological measures. During the initial assessment the patient reported a pain level of seven out of 10 for both legs. On 1/12/23, the patient reported a pain level of eight out of 10 for both legs and seven of 10 in the abdomen. On 1/17/23, the patient reported abdominal pain six of 10. On 1/19/23, the patient reported a pain level eight of 10 in both legs and abdomen. On 1/20/23, the patient was brought to the Emergency Department (ED) with an “accidental overdose.” The patient told the ED that “He is feeling discomfort in his ‘lower half’.” An interview with PT #7 on 2/9/23 at 2:30 p.m. confirmed the physician was not notified of the pain. The PT stated the pain “was not new” for the patient, and the patient had “peripheral neuropathy from years of uncontrolled diabetes.” The PT also stated that the patient’s abdominal had been evaluated by a physician. An interview with Patient Care Manager on 2/9/23 at 3:15 p.m. confirmed there was no evidence the physician was notified of the patient’s pain levels.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, observation and staff interviews the registered nurse (RN) contaminated a clean area with personal clothing, failed to perform hand hygiene after coming in contact with contaminated surfaces, failed to disinfect personal jewelry after coming in contact with the patient’s skin and, failed to disinfect a permanent marker after handling it with a dirty glove; and the occupational therapist failed to perform hand hygiene prior to entering the clinical bag after touching the patient and after handling used equipment and placed clean equipment on the same barrier and in the same location that the equipment was placed immediately after being used on the patient for 2 of 7 patient observations. (Patient #11 and 14) Findings included: PolicyStat ID 11735211, titled Home Health Bag Technique and last revised 05/2022, was received from the agency director on 02/09/23 at 9:30 AM. This policy revealed, “…When the visit is completed, reusable equipment will be cleaned using alcohol and/or soap and water as appropriate, hands will be washed and equipment will be returned to the bag…Hands will be decontaminated prior to returning clean equipment to the bag…” 2. Patient #14 was admitted to the agency on 01/08/23 with diagnoses including aphasia (a disorder that affects communication) following cerebral infarction (stroke), hypertension (high blood pressure), unilateral (one side) primary osteoarthritis (wearing down of joint cartilage), right hip, and morbid obesity. Plan of Care from 01/08/23 to 03/08/23 included orders for physical therapy 3 times per week for 1 week and to times per week for 4 weeks, speech therapy 1 time per week for 2 weeks and 2 times per week for 3 weeks, and occupational therapy 1 time per week for 4 weeks. Employee #6, an Occupational Therapist, conducted home visit on 02/08/23 at approximately 4:00 PM. During the home visit, Employee #6 was observed obtaining vital signs on Patient #14 and proceeded to document on her computer without performing hand hygiene between tasks. Employee #6 then reached into her clinical bag without performing hand hygiene and removed an individual, prepackaged cleansing wipe. Employee #6 used the cleansing wipe to clean the equipment used to take vital signs and placed the clean equipment on the same barrier and in the same location that was used when the equipment was used. Employee #6 was observed entering her clinical bag again without performing hand hygiene to remove a thermometer. Following the home visit, upon hearing the observations made during the home visit, Employee #6 stated, that she did not recall specifically whether she had performed hygiene between tasks and stated that she probably had been thinking that the frequent use of the cleansing wipes being used to clean the equipment would also clean her hands in the process. The agency’s, Employee #8, Rehabilitation Manager was present during the home visit and subsequent interview with Employee #6. Employee #8 confirmed that he also observed the lack of hand hygiene between tasks and use of the same barrier and area for used and clean equipment. 1. Patient #11 admitted 12/20/22 with diagnoses of rectal abscess and diabetes mellitus. The Plan of Care for 12/20/22-03/02/23 included orders for skilled nurse visits 3 times a week. On 02/08/23 at approximately 9:00 A.M. a home visit was observed with RN #3. Prior to the dressing change, RN #3 removed a hat from her head, placed it on clean moisture barrier pads and continued to use the pads to protect clean wound care supplies. While performing wound care RN #3 failed to perform hand hygiene after her hand came in contact with a contaminated waste disposal bag. RN #3 wore a bracelet that came in contact with the patient’s skin during care, no decontamination of the bracelet was observed. After completing wound care, RN #3 failed to remove gloves and perform hand hygiene before removing a permanent marker from her shirt pocket. After writing on the patient’s wound dressing, the marker was placed back into her shirt pocket. No disinfection of the marker was observed. During medication review, RN #3 removed the marker from her shirt pocket and used it to write on the medication bottles. An interview was conducted with RN #3 on 02/09/23 at approximately 2:40 P.M. RN #3 stated that her hat should not have been placed on clean items. RN #3 stated that it is “really hard” not to contaminate your gloves (hands) when discarding the “sticky film” while placing a wound vac [Vacuum assisted closure using suction pump, tubing and dressing to promote healing]. RN #3 stated that her gloves should have been removed and hand hygiene performed after putting her hands in the trash bag. RN #3 stated that she “normally puts the bracelet inside my glove” and “didn’t notice it [bracelet] touching [patient’s skin].” RN #3 stated, “the tip of the sharpie never came in contact with the patient’s skin.” An interview was conducted with agency director on 02/09/23 at approximately 2:55 P.M. The agency director stated that the expectation is for the RN to place her hat in a coat pocket or outside zipper pocket of her bag. The agency directed stated that RN #3 should have removed her gloves and performed hand hygiene after coming in contact with a contaminated surface. The agency director stated that they “will evaluate the jewelry policy.” The agency director stated that hand hygiene should have been performed prior to handling the marker.

An onsite recertification survey was conducted January 4-7, 2021. No deficiencies to Emergency Preparedness program were identified.

An onsite recertification survey was conducted January 4-7, 2021. Deficiencies to the Medicare Conditions of Participation were identified.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must 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 that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interview the agency failed to notify the physician of vital signs out of parameters for 6 of 21 patients (#7, 10, 14, 13, 15, and 18). Findings include: 1. Patient #7 was admitted on 12/29/20 with type 2 diabetes with foot ulcer and with hypertensive heart and chronic kidney disease. The Plan of Care (POC) for 12/9/20-2/6/21 included orders for skilled nursing 1 time per week for 1 week, 2 time per week for 2 weeks, 1 time per week for 4 weeks, and 3 visits as needed. The POC also included orders for "Clinician to assess vital signs at every visit ...Agency Standard Parameters: Call for Systolic BP less that 80 or greater than 160 Call for Diastolic BP less than 50 or greater than 100 ....SN [skilled nurse] to notify physician if patient is asymptomatic of outside of agency parameters of vitals." On 12/9/20, RN #20 conducted the initial assessment. An interview with team leader # 15 on 1/7/21 at 2:45 p.m. confirmed there was no evidence that the physician was notified of the blood pressure outside of parameters. 2. Patient #10 was admitted on 10/6/20 with encounter for adjustment and management of vascular access device, orthostatic hypotension, cardiac arrhythmias, and gastroparesis (a condition that affects the normal muscle movements of the stomach). The Plan of Care for 12/5/20-2/2/21 included orders for "SN [skilled nurse] to notify physician if patient is symptomatic or outside of agency parameters of vitals ... Agency Standard Parameters ...Call for Heart Rate less than 50 bpm [beats per minute] or greater than 110 bpm ..."On 12/15/20, the heart rate was 114 and on 12/22/20 heart rate was 118. In an interview with RN #7 on 1/7/21 at 10:45 a.m., it was confirmed there was no evidence that the physician was notified of the heart rate being outside of parameters. The RN stated, "I probably need to get patient specific parameters." 3. Patient #14 was admitted on 12/18/20 with an infection of obstetric surgical wound. The Plan of Care for 12/18/20-2/15/21 included orders for skilled nursing 1 time per week for 1 week, then 3 visits per week for 6 weeks. The POC also included orders for "Clinician to assess vital signs at every visit ...Agency Standard Parameters: Call for Systolic BP less than 80 or greater than 160 Call for Diastolic BP less than 50 or greater than 100." RN #19 conducted an initial assessment visit on 12/18/20. The patient's blood pressure was 160/110. An interview with team leader # 15 on 1/7/21 at 2:45 p.m. confirmed there was no evidence that the physician was notified of the blood pressure outside of parameters. 4. Patient # 13 had a Start of Care [SOC] Date of 12/11/20 and diagnoses of Pressure Ulcer of Left Buttock [unstageable] and Pressure Ulcer of Left Buttock, Stage II. A review of the Plan of Care [POC] for the certification period 12/11/20 to 2/8/21 revealed orders for PT [physical therapy] 1 week 1; 2 week 4 and Clinician to assess vital signs at every visit. A review of the clinical record revealed no vital signs were obtained during the 12/12/20 PT visit. An interview was conducted the rehabilitation supervisor [employee 15] on 1/7/21 at approximately 2 pm. During the interview employee 15 confirmed the the physician was not alerted vital signs were omitted during the 12/12/20 visit. 5. Patient # 15 had a Start of Care [SOC] date of 12/20/20 and a diagnosis of Dehiscence of Amputation Stump and Chronic Osteomyelitis of left ankle and foot. A review of the Plan of Care [POC] for the certification period 12/20/20 to 2/17/21 revealed orders for skilled nursing 3 week 8 and 4 PRN [as needed] wound vac, new orders, signs of wound infection, new medications or lab orders; PT [physical therapy] 2 week 4; Clinician to assess vital signs at each visit and notify physician if vital signs outside of agency parameters of systolic blood pressure less than 80 or greater than 160 or diastolic blood pressure less than 50 or greater than 100. A review of the clinical record revealed RN # 16 documented the following blood pressures: 12/22/20-172/80, 12/26/20- 172/80. Further review of the clinical record revealed no vital signs were obtained during the 12/28/20 visit by PT # 17. Neither RN # 16 nor PT# 17 were available for an interview. An interview was conducted with the rehabilitation supervisor [employee # 15] on 1/7/21 at approximately 2:30 pm. During the interview employee # 15 confirmed the physician was not contacted regarding the blood pressure readings being outside the given parameters nor was the physician notified vital signs were omitted during the visit. 6. Patient # 18 had a Start of Care [SOC] date of 12/9/20 and diagnoses of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy [numbness or tingling of an extremity], Atherosclerotic Heart Disease and Hypertensive Heart and Chronic Kidney Disease with Heart Failure. A review of the Plan of Care [POC] for the certification period 12/9/20 to 2/6/21 revealed orders for skilled nursing 1 week 1; 2 week 2; 1 week 3; 3 PRN [as needed] for AMS [altered mental status], falls, increase SOB [shortness of breath], new medications and clinician to assess vital signs at every visit. A review of the clinical record revealed no vital signs were obtained during the visit by LPN # 11 on 12/14/20. LPN # 11 was not available for interview. On 1/7/21 at approximately 2:15 pm an interview was conducted with the rehabilitation supervisor [employee # 15]. During the interview employee # 15 the confirmed the physician was not alerted vital signs were not assessed.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians involved in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to communicate a change in the Plan of Care [POC] related to wound care for 1 of 4 patients with an order for negative pressure wound therapy [wound vac] [#15]. The findings included: Patient # 15 had a Start of Care [SOC] date of 12/20/20 and a diagnosis of Dehiscence of Amputation Stump and Chronic Osteomyelitis of left ankle and foot. A review of the Plan of Care [POC] for the certification period 12/20/20 to 2/17/21 revealed orders for skilled nursing 3 week 8 and 4 PRN [as needed] wound vac, new orders, signs of wound infection, new medications or lab orders and SN to perform wound vac changes to left foot amputation site 3 times per week. A review of the clinical record revealed a wound vac was placed to left foot on 12/20/20 by RN # 7. Further review of the clinical record revealed RN #18 did a routine wound vac change on 12/27/20 in accordance with the plan of care. On 12/29/20 Patient # 15's family contacted triage to report the wound vac had malfunctioned. RN # 16 made a visit later 12/29/20 and was unable to get the vac to work. Patient # 15 was instructed to apply a wet to dry dressing. The clinical record indicated the wound vac was not replaced nor was it functioning from 12/29/20-1/4/21. The physician was not contacted regarding the patient's wound no longer having the wound vac. RN # 16 was unavailable for interview. On 1/7/21 at approximately 2:30 pm an interview was conducted with the rehabilitation supervisor [employee # 15]. During the interview employee # 15 confirmed there was no evidence the physician was notified the wound to the left foot had not received vac therapy from 12/29/20-1/4/21.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the home health aide failed to follow the Plan of Care for 1 of 3 patients with a home health aide assigned (#4). Findings include: Patient #4 was admitted on 11/9/20. The Plan of Care for 11/9/20-1/7/21 included orders for physical therapy 2 times per week for 8 weeks. On 11/28/20 an order was obtained for a Home Health Aide 2 times per week for 6 weeks. The occupational therapist visited on 12/1/20 and documented the patient stated she had taken a shower with the assistance of the home health aide. The Home Health Aide Plan of Care revealed, "Aide will assist with sink bath ...each visit." The occupational therapist visited on 12/1/20 and documented the patient stated she had taken a shower with the assistance of the home health aide. The aide visited on 12/1/20, 12/3, 12/9, 12/10, 12/14, 12/17, 12/21/, 12/22, and 1/4/21. Sink bath was checked off for each visit.