Every finding on record at Vns Ithaca Tompkins Co Chha

This Statement of Deficiencies report includes the results of a review of the agency's compliance with emergency preparedness requirements completed during the recertification survey conducted 12/05/23 - 12/13/23. The following information was reviewed, on 12/04/23, during the pre-survey preparation: accuracy of contact information in the Health Commerce System. The following information was reviewed during the survey: the agency's emergency preparedness policies and procedures, the emergency patient roster and staff call down list. Interviews were conducted with the Administrator, Director of Patient Services and Clinical Managers. No federal deficiencies related to emergency preparedness were cited. State Deficiency J 1156 Governing Authority was cited.

The following statement of deficiencies represents the result of a partial extended recertification survey of Visiting Nurse Services of Ithaca and Tompkins County conducted 12/05/23 through 12/13/23. A standard recertification survey was initiated on 12/06/23. Deficient practices were identified within Level 1 standards in 484.55 Condition of participation: Comprehensive assessment of patients, resulting in a partial extended survey. The survey consisted of a review of 17 clinical records including 7 observational home visits and 5 discharge records, 9 personnel records, 2 contracts, pertinent policies and procedures, Quality Improvement Meeting Minutes and Governing Body Minutes for the past 12 months, the agency's Admission Packet, Emergency Preparedness Plan, and On-call and Complaint Logs. Pre-survey activities, on 12/04/23, consisted of review of the agency's Health Commerce System account, internet Quality Improvement Evaluation System Potentially Avoidable Event Reports for the period 09/22 – 08/23, and compliance with report submission for the 2022 statistical report. The Administrator, Director of Patient Services and Clinical Managers were interviewed. Findings were reviewed at the exit conference on 12/13/23. The following deficiencies were identified as a result of the survey: Federal Standard Level Deficiencies: G 0528 Health, psychosocial, functional, cognition, G 0536 A review of all current medications, G 0574 Plan of care must include the following, G 0798 Home health aide assignment and duties, and G 0808 Onsite supervisory visit every 14 days. State Deficiencies: J 1422 Personnel.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on review of clinical records, observational home visits, policies and procedures, and interviews with the Administrator, Director of Patient Services and Clinical Managers, it was determined in 8 of 17 patients (patients #1, 2, 6, 8, 9, 10, 13, and 17) the agency failed to ensure comprehensive assessments were of sufficient scope to identify all patient needs. Evidence as follows: 1. Patient #8 was admitted to the agency on 05/18/23 with diagnoses of pneumothorax, pneumonia, sepsis, chronic obstructive pulmonary disease, and sleep apnea. On 05/18/23 the nurse visited the patient for the initial assessment and failed to perform a comprehensive assessment of all the patient's needs as follows: Pain The nurse documented the patient had knee pain at a level of 2 on a scale of 1 to 10 at the time of the assessment, and a level 3 out of 10 after pain medications. The patient last took a pain medication at 8:00 p.m. the previous day. Pain was described as intermittent stabbing, burning, and aching, aggravated with movement and alleviated with medications. The medication list included the following medications for pain: -Tylenol 325 mg, 2 tablets every 6 hours as needed for mild pain -camphor-menthol topically three times a day as needed -hyoscyamine 0.125 mg under the tongue as needed -Lidocaine 5% topical 1-2 patches on most painful area for up to 12 hours. The nurse failed to assess which medications were used for pain, the frequency of use, if the patient was using the topical medications and locations applied. EpiPen The medication list included an EpiPen 0.3 mg/0.3 ml for allergies to bees and wasps. The nurse failed to document the presence of the EpiPen and review of use of the medication. Respiratory treatments The medication list included an albuterol inhaler 2 puffs every 6 hours as needed for shortness of breath or wheezing, ipratropium 0.5 mg-albuterol 3 mg in 3 ml nebulization solution administered daily, and Trelegy Ellipta (combination steroid and bronchodilators) 1 puff daily. The nurse documented the patient had a moist/loose cough and yellow thick sputum. The nurse failed to assess the frequency of use of inhaler and effectiveness of respiratory medications. On 12/11/23 at 2 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services and clinical managers. They submitted additional information which did not change the findings. Patient #2 was admitted to the agency on 11/30/23 with diagnoses of atrial flutter, myocardial infarction, hypertension, heart failure and dementia. Notes from 11/25/23-11/29/23 hospitalization revealed the patient had fallen asleep on 11/25/22 and knocked hot coffee onto the left thigh causing redness and discomfort to the site. On 11/26/23 the patient was noted to have a blister to the left thigh. On 11/30/23 the nurse visited the patient for the initial assessment and documented skin was intact and within normal limits. There was no documentation of the left thigh burn area. The 11/30/23-01/28/23 Plan of Care included a plan to teach the patient/caregiver signs and symptoms of skin breakdown, how to prevent and when to notify the physician or nurse for concerns. On 12/04/23 the nurse visited the patient and documented the patient had a wound 4 by 3 centimeters to the inner aspect of the left upper leg obtained during the last hospital stay. The area had redness and was scabbed over. The caregiver was caring for the wound and demonstrated care. The 12/05/23 order included application of aloe to the burn, watch for sign of infection and call the nurse or physician for any issues with infection or healing. There was no evidence the nurse performed a complete skin assessment during the initial assessment. On 12/11/23 at 2 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services and clinical managers. They submitted additional information which did not change the findings. Patient #9 was admitted to the agency on 09/05/20 with diagnoses of heart disease, hypertension, benign prostatic hyperplasia and urinary retention with a urinary catheter. The nurse visited the patient on 10/16/23 for the recertification visit and failed to perform a comprehensive assessment of all the patient's needs. The 08/21/23-10/19/23 plan of care medication list included Nitroglycerin 0.4 mg under the tongue every 5 minutes for up to three doses as needed for severe pain. The nurse documented under cardiovascular "dizziness, fatigue" and failed to assess if the patient had required the use of the nitroglycerin since the last assessment. The medication list also included an as needed respiratory inhaler ProAir 90 microgram per puff aerosol inhaler, 2 puffs every 4 hours for cough. The SN documented the patient had a dry, hacky cough, had an inhaler and was short of breath with moderate exertion and failed to assess how often the patient required the as needed respiratory medication and the effectiveness of the treatment. On 12/11/23 at 2 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services and clinical managers. They submitted additional information which did not change the findings. Home visit 2. Patient #1 was admitted to the agency on 11/22/23 with diagnoses of leukoencephalopathy, congestive heart failure, hemiplegia, and hemiparesis. The 11/22/23 initial comprehensive nursing assessment the nurse performed a Braden scale skin assessment that indicated the following: -sensory perception very limited -moisture, constantly -activity, bedbound -mobility, unable to move with assistance -nutrition, excellent -friction and shear, problem as patient slides in bed and chair -for a total score of 11 indicating high risk for skin breakdown The patient is bed bound and requires a Hoyer lift machine for transfers in and out of bed. And is total care with activities of daily living. The patient is incontinent of bowel and bladder and wears a brief. On the 11/22/23 visit the nurse documented the patient's buttocks is red and intact. The 12/05/23 nurse visit , there was no evidence the nurse assessed patients skin for breakdown. On 12/08/23 at 1:30 p. m. the surveyor conducted an observational home visit with skilled nurse present. The skilled nurse failed to assess patient’s skin or any bony prominences for abnormalities of skin changes. On 12/11/23 at 2 p.m. the surveyor reviewed the record with the Administrator/DPS and clinical managers. They submitted additional information which did not change the findings. Failure to of the agency staff to perform a comprehensive assessment of the patients may result in unmet patient needs and negative patient outcomes. 1. Patient #17 was admitted to the agency on 07/26/22 with diagnoses that included myelodysplastic syndrome, lymphedema, breast cancer and a pressure ulcer to the sacral region. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for both an increase in number of pressure ulcers, and discharged to the community with an unhealed stage 2 pressure ulcer. Pressure Ulcers On 07/26/22, the nurse visited and performed the comprehensive assessment documenting the patient had been discharged from rehab and returned to living alone at home. The patient was unsteady with a walker and used a wheelchair in the home. Assessment of the skin included the patient's history of a pressure ulcer, "which is currently healed." Further assessment included the patient had no pressure ulcers or skin injury, was educated on pressure relief, and was to continue to apply barrier ointment. There was no evidence the patient had barrier ointment on hand or was able to self-apply. On 07/29, 08/04, 08/08, 08/17, 08/26, 08/31, 09/08, 09/14, 09/22, 10/05, 10/13, 10/21/22, the nurse visited the patient and failed to assess the patient's skin. On 10/28/22, during the nurses visit, the patient complained of a feeling like a sore on the tailbone. The nurse assessed the site and found "two 0.5cm x 0.5cm pressure sores." The SN applied "Desitin" and called the primary care provider to obtain orders for wound care. The nurse failed to assess the patient's ability to self-manage sacral wound care, On 11/01, 11/04, 11/08, 11/10, 11/15, and 11/17/22, the SN visited, performed wound care, and failed to assess the rest of the body's skin. On 11/22/22, the nurse visited for wound care and recertification and documented, "wound on buttocks near coccyx was assessed and had signs of improvement; a skilled nurse is still necessary due to the patient not having anyone else to help with wound care or apply Meplilex." Also documented was, the patient complained today of pain on the back of the right upper leg where it met the wheelchair seat edge. The nurse assessed the site and found a new stage 2 pressure ulcer that measured 1.0cm x 1.0cm 0.2cm. Area cleansed with normal saline, pat dry and Mepilex cut to size to protect area. The nurse failed to assess the skin for further area of pressure and skin breakdown. On 12/12/23,at 2:00p.m., the record was reviewed with the Administrator, Director of Patient Services, and Clinical Managers, who acknowledged the findings and offered no additional information. 2. Patient #10 was admitted to the agency on 09/27/21 with diagnoses that included multiple sclerosis, urinary tract infection, type 2 diabetes, and spinal stenosis. The 09/27/21 Home Health Certification and Plan of Care included orders for skilled nursing to see the patient 1 time for 1 week, another for 1 time a week for another week, and then 1 time every 4 weeks to change the suprapubic urinary catheter every 4 weeks. Urinary Tract Infection (UTI) On 10/11/21, the patient called the agency and requested a call-back from a nurse when she thought she had a UTI. She also inquired if a nurse could see her "sooner than Thursday." The agency failed to provide a more expediant visit to the patient, and visited on the previously scheduled catheter change visit day, 4 days after the patient called with symptoms of a possible UTI. On Thursday, 10/14/21, the nurse visited the patient and documented that the purpose of the visit was to change the suprapubic catheter, obtain a urine sample, and assess cardiopulmonary status. The nurse failed to assess the symptoms the patient was having, which led the patient to call with the conclusion of a possible UTI. The agency failed to assess the patient timely with a potentially serious issue and to notify the patient to discuss follow-up with the results of the urine sample and determine if the patient continued to have symptoms. On 10/21/21, the physical therapist called the patient's primary care provider to report that "pt had potential UTI and canceled both our PT appointments this week d/t not feeling up to exercise." The nurse failed to follow up when the patient continued to have symptoms, as noted by the PT. Suprapubic catheter On 09/27/21, the nurse noted the patient had a suprapubic catheter the agency will change every 4 weeks. The nurse failed to assess the patient and caregiver's comprehension and technique to carry out the following procedures safely; - Changing the bedside bag to a leg bag and vice versa. - Clean the bags with dilute white vinegar, rinse them with water, and hang them to dry. - Wash the catheter site with soap and water. Diabetes On 09/27/21, the nurse noted the patient had a recent range of finger-stick blood glucose readings from 140 to 295. The 09/27/21 Plan of Care included "RN to check BS (blood sugar) log QV (every visit) and report to MD BS 250". There was no evidence the SN notified the patient's primary care physician of the 295 reading out of range, or determined if the patient had completed the notification. On 12/13/23 at 9:00 a.m., the findings were reviewed with the Administrator, Director of Patient Services, and Clinical Managers, who acknowledged the findings and offered no additional information. Patient #13 was admitted to the agency on 09/26/22 with diagnoses that included cellulitis of the right lower limb, type 2 diabetes, and morbid obesity. The patient was selected from the Internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for development of a urinary tract infection. On 09/26/23, the nurse visited for the initial comprehensive assessment and noted the patient was recently discharged from a rehabilitation unit and was now living alone at home with support from a significant other who resides nearby. The nurse documented the patient had vision impairment; "cannot see medication labels or newsprint but can see obstacles in path and surrounding layout. Can count fingers at arm's length." Urinary Catheterization On 09/26/23, during the initial comprehensive assessment, the SN made the following assessment entries: - the patient requires a urinary catheter - had urinary incontinence - did not have a "Foley" (an indwelling urinary catheter) - for catheter type, indicated "straight." The visit narrative summary included the patient's significant other would assist with wound care, but failed to include if the significant other would assist would be provided with straight catheterization, the patient was visually impaired and lived alone. The nurse failed to: Assess how often the patient self-catheterized Observe the patient demonstrate self-catheterization successfully using a sterile technique Assess self-catheterization supplies The second, third, and fourth nurse visit notes dated 10/03/22, 10/13/22, and 10/20/22 did not include an assessment of the genitourinary system. The SN failed to assess the patient's urination, incontinence, and self-catheterization during those visits. The 01/09/23 discharge SN note included the patient was "back on Keflex (an antibiotic) for UTI." Wound Care On 09/26/22, the nurse documented right thigh wound care was performed during the visit as follows; - Cleansed with normal saline - Pat dry - Apply dry gauze and cover with ABD pad - Secure with tape There was no evidence the patient demonstrated wound care during the visit, and the caregiver was not present at the visit. The nurse failed to assess the patient or caregiver ability to provide demonstrate the procedure and ensure daily wound care would be provided. On 12/12/23 at 2:00 p.m.,, the findings were reviewed with the Administrator, Director of Patient Services, and Clinical Managers, who acknowledged the findings and offered no additional information. 1. Patient #16 was admitted to the agency on 10/13/22 with diagnoses of heart failure with a Left Ventricular Assist Device, and chronic obstructive pulmonary disease. The patient was selected from the internet Quality Improvement Evaluation System Potentially Avoidable Event Reports for increased in number of pressure ulcers. The 10/13/22 plan of care included a dressing change to the driveline (catheter) a surgical incision located in the right abdominal chest cavity that is attached to the Left Ventricular Assist Device. The 10/13/22 plan of care orders included: - “Pt to wear a stabilizing belt or abdominal binder at all times to keep driveline in place, change stabilizing device weekly and as needed to ensure that all driveline is not kinked and is attached to the controller.” - “Daily driveline dressing change: clean skin and first 3 inches of driveline with ____ in a spiral motion, wipe with 2 NS moistened gauze pads x2, pat dry with 4x4 in spiral motion, after cleaning, apply drain sponges, alternating so that slits are rotated 90-180 degrees, tape with paper tape in an occlusive fashion”. On 10/13/22 the initial comprehensive visit the nurse documented, patient wears a vest to secure Left Ventricular Assist Device battery. Daughter assists patient in changing sterile dressing every 3 days or as needed. Driveline/Left Ventricular Assist Device site was not assessed due to dressing being changed earlier that day. On 10/20/22 there was no documentation noted about the driveline/Left Ventricular Assist Device dressing or site. On 10/24/22 an on-call nurse visit was made with focus on nose bleeds, the nurse had documented the driveline/Left Ventricular Assist Device site will be assessed next visit. On 10/27/22 the nurse had documented daughter assists patient in changing sterile dressing every 3 days and as needed. Driveline/ Left Ventricular Assist Device site was not assessed due to dressing being changed day of visit and will be assessed next visit. On 11/01/22 the nurse had documented daughter assists patient in changing sterile dressing every 3 days and as needed. Driveline/LVAD site was not assessed due to dressing being changed day of visit. On 11/04/22 the nurse documented “pt preformed driveline dressing change without concerns. Upon assessment no redness, swelling nor drainage as noted". On 11/10/22 the nurse had documented the driveline/Left Ventricular Assist Device dressing had been changed yesterday and did not assess, dressing clean and dry. On 11/11/22 the nurse had documented driveline/ Left Ventricular Assist Device dressing changed with aseptic technique, no s/s of infection, scant thick drainage noted, patient reported this was base line. On 11/17/23 the nurse had documented patient reported that he or his daughter perform dressing changes to driveline/Left Ventricular Assist Device site. On 11/23/22 a discharge to agency visit, the nurse had documented, patient states that he and his daughter perform dressing changes for the driveline /Left Ventricular Assist Device site. The nurse failed to: Document teaching the driveline/Left Ventricular Assist Device dressings such as, frequency and equipment needed for the dressing changes. Assess return demonstration with the patient and or caregiver. Assess what cleaning agent was being used for the dressing changes, and if infection control practices were followed. Assess what equipment was in the home for dressing changes. Assess if patient had been wearing a stabilizing belt or abdominal binder at all times to keep driveline in place, or if stabilizing device had been changed weekly or required more frequent changes to ensure that all driveline is not kinked and is attached to the controller. It was unclear what the patient or caregiver were using to clean the driveline, there was no cleaning agent included in the dressing order. On 12/11/23, at 2 p.m. the findings were reviewed with the Administrator, Director of Patient Services, and Clinical Managers, who acknowledged the findings and offered no additional information.

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 a review of clinical records and interviews with the Administrator, Director of Patient Services and Clinical Managers, it was determined in 2 out of 17 records (patients #1 and 8) the nurse failed to perform complete and accurate medication assessments. Evidence as follows: Home Visit Patient #8 was admitted to the agency on 05/18/23 with diagnoses of pneumothorax, pneumonia, sepsis, chronic obstructive pulmonary disease, and sleep apnea. The nurse failed to perform complete medication reviews to ensure the agency maintained an accurate list of medications. On 12/07/23 at 2:30 p.m. the surveyor conducted an observational home visit with the nurse. During the visit the nurse asked the patient if there were any changes in medications and the patient stated there were no changes. Following the visit, the surveyor interviewed the patient and reviewed current medications with the patient and compared them with the agency list. The following medications were listed as current in the patient record, not matching the patient interview: -Eliquis (anticoagulant) 5 mg twice daily. The patient stated the current dose as 1/2 of a 5 mg tablet twice daily. -colchicine 0.6 mg daily. The patient stated this medication was only taking as needed. -Jardiance (diabetes medication) 10 mg daily. The patient stated the dosage was reduced to 1/2 of a 10 mg tablet. -lidocaine 5% topical patch 1-2 patches on most painful area for up to 12 hours daily. The patient stated this medication was no longer being used. -ipratropium 0.5 mg-albuterol 3 mg/3 ml nebulized daily. The patient stated this medication was being taken twice daily. -torsemide 20 mg tablet daily. The patient stated the current dosage was 1/2 tablet every other day. On 12/11/23 at 2 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services and clinical managers. No additional information was provided. Home visit 1. Patient #1 was admitted to the agency on 11/22/23 with diagnoses of leukoencephalopathy, congestive heart failure, hemiplegia, and hemiparesis. On 12/08/23 at 1:30 p.m. the surveyor conducted an observational visit with skilled nurse present. After the skilled nurse left the visit, the surveyor reviewed the home list of medications with the caregiver. On 12/11/23 at 12:30 p.m. the agency provided a policy titled medication reconciliation policy dated 2012 section 12.06. The policy requires a complete medication reconciliation should be performed at the time of admission to home care, comparing the medications the patient has in the home with the list of current medications form the discharge agency or form the primary care provider. The 11/22/23 plan of care medication listed the following medications that were not included on the patient’s home list of medications. - Amlodipine 10 mg tablet by moth daily - Entresto 24 mg-26 mg tablet by mouth two times a day - Gen teal tears to both eyes every 2 hours as needed with maximum daily dose 24 drops to each eye. - Magnesium hydroxide 400 mg-5 ml by mouth every 6 hours as needed for constipation. - Melatonin 3 mg by mouth at bedtime as needed for sleep. - Neomycin-polymyxin-dexameth 3.5 mg eye drops to both eyes three times a day. - Spiriva Respimat 1.25 mcg inhalant 2 puff daily. - Prednisone 5 mg daily. On 12/08/23 during the surveyor’s observational visit, the home list included the following medications that were not included in the patient’s agency medication profile. Ciprodex ear drops 4 drops to left ear 2 times a day. Prednisone 10 mg daily tapering down dose. The SN failed to accurately perform a medication reconciliation at the time of admission and with ongoing visit. On 12/11/23 at 2 p.m. the above findings were reviewed with the Administrator, Director of Patient services and clinical managers, they acknowledged the findings and provided no additional information. Failure to perform complete and accurate medication reviews has the potential for patients taking medications inconsistent with the physician's intentions, and possible negative patient outcomes.

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 a review of clinical records, observational home visits, and interviews with the Administrator, Director of Patient Services and Clinical Managers, it was determined in 4 of 17 records (patients #10, 13, 16 and 17) the agency failed to develop complete and accurate plans of care that were individualized to address the total needs of the patients. Evidence as follows: Home visit 1. Patient #1 was admitted to the agency on 11/22/23 with diagnoses of leukoencephalopathy, congestive heart failure, hemiplegia, and hemiparesis. On 12/08/23 the surveyor conducted an observational home visit with skilled nurse present the surveyor observed a large urinary drainage bag in the bathroom. The nurse asked the patient if he had a catheter, the patient’s response was “I don’t have one on right now”. There was no further discussion about any home equipment used. On 12/08/23 the nurse had documented in the assessment “orders refer to texes catheter – none in place”. The 11/22/23 plan of care failed to include: Orders for use of external male urinary catheter device. On 12/11/23, at 2 p.m. the findings were reviewed with the Administrator, Director of Patient Services, and Clinical Managers, who acknowledged the findings and offered no additional information. 2. Patient #16 was admitted to the agency on 10/13/22 with diagnoses of heart failure with a Left Ventricular Assist Device, and chronic obstructive pulmonary disease. The patient was selected from the internet Quality Improvement Evaluation System Potentially Avoidable Event Reports for Urinary Tract Infections. The 10/13/22 plan of care included a dressing change to the driveline (catheter) a surgical incision located in right abdominal chest cavity that is attached to the Left Ventricular Assist Device. The order included: - “Daily driveline dressing change: clean skin and first 3 inches of driveline with ____ in a spiral motion, wipe with 2 NS moistened gauze pads x2, pat dry with 4x4 in spiral motion, after cleaning, apply drain sponges, alternating so that slits are rotated 90-180 degrees, tape with paper tape in an occlusive fashion”. The 10/13/22 plan of care failed to include the cleaning agent to be used for cleaning the driveline. On 12/12/23, at 2 p.m. the findings were reviewed with the Administrator, Director of Patient Services, and Clinical Managers, who acknowledged the findings and offered no additional information. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. Patient #17 was admitted to the agency on 07/26/22 with diagnoses that included myelodysplastic syndrome, lymphedema, breast cancer and a pressure ulcer to the sacral region. The patient was selected from the internet Quality Improvement Evaluation System Potentially Avoidable Event Reports for both an increase in number of pressure ulcers, and discharged to the community with an unhealed stage 2 pressure ulcer. The 11/23/22 Home Health Certification and Plan of Care was incomplete/inaccurate as follows: The wound care order with a start date 11/01/22 included, apply Desitin to wound and cover with Mepilex border dressing. The Order failed to include: - The frequency of the dressing change - Who was to perform the dressing change, nurse and/or caregiver On 12/12/23 at 2:00 p.m., the findings were reviewed with the Administrator, Director of Patient Services and Clinical Managers who acknowledged the findings and offered no additional information. Patient #10 was admitted to the agency on 09/27/21 with diagnoses that included multiple sclerosis, urinary tract infection, type 2 diabetes, and spinal stenosis. The 09/27/21 Home Health Certification and Plan of Care failed to include all necessary information to meet the needs of the patient. On 09/27/21, the patient indicated to the skilled nurse that during the initial comprehensive assessment, the finger stick blood glucose was tested 4 times daily. The plan of care order is to “check FSBS QAM and record” (once each morning). The nurse failed to contact the physician and update the plan of care. On 12/13/23 at 9:00 a.m., the findings were reviewed with the Administrator, Director of Patient Services, and Clinical Managers, who acknowledged the findings and offered no additional information. Patient #13 was admitted to the agency on 09/26/22 with diagnoses that included cellulitis of the right lower limb, type 2 diabetes, and morbid obesity. The patient was selected from the internet Quality Improvement Evaluation System Potentially Avoidable Event Reports for development of a urinary tract infection. The Home Health Certifications and Plans of Care dated 09/26/22 and 11/25/22 were incomplete/inaccurate as follows: Straight Catheterization On 09/26/22, the nurse identified the patient's mode of urinary elimination was via straight catheter. The plan of care failed to include an order for catheterization; including frequency, patient preparation procedure, solution(s) to be used, catheter size and who was to perform. The durable medical equipment failed to include straight catheterization equipment including the catheters and cleansing solution(s). On 12/12/23 at 2:00 p.m., the findings were reviewed with the Administrator, Director of Patient Services and Clinical Managers who acknowledged the findings and offered no additional information.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on reviews of 4 clinical records for patients receiving home health aide service (patient's # 2, 9, 10 and 17) and interviews with the Administrator, Director of Patient Services and Clinical Managers, in 1 out of 4 records (patient #17) the skilled nurse failed to develop complete and accurate aide written instructions. This was evidenced by: 1. Patient #17 was admitted to the agency on 07/26/22 with diagnoses that included myelodysplastic syndrome, lymphedema, breast cancer, and a pressure ulcer to the sacral region. The patient was selected from the internet Quality Improvement Evaluation System Potentially Avoidable Event Reports for both an increase in number of pressure ulcers, and discharged to the community with an unhealed stage 2 pressure ulcer. The 07/26/22 and 09/24/22 Home Health Certification and Plans of Care included a Home Health Aide 1 time weekly for personal care and light housekeeping. On 07/26/22 the nurse documented in the initial assessment the patient's history of a sacral pressure ulcer and patient was to continue to apply barrier ointment. On 11/01/22 the nurse obtained an order for wound care: apply desitin to wound, cover with mepilex dressing. The Non-Skilled Care Plans dated 07/26/22, revised 09/23/22, included "lotion" to the skin and failed to include barrier ointment to the sacral area or any special treatment of the sacral area while bathing. On 12/12/23 at 2 p.m., the record was reviewed with the Administrator, Director of Patient Services, and Clinical Managers, who acknowledged the findings and offered no additional information. Failure to ensure that home health aide care plans are complete has the potential for unmet patient needs.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on reviews of 4 clinical records for patients receiving home health aide service (patient's # 2, 9, 10 and 17) and interviews with the Administrator, Director of Patient Services and Clinical Managers, in 2 out of 4 records (patients #9 and 17) the skilled nurse failed to ensure that all home health aides providing services to patients receiving skilled services are supervised no less frequently than every two weeks. The findings are: 1. Patient #9 was admitted to the agency on 09/05/20 with diagnoses of heart disease, hypertension, benign prostatic hyperplasia and urinary retention with a urinary catheter. The 10/20/23-12/18/23 Plan of Care included nurse visits two times a month and home health aide service once a week for 1 hour. On 11/08/23 the nurse visited the patient and performed a supervisory visit. The next supervisory visit was on 12/06/23 greater than 14 days as required. On 12/11/23 at 2 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services and clinical managers. They submitted additional information which did not change the findings. 2. Patient #17 was admitted to the agency on 07/26/22 with diagnoses that included myelodysplastic syndrome, lymphedema, breast cancer, and a pressure ulcer to the sacral region. The patient was selected from the Internet Quality Improvement Evaluation System Potentially Avoidable Event Reports for both an increase in number of pressure ulcers, and discharged to the community with an unhealed stage 2 pressure ulcer. The Home Health Certification and Plan of Care dated 07/26/23 included an order for a home health aide to visit once weekly for 9 weeks. On 09/22/22, the skilled nurse visited and completed a supervisory visit of the aide. The visit notes indicated 27 days since last supervision. On 10/13/23, the nurse completed a supervisory visit. The visit note indicated 21 days since last supervisory visit. On 11/04/22, the nurse visited and completed a supervisory visit of the aide. No further supervision occurred through the recertification visit on 11/23/22, which indicated 19 days since the last aide supervisory visit. The Agency failed to ensure supervisory visits were completed at least every 14 days. On 12/12/23 at 2:00 p.m.,, the findings were reviewed with the Administrator/Director of Patient Services and Clinical Managers, who acknowledged the findings and offered no additional information. Failure to ensure that home health aide supervision is conducted every fourteen 14 days, has the potential for negative patient outcomes.

This Statement of Deficiencies report is the result of a recertification survey conducted 01/05/21 - 01/14/21. The following information was reviewed on 12/29/20, during the pre-survey preparation: participation in the required emergency drills, and accuracy of contact information in the Health Commerce System. The following information was reviewed during the survey: the agency's emergency preparedness policies and procedures, the emergency patient roster and staff call down list. Interviews were conducted with the Administrator and Director of Patient Services. No federal deficiencies were cited. State Deficiency J 1156 Governing Authority was cited.

The following statement of deficiencies represents the result of a partial extended recertification survey of Visiting Nurse Service of Ithaca and Tompkins County conducted 01/05/21 through 01/14/21. A standard recertification survey was initiated on 01/05/21. Deficient practices were identified within Level 1 standards in Conditions 484.55, 484.60 and 484.80, resulting in a partial extended survey. The survey consisted of a review of 17 clinical records including 7 observational home visits and 5 discharge records, 13 personnel records, 2 contracts, pertinent policies and procedures including COVID-19 and Infection Control, Quality Improvement Meeting Minutes and Governing Body Minutes for the past 12 months, the agency's Admission Packet, Emergency Preparedness Plan, and On-call and Complaint Logs. Pre-survey activities, on 12/29/20, consisted of review of the agency's Health Commerce System account, Certification and Survey Provider Enhanced Reports (CASPER) for the period 10/01/2019 - 09/30/2020, and compliance with report submissions for the 2018 statistical report and Emergency Drill conducted 06/11/19 through 06/13/19. The Administrator, Director of Patient Services, Clinical Manager / Rehabilitation Director and QAPI Coordinator / Compliance Officer were interviewed throughout the survey and findings were reviewed with them at the exit conference on 01/14/21. The following deficiencies are identified as a result of the survey: Federal Standard Level Deficiencies: G 528 The patient's current health, psychosocial, functional, and cognitive status, G 536 Review of all medications, G 574 Plan of care must include the following, G 590 Promptly alert relevant physician of changes or needs, G 682 Infection prevention and G 798 Home Health Aide assignment and duties. State Deficiencies: J 1156 Governing Authority, W 606 Responsibilities of home care services entities, R 504 General requirements and R 1022 Responsibilities of providers; required notifications.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on a review of clinical records and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Manager, it was determined in 8 out of 17 records (patients #1, 2, 4, 7, 8, 10, 13 and 16) the skilled nurse (SN) failed to complete a comprehensive assessment of sufficient scope to ensure all patient's needs were identified. This was evidenced by: HV 1. Patient #4 was admitted to the agency on 10/27/20 with diagnoses of amyotrophic lateral sclerosis (ALS), respiratory failure and panic disorder. Referral information included an office visit note dated 10/21/20 that stated the patient required a Trilogy (mechanical) ventilator around the clock only removed for short periods such as to have teeth brushed. The patient received tube feedings continuously overnight and intermittent syringe feedings during the day and was no longer able to take any feedings by mouth after trying spoon feeding over the summer and quickly choking. On 10/27/20 the skilled nurse (SN) visited the patient for the initial comprehensive assessment and failed to perform a comprehensive assessment of all the patient's needs as follows: Ventilator - The SN documented the patient had a Trilogy (mechanical) ventilator and failed to the assess ventilator settings and whether the patient had backup electricity such as a generator should there be a power failure. Nutrition - The SN documented the patient was receiving nothing by mouth (NPO), had a gastrostomy (G-tube) which was managed by the spouse and was within normal limits (WNL) and the patient was receiving tube feedings overnight. The SN failed to assess the G-tube placement, status of the tube site including any dressing, or observe the caregiver performing care. Medication administration - The SN documented the medications were managed by the patient's spouse who verbalized understanding of medications, however there was no evidence the SN assessed the method of medication delivery. On 01/12/21 at 1:00 PM the surveyor reviewed the record with the Administrator, DPS, Clinical Manager and QAPI Coordinator. They acknowledged the findings and provided no additional information. 2. Patient #8 was admitted to the agency on 11/27/20 with diagnoses of diverticulitis with bowel perforation, peritonitis and sepsis, surgery of the gastrointestinal tract with colostomy, and a history of breast cancer and venous thrombosis. The 11/25/20 referral information included Eliquis 5 mg BID, colostomy care and a wet to dry dressing twice daily to an abdominal wound. The discharge instructions included use of an incentive spirometer to decrease risk for pneumonia, daily weights and reporting an increase of 3 lbs in one day or 5 lbs in one week. On 11/27/20 the skilled nurse (SN) visited the patient for the initial comprehensive assessment and failed to assess the following: - The SN documented the patient had a heart rate of 108 and oxygen saturation decreased to 90% which increased to 95% with deep breathing. The physician was notified and instructed the patient go to the emergency room and the patient declined. The SN failed to assess if the patient had the incentive spirometer and was using it. - The SN documented ostomy on abdomen and failed to assess the stoma and the amount and consistency of any output. - The SN documented the patient had 2+ edema of bilateral lower extremities (feet and ankles)and failed to assess for the use of compression stockings. On 01/12/21 at 1:00 PM the surveyor reviewed the record with the Administrator, DPS, Clinical Manager and QAPI Coordinator. They acknowledged the findings and provided no additional information. 3. Patient #13 was admitted to the agency on 06/25/20 with diagnoses of pneumonia vs. radiation induced pneumonitis, lung cancer, type 2 diabetes and hypertension. The SN failed to adequately assess the patient's diabetes. The 06/25/20 Plan of Care included a diagnosis of type 2 diabetes and the anti-diabetic medication Januvia. On 06/25/20 the SN visited the patient for an initial comprehensive assessment and failed to assess the patient's diabetic status. On 06/30/20 the patient was admitted to Hospice and discharged from the agency. On 01/12/21 at 1 p.m. the record was reviewed with the Administrator, DPS, Clinical Manager and QAPI Coordinator who acknowledged the findings and provided no additional information. Failure to ensure the initial comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes.

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 a review of clinical records and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Manager, it was determined in 6 out of 17 records (patients # 2, 3, 5, 6, 9, and 11) the skilled nurse (SN) failed to perform complete and accurate medication assessments. Evidence as follows: HV 1. Patient #6 was admitted to the agency on 12/10/20 with diagnoses of pressure ulcer to sacrum, deep tissue injuries to buttocks, calf and thigh, type 2 diabetes, rheumatoid arthritis, hypertension and atrial fibrillation. The 12/10/20 Plan of Care included SN visits twice weekly for wound care. Referral information included a visit note from the primary care physician's office dated 12/08/20. The visit note included the following medications Januvia 25 mg once daily, Glucophage (Metformin) 500 mg twice daily and Novolog Flexpen 100 units per ml, subcutaneous injection, 4-6 units with meals as directed for elevated glucose; and methotrexate 2.5 mg 6 tablets every week on Saturday for rheumatoid arthritis. The 12/10/20 Plan of Care and agency medication list included only one anti-diabetic medication: Novolog Flexpen 100 units per ml, subcutaneous injection, 4-6 units, with meals 3 times daily; and did not include methotrexate. On 12/10/20 the SN visited the patient for an initial comprehensive assessment and documented the patient's son managed the patient's medications and that medications were reconciled. The SN failed to contact the physician to clarify the range 4-6 units Novolog Flexpen, or discuss and clarify if the Januvia, Metformin and methotrexate should be continued as listed on the referral. On 01/07/21 at 1:30 PM the surveyor completed an observational home visit with the SN. The SN asked the primary caregiver (PCG) whether the patient had any medication changes since the last visit, the PCG stated she had not. After the visit the surveyor interviewed the PCG and asked how the patient's Novolog, ordered as 4-6 units, was actually administered. The PCG stated the patient's blood sugar is checked prior to each meal and the amount of Novolog administered depends upon the blood sugar reading; typically, if less than 200 no Novolog is administered, if between 200-250 4 units is administered, if above 250 the dose is 6 units. The PCG stated that the patient's current medications also included Januvia 25 mg every morning, Metformin 500 mg twice daily and methotrexate 2.5 mg 6 tabs once weekly. From the start of care on 12/10/20 through 01/07/21 the SN visited the patient 2-3 times per week, a total of 12 visits, and failed to perform complete and accurate medication reviews. On 01/12/21 at 1 P.M. the record was reviewed with the Administrator, DPS, Clinical Manager and QAPI Coordinator who acknowledged the findings and provided no additional information. HV 2. Patient #3 was admitted to the agency on 12/23/20 with diagnoses of osteomyelitis left ankle/foot, polyneuropathy, chronic pancreatitis, gastrointestinal bleed, pneumonia and respiratory failure. The skilled nurse (SN) failed to perform a complete medication review to identify a potential adverse drug reaction. The 12/23/20 Plan of Care included the medication lipase - protease - amylase (Zenpep - aids digestion). On 12/23/20 the SN visited the patient and documented the patient had not yet obtained Zenpep from pharmacy. On 12/24/21 the SN visited and documented "med list reviewed, no med changes or problems identified", Zenpep was not mentioned. On 12/31/20 the SN visited and documented "Zenpep in home this visit, patient verbalizes understanding of this." On 01/07/21 at 11 AM the surveyor completed an observational visit with the SN. The SN asked the patient if she had any medication changes and the patient stated she had not. The SN documented "med list reviewed, no med changes or problems identified." After completion of the SN visit, the surveyor interviewed the patient and reviewed all medications with the patient. The patient stated that when she arrived home from the hospital she did not have the Zenpep and obtained it 4-5 days later. She stated that she took the medication for 2-3 days then began having bloody bowel movements and therefore stopped taking the medication. The patient told the surveyor she had an upcoming telemedicine appointment with her gastroenterologist, and she would discuss it then. The skilled nurse (SN) failed to perform a complete medication review. On 01/12/21 at 1 PM the record was reviewed with the Administrator, DPS, Clinical Manager and QAPI Coordinator who acknowledged the findings and provided no additional information. HV 3. Patient #5 was admitted to the agency 05/06/20 with diagnoses of chronic obstructive pulmonary disease, tachycardia, nausea and long-term use of anticoagulants. The patient was visited by the agency weekly for medication pre-pours. The 01/01/21 plan of care included the medication cholestyramine 4 gm daily as needed for nausea. On 01/06/21 the surveyor completed an observational visit with the skilled nurse (SN). During the visit the SN reviewed use of PRN pain medications, rescue inhaler, Senna for constipation and loperamide for diarrhea. The patient reported that morning she took her medications too early and vomited. The patient stated that she is frequently nauseous in the morning and vomits if she tries to eat or take medications too early. The SN failed to review use of cholestyramine as needed for nausea. Following the visit, the surveyor interviewed the patient and asked whether she used the cholestyramine for her nausea; the patient reported that she has not used that medication in a very long time and had none in the home. The SN failed to ensure that all medications ordered by the physician are available to the patient and being taken properly. On 01/12/21 at 1 p.m. the record was reviewed with the Administrator, DPS, Clinical Manager and QAPI Coordinator who acknowledged the findings and provided no additional information. Failure to perform complete and accurate medication reviews has the potential for patients taking medications inconsistent with the physician's intentions, and possible negative patient outcomes.

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 may choose to include. This ELEMENT is not met as evidenced by: Based on a review of clinical records and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Manager, it was determined in 10 out of 17 records (patients # 2, 3, 4, 6, 8, 10, 11, 13, 14 and 15) the agency failed to develop individualized plans of care that were complete, accurate, and addressed the total needs of the patient. This was evidenced by: HV 1. Patient #3 was admitted to the agency on 12/23/20 with diagnoses of osteomyelitis left ankle/foot, polyneuropathy, chronic pancreatitis, gastrointestinal bleed, pneumonia and respiratory failure. The SN failed to ensure the Plan of Care was complete and met the patient's needs. On 12/23/20 the SN visited the patient for an initial comprehensive assessment to establish the plan of care and noted edema (swelling due to excess fluid) was present. The 12/23/20 Plan of Care included SN to assess edema measurements and specific location. The Plan of Care failed to include parameters to report increased edema measurements and did not include any additional interventions for edema. On 01/07/21 at 11 AM the surveyor completed an observational visit with the SN and observed the following: The patient reported increased edema to the SN who obtained measurements and documented an increase of over 3 cm at calves and ankles, and approximately 2 cm at instep, bilaterally, since the last documented measurements on 12/24/20. The patient asked the SN whether she should wear compression stockings and the SN stated she should; the patient retrieved a pair of tubigrips (type of compression sock) from a basket on her dresser and the SN helped her apply them. The SN educated the patient to limit salt intake, elevate extremities, perform ankle pumps, and use compression stockings or tubigrips. Although the SN communicated with the physician, the SN failed to obtain orders or update the Plan of Care to include the treatments and interventions discussed at the 01/07/21 visit including reduced salt diet, elevation of extremities, performing ankle pumps, and use of compression stockings or tubigrips. On 01/12/21 at 1 PM the record was reviewed with the Administrator, DPS, Clinical Manager and QAPI Coordinator who acknowledged the findings and provided no additional information. HV 2. Patient #4 was admitted to the agency on 10/27/20 with diagnoses of amyotrophic lateral sclerosis (ALS), respiratory failure, and panic disorder. The SN failed to ensure the Plan of Care was complete and met the patient's needs. The 10/21/20 referral included the patient using a Trilogy (mechanical) ventilator around the clock only removed for short periods such as to have teeth brushed. The patient received tube feedings continuously overnight and intermittent syringe feedings during the day, and was unable to take any feedings by mouth after trying spoon feeding over the summer and quickly starting choking. On 10/27/20 the skilled nurse (SN) visited the patient for the initial comprehensive assessment and failed to develop a plan of care addressing all of the patient's needs as follows: Ventilator - The SN documented the patient had a Trilogy (mechanical) ventilator. - The 10/27/20 Plan of Care included Trilogy ventilator managed by spouse and failed to include specific settings and frequency of use. Nutrition - The SN documented the patient was receiving nothing by mouth (NPO), had a gastrostomy (G-tube) which was managed by the spouse and the patient was receiving tube feedings overnight. - The 10/27/20 Plan of Care failed to include G-tube site care; type of enteral formula, rate and frequency; frequency and amount of flushes; and checking for placement or residual. Medication administration - The SN documented medications were managed by the patient's spouse who verbalized understanding of medications. - The 10/27/20 Plan of Care included a list of medications to be administered "orally or by gastric tube" which was inconsistent with the patient's status of NPO. On 01/12/21 at 1:00 PM the surveyor reviewed the record with the Administrator, DPS, Clinical Manager and QAPI Coordinator. They acknowledged the findings and provided no additional information. HV 3. Patient #6 was admitted to the agency on 12/10/20 with diagnoses of pressure ulcer to sacrum, deep tissue injuries to right and left buttocks, calf and thigh, type 2 diabetes, rheumatoid arthritis, hypertension and atrial fibrillation. The SN failed to ensure the Plan of Care was complete and met the patient's needs. The patient's 12/10/20 Plan of Care included: - Novolog (fast acting insulin) Flexpen 100 units per ml, subcutaneous injection, 4-6 units, with meals 3 times daily - SN to instruct patient/caregiver to check finger stick blood sugar every morning and record - SN to check blood sugar log each visit and report to MD if blood sugar is less than 60 or greater than 250 mg/dL On 01/07/21 the surveyor completed an observational home visit with the SN. The SN asked the patient's primary caregiver (PCG) what the patient's blood sugar reading was that day, the PCG stated it was 174, and that since the last SN visit it ranged from 120-250. Following the SN's visit, the surveyor interviewed the PCG and asked how the patient's Novolog dosage, ordered in the Plan of Care as 4-6 units, was determined. The PCG stated that the patient's blood sugar is checked 3 times daily prior to each meal and the amount of Novolog administered is based upon the blood sugar reading; typically, if less than 200, no Novolog is administered; if between 200-250, 4 units is administered; if above 250 the dose is 6 units. The PCG showed the surveyor a yellow legal pad with a log recording the patient's blood sugars and amount of Novolog administered. The agency Plan of Care failed to include the correct frequency of blood sugar monitoring and a sliding scale to determine the amount of Novolog to be administered. On 01/12/21 at 1 PM the record was reviewed with the Administrator, DPS, Clinical Manager and QAPI Coordinator who acknowledged the findings and provided no additional information. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs.

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 a review of clinical records and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Manager, it was determined for 7 out of 17 records (patients # 3, 4, 5, 9, 10, 16 and 17), the skilled nurse (SN) failed to promptly alert the physician to patient's needs, or changes in the patient's condition, to determine whether the plan of care should be altered. This was evidenced by: 1. Patient #10 was admitted to the agency on 12/07/20 with diagnoses of infected left knee prosthesis with removal and insertion of an antibiotic spacer, coronary artery disease, diabetes and chronic atrial fibrillation. The skilled nurse (SN) failed to report skin breakdown to the physician in order to prevent further deterioration. The 12/04/20 referral information included the patient had a left knee immobilizer (brace) which could only be removed for skin checks and cleansing. On 12/07/20 the SN visited the patient for the initial comprehensive assessment and documented the patient had some redness and signs of irritation on the back of the left leg from the immobilizer and the family member had placed padding on the area for protection and would keep an eye on it. There was no evidence the physician was notified of the skin irritation to discuss preventative care measures. On 12/8, 12/10 and 12/14/20 the SN visited and failed to document a skin assessment of the area behind the immobilizer. On 12/15/20 the on call SN documented in an activity note the patient's family member called to report a pressure area behind the affected knee from the brace. Without conducting a home visit to assess the area, the SN instructed the family member to wash the area, pat dry and apply 3 x 3 gauze and neosporin (antibiotic) ointment. The on-call SN documented the patient would need a visit the next day for wound assessment and treatment orders. On 12/16/20 the SN visited the patient and documented a "reddened area that looks like a bruise". The SN applied a non-adherent dressing, wrapped with gauze, and put a wash cloth between the metal part of brace and patient's leg. The SN failed to contact the physician to obtain treatment orders or discuss options to prevent further skin breakdown. On 12/21/20 the SN visited the patient and documented a reddened area that looked like a bruise and classified the area as a stage 1 pressure ulcer to the back of the left lower leg. There was no evidence the physician was notified. On 12/28/20 the SN visited and there was no documentation regarding the pressure area. On 12/29/20 the SN visited the patient and documented the presence of a stage 1 pressure ulcer. There was no evidence the physician was notified. On 01/04/21 the SN visited the patient and documented bloody drainage on a foam dressing and two stage 2 pressure ulcers, 1.4 cm x 0.5 cm x 0.1 cm and 1.6 cm x 1.5 cm x 0.1 cm. The SN washed the areas with normal saline and applied Optifoam. There was no evidence the physician was notified of the new wounds to obtain orders for the treatment. On 01/12/21 at 1:00 PM the surveyor reviewed the record with the Administrator, DPS, Clinical Manager and QAPI Coordinator. They acknowledged the findings and provided no additional information. 2. Patient #9 was admitted to the agency on 11/12/20 with diagnoses of fractured right femur, atherosclerotic heart disease, hypertension, hyperlipidemia, Hyperkalemia and hyponatremia. The skilled nurse (SN) failed to notify the physician of changes in the patient's condition or plan of care as follows: Decreased heart rate The 11/12/20 Plan of Care included notifying the physician of if the patient's heart rate was greater than 100 or less than 50. - On 11/25/20 the SN visited the patient for routine assessment. The SN documented the patient's heart rate was 48. Although the SN contacted the physician's office regarding another issue on that date, there was no evidence the SN notified the physician of the decreased heart rate. Aide assignment The Plan of Care included the patient was to receive a home health aide weekly. No home health aide visited during the 23-day period from 12/3-12/26/20. - There was no evidence the SN contacted the physician to alter the plan of care or notify the physician of missed visits. On 01/12/21 at 1:00 PM the surveyor reviewed the record with the Administrator, DPS, Clinical Manager and QAPI Coordinator. They acknowledged the findings and provided no additional information. 3. Patient #16 was admitted to the agency on 08/06/20 with diagnoses of osteomyelitis, left great toe amputation, diabetes and chronic obstructive pulmonary disease. The 08/05/20 referral information included the patient was on home oxygen 2 liters nasal cannula at night. On 08/06/20 the skilled nurse (SN) visited the patient and documented the patient stated she was supposed to have oxygen at night because her oxygen level dropped during sleep, and the patient stated she had too much going on to follow up with home oxygen set up. There was no evidence the SN notified the physician of the patient's lack of oxygen to determine if there was a need, and if so, obtain orders and facilitate oxygen delivery. On 01/12/21 at 1:00 PM the surveyor reviewed the record with the Administrator, DPS, Clinical Manager and QAPI Coordinator. They acknowledged the findings and provided no additional information. Failure to ensure the physician is notified regarding changes in the patient's condition has the potential for unmet patient needs.

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 7 observational home visits and review of agency policies and procedures, it was determined during 1 of 7 home visits (patient # 6), the skilled nurse (SN) failed to follow accepted standards of infection control practices. Evidence as follows: HV Patient #6 was admitted to the agency on 12/10/20 with diagnosis of pressure ulcer to sacrum, deep tissue injuries to buttocks, calf and thigh, Type 2 diabetes, rheumatoid arthritis, hypertension and atrial fibrillation. The 12/10/20 Plan of Care included SN visits twice weekly for wound care. On 01/07/21 at 1:30 p.m. the surveyor completed an observational home visit with the SN to perform the following wound care: - mid-back: clean with normal saline, pat dry, apply Optifoam dressing - coccyx: clean with normal saline, pat dry, apply MediHoney to wound base, use skin prep, cover with Optifoam dressing The surveyor observed the following: The SN gathered supplies for wound care to mid-back. Without establishing a clean field, the SN placed the unopened dressing, gauze, saline and gloves on a table behind the patient, half on and half off a cloth placemat, thus contaminating the packaging and the gloves. The SN then removed patient belongings including a box of tissues and beverage mug from a folding table, gathered supplies for wound care to the coccyx, and without establishing a clean field set the items directly on the table next to the patient, thus contaminating the outside of the supplies and the gloves. On 01/08/21 at 10 a.m. the surveyor requested the agency's wound care policies. Review of the policy titled WOUND CARE: DRESSING APPLICATION, from The Visiting Nurses Association of America Copyright 2014, revealed the SN is to "Establish a clean field (sterile, if necessary) with all the supplies and equipment that will be necessary." On 01/12/21 at 1 p.m. the record was reviewed with the Administrator, DPS, Clinical Manager and QAPI Coordinator who acknowledged the findings and provided no additional information. Failure to follow accepted standards of practice, and agency policy and procedure has the potential for unmet patient needs and possible negative patient outcomes.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on review of clinical records for patients receiving home health aide (HHA) service and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Manager, it was determined in 5 of 7 records (patients # 3, 8, 10, 11 and 12) the skilled nurse (SN) failed to developed complete and accurate aide written instructions. This was evidenced by: 1. Patient #11 was admitted to the agency on 09/14/20 with diagnoses of type 2 diabetes with chronic kidney disease, Hashimoto encephalopathy, and hypothyroidism. The 09/14/20 plan of care included home health aide services 2 times per week. The skilled nurse (SN) failed to ensure the 09/14/20 HHA care plan included all necessary instructions to care for the patient: On 09/14/20 the SN visited the patient for the initial comprehensive assessment and documented the patient had a stage 1 pressure ulcer to the coccyx and the plan was to treat the area with barrier cream and pressure relief. The HHA care plan included instruction for the aide to apply "lotion" and failed to included instructions for the barrier cream or instructions for positioning to relieve pressure. The SN documented the patient had an indwelling (Foley) catheter 16 fr with a 10 cc balloon. The HHA plan included "pt has Foley cath" and failed to include specifics for what the HHA was do to care for the catheter such as emptying the catheter bag or providing catheter care. The 09/14/20 Plan of Care included multiple medications for diabetes including Trulicity 0.75 mg injection every week, Glipizide 5 mg every day, and Lantus insulin 32 units every day and a low carbohydrate diet. The HHA care plan failed to include diabetic precautions. On 01/12/21 at 1:00 PM the surveyor reviewed the record with the Administrator, DPS, Clinical Manager and QAPI Coordinator. They acknowledged the findings and provided no additional information. 2. Patient #8 was admitted to the agency on 11/27/20 with diagnoses of diverticulitis with bowel perforation, peritonitis, sepsis, and surgery of the gastrointestinal tract with a colostomy. The patient also had a history of breast cancer and venous thrombosis. The 11/27/20 plan of care include HHA services 3 times per week to provide personal care. On 11/27/20 the skilled nurse (SN) visited the patient for the initial comprehensive assessment and documented an ostomy and dressing on abdomen, and the patient had 2+ edema. The 11/27/20 Plan of Care included Eliquis (anticoagulant) 5 mg BID, colostomy and wound care to the abdomen replacing wet to dry dressing twice daily, and SN instruction regarding compression stocking application/management. The 11/29/20 Home Health Aide (HHA) care plan failed to include the following: - bleeding precautions - any instructions regarding the colostomy including emptying the bag - the presence of a dressing and changes to report - instructions regarding compression stockings On 01/12/21 at 1:00 PM the surveyor reviewed the record with the Administrator, DPS, Clinical Manager and QAPI Coordinator. They acknowledged the findings and provided no additional information. 3. Patient # 12 was admitted to the agency 07/17/20 with diagnoses of sepsis, pneumonia, urinary tract infection and multiple myeloma. The 11/14/20 Plan of Care included HHA services 2 times per week to provide personal care. On 07/17/20 the SN visited the patient for an initial assessment and documented the patient was incontinent and wore an adult brief. On 11/09/20 the SN visited the patient for a recertification assessment and documented the patient was incontinent and had excoriation to buttocks. The caregiver was educated on use of barrier ointment and to change patient's position every 2 hours to offset pressure. The 11/14/20 aide care plan failed to include instructions for: - use of adult brief - barrier ointment - frequent change of position for pressure relief On 01/12/21 at 1:00 PM the surveyor reviewed the record with the Administrator, DPS, Clinical Manager and QAPI Coordinator. They acknowledged the findings and provided no additional information. Failure to ensure that home health aide care plans are complete has the potential for unmet patient needs.