Every finding on record at Western Health Resources

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey from 6/4/2024 to 6/8/2024. Intake No.#107315 Representing the Department of Public Health: Surveyor ID # 43979 -RN - HFEN Surveyor ID # 43929 -RN - HFEN Surveyor ID # 49473 -RN - HFEN Census: 82 Sample Size: 10 Home Visits: 3 Closed Record review: 2 On 6/7/2024 at 5:05 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the agency’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s Administrator (ADM), Acting Director of Patient Care Services (DPCS), Clinical Managers, RN Clinical Managers, Director of HR, Director of Finance, RN nurse educator, and Clinical Informaticist, for the agency’s failure to follow and implement the plan of care and notify physician for the patients’ current health status for Patient 7, Patient 8, and Patient 9 by failing to; Follow and implement the plan of care and notify the physician for the patients’ current health status for three of ten sampled patients (Patient 7, Patient 8, and Patient 9) by failing to: 1. Ensure to assess Patient 7 for changes in condition (COC, a sudden clinically important deviation from a patient's baseline in physical, behavioral, or functional domains) related to Patient 7’s diagnoses of congestive heart failure (CHF, the heart cannot pump enough blood, a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). On 5/25/2024, Patient 7 experienced shortness of breath with ambulation (walking), had minimal verbal answers, and edema (swelling) to both legs. Registered Nurse 4 did not notify Medical Doctor 1 (MD1) of Patient 7’s COC and did not assess Patient 7’s oxygen saturation (the amount of oxygen that's circulating in your blood). On 5/27/2024, Patient 7 reported to RN 2 feeling tired. Patient 7 had a change in blood pressure readings from 102/68 on 5/25/2024, to 92/60 on 5/27/2024. RN 2 did not notify MD1 of Patient 7’s COC. On 5/31/2024, Patient 7’s blood pressure readings were 82/58, 82/62, and 89/70 (low). RN3 left a message to MD1’s office and did not follow up the same day. 2. Ensure Patient 7 received daily Skilled Nurse (SN) visits. The HHA did not conduct a SN a nurse visit on 5/26/2024, as indicated in the physician’s orders. 3. Notify Patient 8’s physician of his low blood pressure reading. On 4/4/2024, the Physical Therapist (PT) noted Patient 8’s blood pressure of 83/67, 84/65, 86/61 (low). 4. Ensure to assess and monitoring Patient 9’s blood sugar readings and ensure Patient 9’s glucometer (an instrument for measuring the concentration of sugar in the blood) was functional. (Refer to G572). On 6/5/2024, during a home visit Patient 9 reported to RN3 his glucometer was not working for the past 10 days. RN3 did not notify Patient 9’s physician that Patient 9 was not monitoring his blood sugar for the past 10 days. These deficient practices resulted in Patient 7 being hospitalized twice (5/28/2024 and 6/3/2024) and the physician was not aware of Patient 7 not receiving services as indicated in the plan of care. Patient 8 had the potential to experience undetected serious complications of low blood pressure that included, dizziness, fainting, unsteadiness, and fall, that could lead to hospitalization. Patient 9 had the potential to experience undetected serious complications due to hyperglycemia (high blood sugar level) that included eye problems, kidney damage, nerve damage, and/or hypoglycemia (low blood sugar level) that included blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness. During the complaint validation survey on 6/8/2024, the agency submitted the IJ removal plan at 12:01 p.m. and 1:28 p.m., the survey team reviewed and informed the agency was not acceptable. The agency re-submitted a revised IJ removal plan at 4:34 p.m., the team reviewed and informed the agency was not acceptable. The team completed the survey tasks and conducted an exit conference at 5:37 p.m. on 6/8/2024, in the presence of administrative director of operations/administrator, post-acute care executive, two clinical managers, and RN Nurse Educator, and the IJ was not removed. The HHA submitted an IJ removal plan, and the IJ removal plan was reviewed and accepted on 6/24/2024 as follows: CORRECTIVE ACTIONS Patient 7: It was identified that a complete assessment was not conducted on S/25/24and 5/27 /24and abnormal findings were not communicated to the physician. On 06/07 /24, the Clinical Educator completed a comprehensive chart audit on patient 7 to identify opportunities for education and necessary care planning follow-up. It was identified that the clinicians failed to follow the established policies and procedures. On 06/08/24, the identified clinicians and clinical managers were provided 1:1 counseling with Post Acute Care Executive and Director of Quality, Risk, and Education regarding these findings; includes documentation of parameters specific to congestive heart failure ,diabetes, and wounds at every visit; reporting all results outside of ordered parameters and any relevant changes in patient condition to the physician; documenting the communication and obtaining new orders, as needed; and completing appropriate follow-up to ensure complete delivery of care provided. This counseling included a comprehensive chart review and discussion of opportunities for improvement in care, documentation, and follow up. Patient 7 is currently acutely hospitalized. Patient 8: It was identified that on 4/4/24, the clinician did not notify the physician of abnormal findings. Patient 8 was discharged on 04/04/24. On 06/08/24, the Clinical Educator completed a comprehensive chart audit on patients to identify opportunities for education. It was identified that the clinician failed to follow the established policies and procedures. On 06/08/24, the identified clinician was provided 1:1 counseling with agency administrator regarding these findings; reporting all results outside of ordered parameters and any relevant changes in patient condition to the physician; documenting the communication and obtaining new orders, as needed; and completing appropriate follow-up to ensure complete delivery of care provided. Patient 9: It was identified that the patient's blood glucose was not being monitored in multiple visits, nor did the clinicians ensure that the patient's glucometer was working. On 06/05/24, the physician was notified that the patient did not have a working glucometer. On 06/07/24, a comprehensive chart review was completed by the Clinical Educator to identify opportunities for education and necessary care planning follow-up. It was identified that the clinic·1ans failed to follow the established policies and procedures. On 06/08/24, the clinical manager team obtained a working glucometer for this patient. On 06/08/24, an additional visit was added to provide follow-up. On 06/08/24, prior to the visit, the clinician performing the visit and clinical managers were provided 1:1 counseling with Post Acute Care Executive and Director of Quality, Risk and Education regarding these findings; documentation of parameters specific to congestive heart failure, diabetes, and wounds at every visit; reporting all results outside of ordered parameters and any relevant changes in patient condition to the physician; documenting the communication and obtaining new orders, as needed; and completing appropriate follow-up to ensure complete delivery of care provided. The 06/08/24visitwas a supervisory visit completed by the clinical manager. The working glucometer along with education on the use of the glucometer, frequency of blood sugar testing, blood sugar parameters, and when to report blood sugar outside of parameters was provide to the patient at this visit. Blood sugar reading was obtained and documented during visit. DESCRIPTION OF HOW OTI-IER PATIENTS POTENTIALLY AFFECTED WERE IDENTIFIED AND IMMEDIATE MEASURES AND SYSTEMATIC CHANGES PERFORMED On 06/08/2024, education and counselling were provided by corporate and agency leadership teams to 100% of clinicians seeing patients on 06/08/24and 06/09/24. This education/counseling consisted of a review of survey findings and comprehensive chart audits; documentation of parameters specific to congestive heart failure, and diabetes at every visit; reporting all results outside of ordered parameter5 and any relevant changes in patient condition to the physician. This education was provided again to all clinicians working on06/10/24 by the agency leadership team and subsequent 1:1 education was provided by agency leadership to any clinicians that were out of the office06/08-06/10 /24 upon beginning of their shift. Education was provided to 100% of staff by 06/12/24. On 06/08/24, Corporate leadership team provided education to the agency leadership team on the supervisory visit process. On 06/ 08/24, two additional focused supervisory visits were completed by corporate and agency leadership team to ensure appropriate care planning, plan of care is followed, appropriate assessment and documentation is completed, identification of any changes in patient condition, and appropriate communication with the physician is completed. MONITORING PROCESS On 06/08/24, corporate leadership team provided agency leadership education and mentoring on implementation of the pla11 of correction; appropriate workflow monitoring and processing; and effective follow up of clinical findings. Daily meetings were implemented by corporate leadership, beginning 06/07/24, for a period of 1 week to monitor and assess the effectiveness of the current plan and provide ongoing mentoring to the agency leadership. These meetings between corporate leadership and agency leadership will be completed twice a week for the second week, 1 time per week for 1 month, and then 1 time per month for an additional 2 months. Focused supervisory visits with 100%of clinicians will be completed by corporate or agency leadership team by 06/21/24 to ensure appropriate care planning, plan of care is followed, appropriate assessment and documentation Is completed, identification of any changes in patient condition, and appropriate communication with the physician is completed. On 6/25/2024 the survey team conducted an onsite visit for the verification of the written IJ removal plan implementation. The IJ was removed on 6/25/2024 at 2:23 p.m., in the presence of the Administrator, RN Clinical Manager, PT clinical manager, Post Acute Executive for Home care services, Quality Assurance Team, Post Acute Director Hospice Services, Director of finance, Clinical Educator, Informatics, EMR Analyst, Project Coordinator, and Director of Risk Management. The following Condition of Participation was not met. 484.60 Care planning, coordination of services, and quality of care.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to review and document all the medications and treatments the patients were currently taking for three of ten sampled patients (Patient 2, Patient 5, and Patient 9). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking that could place the patients at risk for medication errors and adverse drug reactions. 1. During a review of Patient 2’s “Patient Information Report” indicated effective date of 5/2/2024, with a primary diagnosis of pressure ulcer of sacral region stage (damage to tailbone skin due to constant pressure). During a review of Patient 2’s medical record form titled “Order Number: 628201” dated 5/27/2024, indicated “Right and left heel eschar may apply betadine and cover w foam dressing. Change 2x week…” During a review of Patient 2’s medical record form titled “Medication List” printed on 6/4/2024, indicated “Providone-iodine 10% topical solution daily wound care right and left heel wound care”. Patient 2’s “Medication List” did not indicate Patient 2 was using Lidocaine ointment and pain-relieving cream. During a joint home visit observation and interview on 6/5/2024 at 11:20 a.m., with Registered Nurse 1 (RN1) at Patient 2’s home, RN1 stated she was not aware Patient 2 was using Lidocaine or pain-relieving creams. RN1 stated all the patients’ medications should be listed on their medication list to ensure everyone be aware of what the patient uses. RN1 stated Patient 2’s medication/treatment list should have been updated to reflect bilateral heel wound dressings were being changed twice a week and not daily as noted on the medication list. During an interview on 6/5/2024 at 1 p.m. with RN1, RN1 stated medication changes occur all the time. RN1 stated she reconciled patients’ medications at every visit to prevent hospitalization. 2. A review of Patient 5’s record titled, “Home Health Certification and Plan of Care”, for certification period 5/6/2024 to 7/4/2024, indicated a start of care date on 3/7/2024, with diagnoses including orthopedic after care following surgical amputation (removal of a body part). During a concurrent observation and interview of the medication review on 6/5/2024, at 10:47 a.m., Registered Nurse 2 (RN 2) asked Patient 5 about the medications being taken using record titled, “Medicine List”, printed on 6/4/2024. RN 2 asked about each of the medications listed. There were no medicine bottles observed during the review. The following interviews did not align with what was documented on the record: Iron (a supplement). Patient 5 stated the doctor had changed the frequency of the medication to once daily at bedtime, 2 days ago. The record indicated to take the medication 2 times daily. Levalbuterol (to help with breathing problems). Patient 5 stated the doctor had discontinued the medication 3 days ago. A record review of Patient 5’s record titled “Home Health Certification and Plan of Care”, for certification period 5/6/2024 to 7/4/2024, indicated the nurse was to visit the patient daily for 5 weeks. 3. During a review of Patient 9’s medical record form titled “Patient Information Report” indicated effective date of 5/9/2024, with a primary diagnosis of anoxic brain damage (brain damage caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation). During a concurrent observation, interview, and record review, at the home visit with Registered Nurse 3, (RN 3) on 6/5/2024 at 10:00 a.m., Patient 9 consented to visit. RN 3 conducted a medication reconciliation of Patient 9’s medications at 11:00 a.m. using the medical record titled “Medicine List” printed on 6/4/2024. The following was observed: Tylenol (to treat pain; also known as Acetaminophen) 500 mg caplet (coated oral tablet). The medicine list indicated Acetaminophen 325 mg 2 tablets as needed, every 4 hours for mild pain. Patient 9 stated he started taking the medication about 2 months ago and takes it every 6 to 8 hours as needed. Linzess (to treat long term constipation) 145 mcg (microgram – unit dose) capsule. The bottle label indicated 1 capsule daily in the morning 30 min (minutes) before breakfast. The medicine list indicated Linzess 145 mcg 1 capsule oral daily for chronic (long term) constipation. Patient 9 stated he takes it every 2 days, if he had a bowel movement the previous day, he takes it the next day. RN 3 was observed altering medication label on the bottle with a pen, crossed out “daily” and wrote “every 2 days”. Omeprazole (to treat excess stomach acid) 40 mg capsule delayed release-oral 1 capsule daily was listed in the medicine list but not at home. Patient 9 stated he stopped taking the medication for about one month as instructed by his primary doctor. RN 3 stated that medication reconciliation is done every visit. If there are changes, the doctor must be notified to obtain new orders. New orders are entered to the EMR (electronic medical record) for review and approval. Once updated, the medicine list will be reprinted and brought to next patient’s visit. During an interview on 6/5/2024, at 3:09 p.m., the Director of Patient Care Services (DPCS) stated medication reconciliation should be done every visit. The process is as follows: First ask the patient to gather all their medicine bottles, to visually see them. I want to match their labels and our orders to make sure they are correct, accurate. Go over the medications with the patient/family. To make sure they understand how to take the medications. Go over the allergies, safety of the medication. The DPCS stated the record “Medicine List” is used to make sure patient’s bottles match the records the HHA has, to update the list, and provide a copy to the patient with the most updated list with the changes. The DPCS stated medication reconciliation was important for patient safety to make sure they are taking the correct medications. Make sure medications are correct to prevent re-hospitalization. During an interview on 6/7/2024 at 11:07 a.m., the Registered Nurse Educator (RNE) stated nurses cannot alter the medication list and medication bottle label. The doctor should be notified first for clarification of orders then update medication list if there’s any changes. The updated medication list is given to patient on next visit. If orders are not clarified and the nurse alters the medication label and medication list, this can lead to incorrect administration of medication. During a review of facility’s policy and procedure titled “Medication Administration & Reconciliation” revised 12/16/2021, indicated “The clinician, with patient involvement, will obtain and document a complete list of the patients’ current medications upon the patient’s admission to the Agency. Medication reconciliation will be conducted at each skilled visit.”

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation (COP, refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding Care Planning, Coordination, Quality of Care was met as follows: The HHA failed to follow and implement the plan of care and notify the physician for the patients’ current health status for three of ten sampled patients (Patient 7, Patient 8, and Patient 9) by failing to: 1. Ensure to assess Patient 7 for changes in condition (COC, a sudden clinically important deviation from a patient's baseline in physical, behavioral, or functional domains) related to Patient 7’s diagnoses of congestive heart failure (CHF, the heart cannot pump enough blood, a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). (Refer to G572). On 5/25/2024, Patient 7 experienced shortness of breath with ambulation (walking), had minimal verbal answers, and edema (swelling) to both legs. Registered Nurse 4 did not notify Medical Doctor 1 (MD1) of Patient 7’s COC and did not assess Patient 7’s oxygen saturation (the amount of oxygen that's circulating in your blood). On 5/27/2024, Patient 7 reported to RN 2 feeling tired. Patient 7 had a change in blood pressure readings from 102/68 on 5/25/2024, to 92/60 on 5/27/2024. RN 2 did not notify MD1 of Patient 7’s COC. On 5/31/2024, Patient 7’s blood pressure readings were 82/58, 82/62, and 89/70 (low). RN3 left a message to MD1’s office and did not follow up the same day. 2. Ensure Patient 7 received daily Skilled Nurse (SN) visits. (Refer to G572). The HHA did not conduct a SN a nurse visit on 5/26/2024, as indicated in the physician’s orders. 3. Notify Patient 8’s physician of his low blood pressure reading. (Refer to G572). On 4/4/2024, the Physical Therapist (PT) noted Patient 8’s blood pressure of 83/67, 84/65, 86/61 (low). 4. Ensure to assess and monitoring Patient 9’s blood sugar readings and ensure Patient 9’s glucometer (an instrument for measuring the concentration of sugar in the blood) was functional. (Refer to G572). On 6/5/2024, during a home visit Patient 9 reported to RN3 his glucometer was not working for the past 10 days. RN 3 did not notify Patient 9’s physician that Patient 9 was not monitoring his blood sugar for the past 10 days. These deficient practices resulted in Patient 7 being hospitalized twice (5/28/2024 and 6/3/2024) and the physician was not aware of Patient 7 not receiving services as indicated in the plan of care. Patient 8 had the potential to experience undetected serious complications of low blood pressure that included, dizziness, fainting, unsteadiness, and fall, that could lead to hospitalization. Patient 9 had the potential to experience undetected serious complications due to hyperglycemia (high blood sugar level) that included eye problems, kidney damage, nerve damage, and/or hypoglycemia (low blood sugar level) that included blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness. The cumulative effect of these systemic practices resulted in failure of the HHA to deliver statutorily (written law) mandated compliance with the Federal (government) Regulations for Care Planning, Coordination of Services, and Quality of Care, to ensure the provision of health care services in a safe manner.

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 observation, interview, and record review the Home Health Agency (HHA) failed to follow and implement the plan of care and notify the physicians for the patients’ current health status for three of ten sampled patients (Patient 7, Patient 8, and Patient 9) by failing to: 1. Ensure to assess Patient 7 for changes in condition (COC, a sudden clinically important deviation from a patient's baseline in physical, behavioral, or functional domains) related to Patient 7’s diagnoses of congestive heart failure (CHF, the heart cannot pump enough blood, a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). On 5/25/2024, Patient 7 experienced shortness of breath with ambulation (walking), had minimal verbal answers, and edema (swelling) to both legs. Registered Nurse 4 did not notify Medical Doctor 1 (MD1) of Patient 7’s COC and did not assess Patient 7’s oxygen saturation (the amount of oxygen that's circulating in your blood). On 5/27/2024, Patient 7 reported to RN 2 feeling tired. Patient 7 had a change in blood pressure readings from 102/68 on 5/25/2024, to 92/60 on 5/27/2024. RN 2 did not notify MD1 of Patient 7’s COC. On 5/31/2024, Patient 7’s blood pressure readings were 82/58, 82/62, and 89/70 (low). RN3 left a message to MD1’s office and did not follow up the same day. 2. Ensure Patient 7 received daily Skilled Nurse (SN) visits. The HHA did not conduct a SN a nurse visit on 5/26/2024, as indicated in the physician’s orders. 3. Notify Patient 8’s physician of his low blood pressure reading. On 4/4/2024, the Physical Therapist (PT) noted Patient 8’s blood pressure of 83/67, 84/65, 86/61 (low). 4. Ensure to assess and monitoring Patient 9’s blood sugar readings and ensure Patient 9’s glucometer (an instrument for measuring the concentration of sugar in the blood) was functional. On 6/5/2024, during a home visit Patient 9 reported to RN3 his glucometer was not working for the past 10 days. RN did not notify Patient 9’s physician that Patient 9 was not monitoring his blood sugar for the past 10 days. These deficient practices resulted in Patient 7 being hospitalized twice (5/28/2024 and 6/3/2024) and the physician was not aware of Patient 7 not receiving services as indicated in the plan of care. Patient 8 had the potential to experience undetected serious complications of low blood pressure that included, dizziness, fainting, unsteadiness, and fall, that could lead to hospitalization. Patient 9 had the potential to experience undetected serious complications due to hyperglycemia (high blood sugar level) that included eye problems, kidney damage, nerve damage, and/or hypoglycemia (low blood sugar level) that included blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness. On 6/7/2024 at 5:05 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the HHA’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s Administrator (ADM), Acting Director of Patient Care Services (DPCS), Clinical Managers, RN Clinical Managers, Director of HR, Director of Finance, RN nurse educator, and Clinical Informaticist, for the agency’s failure to follow and implement the plan of care and notify physician for the patients’ current health status for Patient 7, Patient 8, and Patient 9. During the complaint validation survey on 6/8/2024, the agency submitted the IJ removal plan at 12:01 p.m. and 1:28 p.m., the survey team reviewed and informed the agency was not acceptable. The agency re-submitted a revised IJ removal plan at 4:34 p.m., the team reviewed and informed the agency was not acceptable. The team completed the survey tasks and conducted an exit conference at 5:37 p.m. on 6/8/2024, in the presence of administrative director of operations/administrator, post-acute care executive, two clinical managers, and RN Nurse Educator, and the IJ was not removed. Findings: a. During a review of Patient 7’s Home Health Certification and Plan of Care, for certification period 5/9/2024 to 7/7/2024, the Home Health Certification and Plan of Care indicated a start of care date on 3/10/2024, with diagnoses including hypertensive heart disease with heart failure (a condition in which the heart does not work well) the Home Health Certification and Plan of Care indicated the SN (skilled nurse) was to “evaluate…and to assess comorbidities (illnesses that contribute to health status decline and/or death) including CHF….Venous insufficiency (vein legs are damaged, causing swelling and skin changes) and other conditions that arise during this episode to identify changes and intervene to minimize complications…May perform O2 (oxygen) saturation levels (measure how much oxygen is in the body) levels prn (as needed) for signs and/or symptoms of complications.” During a review of Patient 7’s record of the General Acute Care Hospital (GACH), dated 5/27/2024, the GACH record indicated Patient 7 was admitted to the hospital on 5/27/2024 with lower extremity edema, cellulitis (bacterial skin infection), and renal (kidney) failure. During a record review of Patient 7’s record titled “Order Number: 630533,” dated 5/31/2024, the “Order Number: 630533,” indicated, “Skilled nurse to observe and assess cardiovascular system to identify changes and intervene to minimize complications.” During a record review of Patient 7’s GACH document titled, “ED Physician Notes,” dated 6/3/2024, the ED Physician Notes indicated the GACH admitted Patient 7 with diagnoses of Odynophagia (painful swallowing), CHF, and Peripheral Edema (swelling of arms and legs). During a concurrent interview and record review, on 6/7/2024, at 1:16 p.m., with Registered Nurse Educator (RNE), Patient 7’s Visit Note Report, dated on 5/25/2024 was reviewed. The RNE stated the Visit Note Report indicated Patient 7’s edema in the lower extremities (legs) was increasing and was weeping (fluid coming out of the skin). RNE stated the Visit Note Report indicated Patient 7 had 4+ edema (swelling in part of the body, the pressure leaves a dent of 8-millimeter [mm, a unit of measurement] or deeper) on the lower right leg and 3+ edema (putting pressure on the skin leaves a 5-6 mm of indentation). The RNE stated Patient 7 was also experiencing shortness of breath while walking and had minimal verbal answers. The RNE stated the O2 saturation level was not assessed by RN4 due to Patient 7’s finger being cold. RNE stated the Visit Note Report indicated, “Unable to get reading due to finger being very cold.” The RNE stated based on Patient 7’s report of feeling short of breath upon walking, and the clinical situation, obtaining an oxygen saturation assessment was needed, for the purpose of a comprehensive assessment for CHF. The RNE stated an O2 reading would show the perfusion (the flow of fluid or blood to cells and tissues), the output of the heart providing oxygen to all the appropriate organs in the body. The RNE stated there was no additional assessments done to assess perfusion for Patient 7. During a concurrent interview and record review, on 6/7/2024, at 1:16 p.m., with the RNE reviewed Patient 7’s record titled “Order Number: 627547,” dated 5/24/2024 was reviewed. The RNE stated Patient 7’s record titled “Order Number: 627547,” indicated MD 1 had ordered daily visits for four days. The RNE stated patient 7 was supposed to have a visit on 5/26/2024. The RNE stated there was no documented evidence patient was seen this day. The RNE stated the HHA did not notify MD1 that Patient 7 was not seen. The RNE stated the HHA needed to notify MD1. During a concurrent interview and record review, on 6/7/2024, at 1:16 p.m., the RNE reviewed Patient 7’s record titled, “Visit Note Report” dated on 5/25/2024. The RNE stated Patient 7’s edema was increasing and weeping, Patient 7 was experiencing shortness of breath while walking, fingers were cold, and an oxygen saturation assessment was not done. During a concurrent interview and record review, on 6/7/2024, at 2:09 p.m., with the RNE, Patient 7’s Visit Note Report, dated 5/27/2024, was reviewed. The RNE stated there was no comprehensive cardiac (heart) assessment. The RNE stated the expectation was to assess heart sounds, whether there was shortness of breath with activity, evaluating the pulses to see if there was perfusion, evaluate the color of the skin, since cardiac perfusion was an issue for Patient 7. The RNE stated Patient 7’s blood pressure (BP) was 92/60 and even though the reading was not out of parameters, this was a change for Patient 7. The RNE stated on the previous visit of 5/25/2024, Patient 7’s blood pressure (BP) was 102/68. The RNE stated the Visit Note Report indicated Patient 7 was feeling tired. The RNE stated the respiratory assessment was not comprehensive either. The RNE stated respiratory system assessment was also part of the cardiac assessment. The RNE stated Patient 7 had a COC and warranted a notification to the MD1. The RNE stated RN3 did not notify MD1 of Patient 7’s COC. During a concurrent interview and record review, on 6/7/2024, at 2:09 p.m., with the RNE, Patient 7’s reviewed Patient 7’s record titled, “Visit Note Report”, dated on 5/27/2024. The RNE stated the record indicated Patient 7’s BP to be 92/60. The previous BP reading on 5/25/2024 was 102/68. During an interview on 6/7/2024, at 2:16 p.m., the RNE stated Patient 7 was hospitalized on 5/28/2024. The RNE stated the hospitalization could have been prevented. The RNE stated the HHA wrote an order to see Patient 7 daily. The RNE stated interventions included to notify MD1 about the status of Patient 7’s COC on 5/25/2024. During a concurrent interview and record review, on 6/7/2024, at 2:20 p.m., with the RNE, Patient 7’s record titled, “Visit Note Report”, dated on 5/31/2024 was reviewed. The RNE stated the Visit Note report indicated Patient 7’s blood pressure readings were 82/58, 82/62, and 89/70. The RNE stated Patient 7 was hypotensive (decreased blood pressure below parameters) and was having symptoms of heart compromise (heart problem). The RNE stated the Visit Note Report indicated the nurse (RN2) left a message to MD1 on 5/31/2024. The RNE stated there was no documentation of confirmation MD1 received the message. The RNE stated the nurse (RN) needed to follow up with MD1 on the day of the visit 5/31/2024 and needed to speak to MD1 verbally to avoid hospitalization. The RNE stated Patient 7 was hospitalized on 6/3/2024. During an interview on 6/7/2024, at 3:33 p.m., with MD 1, MD1 stated he needed to be notified of Patient 7’s COC on 5/25/2024 and on 5/27/2024. MD 1 stated Patient 7 probably was not getting enough oxygen in the body. MD 1 stated the HHA did not notify him that Patient 7 was not seen on 5/26/2024. MD 1 stated it was important for Patient 7 to have daily home visits because of his progressive edema and heart failure. MD1 stated Patient 7 needed to go to the hospital for further evaluation. MD 1 stated he did not recall if he spoke to the nurses directly. MD 1 stated Patient 7’s was currently still hospitalized. MD1 stated Patient 7 had a large pericardial effusion (buildup of extra fluid in the space around the heart) and had to have a pericardiocentesis (removal of the excess fluid in the space around the heart). MD 1 stated Patient 7 currently had a drainage catheter (a tube inserted into the body to drain fluid). b. During a review of Patient 8’s Patient Information Report indicated a start of care on 3/9/2024, with a primary diagnosis of encephalopathy (brain function affected). During a review of Patient 8’s Home Health Certification and Plan of Care, dated from 3/9/2024 to 5/7/2024, the Home Health Certification and Plan of Care indicated “Skilled nurse to evaluate and address underlying issues to reduce risk of hospitalization and emergent care… Physical Therapist to evaluate and address underlying issues to reduce risk of hospitalization and emergent care visits… Physical Therapist to observe and assess cardiovascular system to identify changes and intervene to minimize complications. License professionals to report vital signs falling outside the following established parameters: systolic BP 180; diastolic BP 100… Goals/Rehabilitation/Discharge Plans: Cardiovascular exacerbations will be identified promptly, and interventions initiated to minimize risks.” During a concurrent interview and record review, on 6/6/2024, at 12:35 p.m., with the Administrator (ADM), the ADM reviewed Patient 8’s medical record form titled, “Visit Note Report” dated 4/2/2024. The ADM stated the Visit Note Report record indicated under “Therapy Assessment /Plan,” Patient 8’s blood pressure readings were 83/67, 84/65 and 86/61. The ADM stated the physical therapists (in general) were expected to notify the doctor during the same day of the visit for patient change of condition such as low blood pressure readings. The ADM stated there was no documented evidence the PT notified the doctor of Patient 8’s low blood pressure readings. The ADM stated that it could potentially lead to adverse events that be addressed such as hospitalization. c. During a review of Patient 9’s Patient Information Report, indicated a start of care on 5/9/2024, with a primary diagnosis of anoxic brain damage (brain damage caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation). During a concurrent joint home visit observation and interview, on 6/5/2024 at 10 a.m., with RN 3, and with Patient 9, at Patient 9’s home, RN3 was observed checking Patient 9’s vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). RN 3 asked Patient 9 for his most recent blood sugar levels. Patient 9 stated he did not check his blood sugar, the “machine,” to check his blood sugar was not working for the past ten days. RN 3 stated usually the nurses (in general) would only check the blood sugar level for Patient 9 during the start of care and not every visit unless the plan of care specifically indicated the nurse should perform the blood sugar test. During a concurrent interview and record review, on 6/7/2024, at 2:45 p.m., with the RNE, Patient 9’s medical record “Visit Note Report” dated 5/26/2024 and 5/31/2024 was reviewed. The RNE stated the Visit Note Report indicated under “Assessment…Endocrine/Hematopoietic (the glands and organs that make hormones and release them directly into the blood) …Does the patient measure blood sugar using a home glucometer? No.” During a concurrent interview and record review, 6/7/2024, at 2:45 p.m., with the RNE, Patient 9’s Visit Note Report, dated 6/3/2024, the RNE stated the Visit Note Report indicated under “Assessment…Endocrine/Hematopoietic…was endocrine/hematopoietic assessed? No.” The RNE stated the nurses (in general) needed to notify the physician Patient 9’s home glucometer was not working during the same day of the visit. The RNE stated there was no evidence of documentation that the doctor was notified of Patient 9’s nonfunctioning home glucometer and no blood sugar test. The RNE stated Patient 9 could have hypo/hyperglycemic (low and high blood sugar) episodes without knowing it. During a concurrent interview and record on 6/7/2024, at 3 p.m., with the RNE, Patient 9’s medical record form titled “Home Health Certification and Plan of Care” dated from 5/9/2024 to 7/7/2024, was reviewed. The RNE stated Home Health Certification and Plan of Care indicated “Skilled nurse to evaluate and develop plan of care to be signed by physician and to assess co-morbidities including…Diabetes Mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels)… Skilled nurse to address underlying issues to reduce risk of hospitalization and emergent care… Skilled nurse for instructions/reinforcement of diabetic care to include symptoms of hypo/hyperglycemia….Skilled Nurse will educate blood glucose testing, to include frequency of daily, reporting blood sugar results greater than 300 mg/dl or less than 70 mg/dl for two or more consecutive days or as ordered by MD (medical doctor)…Skilled nurse for monitoring, management and education of hypoglycemic medication regimen… Goals/Rehabilitation/Discharge Plans: The Patient/Caregiver will be knowledgeable of hypoglycemic therapy as evidenced by blood sugar control without hypo/hyperglycemic episodes through 9 weeks… Patient/Caregiver will verbalize/demonstrate knowledge of management of diabetes as evidenced by decreased symptoms, stabilization of blood glucose within parameters set by physician and no unplanned hospitalizations through 7 weeks.” The RNE stated the plan of care was not followed. The RNE stated RN3 and other nurses (in general) would not be able to properly assess Patient 9’s blood sugar level if Patient 9’s home glucometer was not working. The RNE stated if Patient 9’s plan of care was not followed, there was a potential risk to affect Patient 9’s overall health. The RNE stated it was important to follow Patient 9’s plan of care for Patient 9’s overall health management and avoid hypo/hyperglycemic episodes. During a review of facility’s policy and procedure titled “Expectations and Responsibilities for Field Staff” revised 1/19/2022, indicated “The Agency maintains a certain level of expectation for all field staff. This includes specifically defined responsibilities. Home Health Only: Note the patients vital signs in the electronic medical record and report to the physician if the vital signs are not within established parameters as detailed below: Agency Specific Parameters: Notify/Instruct to notify MD when systolic BP >180 or 100 or 300 mg/dl at any time, or During a review of facility’s policy and procedure titled “Skilled Nursing-Registered Nurses” revised 4/22/2021, indicated “The RN Case Manager will evaluate patients with physician orders for home care. The RN/ Case Manger will: gather information relevant to care, treatment, and services including… any medical equipment in the home. Assess the patients need for equipment and communicate the needs to the physician. Communicate findings to the physician… Document the vital signs as ordered and report to the physician if the vital signs are not within established parameters.” During a review of facility’s policy and procedure titled “Care Planning and Coordination of Services” revised 4/4/2023, indicated “The agency ensures that each patient receives the home health services that are written in the individualized plan of care. The agency promptly alerts the physician or allowed practitioner (s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. All plans of treatment and notification to the physician or allowed practitioner, are included in the patients’ health record. Patients care is coordinated using an interdisciplinary approach to support the implementation of the care plan. The range of health services workers includes those disciplines providing care, whether directly or under arrangement.”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the HHA failed to ensure the Plan of Care (POC) included information necessary to care for one of ten sampled patients (Patient 2) by not indicating the wound treatment needed for his left anterior foot wound. This deficient practice had the potential to result in delay in care by not receiving the identified needs and services, that could cause a delay in healing that could lead to infection and hospitalization. Findings: During a review of Patient 2’s medical record form titled “Patient Information Report” indicated effective date of 5/2/2024, with a primary diagnosis of pressure ulcer of sacral region stage (damage to tailbone skin due to constant pressure). During a joint home visit on 6/5/2024 at 11:20 a.m. with Registered Nurse 1 (RN1) to Patient 2’s home, RN1 noted cleaning Patient 2’s left anterior foot wound with betadine. Patient 2’s Care Giver 1 (CG1) stated it was a superficial wound that improved. During an interview on 6/5/2024 at 1 p.m. with RN1, RN1 stated she was “just” cleaning Patient 2’s left anterior wound with betadine and not covering it with a dressing. RN1 stated Patient 2’s left anterior foot wound was getting better. RN1 stated a wound treatment needed to be listed on Patient 2’s POC to make everyone involved in his care aware of what he was receiving. During a concurrent interview and record review on 6/6/2024 at 1:20 p.m. with Registered Nurse Educator (RNE) of Patient 2’s Electronic Medical Record (EMR), RNE stated she was unable to locate the wound treatment order for Patient 2’s left anterior foot wound. RNE stated a physician’s order was needed to apply and clean any wound with betadine. RNE stated “everything we put in or on a patient needs an order.” During a review of facility’s policy and procedure titled “Wound Care” revised 10/1/2018, indicated “The following agents are considered to be cytotoxic and should be used only as appropriate. i. providon-iodine. All treatments, including cleansing… require written physician orders.” During a review of facility’s policy and procedure titled “Physicians and other allowed practitioners providing orders” revised 3/5/2024, indicated “The agency provides care under specific orders from a physician or other allowed practitioner. Drugs, services, and treatments are administered only as ordered by a physician or other allowed practitioner.”

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to ensure one of ten sample patients (Patient 2) had a left anterior foot wound treatment order before receiving wound treatment care. This deficient practice had the potential to result in skilled nurse providing a wrong treatment that could prolong the healing process and possibly cause infection and hospitalization. Findings: During a review of Patient 2’s medical record form titled “Patient Information Report” indicated effective date of 5/2/2024, with a primary diagnosis of pressure ulcer of sacral region stage (damage to tailbone skin due to constant pressure). During a joint home visit on 6/5/2024 at 11:20 a.m. with Registered Nurse 1 (RN1) at Patient 2’s home, RN1 was observed cleaning Patient 2’s left anterior foot wound with betadine. Patient 2’s Care Giver 1 (CG1) stated it was a superficial wound that improved. During an interview on 6/5/2024 at 1 p.m. with RN1, RN1 stated she was “just” cleaning Patient 2’s left anterior wound with betadine and not covering it with a dressing. RN1 stated Patient 2’s left anterior foot wound was getting better. RN1 stated a wound treatment needed to be listed on Patient 2’s POC to make all aware of what he was receiving. During a concurrent interview and record review on 6/6/2024 at 1:20 p.m. with Registered Nurse Educator (RNE) of Patient 2’s Electronic Medical Record (EMR), RNE stated she was unable to locate a wound treatment order for Patient 2’s left anterior foot wound. RNE stated a physician’s order was needed to apply and clean any wound with betadine. RNE stated “everything we put in or on a patient needs an order.” During a review of facility’s policy and procedure titled “Wound Care” revised 10/1/2018, indicated “The following agents are considered to be cytotoxic and should be used only as appropriate. i. providon-iodine. All treatments, including cleansing… require written physician orders.” During a review of facility’s policy and procedure titled “Physicians and other allowed practitioners providing orders” revised 3/5/2024, indicated “The agency provides care under specific orders from a physician or other allowed practitioner. Drugs, services, and treatments are administered only as ordered by a physician or other allowed practitioner.”

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to provide written information regarding the plan of care (POC) for three of ten sampled patients (Patient 2, Patient 5, and Patient 9) and their Caregivers. This deficient practice resulted in patients and their representatives not knowing their care team or their treatment course ordered. Findings: 1. During a review of Patient 2’s medical record form titled “Patient Information Report” indicated effective date of 5/2/2024, with a primary diagnosis of pressure ulcer of sacral region stage (damage to tailbone skin due to constant pressure). During a joint home visit on 6/5/2024 at 11:20 a.m. with Registered Nurse 1 (RN1) to Patient 2’s home, RN1 stated she did not provide Patient 2 a copy of his plan of care (POC). Patient 2’s Care Giver 1 (CG1) stated she had never seen Patient 2’s POC when it was showed to her. During an interview on 6/5/2024 at 1 p.m. with RN1, RN1 stated patients need a copy of their plan of care for continuity of care. 2. A review of Patient 5’s record titled, “Home Health Certification and Plan of Care”, for certification period 5/6/2024 to 7/4/2024, indicated a start of care date on 3/7/2024, with diagnoses including orthopedic after care following surgical amputation (removal of a body part). During a concurrent observation and interview on 6/5/2024, at 10:44 a.m., Registered Nurse 2 (RN 2) reviewed the written material/booklet provided to Patient 5. The plan of care was not observed inside the written material/booklet provided to Patient 5 by the HHA. RN 2 stated the POC was not in the written material provided to the patient. RN stated she did not think the HHA provides a copy of the POC to the patients. 3. During a review of Patient 9’s medical record form titled “Home Health Certification and Plan of Care”, for certification period 5/9/2024-7/7/2024, indicated a start of 5/9/2024, with a primary diagnosis of anoxic brain damage (brain damage caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation). During an interview at the home visit with Registered Nurse 3, (RN 3) on 6/5/2024 at 10:00 a.m., Patient 9 consented to visit. Patient 9 stated he does not have a copy of the plan of care. RN 3 stated the copy of plan of care is not usually given to the patients, only handouts (printed instructional document) for teaching. During a review of facility’s policy and procedure titled “Care Planning and Coordination of Services” revised 4/4/2023, indicated “The plan of care has patient specific interventions, measurable goals, and timeframes. The agency provides the patient and caregiver with a copy of written instructions outlining: The visit schedule, including frequency of visits by agency personnel and personnel acting on behalf of the agency. Any treatments to be administered by agency personnel and personnel acting on behalf of the agency, including therapy services. Any other pertinent instructions related to the patients care and treatments that the agency will provide.” During a review of facility’s policy and procedure titled “Patient Rights” revised 8/7/2019, indicated “The patient has the right to: Participate in, be informed about… the care to be furnished; the disciplines that will furnish the care; the frequency of visits. Be advised of e. receive proper written notice, in advance of a specific service being furnished, if the Agency believes that the service may be non-covered care;”