Every finding on record at Whitewater Healthcare, LLC

An unannounced Federal Medicare investigation was conducted at your home health agency from 4/07/25 to 4/08/25 regarding complaint #137110. The following deficiencies were found : The following abbreviations were used in this report: ml - milliliters NP - Nurse Practitioner NS - Normal Saline POC - Plan of Care RN - Registered Nurse SN - Skilled Nurse VAD - Ventricular Assist Device

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, it was determined the facility failed to follow the POC for 1 of 7 patients (Patient #4) whose records were reviewed. This allowed for the wrong amount of fluids to be provided to the patient and had the potential for harm to the patient. Findings include: Patient #4 was an 47 year old male admitted to the agency 12/31/2023 with a primary diagnosis of gastroparesis. Additional diagnoses included atherosclerosis heart disease, schizophrenia, bipolar disease, anxiety disorder, and gastro-esophageal reflux disease without esophagitis. . His record, for the certification period 12/20/24 to his discharge documented 2/9/25, was reviewed. Patient #4 received SN services. Patient #4's POC dated 12/20/24 stated. "Skilled nurse may infuse 1000 mL NS via gravity." Patient #4 received a SN visit dated 1/03/2025 with a narrative note that stated, "2000 mL normal saline infused." Patient #4 received a SN visit dated 1/10/2025 with a narrative note that stated, "2000 mL normal saline infused." The home health administrator was interviewed on 4/8/25 beginning at 2:30 pm. The administrator confirmed the POC ordered 1000mL infusion and on SN visits dated 1/03/2025 and 1/10/2025 the medical record recorded, "2000 mL normal saline infused." The administrator confirmed the amount of NS provided was not the amount in the order included on the POC. The agency failed to ensure Patient #4's POC was followed.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, it was determined the facility failed to ensure an accurate POC for 1 of 7 patients (Patient #4) whose records were reviewed. This allowed for an inaccurate POC and had the potential for harm to the patient. Findings include: Patient #4 was an 47 year old male admitted to the agency 12/31/2023 with a primary diagnosis of encounter for adjust ment and management of VAD and gastroparesis. Additional diagnoses included atherosclerosis heart disease, schizophrenia, bipolar disease, anxiety disorder, and gastro-esophageal reflux disease without esophagitis. His record, for the certification period 12/20/24 to his discharge documented 2/9/25 was reviewed. Patient #4 received SN services. Patient #4's POC dated 12/20/24 included diagnosis "1. Encounter for adjustment and management of VAD" The home health administrator was emailed on 4/11/225. The administrator confirmed that the facility had no record of the patient having a VAD. The agency failed to ensure Patient #4's POC was accurate.

A recertification survey conducted at your agency from 11/13/23 to 11/16/23 included emergency preparedness. No deficiencies were cited. Symbii Home Health is in compliance with 42 CFR §484.102.

A federal medicare recertification survey was conducted at your agency from 11/13/23 to 11/16/23. The following deficiencies were cited: Abbreviations used in this report include: CHF - Congestive Heart Failure CKD - Chronic Kidney Disease DCS - Director of Clinical Services mg - Milligram MSW - Medical Social Worker OT - Occupational Therapy POC - Plan of Care PT - Physical Therapy RN - Registered Nurse ROC - Resumption of Care SN - Skilled Nursing SOC - Start 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, policy review, patient interview, and staff interview, it was determined the facility failed to reconcile medications for 2 of 8 patients (Patient #12 and #5) whose records were reviewed and whose home visits were observed. This caused high alert medications to be missing from the medication list. Findings include: 2. Patient #5 was a 71 year old female admitted to the agency on 9/25/23 with a diagnosis of metabolic encephalopathy. Additional diagnosis included acute kidney failure, CHF, and type 2 diabetes. Her record for the certification period 9/25/23 to 11/23/23 was reviewed. An SN visit to Patient #5’s home was conducted on 11/14/23 beginning at 3:00 PM. During the visit, surveyors observed Patient #5’s medications and reviewed her medication list with Patient #5 and the agency’s nurse. The following medications were found in the home, but missing from the medication list: - Plavix 75 mg - Fenofibrate 145 mg - Farxiga 10 mg - Aspirin 81 mg Patient #5 was interviewed during the SN visit and confirmed she was taking the above medications. Patient #5 stated she had been taking Plavix (a blood thinner) for four years. The agency nurse was interviewed on 11/14/23 beginning at 3:47 PM and she confirmed the listed medications were not on Patient #5’s medication list. A policy titled, “Comprehensive Assessment,” revised August 2023 stated the comprehensive assessment included, “Review of medication history, as applicable to care and service and current medication use, including prescription, over-the-counter medications and herbal medications, and allergic reactions identifying significant drug interactions, duplicative drug therapy, potential adverse effects and drug reactions.” This policy was not followed. Examples include: 1. Patient #12 was a 69 year old male admitted to the agency on 10/27/23 with a diagnosis of rectal cancer. Additional diagnoses included bacteremia, CHF, and chronic kidney disease. His record for the certification period 10/27/23 to 12/25/23 was reviewed. An SN visit to Patient #12’s home was conducted on 11/15/23 beginning at 1:00 PM. During the visit, surveyors observed Patient #12’s medication box and reviewed his medication list with him. The following medications were found in the medication box but missing from the medication list: - KlorconM20 - Potassium 550 mg - Vitamin D+ - Cayenne pepper supplement Patient #12 was interviewed during the SN visit and confirmed he was taking the above medications. When his medication list was reviewed with him and asked if he was taking any other medications, he stated he took hydrocodone/acetaminophen 5/325 as needed and ibuprofen as needed. He stated he ran out of the hydrocodone/acetaminophen the day before and was going to ask his physician for something stronger. The DCS was interviewed on 11/16/23 at 10:19 AM and the observations of Patient #12’s medications were reviewed with her. She confirmed the medication list did not include all medications Patient #12 was taking.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on medical record review and staff interview, it was determined the facility failed to ensure the comprehensive assessment was updated for 1 of 17 patients (Patient #10) whose records were reviewed. This failure caused neurological symptoms after a stroke to not be assessed. Findings include: Patient #10 was an 83 year old female admitted to the agency 9/20/23 with a primary diagnosis of nonsurgical wound. Additional diagnoses included chronic kidney disease, CHF, and type 2 diabetes. Her record, for the certification period 9/20/23 to 11/18/23 was reviewed. She received SN, PT, OT, and aide services. Patient #10 was hospitalized from 9/26/23 to 10/01/23 and 10/19/23 to 10/23/23. She had ROC visits on 10/01/23 and 10/23/23. Patient #10’s medical record included an ROC note signed by the RN. The note stated, “PT [patient] RESUMING TO HOME HEALTH AFTER A HOSPITALIZATION THAT WAS R/T [related to] A CVA [cerebrovascular accident, or stroke].” There was no neurological assessment in the note to determine whether Patient #10 had any residual symptoms after having a stroke. The DCS was interviewed on 11/16/23 at 10:19 AM and Patient #10’s record was reviewed with her. She confirmed there was no neurological assessment on Patient #10’s ROC visit after hospitalization for a stroke. The facility failed to ensure the comprehensive assessment was updated after a stroke.

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 policy review, medical record review, and staff interview, it was determined the facility failed to follow the POC for 1 of 17 patients (Patient #10) whose records were reviewed. This created lack of wound assessment and had the potential for changes with the wound to go unnoticed. Findings include: A facility policy titled “Organization-Specific List of Procedures and Treatments: Wound Management,” undated, stated, “wounds are to be measured each week, at SOC, ROC, and re-certification.” This policy was not followed. An example includes: Patient #10 was an 83 year old female admitted to the agency 9/20/23 with a primary diagnosis of nonsurgical wound. Additional diagnoses included chronic kidney disease, CHF, and type 2 diabetes. Her record, for the certification period 9/20/23 to 11/18/23 was reviewed. She received SN, PT, OT, and aide services. Patient #10 was hospitalized from 9/26/23 to 10/01/23 and 10/19/23 to 10/23/23. She had ROC visits on 10/01/23 and 10/23/23. Patient #10’s POC stated wound care was to be performed by SN twice weekly. Patient #10 had 2 wounds documented in her record which were missing weekly measurements: - Wound #1 was measured on 9/20/23, 10/01/23, 10/27/23, and 11/10/23. It was not measured between 10/01/23 and her hospitalization on 10/19/23. It was not measured again until 10/27/23, 4 days after the ROC visit. After this, the wound was not measured until 11/10/23. - Wound #2 was measured on 9/20/23, 10/01/23, 10/27/23, and 11/10/23. It was not measured between 10/01/23 and her hospitalization on 10/19/23. It was not measured again until 10/27/23, 4 days after the ROC visit. After this, the wound was not measured until 11/10/23. The DCS was interviewed on 11/16/23 at 10:19 AM and Patient #10’s record was reviewed with her. She confirmed Patient #10’s wounds were not measured weekly per policy. The agency failed to ensure Patient #10’s wounds were measured weekly.

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 medical record review and staff interview, it was determined the agency failed to ensure the POCs included all interventions, and goals for 1 of 17 patients (Patient #7) whose records were reviewed. This failure resulted in incomplete POCs and had the potential to result in unmet patient needs. Findings include: Patient #7 was an 61 year old male admitted to the agency on 9/01/23 with a primary diagnosis of wound care and Pruritus. Additional diagnosis included DM type 2, Chronic Kidney Disease with kidney failure. He received PT, SN and MSW services. His record, including the POC, for the certification periods 9/1/23 to 10/31/23, and 10/31/23 to current, was reviewed. Patient #7 record included a RN Recertification comprehensive assessment, dated 10/27/23, signed by the RNCM. The assessment stated Patient #7 had a diagnosis of DM type 2 with a severity code of two, meaning symptoms were controlled with difficulty and needed ongoing monitoring. Patient #7's POC did not include goals or interventions to monitor his DM type 2. Additionally, Patient #7’s POC had a diagnosis of Chronic Kidney Disease with kidney failure with a severity code of two, meaning symptoms were controlled with difficulty and needed ongoing monitoring. Patient #7’s POC did not included goals or interventions to monitor his Chronic Kidney Disease with kidney failure. The DCS was interviewed on 11/215/23 beginning at 1:30 PM and Patient #7’s medical record was reviewed in her presences. She confirmed the POC did not include goals or interventions related to monitoring Patient #7's DM type 2, and Chronic Kidney Disease. Patient #7's POC did not include all relevant goals and interventions. gdfg