Every finding on record at Washington County Public Health and Home Care

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 12/18/23 through 12/20/23 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 12/18/23 through 12/20/23. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 48 patients at the time of the survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 2 of 7 sampled patients. (Patients #1 and #6) Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: According to the agency policy, titled Plan of Care and Physician’s Orders, dated 6/23/22, all home health services furnished to patients must follow a written plan of care, established and periodically reviewed by a doctor of medicine, osteopathy, podiatry or other allowed non-physician practitioner. The registered nurse will develop the plan of care, including notation of the specific services to be provided, actions to be taken to meet the patient’s goals and, as appropriate, the type, frequency and duration of such services or actions. During an interview on 12/19/23 at 4:25 PM, the Clinical Manager reported the missed visits are documented on an interim physician order. 1. Patient #1 had a start of care date of 10/3/23. Clinical record review revealed: a. Plan of Care, dated 10/3/23 to 12/1/23, included orders for home health aide services 2 times a week. b. Documentation in the patient schedule identified the home health aide visit, dated 11/24/23, as a missed visit. The clinical record lacked documentation of the reason for the missed visit and the physician was notified of the missed visit. c. Interim physician order, dated 11/13/23, for Physical Therapy services 2 times a week for 3 weeks. d. Physical Therapy missed appointment form, dated 11/17/23, included documentation the patient canceled the therapy visit for 11/17/23. The clinical record lacked documentation the physician was notified of the missed visit. The agency failed to notify the physician of the failure to meet the order frequency for the home health aide and physical therapy visits. 2. Patient #6 had a start of care date of 2/21/23 and a discharge date of 3/20/23. Clinical record review revealed: a. Plan of Care, dated 2/21/23 to 4/21/23, included orders for skilled nursing services 2 times a week for 3 weeks and 1 time a week for 6 weeks. b. Skilled nurse visit note, dated 2/28/23, included documentation of a refused or not at home visit. The clinical record lacked documentation the physician was notified of the missed visit. c. Skilled nurse visit note, dated 3/14/23, included documentation of a refused or not at home visit. The clinical record lacked documentation the physician was notified of the missed visit. d. Documentation in the patient schedule identified the home health aide visit, dated 2/28/23, as a missed visit. The clinical record lacked documentation of the reason for and the physician was notified of the missed visit. e. Documentation of a missed speech therapy visit form, dated 3/3/23, included documentation the speech therapy visit for 3/3/23 was missed due to therapist illness. The clinical record lacked documentation the physician was notified of the missed visit. The agency failed to notify the physician of the failure to meet the order frequency for the skilled nursing, home health aide and speech therapy visits. The above stated findings were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

The Department of Inspections and Appeals conducted a COVID-19 Focused Infection Control Survey in conjunction with with a complaint survey, complaint #96458-C from 4/12/21 through 4/15/21. The complaint survey found the agency was operating out of compliance with the following Conditions of Participation: 1) Condition of Participation 42 CFR 484.50: Patient Rights and 2) Condition of Participation 42 CFR 484.80: Home Health Aide Services. The complaint investigation survey for complaint #96458-C identified allegations related to the following Medicare Conditions of Participation: 1) 42 CFR 484.55 Comprehensive Assessment, was not substantiated; and, 2) 42 CFR 484.80 Home Health Aide Services, was substantiated with related deficiencies (see G0750, G0768, G0798, G0800, G0804). The agency was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. As a result of the agency's noncompliance with the Medicare Conditions of Participation for home health agencies, the home health agency and its registered nurses are prohibited from providing basic skills competency training, and prohibited from providing evaluation of home health aide written basic skills testing and evaluation of demonstrated competency of the hands on basic skills for the agency's home health aides for 2 years, beginning on 4/15/21 and ending on 4/15/23.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to do the following: 1) ensure patients had the right to be informed about changes in the plan of care and refuse care in advance of or during treatment with respect to the disciplines providing care and frequency of visits (G0434); 2) ensure staff investigated complaints related to care agency staff failed to furnish or furnished inappropriately (G0480); 3) ensure agency staff documented the existence and resolution of complaints (G0484); and, 4) ensure agency staff took action to prevent further potential violations (G0486). The systemic practice resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of the agency's 55 patients.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, patient, family and staff interview, the agency failed to ensure patients had the right to be informed about changes in the plan of care with respect to frequency of visits for 1 of 9 patients sampled with home health aide services (Patient #2). The agency reported 50 out of 55 patients received home health aide services at the time of the survey. Failure to ensure agency staff informed patients about changes in the plan of care with respect to frequency of visits resulted in agency patients not receiving care and services according to the patient and agency's service agreement. Findings include: Review of the agency's policy, titled Patient Rights and Responsibilities Form, dated 10/2020, identified agency staff will advise the patient of the disciplines who will furnish care to the patient and the proposed frequency of the visits. The patient will be able to participate in the physician's medical orders and notified in a timely manner of any changes to the plan. Agency staff will advise the patient verbally and in writing of the cost of services before services begin. If payment or services change, agency staff will notify the patient of the change prior to the agency acting on the change. Review of the agency's policy, titled Patient Rights, dated 10/2020, revealed the patient signs the Consent/Financial form to acknowledge receipt and explanation of patient rights. Patient #2 had a start of care date of 2/25/21. Review of the clinical record revealed the following: a. A Consent/Financial form, dated 2/25/21 with a signature by Patient #2 and Staff G, Registered Nurse (RN), included the following statement: "I understand the services will be included in my Plan of Care as indicated, and I agree on the intended frequency of services, skilled nursing every 56 to 60 days and home health aide services 3 times per week. The form indicated the patient was paying privately for services. b. The comprehensive assessment completed at the start of care, dated 2/25/21 and signed complete on 3/1/21, included documentation Staff G, RN, assessed the patient was alert and oriented with some forgetfulness, but the patient's short and long term memory were intact. She assessed the patient required set-up assistance with grooming and dressing and required intermittent assistance of another person to bath for either supervision, encouragement or help with hard to reach places. The nurse assessed the patient required assistance with personal cares and associated tasks to ensure safety and proper hygiene. She identified the patient would receive skilled nursing services once every 56 to 60 days and home health aide services 2 times per week. c. The Plan of Care (POC), dated 2/25/21 to 4/25/21, included physician orders for home health aide services 2 times per week. d. An interim physician order, dated 3/22/21, included a physician order to increase home health aide services to 3 times per week. On 4/13/21 at 2:26 PM, during an interview, Staff G, RN, explained the patient had signed the Consent/Financial form to receive home health aide services 3 times per week, but then she talked about it with the patient and Staff G reported the patient agreed to try just 2 times per week. Staff G, RN, explained she should have had the patient resign the Consent/Financial agreement. She reported she increased home health aide services to 3 times a week when the patient requested it. On 4/13/21 at 4:29 PM, during an interview, the patient's significant other reported the patient called the significant other right after Staff G, RN, left on 2/25/21. The patient reported he/she would be receiving home health aide services 3 times per week, on Monday, Wednesday and Friday. The significant other explained the patient requested home health aide services 3 times per week and never agreed to less. The significant other reported complaining to the agency after the first week about the lack of care and frequency of services on behalf of the patient. On 4/14/21 at 9:15 AM, during a home visit observation with Staff F, Licensed Practical Nurse (LPN)/Home Health Aide, the surveyor reviewed the admission packet and paper work provided to the patient. The patient did not have copy of a Plan of Care or home health aide care plan. The patient had a copy of the Consent/Financial agreement which indicated the patient would receive home health aide services 3 times per week. In an interview, during the same home visit observation, the patient confirmed not receiving a Plan of Care or home health aide care plan. The patient reported he/she did not agree to home health aide services 2 times per week. The patient explained he/she had requested and thought he/she would be receiving home health aide services 3 times per week. On 4/14/21 at 3:53 PM, during an interview, the patient's POC physician reported he signed the POC with home health aide services 2 times per week, because this is what the home health agency sent him to sign for orders. The POC physician explained the patient had a history of frequent falls and required assistance with bathing/showers. The physician reported he offered to admit the patient to a skilled rehabilitation facility, as the patient requires assistance more than 3 times per week and more assistance than what a home health agency can reasonably provide, but the patient refused. Agency staff failed to ensure the patient was in agreement with changes to the frequency of the delivery of home health aide services prior to implementing those changes. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, review of the agency's complaint log, patient, patient's significant other and staff interviews, the agency failed to ensure agency staff investigated complaints of care that failed to be furnished for 1 of 9 sampled patients (Patient #2) who received home health aide services. The agency reported a census of 55 at the time of the survey including 50 patients receiving home health aide services. Failure to ensure agency staff investigated complaints of care that failed to be furnished placed agency patients resulted in agency patient's not receiving care and services to meet the needs of the patients. Findings include: Review of the agency's policy, titled Patient Complaint/Appeal Policy, dated 12/2020, revealed any patient has the right to voice a complaint/grievance if there is dissatisfaction with the services or a concerns regarding patient rights. The patient has a right to appeal the resolution of a complaint if dissatisfied with the complaint response. The policy identified the Clinical Manager, or other designated individual, will receive complaints made by the patient or patient's family. If a complaint is made, agency staff will investigate the complaint and provide a response to the complainant within 5 working days. Agency staff will maintain documentation of the complaint in the complaint log and include the investigation process, all appeals, the hearing record and the disposition of the case. On 4/12/21, review of the agency's complaint log since the last survey, dated 12/17/2020, revealed one complaint in relation to Patient #2, dated 4/5/21. An email, dated 4/5/21, sent by the patient's significant other identified the patient and significant other had not received any response in relation to previous complaints made about the issues with the care the agency had been providing to the patient. The significant other complained the home health aide was mixing topical medicated cream with body lotion before applying it to the patient's back. The significant other reported the topical was supposed to be applied all over the patient's body. The home health aide had not been assisting with washing the patient's buttocks. The patient was unable to reach and and do this task. The home health aide refused to clip the patient's toe and finger nails. The home health aide had not been applying the patient's scalp medicine and the patient's scalp redness and itching were worse. The significant other reported the patient had a fall, and no one from the agency followed up. The significant other said the Clinical Manager told the patient and significant other the home health aides are unable to provide topical medications. In response to the email, dated 4/5/21, the complaint log included the following entries: a. On 4/6/21, the Clinical Manager documented she attempted to contact the significant other. There was no answer and she was unable to leave a message. b. On 4/6/21, the Clinical Manager documented she spoke with the patient's primary nurse, Staff G, RN. Staff G, RN, planned to review the home health aide care plan and assigned tasks. The Clinical Manager documented a plan to discuss concerns with the patient's home health aide, Staff D, Home Health Aide, on 4/7/21. c. On 4/7/21, the Clinical Manager documented Staff D, Home Health Aide, was sick and she was unable to speak with her. The Clinical Manager sent Staff F, Licensed Practical Nurse (LPN)/Home Health Aide), to provide cares for the patient. d. On 4/7/21, the Clinical Manager documented she spoke with Staff G, RN, and corrections on the home health aide care plan was going to be made. e. On 4/12/21 at 8:30 AM, the Clinical Manager documented a plan to speak with Staff D, Home Health Aide, on 4/15/21 and to keep Staff F, LPN/Home Health Aide, going into the home to provide cares to the patient. The complaint log contained 2 previous emails in relation to Patient #2. An email sent by the patient, dated 3/12/21, included documentation which identified the patient's significant other had sent previous emails about the care the agency had been providing to the patient. The patient asked if the agency had been able to reach the patient's Plan of Care (POC) physician, but did not identify why the patient needed the agency to contact the physician regarding care. The patient documented Staff D, Home Health Aide, was nice and the patient had thanked her for the help she had been providing. A second email by the Clinical Manager, dated 3/16/21, identified the Clinical Manager had spoke with the patient's POC physician and was waiting for further documentation. The Clinical Manager documented she was glad the patient was pleased with the care the agency provided and wanted to clear up any confusion related to the home health aides applying medicated prescription creams. The Clinical Manager reported the home health aides could not apply the medicated creams, but could assist the patient in applying them. Patient #2 had a start of care date of 2/25/21. Review of the clinical record revealed the following: a. A Consent/Financial form, dated 2/25/21 with a signature by Patient #2 and Staff G, Registered Nurse (RN), included the following statement: "I understand the services will be included in my Plan of Care as indicated, and I agree on the intended frequency of services, skilled nursing every 56 to 60 days and home health aide services 3 times per week. The form indicated the patient was paying privately for services. b. The comprehensive assessment completed at the start of care, dated 2/25/21 and signed complete on 3/1/21, included documentation Staff G, RN, assessed the patient was alert and oriented with some forgetfulness, but the patient's short and long term memory were intact. She assessed the patient required set-up assistance with grooming and dressing and required intermittent assistance of another person to bath for either supervision, encouragement or help with hard to reach places. The nurse assessed the patient required assistance with personal cares and associated tasks to ensure safety and proper hygiene. She identified the patient the patient would receive skilled nursing services once every 56 to 60 days and home health aide services 2 times per week. c. The Plan of Care (POC), dated 2/25/21 to 4/25/21, identified the patient had diagnoses of dementia, incontinent of bowel and bladder and chronic pain and included physician orders for home health aide services 2 times per week. The POC included the following home health aide interventions: assist with dressing or undressing, assist with shampoo, assist with shower and to cover the wound on the patient's lower back, assist with transfers in and out of the shower, perform bed bath, perform nail care of fingers and toes, perform skin care (apply over-the-counter skin moisturizer to dry areas per patient's direction), report falls, injuries or skin breakdown. The POC included orders for the following topical medications: Hydrocortisone 2.5 percent cream, apply topically twice per day; Ketoconazole 2 percent cream, apply topically 2 times per day; Nystatin 100,000 units/gram cream, apply once daily; and, Triamcinolone Acetonide 0.1 percent, apply once per day. d. An interim physician order, dated 3/18/21, included a verbal physician order to increase home health aide services to 3 times per week starting on 3/22/21. e. The home health aide visit notes, dated 3/2, 3/5, 3/8, 3/12, 3/16, 3/21, 3/22, 3/29, 3/31, 4/2, 4/6 and 4/9/21, included documentation Staff D, Home Health Aide, provided personal cares to the patient. She documented the patient refused toe and finger nail care every visit. She documented she applied over-the-counter lotion to the skin every visit, and never documented if or when she applied any of the topical medications. For the visits, dated 3/2, 3/5 and 3/8/21, she documented she assisted the patient with a bed bath. For the visits, dated 3/12, 3/16, 3/21, 3/22, 3/29, 3/31, 4/2, 4/6 and 4/9/21, Staff D, Home Health Aide, documented she assisted the patient in and out of the shower, but did not assist the patient with showering and covering the wound on the patient's lower back due to the patient refusing or it not being applicable. f. The home health aide visits notes, dated 4/7 and 4/12/21, included documentation Staff F, LPN/Home Health Aide, provided home health aide services to the patient. She documented the patient refused finger and toe nail care and shower assist and covering the patient lower back wound were not applicable. Application of any topical medications was not documented. On 4/13/21 at 2:26 PM, during an interview, Staff G, RN, explained the patient had signed the Consent/Financial form to receive home health aide services 3 times per week, but then she talked about it with the patient and she reported he agreed to try just 2 times per week. Staff G, RN, explained she should have had the patient resign the Consent/Financial agreement. She reported she increased home health aide services to 3 times a week when the patient requested it. Staff G, RN, explained she was unaware the patient or patient's significant other had any complaints about care Staff D, Home Health Aide, provided until last week. Staff G, RN, explained the patient's significant other sent an email with complaints about care the patient was receiving to the Administrator and Clinical Manager. She was unaware when Staff D, Home Health Aide, started to apply medicated creams to the patient and did not know if Staff F, LPN/Home Health Aide, was applying medicated creams. She was unaware this was a problem prior to 4/5/21. Staff G, RN, reported when she completed the comprehensive assessment at the start of care, the patient reported being able to take medications independently. She was unaware of the patient required assistance with topical medications. She explained the patient was applying the topical medications prior to services and also has teenage child living in the home to assist the patient. Staff G, RN, reported the patient was alert and oriented and able to speak for on the patient's own behalf. On 4/13/21 at 2:39 PM, during an interview, Staff F, LPN/Home Health Aide, reported she put Triamcinolone and Ketoconazole on the patient on 4/7/21, but just lotion on 4/12/21. She explained the patient refused medicated creams on 4/12. She reported 4/7/21 was the first time she saw the patient and provided cares. She explained she was unaware the shower assist was on the same line in the documentation as the wound covering. The patient no longer had a wound to cover. She did assist the patient with a shower both times. On 4/13/21 at 2:54 PM, during an interview, Staff D, Home Health Aide, explained she used the hand held shower to wash the patient's hair and completed the rest of the patient's bath in the bed for the first 2 weeks due to the patient's back wound and external nerve stimulator. She reported the patient had an external sacral nerve stimulator until 3/9/21, and then after the surgery on 3/9, the nerve stimulator was internal, and the patient was able to shower and no longer required a wound covering. When assisting the patient with a bed bath or a shower, Staff D reported she assisted the patient with washing the patient's hair, back, lower legs and feet. When asked if she washed the patient's buttocks area, Staff D reported she likes to encourage patients to do what they can for themselves. She explained the patient wanted to be as independent as possible and the patient washed the patient's own chest, arms, groin and buttocks areas. When asked if Staff D, Home Health Aide, was aware of any complaints, she reported the patient's significant other complained to the patient's physician about the patient needing more services. Staff D, Home Health Aide, reported she told the nurse about the complaint and the nurse increased the patient to home health aide services 3 times per week. When asked about the use of medicated creams, Staff D, Home Health Aide, reported at the beginning, nothing was said to her about applying the topical medications. She reported she started to do the medicated creams around the same time the patient switched over to just a shower after the second surgery on 3/9/21. She did not know for sure what the medications were for; the patient directs her. Staff D, Home Health Aide, reported she was just putting lotion on the patient at first, but then started mixing the Triamcinolone with the regular lotion and then applied them together the last couple times. She explained she did not talk with Staff G, RN, about doing the medicated creams. Staff D, Home Health Aide, reported she did not do the Nystatin cream, the patient was able to apply the cream to his own groin. She reported she put the Ketoconazole on the patient's hand and helped direct the patient where to apply it to his/her head. She denied putting the Hydrocortisone on the patient. She reported putting Triamcinolone on the patient's back. Staff D, Home Health Aide, was unaware the patient or significant other had made any complaints regarding the care she provided to the patient. On 4/13/21 at 4:29 PM, during an interview, the significant other does not live with the patient and emphasized not being the patient's caregiver. The significant other explained while he/she is not present when the home health aide comes to provide care, the patient always calls the significant other directly after the home health aide completes the visit. The significant other described the patient as having a brain injury and difficulty understanding things at times, but alert and oriented and able to speak for the patient's own self. The significant other reported calling the agency and talking with the Clinical Manager about services and the patient's needs prior to the patient's first surgery on 2/23/21. According to the significant other, the Clinical Manager assured the significant other the agency would be able to meet the needs of the patient. The patient called the significant other right after Staff G, RN, completed an initial visit on 2/25/21. The patient reported he/she would be receiving home health aide services 3 times per week, on Monday, Wednesday and Friday. The significant other explained the patient requested home health aide services 3 times per week and never agreed to less. The significant other expressed concerns the agency did not provide home health aide services until 3/2/21, a week after the patient's first surgery on 2/23/21. The significant other reported complaining to the agency after the first week about the lack of care and frequency of services on behalf of the patient. The significant other reported complaining via email several times to the agency regarding the care the home health aide provided. The significant other explained the patient was under a restriction of no lifting, bending or twisting due the surgeries on the patient's lower back, and the patient can not reach his/her own buttock to clean it. The significant other reported the home health would hand the patient a wash cloth and tell the patient to clean his/her own buttock area. The home health aide refused to cut or trim the patient's toe and finger nails. The patient is numb on the left side and unable to do nails on the right hand or reach the patient's own feet. The significant other reported the patient could reach the patient's head to put on the Ketoconazole on, but is supposed to put this on the reddened areas and can not see to do this. The patient also has medication for the patient's toes to put on, but is unable to reach to do this. When the significant other complained about the home health aide not applying the topical medications, the significant other reported the Clinical Manager told them the home health aides could not do this. However, the home health aide started to apply some of the medicated creams and the home health aide reported this was at the direction of the nurse. The home health aide was mixing the Triamcinolone with regular lotion and then putting this on the patient's back. The significant other expressed concerns because the home health aide mixed the medicated cream and also concerned, because the home health aide would only put the Triamcinolone on the patient's back when it was supposed to be applied all over. The significant other reported the email the patient sent to the agency on 3/12/21 was about the frequency of services issue and about the cares the home health aide had been providing and the patient had been sarcastic about thanking the agency for the services provided so far. The significant other sent an email to the agency and explained concerns with the home health aide not applying medicated creams and not providing adequate perineum care. The significant other reported the Clinical Manager responded on 3/16/21 about the frequency of services and medicated creams, but there was no other response until 4/12/21 about any of the other complaints. The significant other reported the patient had not received good perineum care and had all of the medicated creams applied until Staff F, LPN/Home Health Aide, provided cares on 4/7/21. However, the patient still has not had nail care done. On 4/14/21 at 8:10 AM, during an interview, the Clinical Manager reported the first complaint she received from the patient's significant other was on 4/5/21. She explained the significant other had contacted her prior to the 3/16/21 email the Clinical Manager sent the patient about the home health aides applying medicated creams. The Clinical Manager told the significant other the home health aides could not apply the topical medications per State regulations. The Clinical Manager was unaware the home health aides could do a competency evaluation with a successful return demonstration with a RN and be approved to apply topical medications. The Clinical Manager reported she had not spoken with Staff D, Home Health Aide, regarding the complaint made by the patient's significant other on 4/5/21. The Clinical Manager explained Staff D, Home Health Aide, was sick the next time she was scheduled to work and the Clinical Manager likes to have those types of discussion in person. The Clinical Manager reported staff had to have a physician order to apply medicated creams, and they did not have an order for this. On 4/14/21, beginning at 9:15 AM, during a home visit observation with Staff F, LPN/Home Health Aide, the surveyor reviewed the admission packet and paper work provided to the patient. The patient did not have copy of a Plan of Care or home health aide assignment. Staff F, LPN/Home Health Aide, assisted the patient with undressing, getting the shower, washing the patient's hair, right arm, back, legs and buttock area. The patient washed the patient's own groin, chest and left arm. Staff F, LPN/Home Health Aide, assisted the patient out of the shower, drying off and dressing. She applied Ketoconazole to the red areas on the patient's head, Triamcinolone to the patient's arms and legs per the patient's directions, Ciclopirox (an antifungal) to the toe nails on both feet. She did not offer to trim or file the patient's nails. The surveyor observed the patient walked with a cane in the right hand and was able to transfer from the bed and chair independently. The patient displayed a lack of use with the left hand and arm. In an interview, during the same home visit observation, the patient reported having a conference call with the Clinical Manager and significant other prior to the patient's first surgery on 2/23/21. The patient reported the significant other talked with the Clinical Manager about the patient's needs including shower assistance and assistance with applying the medicated creams. The patient confirmed not receiving a Plan of Care or home health aide care plan. The patient reported he/she did not agree to home health aide services 2 times per week. The patient explained he/she had requested and thought he/she would be receiving home health aide services 3 times per week. The patient did not think he/she had specifically discussed a need with Staff G, RN, during the initial visit about the need for assistance with medicated creams, but was insistent the Clinical Manager was aware. The patient reported his/her significant other sent multiple emails to the Administrator and Clinical Manager about concerns with not getting help with the medicated creams and not receiving assistance with perineum care. The patient reported being too embarrassed to say anything about the home health aide not cleaning his/her buttock area, so the significant other had complained for the patient. The patient reported being on a restriction after both the surgery on 2/23 and the surgery on 3/9/21 to not bend, twist or lift and also has left-sided numbness on the whole left side. The patient also had a fall about 3 weeks ago, and hurt his/her left hip. The patient has had hip replacement and now has increased pain and balance issues and still can not reach the buttock area to clean it. The patient reported the nurse did not come to assess the patient after the fall, but the patient did go to the emergency room and followed up with the patient's own physician. The patient reported he/she does clean his/her own groin area, but the home health aide never asked the patient if needed help with the buttock area. The patient tried to indicate and show the home health aide his/her inability to reach and clean the buttock area, but the home health aide told the patient that he/she had to do it. The patient reported one time asking the home health aide to help with cleaning his/her buttock area, and the home health aide just sprayed the area down with the hand held shower head. The patient reported the home health aide never offered to trim or file his/her nails. The patient denied refusing to have the home health aide do his/her nails. The patient reported asking the home health aide 2 different times to trim his/her nails. The first time the patient asked, the home health aide reportedly told the patient she did not like to trim nails. The second time the patient asked, the home health aide reportedly told him/her something about waiting because the patient had a doctor appointment and then maybe doing the nails the following week. The patient reported the email he/she sent on 3/12/21 was about saying Staff D, Home Health Aide, was nice, but services were not right and the referral was not done right. The patient reported the significant other sent a follow up email to explain this, but the agency did not send a response. The patient reported the significant other sent multiple emails to the agency about problems with care. The patient reported putting the Nystatin cream to the groin area on independently, but required assistance with the other topical medications. The patient explained he/she had received home health services through this agency in the past and had not had any problems. The patient reported receiving excellent care since Staff F, LPN/Home Health Aide took over; however, she has not done the patient's nails either. On 4/14/21 at 10:35 AM, during an interview, the Clinical Manager reported the significant other did call her prior the patient's first surgery on 2/23/21 and prior to admit. She reported they discussed the patient's possible need for wound care and the need for home health aide services, but never discussed the patient needing assistance with applying medicated creams. The Clinical Manager explained when the RN admitted the patient, the patient denied needing assistance with medications. The patient had been able to do the medicated creams prior to admittance with the patient's teenage child living the home. The Clinical Manager confirmed the significant other had sent emails prior to 3/12/21 about the medicated cream application and about problems with the care the home health aide was providing. The Clinical Manager reported she spoke with the patient and called the patient a couple different times and the patient said everything was fine. The Clinical Manager did not have documentation of any of the other emails the significant other sent or documentation of any of the phone calls with the patient. The Clinical Manager reported she did not do a good job with documenting everything and probably deleted the emails sent. The Clinical Manager reported she and the Administrator tried to call the significant other multiple times in response to the emails and could not reach the significant other. She did not have any documentation of this. The Clinical Manager reported being unaware of Staff D, Home Health Aide, not cleaning the patient's buttocks or doing the patient's nails. The surveyor asked if the solution after this last complaint was to put Staff F, LPN/Home Health Aide, in with the patient in order to do medicated creams, why did they not do this when the patient first complained. The Clinical Manager responded, "I don't know." On 4/14/21 at 11:46 AM, during an interview with the Administrator and Clinical Manager, the Administrator reported the patient's significant other called and emailed with concerns about level of care the agency provided to the patient and about the patient not receiving good perineal care. The Administrator understood the significant other was upset and they were trying to resolve the issues. The Administrator brought the concerns the Clinical Manager's attention when the significant other contacted her. Both the Administrator and Clinical Manager confirmed the significant other called and emailed multiple times throughout March and into April with concerns. The Administrator reported they played phone tag a lot due to each others schedules. Both the Administrator and Clinical Manager confirmed they did not document the contacts with the significant other. On 4/14/21 at 3:39 PM, during an interview, the patient reported he/she had been using Ketoconazole for years and using the Ciclopirox for a long time. The patient reported the Triamcinolone was newer, approximately mid February 2021, due to a full body rash he/she developed in relation to a Covid 19 immunization reaction. The patient reported he/she could not apply the Triamcinolone to his/her back, right arm and lower legs without help. The patient can reach, but can not see to apply the Ketoconazole without assistance. The patient can not reach his/her toes at all to apply the Ciclopirox. The patient does the Nystatin independently. The patient reported prior to home health aide services, the patient's significant other assisted with applying topical medications, but this was not consistent, as the significant other could only come over and help a couple times a week. The patient reported when he/she was previously on services, Staff D, Home Health Aide, and 2 other home health aides applied the topical medications. On 4/14/21 at 3:53 PM, during an interview, the patient's POC physician reported the patient's gastrointestinal surgeon requested he put in a referral to the home health agency for services for the patient. He reported the patient had frequent falls and required assistance with bathing and showering due to safety concerns. The POC physician reported the significant other had complained he and the home health agency had not put services in soon enough for the patient and would have liked services to start prior to the patient's first surgery. The POC physician reported the patient was not eligible prior to the surgery. The patient's POC physician reported he signed the POC with home health aide services 2 times per week, because this is what the home health agency sent him to sign for orders. The POC physician reported he offered to admit the patient to a skilled rehabilitation facility, as the patient requires assistance more than 3 times per week and more than what a home health agency can reasonably provide, but the patient refused. He explained even if the home health agency had been applying the medicated creams 3 times a week, this would not be enough to be effective. He reported the agency has not contacted him about orders for agency staff to apply the medicated creams. On 4/15/21 at 9:45 AM, during an interview, the Clinical Manager reported the patient had received home health agency services more than a year ago. She was unaware the home health aides at that time had been applying the topical medications. Agency staff failed to investigate complaints of care agency home health aide staff failed to furnish. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, review of the agency complaint log, patient, patient's significant other and staff interview, the agency failed to ensure the documentation of complaints and the resolution of a complaints made by agency patients for 1 of 9 sampled patients (Patient #2) who received home health aide services. The agency reported a census of 55 at the time of the survey including 50 patients receiving home health aide services. Failure to document and maintain evidence of complaints and the resolution of the complaints allows the problems to persist without being addressed and prevents the home health agency from critically evaluating the nature of the complaints, the investigation, and the resolution of the complaints. This allows problems to continue and worsen over time because patterns are not identified and addressed to improve patient care. Findings include: See G0480 The agency failed to document both the existence of the complaints and the resolution of the complaints. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on clinical record review, review of the agency complaint log, agency policy review, patient, patient's significant other, family and staff interview, the agency failed to ensure staff took action to resolve complaints and prevent further violations for 1 of 9 sampled patients (Patient #2). The agency reported a census of 55 at the time of the survey including 50 patients receiving home health aide services. Failure to staff took action to resolve complaints placed agency patients at risk for not having identified complaints resolved in a satisfactory and timely manner and allowed for repeated offences to occur. Findings include: See G0480 The agency failed to take action and prevent further violations against the home health aide's failure to provide adequate care to meet the needs of the patient. The patient's significant other reported making repeated complaints of inadequate care provided by the home health aide. Even after the agency received the email complaint on 4/5/21, agency staff put the same home health aide in the patient's home on 4/9/21. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

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 clinical record review, agency policy review and staff interview, the agency failed to ensure accurate and thorough completion of all pertinent components of comprehensive assessments for 2 of 7 sampled patients (Patients #3 and #4). The agency reported a current patient census of 55 patients. Failure to accurately and thoroughly complete comprehensive assessments increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: Review of the agency's policy, titled Comprehensive Assessment of Patients, dated 1/20/2020, revealed each patient must receive a patient-specific, comprehensive assessment that accurately reflects the patient's current health status. 1. Patient #3 had a start of care date of 3/30/21. Review of the clinical record revealed the following: The comprehensive assessment completed at the start of care, dated 3/30/21, included documentation of the patient's weight of 341 pounds. The nurse documented she obtained the patient's weight per hospital record. There was no explanation for why the nurse failed to obtain a current weight on the patient for the comprehensive assessment. In the same comprehensive assessment, the nurse documented the following wound assessments: a. upper medial buttocks coccyx/ decubitus/ pressure ulcer with wound measurements of length 1 centimeter (cm) and width 1 cm; b. right upper medial buttocks/ decubitus/ pressure ulcer with wound measurements of length 2 cm and width 2 cm; c. right lower medial buttocks rectal area/ decubitus/ pressure ulcer with wound measurements of length 1 cm and width 0.5 cm; d. left posterior buttocks coccyx/ decubitus/ pressure ulcer with wound measurements of length 4 cm and width 3 cm. On 4/15/21 at 10:07 AM, during an interview, the Clinical Manager reported the nurses should be documenting length, width and depth for all wounds, if there is no depth the nurse should document a 0 for depth. The nurse failed to obtain current physical health status information and inaccurately documented information in the comprehensive assessment. 2. Patient #4 had a start of care date of 3/2/21. Review of the clinical record revealed the following: The comprehensive assessment completed at the start of care, dated 3/2/21, included a registered nurse (RN) assessment of a right heel wound with eschar (a dry dark scab composed of dead tissue covering a wound). The assessment lacked any measurements of the wound. On 4/13/21 at 2:12 PM, during an interview, Staff H, RN, reported she was unsure if she had put measurements of the wound in the comprehensive assessment and agreed to get back to the surveyor on this. On 4/13/21 at 3:10 PM, during an interview, Staff H, RN, confirmed the comprehensive assessment completed by her at the start of care lacked right heel wound measurements. She explained she had taken measurements and put them in her notes, but forgot to put the measurements in the typed assessment. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review, patient, patient's significant other, physician and staff interviews, the agency failed to do the following: 1) ensure home health aides successfully demonstrated competency to a registered nurse prior to performing any task for a patient above and beyond basic skills (G0768); 2) ensure a registered nurse assigned all home health aides specific, individualized tasks for each patient (G0798); 3) ensure agency home health aides followed the care plan to meet the assessed needs of the patients (G0800); and, 4) ensure agency home health aides reported changes in the patient's condition to the registered nurse (G0804). The systemic practice identified the agency's failure to have a process in place to ensure agency staff met the needs of the agency's 50 patients receiving home health aide service.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on clinical record review, personnel file review, patient, patient's significant other and agency staff interview, the agency failed to ensure 1 of 3 sampled home health aides (Staff D), performed tasks requiring extra skills exceeding the level of basic home health aide skills for 2 of 9 sampled patients (Patients #2 and #8), had documented evidence of a successful return competency demonstration signed off by a registered nurse prior to independently performing the extra skill task with a patient. The agency reported 50 out of 55 patients received home health aide services at the time of the survey. The agency employed 5 home health aides at the time of the survey. Failure to ensure home health aides were competent in any assigned skill which exceeded the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: 1. Patient #2 had a start of care date of 2/25/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/25/21 to 4/25/21, included physician orders for home health aide services 2 times per week. The POC included the following home health aide interventions: assist with dressing or undressing, assist with shampoo, assist with shower and to cover the wound on the patient's lower back, assist with transfers in and out of the shower, perform bed bath, perform nail care of fingers and toes, perform skin care (apply over-the-counter skin moisturizer to dry areas per patient's direction), report falls, injuries or skin breakdown. The POC included orders for the following topical medications: Hydrocortisone 2.5 percent cream, apply topically twice per day; Ketoconazole 2 percent cream, apply topically 2 times per day; Nystatin 100,000 units/gram cream, apply once daily; and, Triamcinolone Acetonide 0.1 percent, apply once per day. b. An interim physician order, dated 3/18/21, included a verbal physician order to increase home health aide services to 3 times per week starting on 3/22/21. c. The home health aide visit notes, dated 3/2, 3/5, 3/8, 3/12, 3/16, 3/21, 3/22, 3/29, 3/31, 4/2, 4/6 and 4/9/21, included documentation Staff D, Home Health Aide, provided personal cares to the patient including performing the task of skin by applying over-the-counter lotion. Review of the agency's complaint log revealed a complaint related to Patient #2, dated 4/5/21. An email, dated 4/5/21, sent by the patient's significant other identified the patient and significant other had not received any response in relation to previous complaints. The significant other complained the home health aide was mixing topical medicated cream with body lotion before applying it to the patient's back. On 4/13/21 at 2:26 PM, during an interview, Staff G, RN, reported she was unaware when Staff D, Home Health Aide, started to apply medicated creams to the patient and was unaware this was a problem prior to 4/5/21. Staff G, RN, reported when she completed the comprehensive assessment at the start of care, the patient reported being able to take medications independently. She was unaware of the patient requiring assistance with topical medications. On 4/13/21 at 2:54 PM, during an interview, Staff D, Home Health Aide, explained at the beginning, nothing was said to her about applying the topical medications. She reported she started to do the medicated creams around the same time the patient switched over to just a shower after the second surgery on 3/9/21. She did not know for sure what the medications were for; the patient directed her. Staff D, Home Health Aide, reported she was just putting lotion on the patient at first, but then starting mixing the Triamcinolone with the regular lotion and then applied them together the last couple times. She explained she did not talk with Staff G, RN, about doing the medicated creams. Staff D, Home Health Aide, reported she did not do the Nystatin cream, the patient put this on his/her own groin. She reported she put the Ketoconazole on the patient's hand and helped direct him/her where to apply it to his/her head. She denied putting the Hydrocortisone on the patient. She reported putting Triamcinolone on the patient's back. Staff D, Home Health Aide, had a hire date of 2/1/18. Review of the personnel file for Staff D, Home Health Aide, revealed a lack of competency evaluation by RN for the extra skill task of applying medicated cream on a patient. 2. Patient #8 had a start of care date of 12/6/18. Review of the clinical record revealed the following: a. The Plan of Care, dated 1/24/21 to 3/24/21, included orders for skilled nursing and home health aide services and a medication order for Nystatin 100000 units/milliliter, sprinkle thin layer to affected areas topical 3 times a day as needed redness/yeast. b. The home health aide assignment entered in the electronic medical record, dated 7/27/2020, included RN instructions for the home health aide to complete the task of performing skin care by washing under both breasts, patting dry and the patient to apply Ketaconazole cream in a thin layer to areas of redness. c. The home health aide visit notes, dated 2/8, 2/10, 2/12, 2/17, 2/19, 2/22, 2/24, 2/26, 3/1, 3/3, 3/5, 3/8, 3/10, 3/12, 3/15, 3/17, 3/19, 3/22, 3/24, 3/26, 3/29, 3/31, 4/2, 4/5, 4/7, 4/9 and 4/12/21, included documentation the aide completed the task of skin care (wash under both breasts, pat dry, patient to apply Ketaconazole cream in a thin layer to areas of redness). The patient did not have Ketaconazole cream in the home, the patient was using Nystatin powder to the areas of redness. Staff D, Home Health Aide, provided home health aide services to Patient #8. On 4/14/21 at 11:40 AM, during an interview, Patient #8 reported the home health aides apply Nystatin under the breasts and to the abdominal fold area; the patient then reported the Nystatin to the abdominal fold is supposed to be applied by the patient not the aides. On 4/15/21 at 9:46 AM, during an interview, Staff I, RN, reported the patient was no longer using the Ketaconazole cream, this had been changed to Nystatin powder, Staff I must have forgotten to change on the aide assignment. Staff I reported the patient is aware that the aides are not to apply Nystatin to the abdominal fold area, the patient is responsible for this task. On 4/14/21 at 12:25 PM, during an interview, Staff D, Home Health Aide, reported she has applied the powder under the patient's breasts in the past but is not currently doing this, she had also applied powder under the abdominal fold. Review of the personnel file for Staff D, Home Health Aide, revealed a lack of competency evaluation by RN for the extra skill task of applying medicated powder on a patient. On 4/14/21 at 11:16 AM, during an interview, the Clinical Manager confirmed Staff D, Home Health Aide, had not completed a competency evaluation in the application of any type of topical medication. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

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 clinical record review, agency policy review, patient, patient's significant other and agency staff interview, the agency failed to ensure registered nurses provided individualized and specific written patient care instructions to agency home health aides for 6 of 9 sampled patients receiving home health aide services (Patients #2, #3, #4, #6, #8 and #9). The agency reported 50 out of 55 patients received home health aide services at the time of the survey. Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patient's would receive inappropriate or inconsistent home health aide services. Findings include: Review of the agency's policy, titled Home Care Aide Manager Care Plan Policy, dated 12/2020, identified agency staff create the home health aide care plan during the admission process based on the initial assessment and reflect ongoing changes as they occur. A registered nurse (RN) or Clinical Manager updates the home health aide care plan at recertification (every 56 to 60 days), discharge and as needed to reflect changes in the patient's condition or patient requests). If the RN needs to make changes, the RN will initial the changes on the home health aide care plan and agency designated staff will inform the home health aide(s) of the changes. 1. Patient #2 had a start of care date of 2/25/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/25/21 to 4/25/21, identified the patient had diagnoses of dementia, incontinent of bowel and bladder and chronic pain and included physician orders for home health aide services 2 times per week. The POC included the following home health aide interventions: assist with shower and to cover the wound on the patient's lower back, assist with dressing or undressing, assist with shampoo, assist with transfers in and out of the shower, perform bed bath, perform nail care of fingers and toes, perform skin care (apply over-the-counter skin moisturizer to dry areas per patient's direction), report falls, injuries or skin breakdown. The POC included orders for the following topical medications: Hydrocortisone 2.5 percent cream, apply topically twice per day; Ketoconazole 2 percent cream, apply topically 2 times per day; Nystatin 100,000 units/gram cream, apply once daily; and, Triamcinolone Acetonide 0.1 percent, apply once per day. b. An interim physician order, dated 3/18/21, included a verbal physician order to increase home health aide services to 3 times per week starting on 3/22/21. c. The home health aide visit notes, dated 3/2, 3/5, 3/8, 3/12, 3/16, 3/21, 3/22, 3/29, 3/31, 4/2, 4/6 and 4/9/21, included documentation Staff D, Home Health Aide, provided personal cares to the patient. She documented she applied over-the-counter lotion on the patient. d. The home health aide visits notes, dated 4/7 and 4/12/21, included documentation Staff F, LPN/Home Health Aide, provided home health aide services to the patient. She documented she applied over-the-counter lotion on the patient. On 4/13/21 at 2:26 PM, during an interview, Staff G, RN, reported she was unaware when Staff D, Home Health Aide, started to apply medicated creams to the patient. Staff G, RN, reported when she completed the comprehensive assessment at the start of care, the patient reported being able to take medications independently. She was unaware of the patient requiring assistance with topical medications. Staff G, RN, reported being unsure what Staff F, LPN/Home Health Aide, was doing with the patient as far as application of topical medications. On 4/13/21 at 2:54 PM, during an interview, Staff D, Home Health Aide, explained at the beginning, nothing was said to her about applying the topical medications. She reported she started to do the medicated creams around the same time the patient switched over to just a shower after the second surgery on 3/9/21 based on the patient's request. She explained she did not talk with Staff G, RN, about doing the medicated creams. She reported putting Triamcinolone on the patient's back and putting Ketoconazole on the patient's hand for the patient to apply it to the patient's scalp. On 4/13/21 at 2:39 PM, during an interview, Staff F, LPN/Home Health Aide, reported she put Triamcinolone and Ketoconazole on the patient on 4/7/21, but just lotion on 4/12/21. She explained the patient refused medicated creams on 4/12. She reported 4/7/21 was the first time she saw the patient and provided cares. On 4/14/21, beginning at 9:15 AM, during a home visit observation with Staff F, LPN/Home Health Aide, the surveyor reviewed the admission packet and paper work provided to the patient. The patient did not have copy of a Plan of Care or home health aide care plan/assignment. Staff F, LPN/Home Health Aide, assisted the patient with undressing, getting the shower, washing the patient's hair, right arm, back, legs and buttock area. The patient washed the patient's own groin, chest and left arm. Staff F, LPN/Home Health Aide, assisted the patient out of the shower, drying off and dressing. She applied Ketoconazole to the red areas on the patient's head, Triamcinolone to the patient's arms and legs per the patient's directions, Ciclopirox (an antifungal) to the toe nails on both feet. On 4/14/21 at 10:35 AM, during an interview, the Clinical Manager reported being unaware the home health was applying medicated creams on the patient prior to the complaint made by the patient's significant other, dated 4/5/21. Staff F, LPN/Home Health Aide, was put in the patient's home, because she was able to do the topical medications. The clinical record lacked documentation of an updated home health aide assignment with RN directions to the home health aide to apply topical medications. 2. Patient #4 had a start of care date of 3/2/21. Review of the clinical record revealed the following: a. The POC, dated 3/2/2021 to 4/30/2021, included physician orders for skilled nursing and home health aide services. The POC included home health aide interventions to assist the patient with a home exercise program. b. The home health aide care plan/assignment, dated 3/2/21, included RN instructions to the home health aide to assist the patient with exercise. c. An interim physician order, dated 3/8/21, included orders for physical therapy one time the first week and then 2 times per week for 8 weeks. d. The home health aide visit notes, dated 3/4, 3/9, 3/12, 3/16, 3/23, 3/26, 3/30 and 4/6/21, included documentation Staff E, Home Health Aide, provided home health aide services to the patient. On 3/4, Staff E, Home Health Aide, documented the home exercise program was not applicable. On 3/9, 3/12, 3/16, 3/23, 3/26, 3/30 and 4/6/21, Staff E, Home Health Aide, documented the patient refused to do the home exercise program. e. The home health aide visit notes, dated 3/19, 4/2 and 4/12/21, included documentation Staff F, LPN/Home Health Aide, provided home health aide services. Staff F, LPN/Home Health Aide, documented she completed the home exercise program with the patient on 3/19 and 4/2/21. She documented the patient refused the home exercise program on 4/12/21. On 4/13/21 at 2:34 PM, during an interview, Staff F, LPN/Home Health Aide, explained she really did not know what the home exercise program was or what was involved and no one ever explained it to her. She reported she just helped the patient roll around and get in a chair. On 4/13/21 at 3:10 PM, during an interview, Staff H, RN, reported she put the home exercise program on the home health aide assignment, because sometimes physical therapy gives home instructions for exercises. The therapist will show the home health aide how to do the exercises. She reported the home health aides were not doing this yet. She put this on the plan in anticipation. Staff H, RN, explained the home health aides should be putting "not applicable", because they have not had instruction from physical therapy yet. She explained she probably should not have put this on the home health aide assignment yet. On 4/14/21 at 11:16 AM, during an interview, the Clinical Manager reported the home health aide is not actually assisting the patient with the home exercise program. The home health aides are just supposed to remind the patient to do the exercises therapy left for the patient and follow the exercise sheets. On 4/14/21 at 2:26 PM, during an interview, Staff E, Home Health Aide, reported the patient refused to do any exercises. When asked what she was supposed to do for the home exercise program, Staff E, Home Health Aide, "Nothing now...waiting for patient to finish PT (physical therapy) and then (the patient) may have exercises to do." On 4/14/21 at 3:17 PM, during an interview, the patient reported both Staff E, Home Health Aide, and Staff F, LPN/Home Health Aide, ask the patient if the patient has done the exercises PT left for the patient to do when they do a visit. The patient explained the home health aides do not have time to do the exercises with the patient when they come, because they are spending most of the time on the patient's bath. Patient denies ever refusing to do exercises for PT or when home health aides asked except for one time when the Patient's right hip pain was too severe. The RN failed to specify instructions to the home health aide regarding the patient's home exercise program and whether or not the home health aides should assist with this task or just remind the patient to complete the exercises. 3. Patient #6 had a start of care date of 2/13/13. Review of the clinical record revealed the following: a. The POC, dated 2/20/2021 to 4/20/2021, included orders for skilled nursing one time per week and home health aide services 3 times per week. The POC included orders for the following home health aide interventions: assist with dressing and undressing, assist with shampoo, assist with shower, assist with transfer in and out of shower, perform bed bath per patient direction, perform catheter care, perform nail care (file only), perform skin care (over-the-counter skin moisturizer to dry areas per patient direction), report falls or injury to RN and report skin breakdown to the RN. The POC included orders for Voltaren topical 1 percent apply three times per day as needed to the lower legs and Lidocaine topical 4 percent apply 4 times a day as needed to open wounds. b. A separate home health aide assignment sheet last updated 6/22/2020, included instructions to the home health aide to perform over the counter pain reliever gel to sore muscles per the patient's direction, remove the Mepilex dressing before showering, dry wounds on the right lower leg, apply Triad paste in the wounds and Calmoseptine around wounds, cover with Mepilex and secure with netting. c. The home health aide visit notes, dated 2/22, 3/1 and 3/3/21, included documentation Staff C, Home Health Aide, provided home health aide services. She did not document providing any wound care or applying any topical medications. f. The home health aide visit notes, dated 3/8, 3/10 (Wednesday), 3/15, 3/17 (Wednesday), 3/19 (Friday), 3/22, 3/24 (Wednesday), 3/26 (Friday), 3/29, 3/31 (Wednesday), 4/1 (Thursday), 4/5, 4/7 (Wednesday), included documentation Staff F, LPN/Home Health Aide, provided home health aide services. She did not document applying any topical medications or completing wound care. On 4/13/21 at 2:16 PM, during an interview, Staff G, RN, reported she does wound care on Mondays, and Staff F, LPN/Home Health Aide, does wound care on Wednesdays and Fridays while providing home health aide services. She reported the week of 2/22 and and 3/1/21, the patient went to the hospital wound clinic for treatment and stayed for observation. Staff G, RN, reported the patient applied the Mupirocin to the breast area. She reported the patient was not currently using the Triad paste. She reported Staff F, LPN/Home Health Aide, was applying Voltaren topical medicated gel to lower legs and Lidocaine topical cream. On 4/13/21 at 2:36 PM, during an interview, Staff F, LPN/Home Health Aide, reported she was doing wound care to the lower right leg on Wednesday and Fridays and Staff G, RN, did wound care on Mondays. She reported she has been applying the Voltaren gel on the patient, but not any other topical medications. On 4/14/21 at 7:41 AM, during an interview, Staff C, Home Health Aide, reported she filled in for Staff F, LPN/Home Health Aide, while Staff F was on vacation the weeks of 2/22 and 3/1/21. She denied doing any wound care or applying any topical medications. On 4/14/21 at 8:40 AM, during an interview, the Clinical Manager confirmed the wound care intervention should be on the home health aide care plan since Staff F, LPN/Home Health Aide, was completing this task as a home health aide. She also agreed the Voltaren gel should be identified on the home health aide care plan and the LPN should be documenting she doing these tasks. The home health aide assignment, last updated 6/22/2020, did not match the physician orders given for home health aide interventions on the current POC or the interim physician orders for wound care. The home health assignment did not specify what topical medication the home health aide should apply. 4. Patient #3 had a start of care date of 3/30/21. Review of the clinical record revealed the following: a. The undated paper home health aide assignment, directed the following tasks: assist with transfers from bed to wheelchair; change patient linen; make patient bed; assist with bed bath; skin care, apply over the counter skin moisturizer per patient direction; report skin breakdown to registered nurse (RN); report falls and or injury to RN; perform nail care of fingers and perform nail care of toes. b. The home health aide assignment entered in the electronic medical record (EMR), dated 3/30/21, directed the following tasks: assist with transfers from bed to wheelchair; change patient linen; make patient bed; assist with bed bath; skin care, apply over the counter moisturizing lotion to dry areas of the skin per patient request; report redness, open areas of breakdown to RN; and report falls or injury to RN. On 4/15/21 at 10:07 AM, during an interview, the Clinical Manager reported the paper home health aide assignment should be dated and should match the home health aide assignment entered in the EMR. The clinical record contained two home health aide assignments, the home health aide did not receive specific directions on which assignment to follow and did not receive specific instructions on what each task consisted of. 5. Patient #8 had a start of care date of 12/6/18. Review of the clinical record revealed the following: a. The Plan of Care, dated 1/24/21 to 3/24/21, included primary diagnosis of hemiplegia following other nontraumatic internal hemorrhage affecting right dominant side (stroke with right sided weakness), other pertinent diagnosis of Type 2 diabetes mellitus without complications and medication order for Nystatin 100000 units/milliliter, sprinkle thin layer to affected areas topical 3 times a day as needed redness/yeast. b. The home health aide assignment entered in the electronic medical record, dated 7/27/2020, directed the following tasks: i. assist patient with home exercise program; ii. perform nail care of fingers; iii. skin care - wash under both breasts, pat dry, patient to apply Ketaconazole cream in a thin layer to areas of redness. c. On 4/14/21 at 11:40 AM, during an interview, Patient #8 reported the home health aides apply Nystatin under the breasts, cut finger nails, and apply Nystatin to abdominal fold area; the patient then reported the Nystatin to the abdominal fold is supposed to be applied by the patient not the aides. The in-home caregiver reported the patient had physical therapy in the past and there was a sheet of exercises left in the home for the patient to do, the caregiver and the patient believe this is the home exercise program. d. On 4/15/21 at 9:46 AM, during an interview, Staff I, RN, reported the patient was no longer using the Ketaconazole cream, this had been changed to Nystatin powder, Staff I must have forgotten to change on the aide care plan/assignment. Staff I reported the patient had physical therapy in the past and had left a sheet of exercises for the patient to do, the home health aides are supposed to remind the patient to complete the exercises and nail care of fingers includes clipping, filing and cleaning nails, unless the patient is diabetic then the aides are not to clip the nails. On 4/15/21 at 10:07 AM, during an interview, the Clinical Manager reported the home exercise program means the aides are to remind the patient to complete exercises left in the home by therapy; and nail care can include cutting, filing and cleaning nails unless the patient is diabetic then the aides are not to clip the nails. The tasks of home exercise program, nail care of fingers and skin care failed to include specific and accurate instructions of what each task consisted of. 6. Patient #9 had a start of care date of 10/13/2020. Review of the clinical record revealed the home health aide assignment entered in the electronic medical record, dated 10/12/2020, directed the task to assist patient with exercise. On 4/14/21 at 12:07 PM, during an interview, Staff G, RN, reported the task assist patient with exercise meant the home health aide would walk outside with the patient for safety, Patient #9 was nervous to do this without someone else present in case the patient would fall. On 4/14/21 at 2:24 PM, during an interview, Staff E, Home Health Aide, reported the patient never wanted her to do anything regarding exercise, Staff E wasn't even sure what the exercises were. The task of assist patient with exercise failed to include specific instructions of what the task consisted of. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (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, agency policy review, patient, patient's significant other and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed in writing by the skilled professional assigning the home health aide to the patient for 5 of 9 sampled patients receiving home health aide services (Patients #2, #4, #5, #6 and #8). The agency reported 50 out of 55 patients received home health aide services at the time of the survey. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings include: Review of the agency's policy, titled Home Care Aide Manager Care Plan Policy, dated 12/2020, identified agency staff create the home health aide care plan during the admission process based on the initial assessment and reflect ongoing changes as they occur. A registered nurse (RN) or Clinical Manager updates the home health aide care plan at recertification (every 56-60 days), discharge and as needed to reflect changes in the patient's condition or patient requests). 1. Patient #2 had a start of care date of 2/25/21. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care, dated 2/25/21 and signed complete on 3/1/21, included documentation Staff G, RN, assessed the patient was alert and oriented with some forgetfulness, but the patient's short and long term memory were intact. She assessed the patient required set-up assistance with grooming and dressing and required intermittent assistance of another person to bath for either supervision, encouragement or help with hard to reach places. The nurse assessed the patient required assistance with personal cares and associated tasks to ensure safety and proper hygiene. She identified the patient the patient would receive skilled nursing services once every 56 to 60 days and home health aide services 2 times per week. b. The Plan of Care (POC), dated 2/25/21 to 4/25/21, identified the patient had diagnoses of dementia, incontinent of bowel and bladder and chronic pain and included physician orders for home health aide services 2 times per week. The POC included the following home health aide interventions: assist with dressing or undressing, assist with shampoo, assist with shower and to cover the wound on the patient's lower back, assist with transfers in and out of the shower, perform bed bath, perform nail care of fingers and toes, perform skin care (apply over-the-counter skin moisturizer to dry areas per patient's direction), report falls, injuries or skin breakdown. The POC included orders for the following topical medications: Hydrocortisone 2.5 percent cream, apply topically twice per day; Ketoconazole 2 percent cream, apply topically 2 times per day; Nystatin 100,000 units/gram cream, apply once daily; and, Triamcinolone Acetonide 0.1 percent, apply once per day. d. An interim physician order, dated 3/18/21, included a verbal physician order to increase home health aide services to 3 times per week starting on 3/22/21. e. The home health aide visit notes, dated 3/2, 3/5, 3/8, 3/12, 3/16, 3/21, 3/22, 3/29, 3/31, 4/2, 4/6 and 4/9/21, included documentation Staff D, Home Health Aide, provided home health aide services to the patient. She documented the patient refused toe and finger nail care every visit. She documented she applied over-the-counter lotion to the skin every visit, and never documented if or when she applied any of the topical medications. For the visits, dated 3/12, 3/16, 3/21, 3/22, 3/29, 3/31, 4/2, 4/6 and 4/9/21, Staff D, Home Health Aide, documented she assisted the patient in and out of the shower, but did not assist the patient with showering and covering the wound on the patient's lower back due to the patient refusing or it not being applicable. f. The home health aide visits notes, dated 4/7 and 4/12/21, included documentation Staff F, LPN/Home Health Aide, provided home health aide services to the patient. She documented the patient refused finger and toe nail care and shower assist and covering the patient lower back wound were not applicable. She never documented the application of any topical medications. On 4/13/21 at 2:26 PM, during an interview, Staff G, RN, reported she was unaware when Staff D, Home Health Aide, started to apply medicated creams to the patient. Staff G, RN, reported when she completed the comprehensive assessment at the start of care, the patient reported being able to take medications independently. She was unaware of the patient required assistance with topical medications. Staff G, RN, reported being unsure what Staff F, LPN/Home Health Aide, was doing with the patient as far as application of topical medications. On 4/13/21 at 2:39 PM, during an interview, Staff F, LPN/Home Health Aide, reported she put Triamcinolone and Ketoconazole on the patient on 4/7/21, but just lotion on 4/12/21. She explained the patient refused medicated creams on 4/12. She reported 4/7/21 was the first time she saw the patient and provided cares. She explained she was unaware the shower assist was on the same line in the documentation as the wound covering. The patient no longer had a wound to cover. She did assist the patient with a shower both times. On 4/13/21 at 2:54 PM, during an interview, Staff D, Home Health Aide, explained she used the hand held shower to wash the patient's hair and completed the rest of the patient's bath in the bed for the first 2 weeks due to the patient's back wound and external nerve stimulator. She reported the patient had an external sacral nerve stimulator until 3/9/21, and then after the surgery on 3/9, the nerve stimulator was internal, and the patient was able to shower and no longer required a wound covering. When assisting the patient with a bed bath or a shower, she reported she assisted the patient with washing the patient's hair, back, lower legs and feet. When asked if she washed the patient's buttocks area, she reported she likes to encourage patients to do what they can for themselves. She explained the patient wanted to be as independent as possible and the patient washed the patient's own chest, arms, groin and buttocks areas. When asked about the use of medicated creams, Staff D, Home Health Aide, reported at the beginning, nothing was said to her about applying the topical medications. She reported she started to do the medicated creams around the same time the patient switched over to just a shower after the second surgery on 3/9/21. She did not know for sure what the medications were for; the patient directed her. Staff D, Home Health Aide, reported she was just putting lotion on the patient at first, but then starting mixing the Triamcinolone with the regular lotion and then applied them together the last couple times. She explained she did not talk with Staff G, RN, about doing the medicated creams. Staff D, Home Health Aide, reported she did not do the Nystatin cream, the patient put this on his/her own groin. She reported she put the Ketoconazole on the patient's hand and helped direct the patient where to apply it to his/her head. She denied putting the Hydrocortisone on the patient. She reported putting Triamcinolone on the patient's back. On 4/14/21, beginning at 9:15 AM, during a home visit observation with Staff F, LPN/Home Health Aide, the surveyor reviewed the admission packet and paper work provided to the patient. The patient did not have copy of a Plan of Care or home health aide care plan/assignment. Staff F, LPN/Home Health Aide, assisted the patient with undressing, getting the shower, washing the patient's hair, right arm, back, legs and buttock area. The patient washed the patient's own groin, chest and left arm. Staff F, LPN/Home Health Aide, assisted the patient out of the shower, drying off and dressing. She applied Ketoconazole to the red areas on the patient's head, Triamcinolone to the patient's arms and legs per the patient's directions, Ciclopirox (an antifungal) to the toe nails on both feet. In an interview, during the same home visit observation, the patient reported putting the Nystatin cream to the groin area on independently, but required assistance with the other topical medications. The home health aides failed to follow the home health aide assignment. The home health aides applied topical medications on the patient without written or documented verbal direction from a RN. The home health aides failed to provide finger and toe nail care per the home health aide assignment and the home health aide providing home health aide services until 4/9/21 failed to adequately complete the task of assisting the patient with bathing/showering. 2. Patient #4 had a start of care date of 3/2/21. See G0798 The home health aides either documented they completed the assigned task of assisting the patient with a home exercise program and did not know what this task actually meant or they documented the patient refused when the patient reports they did not refuse. 3. Patient #6 had a start of care date of 2/13/13. See G0798 Staff F, LPN/Home Health Aide, worked as a home health aide. She applied Voltaren gel and completed wound care without clear written instructions from the RN and then also failed to document completing these interventions. 4. Patient #5 had a start of care date of 3/10/21. Review of the clinical record revealed the following: a. The Plan of Care, dated 3/10/21 to 5/8/21, included physician orders for home care aide visits once a week for one week and 2 times a week for 8 weeks. b. The week of 4/5/21 through 4/11/21, included a home care aide visit note, dated 4/6/21, and a missed home care aide visit note, dated 4/9/21, lacked documentation any tasks had been completed or a reason for the missed visit. c. On 4/14/21 at 10:50 AM, during an interview, the Clinical Manager, reported missed visit reasons can be viewed in the electronic medical record by clicking on the visit date and scrolling to the bottom of the page. All disciplines document a reason for a missed visit. The home care aide failed to document the reason for the missed home care aide visit. 5. Patient #8 had a start of care date of 12/6/18. Review of the clinical record revealed the following: a. The Plan of Care, dated 1/24/21 to 3/24/21, included primary diagnosis of hemiplegia following other nontraumatic internal hemorrhage affecting right dominant side (stroke with right sided weakness), other pertinent diagnosis of Type 2 diabetes mellitus without complications and medication order for Nystatin 100000 units/milliliter, sprinkle thin layer to affected areas topical 3 times a day as needed redness/yeast. b. The home health aide assignment entered in the electronic medical record, dated 7/27/2020, directed the following tasks: i. assist patient with home exercise program; ii. perform nail care of fingers; iii. skin care - wash under both breasts, pat dry, patient to apply Ketaconazole cream in a thin layer to areas of redness. c. The home health aide visit notes, dated 2/8, 2/10, 2/12, 2/17, 2/19, 2/22, 2/24, 2/26, 3/1, 3/3, 3/5, 3/8, 3/10, 3/12, 3/15, 3/17, 3/19, 3/22, 3/24, 3/26, 3/29, 3/31, 4/2, 4/5, 4/7, 4/9 and 4/12/21, included documentation the aide completed the task of skin care - wash under both breasts, pat dry, patient to apply Ketaconazole cream in a thin layer to areas of redness. The patient did not have Ketaconazole cream in the home, the patient was using Nystatin powder to the areas of redness. d. The home health aide visit notes, dated 2/8, 2/10, 2/17, 2/19, 2/22, 2/24, 2/26, 3/1, 3/3, 3/8, 3/10, 3/15 and 3/17/21, included documentation the aide completed the task of home exercise program. e. The home health aide visit notes, dated 3/24/21, included documentation the aide completed the task of nail care of fingers. f. On 4/14/21 at 11:40 AM, during an interview, Patient #8 reported the home health aides apply Nystatin under the breasts, cut finger nails, and apply Nystatin to abdominal fold area; the patient then reported the Nystatin to the abdominal fold is supposed to be applied by the patient not the aides. The in-home caregiver reported the patient had physical therapy in the past and there was a sheet of exercises left in the home for the patient to do, the caregiver and the patient believe this is the home exercise program. g. On 4/15/21 at 9:46 AM, during an interview, Staff I, RN, reported the patient was no longer using the Ketaconazole cream, this had been changed to Nystatin powder, Staff I must have forgotten to change on the aide assignment. Staff I reported the patient had physical therapy in the past and physical therapy had left a sheet of exercises for the patient to do, the home health aides are supposed to remind the patient to complete the exercises and nail care of fingers includes clipping, filing and cleaning nails, unless the patient is diabetic then the aides are not to clip the nails. Staff I reported the patient is aware that the aides are not to apply Nystatin to the abdominal fold area, the patient is responsible for this task. h. On 4/14/21 at 12:25 PM, during an interview, Staff D, Home Health Aide, reported she has applied the powder under the patient's breasts in the past but is not currently doing this, she has applied powder under abdominal fold, she cuts the patient's finger nails, and walks with the patient outside during nice weather is the home exercise program. i. On 4/14/21 at 2:15 PM, during an interview, Staff C, Home Care Aide, reported she does not do anything with the home exercise program. j. On 4/15/21 at 10:07 AM, during an interview, the Clinical Manager reported the home exercise program means the aides are to remind the patient to complete exercises left in the home by therapy; and nail care can include cutting, filing and cleaning nails unless the patient is diabetic then the aides are not to clip the nails. The Clinical Manager agreed the aides should not be cutting the patient's nails due to the diagnosis of diabetes. Home Care Aides documented completion of tasks that were not done or completed tasks that were not to be completed. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on clinical record review, agency complaint log review and staff interview, the agency failed to ensure home health aides reported patient concerns to a registered nurse for 2 of 9 sampled patients receiving home health aide services (Patients #2 and #6). The agency reported 50 out of 55 patients received home health aide services at the time of the survey. Failure to ensure that home health aides reported condition changes to a registered nurse (RN) increased the risk of agency staff not meeting the personal care needs of the patients. Findings include: Patient #2 had a start of care date of 2/25/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/25/21 to 4/25/21, identified the patient had diagnoses of dementia, incontinent of bowel and bladder and chronic pain and included physician orders for home health aide services 2 times per week. The POC included the following home health aide interventions: assist with dressing or undressing, assist with shampoo, assist with shower and to cover the wound on the patient's lower back, assist with transfers in and out of the shower, perform bed bath, perform nail care of fingers and toes, perform skin care (apply over-the-counter skin moisturizer to dry areas per patient's direction), report falls, injuries or skin breakdown. he POC included orders for the following topical medications: Hydrocortisone 2.5 percent cream, apply topically twice per day; Ketoconazole 2 percent cream, apply topically 2 times per day; Nystatin 100,000 units/gram cream, apply once daily; and, Triamcinolone Acetonide 0.1 percent, apply once per day. b. An interim physician order, dated 3/18/21, included a verbal physician order to increase home health aide services to 3 times per week starting on 3/22/21. c. The home health aide visit notes, dated 3/2, 3/5, 3/8, 3/12, 3/16, 3/21, 3/22, 3/29, 3/31, 4/2, 4/6 and 4/9/21, included documentation Staff D, Home Health Aide, provided home health aide services to the patient. She documented she applied over-the-counter lotion to the skin every visit, and never documented if or when she applied any of the topical medications. For the visits, dated 3/2, 3/5 and 3/8/21, she documented she assisted the patient with a bed bath. For the visits, dated 3/12, 3/16, 3/21, 3/22, 3/29, 3/31, 4/2, 4/6 and 4/9/21, Staff D, Home Health Aide, documented she assisted the patient in and out of the shower, but did not assist the patient with showering and covering the wound on the patient's lower back due to the patient refusing or it not being applicable. On 4/13/21 at 2:26 PM, during an interview, Staff G, RN, reported she was unaware when Staff D, Home Health Aide, started to apply medicated creams to the patient and was unaware this was a problem prior to 4/5/21. She reported being unaware of when the lower back wound no longer needed to be covered. On 4/13/21 at 2:54 PM, during an interview, Staff D, Home Health Aide, explained at the beginning, nothing was said to her about applying the topical medications. She reported she started to do the medicated creams around the same time the patient switched over to just a shower after the second surgery on 3/9/21 based on the patient's request. She did not know for sure what the medications were for; the patient directs her. Staff D, Home Health Aide, reported she was just putting lotion on the patient at first, but then starting mixing the Triamcinolone with the regular lotion and then applied them together the last couple times. She explained she did not talk with Staff G, RN, about doing the medicated creams. Staff D, Home Health Aide, reported she did not do the Nystatin cream, the patient put this on the patient's own groin. She reported she put the Ketoconazole on the patient's hand and helps direct the patient where to apply it to the patient's head. She denied putting the Hydrocortisone on the patient. She reported putting Triamcinolone on the patient's back. She explained she used the hand held shower to wash the patient's hair and completed the rest of the patient's bath in the bed for the first 2 weeks due to the patient's back wound and external nerve stimulator. She reported the patient had an external sacral nerve stimulator until 3/9/21, and then after the surgery on 3/9, the nerve stimulator was internal, and the patient was able to shower and no longer required a wound covering. Staff D, Home Health Aide, reported the nurse is one that told her she no longer needed to cover the lower back. On 4/13/21 at 2:39 PM, during an interview, Staff F, LPN/Home Health Aide, reported 4/7/21 was the first time she saw the patient and provided cares. She explained the patient no longer had a wound to cover. She did assist the patient with a shower both times. Staff F, LPN/Home Health Aide, reported she needed to talk with Staff G, RN, about taking the wound covering for the lower back of the home health aide assignment. Staff D, Home Health Aide, failed to notify the RN of the patient's need for assistance in applying topical medications and no longer needing to cover a lower back wound with the shower. Staff F, LPN/Home Health Aide, also did not report the patient's condition change of no longer needing a wound cover over the lower back. 2. Patient #6 had a start of care date of 2/13/13. Review of the clinical record revealed the following: a. The POC, dated 2/20/2021 to 4/20/2021, included orders for skilled nursing one time per week and home health aide services 3 times per week. The POC included orders for the following home health aide interventions: assist with dressing and undressing, assist with shampoo, assist with shower, assist with transfer in and out of shower, perform bed bath per patient direction, perform catheter care, perform nail care (file only), perform skin care (over-the-counter skin moisturizer to dry areas per patient direction), report falls or injury to RN and report skin breakdown to the RN. The POC included orders for Voltaren topical 1 percent apply three times per day as needed to the lower legs and Lidocaine topical 4 percent apply 4 times a day as needed to open wounds. b. The home health aide visit notes, dated 3/8, 3/10, 3/15, 3/17, 3/19, 3/22, 3/24, 3/26, 3/29, 3/31, 4/1, 4/5, 4/7 and 4/12/21, included documentation Staff F, LPN/Home Health Aide, provided home health aide services. She did not document applying any topical medications. On 4/13/21 at 2:16 PM, during an interview, Staff G, RN, reported Staff F, LPN/Home Health Aide, was applying Voltaren topical medicated gel to lower legs and Lidocaine topical cream. On 4/13/21 at 2:36 PM, during an interview, Staff F, LPN/Home Health Aide, reported she has been applying the Voltaren gel on the patient, but not any other topical medications. Staff F, LPN/Home Health Aide, failed to notify the RN she was no longer applying topical Lidocaine on the patient. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.