Every finding on record at Willow Health Care Inc

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 03/20/2024. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 03/20/2024. The provider had 16 current patients.

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 policy review, record review, observation and interview, the home health provider failed to ensure staff maintain an accurate and updated medication profile in, but not limited to, two of three home visit observations (Records/Patients #3 and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Oversight,” dated March 2001, showed, in part: - The purpose of the policy is to guide clinical personnel in providing medication administration and/ or education that will promote safe effective use of medication; - Ensure that the comprehensive assessment includes a drug regimen review; and - The clinical record includes all appropriate physician orders for the patient and all over the counter medications for medications prescribed by the physician. RECORD/PATIENT #3: Observation and interview on 03/19/2024 at 11:30 AM, during the patient’s home visit, showed the following medication discrepancy, the patient had a bottle of Melatonin (a sleep aid medication) 3 milligram (mg) tablets and was directed to take one tablet at bedtime. The provider’s medication profile failed to contain this medication. The patient stated that he/she was prescribed the medication by his/her primary care physician had and taken the medication for the past three weeks. RECORD/PATIENT #4: Observation and interview on 03/18/2024 at 1:40 PM, during the patient’s home visit, showed the following medication discrepancy, the provider’s medication profile showed an order for Doxycycline (an antibiotic used to treat infection), 100 mg, take one tablet two times daily. The patient’s daughter/caregiver stated that the patient was no longer taking the medication. During an interview on 03/20/2024, at 9:00 AM, the clinical manager stated that the staff were responsible to ask patients of medication changes during each visit. The staff look at the medication bottles during the first home visit, but he/she was unsure if the staff checked medication bottles in comparison to the medication list each visit.

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, record review, and interview, the home health provider failed to ensure vital signs were assessed as written in the plan of care in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Ongoing Assessment," dated 01/2011, showed in part, using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for: Blood pressure, pulse, respirations, temperature. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 08/08/2021 with a primary diagnosis of encounter for change or removal of nonsurgical wound dressing and secondary diagnoses of subacute osteomyelitis (serious infection of the bone that can be either acute or chronic), liver disease, other ascites (a condition in which fluid collects in spaces within your abdomen), esophageal varices with bleeding (dilated submucosal distal esophageal veins connecting the portal and systemic circulations), gastrointestinal hemorrhage (bleeding), and type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). Review of the document titled, "Addendum to Plan of Treatment," dated 01/23/2024 to 03/22/2024 showed that staff were to assess vital signs and disease process and its associated care and treatment and medication regimen. Review of the skilled nursing (SN) notes showed the following: -A SN note dated 01/22/2024 showed the clinician failed to document vital signs; and -A SN note dated 02/05/2024 showed the clinician failed to document vital signs. During an interview on 03/20/2024 at 9:00 AM, the home health clinical manager stated that he/she would expect vital signs to be taken at every visit.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that documentation was completed in a timely manner in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Entries into the Clinical Record," dated 07/2012, showed entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned in to the office at the end of the workday or morning of the following work day. Outcome and Assessment Information Set (OASIS) documentation must be turned in to the office within 48 hours of the visit. Visit notes will be completed at the time of the visit prior to the patient signing. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 08/08/2021 with a primary diagnosis of encounter for change or removal of nonsurgical wound dressing and secondary diagnoses of subacute osteomyelitis (serious infection of the bone that can be either acute or chronic), liver disease, other ascites (a condition in which fluid collects in spaces within your abdomen), esophageal varices with bleeding (dilated submucosal distal esophageal veins connecting the portal and systemic circulations), gastrointestinal hemorrhage (bleeding), and type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). Review of the clinical record showed the following: -A skilled nursing (SN) visit dated 01/22/2024, signed as completed on 01/29/2024 (seven days later); -A SN visit dated 01/24/2024, signed as completed on 01/27/2024 (three days later); -A SN visit dated 01/29/2024, signed as completed on 02/05/2024 (seven days later); -A SN visit dated 01/31/2024, signed as completed on 02/08/2024 (eight days later); -A SN visit dated 02/05/2024, signed as completed on 02/14/2024 (nine days later); -A SN visit dated 02/07/2024, signed as completed on 02/14/2024 (seven days later); -A SN visit dated 02/12/2024, signed as completed on 02/14/2024 (two days later); -A SN visit dated 02/14/2024, signed as completed on 02/18/2024 (four days later); -A SN visit dated 02/19/2024, signed as completed on 02/21/2024 (two days later); and -A SN visit dated 02/21/2024, signed as completed on 02/24/2024 (three days later). During an interview on 03/20/2024 at 9:00 AM, the home health administrator stated that he/she expected routine visit documentation to be completed within 24 hours. He/she expected clinicians to follow the provider's policy.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 09/15/2021. During the survey it was determined Westwood Home Health agency is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

An extended survey for Medicare certification for Westwood Home Health was completed on 09/15/2021. The agency had 17 current patients. One condition-level deficiency was identified during this survey: -§484.60 Condition of Participation: Care Planning, coordination of services, and quality of care. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey with no deficiencies identified related to the Focused Infection Control Survey. A home health agency that is found out of compliance with certain Conditions of Participation evaluated as part of an extended survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f)(3) - see Tag G788.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and interview, the agency failed to complete the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in one (Patient/Record #1) of five records reviewed. This deficient practice has the potential to affect the immediate needs of all the agency's patients. Findings included: Review of the agency's policy, "Admission Criteria and Process", dated March, 2001, showed that the initial visit must be performed within 48 hours of acceptance of referral information and/or discharge from a referring facility. The director of nursing will assign personnel to conduct assessments of eligibility for services within 48 hours of acceptance of referral information. RECORD/PATIENT #1: Review of the clinical record showed: - The agency's client comprehensive form dated 08/16/2021 showed a referral date of 08/13/2021; - The admission nursing assessment, and the first visit to the patient, was dated 08/16/2021 and - The agency did not conduct the initial assessment until 08/16/2021 (three days after the physician's referral). During an interview on 09/15/2021 at 10:10 AM, the administrator concurred that the initial assessment should be within 48 hours of the patient's referral.

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 policy review, record review, home visit observation, and interview, the agency failed to ensure a complete/accurate medication review and/or update of the patient's medications was completed in, two (Records/Patients #2 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Medication Oversight," date reviewed June 2018, showed in part: - The purpose is to guide clinical personnel in providing medication administration and/or education that will promote safe, effective use of medication; - Ensure that the comprehensive assessment includes a drug regimen review; - Over the counter (OTC) medications are those drugs that the patient purchases and takes without a physician's prescription; - A medication error is a medication administered by staff without a physician's order or a medication ordered by the physician that is omitted or given improperly by staff; - Drug regimen review is a comprehensive review of all medication 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 non-compliance with drug therapy; - Medication profile is a listing of the medications prescribed by the physician for the patient identifying the name, dose, route, frequency and date drug was started or noted and discontinued; - Staff reviews medications at least every 60 days and as part of the comprehensive assessment at each visit; - Nursing and contracted therapy staff will ask the patient at every visit if he/she has any new/changed medications. Contracted staff will notify the skilled nurse or director of nursing (DON) of any medication changes that day and document who was contacted in the patient record; and - Notification may be made by using a software inbox messaging system or by phone. The nurse will make the appropriate medication profile update. RECORD/PATIENT #2: During the patient's home visit observation on 09/14/2021 beginning at 1:00 PM, review of the patient's home medication showed the following discrepancies with the agency's current medication profile: - Agency medication list showed hydrocodone 5 milligram (mg) - acetaminophen 325 mg : take one tablet q (every) four hours as needed (prn) for pain for seven days. Patient and patient's caregiver (cg) stated that patient no longer takes hydrocodone for pain. Cg stated that the patient takes Tylenol 650 mg prn for pain. Agency's list failed to contain tylenol for pain. - Agency medication list showed clonidine HCL (treatment for high blood pressure) 0.1 mg take one tablet three times daily. Cg stated that patient no longer takes three times a day. Cg stated that the patient takes only one tablet daily. Cg stated that patient's physician changed the dosage on 09/09/2021. Record showed skilled nurse visit on 09/09/2021; - Agency list showed Lantus Solostar U-100 insulin subcutaneous (under the skin - treatment for high blood sugar) - 24 units (measure) at bedtime. Patient's cg stated that the patient takes 12 Units at bedtime; - Agency list showed Colace (stool softener) 100 mg daily. Cg stated that the patient takes two capsules daily; and - Agency list showed aspirin (blood thinner) 81 mg daily. Cg stated that the patient no longer takes this medication. During an interview with the clinical manager on 09/14/2021 at 10:00 AM, the clinical manager concurred with the findings and no further information was provided. RECORD/PATIENT #3: A home visit (patient lives in a nursing facility-NF) observation on 09/14/2021 beginning at 11:00 AM showed the following medication discrepancies with the agency medication profile, and the NF patient medication list/medication administration record (MAR) and treatment administration record (TAR): - The agency medication profile showed an order for albuterol sulfate (bronchodilator used to treat wheezing and shortness of breath) 2.5 mg/3 milliliters (ml) (0.083%) solution for nebulization (a small machine that turns liquid medicine into a mist) - one nebulization two times daily starting 05/27/2020. This medication was not included on the NF MAR; - The agency medication profile showed an order for heparin lock (tube/catheter inserted into a blood vessel for medication administration and/or for blood draws) flush (keeps blood flowing smoothly and from clotting in the catheter) 100 USP Units/ml, notes: flush port with 10 ml normal saline (NS) followed by 5 ml heparin flush after drawing labs weekly, 5 ml intravenous one time weekly starting 05/27/2020. The NF MAR showed heparin lock flush 10 unit/ml intravenous syringe (10 ml) syringe (ML) one time weekly; - The agency medication profile showed an order for duloxetine (antidepressant used to treat depression and anxiety) 60 mg capsule, delayed release, one by mouth every day starting 05/24/2020. The NF MAR showed duloxetine 60 mg capsule, delayed release (90 mg), notes: give 60 mg of duloxetine along with 30 mg to = 90 mg by mouth daily; - The agency medication profile showed an order for lovastatin (cholesterol lowering medication) 40 mg tablet, one by mouth at hours of sleep starting 05/17/2021. The NF MAR showed lovastatin 40 mg by mouth one time daily at 5:00 PM; - The agency medication profile showed an order for nystatin (antifungal) 100,000 unit/gram topical cream apply topically two times. Nystatin was not included on the NF MAR or TAR; - The agency medication profile showed an order for Eucerin (moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) topical cream, notes: to right lower extremity as needed for scaly dry skin starting 06/02/2020. Eucerin was not included on the NF MAR or TAR; - The agency medication profile showed Bengay Ultra Strength (treat minor aches and pains of the muscles/joints) (menthol) 5% topical patch, notes: apply to affected area daily as needed for pain. Bengay Ultra Strength was not included on the NF MAR or TAR. During an interview on 09/15/2021 at 11:04 AM, the clinical manager stated that the medications and treatments are compared at recertification and he/she would expect them to match the facility's.

Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient's primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency staff failed to complete a comprehensive assessment to include the patient's primary caregiver(s), if any, and other available supports, including their willingness and ability to provide care, and availability and schedules in, but not limited to one (Record/Patient #5) of five records reviewed. This deficient practice has the potential to affect all patients served by the home health agency. Findings included: Review of the agency policy titled, "Initial and Comprehensive Assessment," dated revised 08/2012, showed in part the following: - The assessment will be patient-specific and comprehensive to include the patient's need for home health care, rehabilitative care, and discharge planning; - The patient's and family's educational needs, abilities, motivation, and readiness to learn; and - Patient and family/caregiver support systems and the type of care the family/caregivers available, capable, and willing to provide. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to the agency on 03/25/2021, with the diagnoses to include diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) with hyperglycemia (elevated blood sugars), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and hypertension (elevated blood pressure). The initial comprehensive assessment showed the patient lived with another person in the home around the clock. The initial comprehensive assessment, related to primary caregiver information, failed to include the patient's specific primary caregiver(s), if any, and other available supports, including their willingness and ability to provide care, and availability and schedules. During and interview on 09/15/2021 at 9:58 AM, the clinical manager stated that she would have expected the comprehensive assessment to include the primary caregiver's information and willingness and ability to provide care.

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 policy review, record review, home visit observation, and interview, the agency failed to: - Write an individualized plan of care that identified patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician or allowed practitioner (G572); - Provide an individualized plan of care that included, but not limited to, all pertinent diagnoses, the types of services, supplies, and equipment required, the frequency and duration of visits to be made, all medications and treatments (G574); - The Home Health Agency (HHA) must promptly alert the relevant physician (s) or allowed practitioner (s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered (G590); - Coordinate care delivery to meet the patient's needs, and involve the patient/representative (if any), and caregiver (s), as appropriate in the coordination of care activities (G608); - Provide a written visit schedule including frequency of discipline visits (G614). The cumulative effect of these deficient practices has the potential to affect the provision of safe care for all patients served by the agency.

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, record review, and interview, the agency failed to ensure that the patients received the home health services that were written on the individualized plan of care when the patients did not receive visits according to the visit frequency ordered on the plan of care in four (Records/Patients #2, #3, #4, and #5) of five full record reviews completed and did not receive other services (Durable Medical Equipment - DME- and blood draw procedures) ordered on the plan of care in two (Records/Patients #3 and #4) of five full record reviews completed. . This deficient practice has the potential to adversely affect the ordered care provided to all the agency's patients. Findings included: Review of the agency policy titled, "Care Planning Process," dated revised 06/2018, showed in part the following: - A written plan of care (POC) will be initiated within five days of start of care and updated at least every 60 days, or as patient's conditions warrants. The patient POC will be developed or revised within five working days of initiation of each service or of the reassessment of the patient. All clinicians involved in the patient's care, either directly or indirectly, will contribute to the plan of care. The patient and family/caregiver will participate in decisions regarding the POC whenever possible. The care planning process will be documented on the POC, clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries; and - The plan of care will be based upon the physician's orders and will encompass the equipment, supplies, and services required to meet the patient's needs. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the agency on 08/19/2021 with type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) with hyperglycemia (elevated blood sugar). Review of the plan of care dated 08/19/2021 through 10/17/2021 showed: - Admit to home health for skilled nurse visits (SN) one time weekly for five weeks; - Resumption of care order following treatment for new diagnosis Non ST Segment Elevation Myocardial Infarction - (NSTEMI - a type of heart attack) and syncope (sudden loss consciousness that is caused by an inadequate flow of blood to the brain) with fall and treatment for left ankle fracture (patient/cg stated thought a sprain), for week of 08/29 showed visits increased to two week/one for week of 08/29; - SN to provide education to patient/caregiver (Cg) on all high risk medications (Lantus - treat blood sugar), aspirin (blood thinner); - Assess and monitor blood sugar every (q) visit and instruct patient/caregiver (Pt/Cg); - Instruct and evaluate Pt/Cg in self-administration of insulin; - Instruct Pt/Cg in correlation between diet, medications, activity and blood sugar levels; - Instruct Pt/Cg in signs/symptoms (s/s) of hypo-hyperglycemia (low/high blood sugar) and actions to take; - Instruct Pt/Cg in the diabetes disease process including complications; - Assess Pt for physiological causes for falls; and - Instruct Pt/Cg in methods to prevent skin breakdown. - Home Health Aide (HHA) services one week one, and then two week for five weeks. Review of the clinical record showed: - On the week 08/29/2021, only one SN visit was completed; and - No communication note or physician order regarding the reason for the missed visit. - Review of the HHA visits showed three missed HHA visits; and - No communication note or physician order regarding the reason for the missed visit. During an interview on 09/15/2021 at 10:30 AM, the clinical manager stated: - There was no second SN visit notes for the week of 08/29 due to a "scheduling error" and - There were no HHA visits completed for 09/03/2021, 09/06/2021 and 09/10/2021 and no documentation notifying the physician of the missed visits. - The clinical manager stated that the HHA is shared with the in-home patients and that there was no aide available for the home health patients on those dates; and - The clinical manager stated that this was not acceptable. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the agency on 05/27/2021 with anemia (a disorder in which the blood has fewer than the normal number of red blood cells). Review of the POC dated 07/21/2021 through 09/18/2021 showed: - SN visits one time weekly for eight weeks; - SN to draw a complete blood count (CBC) and blood bank (BB) to hold tube weekly on Mondays and per physician orders. May use right chest implanted port; and - May draw per venipuncture (puncturing a vein with a needle to obtain a blood sample for lab test) as needed for port malfunction. Review of the clinical record showed: - On Monday, 8/9/2021 the SN documented he/she attempted to draw weekly labs but the port flushed but no blood returned; and - No communication note or physician order regarding the reason for not obtaining the blood work via venipuncture as ordered if port malfunctions. - On Monday, 8/23/2021, no SN visit was completed; and - No communication note or physician order regarding the reason for the missed visit. - On Monday, 9/06/2021, no SN visit was completed; - On Tuesday, 9/07/2021, SN visit completed; and - No communication note or physician order regarding the reason for the missed visit on Monday which was ordered on the POC. - On Monday, 9/13/2021, no SN visit was completed; - On Tuesday, 9/14/2021, SN visit completed; and - No communication note or physician order regarding the reason for the missed visit on Monday.- which was ordered on the POC. During a home visit observation on 9/14/2021 at 11:00 AM, the patient stated he/she expected the SN to come on Monday, 9/13/2021, and he/she found out at 3:00 PM that the nurse wouldn't be there on that day (Monday). During interview on 09/15/2021 at 9:58 AM and 11:04 AM, the clinical manager stated: - There was no SN visit completed on the two Mondays, (9/6 and 9/13) because there was no staff available to draw the patient's blood and there was no documentation notifying the physician. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency on 08/27/2021 with cardiovascular accident (CVA - stroke) with right side hemiplegia (total paralysis on one side of the body only). Review of the POC dated 08/27/2021 through 10/25/2021 showed: - Admit to home health for home health aide visits one time weekly for eight weeks; - Physical therapy to evaluate and treat one time weekly for four weeks; - SN visits scheduled one time weekly for five weeks; and - Durable medical equipment: hospital bed. Review of the clinical record showed: - Week of 09/05/2021 through 09/11/2021) no home health aide visits were completed and no communication note or physician order regarding the reason for the missed visit; - The physical therapy visit note, dated 09/08/2021, showed the physical therapy assistant documented in the comments: Family member states he/she found patient on the floor during the night last night. Patient slid out of bed trying to get to bed side toilet. No injury noted. Family member stated that he/she has asked for hospital bed for the patient and a trapeze bar to assist patient. Patient has single bed now and the bed and mattress slide when patient tries to get into bed and this increased patient's fall risk. There was no documentation why the patient didn't have a hospital bed; and - The SN note, dated 09/09/2021, showed the nurse documented the patient slid out of bed onto knees, no injuries reported. There was no documentation that the patient did not have the hospital bed. During an interview on 09/15/2021 at 11:04 AM, the clinical manager stated: -The patient was to get a hospital bed on the day of admission to home health; and -There was no documentation notifying the physician of the missed home health aide visit. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to the agency on 03/25/2021 with type 2 diabetes mellitus with hyperglycemia. Review of the POC dated 03/25/2021 through 05/23/2021 showed: - Admit to home health for skilled nurse visits one time weekly for five weeks; - SN to provide education to patient/caregiver (Cg) on all high risk medications (clopidogrel - blood thinner, Lantus - long-acting insulin used to treat elevated blood glucose, metformin - anti-diabetic medication, and aspirin); - SN to assess and monitor blood sugar with visit and instruct patient/Cg; - SN to instruct and evaluate patient/Cg in self-administration of insulin, including drawing up insulin, preparing injection site, injecting and disposal of syringe; - SN to instruct patient/Cg in correlation between diet, medications, activity and blood sugar levels; - SN to instruct patient/Cg in signs and symptoms of low and high blood sugar levels and actions to take; - SN to instruct patient/Cg in the diabetes disease process including complications; and - Notify the physician if fasting sugar blood glucose (FSBG) is greater than 400 or less than 60. Review of the clinical record showed: - On the second week of service (week of 03/28/2021) no SN visits were completed; and - No communication note or physician order regarding the reason for the missed visit. During an interview on 09/15/2021 at 9:58 AM, the clinical manager stated: - There was no SN visit notes available for that week; and - There was no documentation notifying the physician of the missed visit.

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 policy review, clinical record review, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all the required elements in one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Care Planning Process," dated revised 06/2018, showed in part the following: - The clinical plan of care includes pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals, and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety interventions, risk for emergency department (ED) visits and hospital re-admissions and all necessary interventions to address the underlying risk factors, discharge plan. Documents include plan of treatment (485) and plans of care; - At the time of the initial assessment, the clinician, along with other involved disciplines will develop the patient plan of care based upon the patient's identified needs and will review it with the patient and family/caregiver; - The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals; - The plan of care (POC) will be based upon the physician's orders and will encompass the equipment, supplies, and services required to meet the patient's needs; - Problems and/or needs related to patient's condition, desires, abilities, family/caregiver support systems, and relevant medication monitoring will be included in the plan of care; and - Services to be provided will be based on prioritized needs of the patient. RECORD/PATIENT #5: Review of the hospital discharge summary, dated 03/24/2021, showed in part the following: - Reason for visit: high blood sugar; - Hospital course: Hyperglycemia (high blood sugar levels) due to noncompliance. Counseling provided. Diabetes education provided. Glycemia (blood sugar) has improved. Mild dehydration (excessive loss of water from the body) due to osmotic diuresis (increased kidney output) secondary to diabetes, has resolved. Hyponatremia (low sodium level) secondary to diuresis, has resolved and will continue to monitor. abnormal TSH (thyroid stimulating hormone). History of peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs. Risk factors include aging, diabetes, and smoking), coronary artery disease (damage or disease in the heart's major blood vessels), and cerebrovascular accident (stroke - damage to the brain from interruption of its blood supply). Continue home medications including dual antiplatelet therapy, blood pressure medications, and statin (reduce cholesterol - chemical in the body tissues and blood, a by-product of fats and fatty acids); - Medication changes: Lantus (long-acting insulin treatment for high blood sugar) increased from 50 units twice daily to 55 units twice daily; - Diet: diabetic; - Patient instructions: Type 2 diabetes (chronic condition that affects the way the body processes blood sugar), diabetes and diet, and opioid (controlled medication) safety; and - Activity Restrictions/Additional instructions: Come back to the emergency room if develop any new complaints or health related issues. Follow-up with endocrinologist (medical doctors who specialize in diagnosing and treating health conditions related to problems with the body's hormones, hormonal glands, and related tissues). Referral provided. Endocrinologist will manage patient's uncontrolled diabetes and abnormal thyroid tests. Also follow-up with primary care. Review of the comprehensive assessment, dated 03/25/2021, showed the following: - The patient was admitted to the home health agency (HHA) with a primary diagnosis of Type 2 Diabetes with hyperglycemia; - Additional diagnoses included: Alzheimer's disease, hypertension (elevated blood pressure), and peripheral vascular disease ; - Risk for hospitalization: history of falls (2 or more falls in the past 12 months), unintentional weight loss of a total of 10 pounds or more in the past 12 months, multiple hospitalizations (2 or more) in the past 6 months, multiple emergency department visits (2 or more) in the past 6 months, reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months, currently taking 5 or more medications, and currently reports exhaustion; - Has pain that does not interfere with activity or movement; - The patient is short of breath when walking more than 20 feet or climbing stairs; - Has chest pain daily that is relieved by rest; - At risk for falling; - Has urinary incontinence; - Has confusion during the day and evening, but not constantly; - Has altered sleep pattern - awakens frequently; - Difficulty falling asleep; - Non-agency caregiver(s) currently provide assistance (failed to say if willing or ability to provide care); - Unstable with ambulation; and - Medications managed by patient with no noted issues. Review of the POC, dated 03/25/2021 through 05/23/2021 failed to be individualized and show the following: - No diagnosis of peripheral vascular disease; - No goals for endocrine system; and - No problems, goals, or interventions for shortness of breath, chest pain, urinary incontinence, confusion, altered sleep pattern, or unstable ambulation. During an interview on 09/15/2021 at 9:58 AM, the clinical manager stated the POC should be individualized and include the diagnosis of peripheral vascular disease, goals for the endocrine system, and problems, goals, and interventions for shortness of breath, chest pain, urinary incontinence, confusion, altered sleep pattern, and unstable ambulation. No further information was provided at the time of exit on 09/15/2021 at 1:20 PM.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in two (Records/Patients #4 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Monitoring Patient's Response/Reporting to Primary Care Physician," dated revised 01/2011, showed in part the following: - Purpose: To provide guidelines for monitoring the patient's condition, response to care and for reporting to the patient's physician; - Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient; - The patient's physician will be contacted on the same day when any of the following occur: - Changes in the patient's condition; - Changes in the patient's expected response to treatment or medications; - Changes that have occurred regarding diagnoses, prognosis, or treatment (including procedure, medications, precautions, and limitations); - When there is any problem implementing the plan of care; - When results are received for relevant laboratory tests ordered, notification will be documented; - All conferences or attempts to communicate with the physician will be documented in the clinical record; - When unable to contact the patient's physician for medical consultation warranted by a change in patient's condition, the following procedures will be followed: The nurse or therapist will immediately notify the Director of Nursing (DON)/designee regarding the need for medical consultation and problems encountered. An attempt will be made by the DON/designee to contact the patient's physician. If the DON/designee is unable to contact the patient's physician, the DON/designee will notify the organization's Medical Director of the change in patient condition and the inability to contact the patient's physician to request medical consultation; and - Based on communication with the physician, a verbal order will be obtained for any change in the plan of care and communicated to all appropriate team members to ensure that care is provided according to the revised plan of care. RECORD/PATIENT #4: Review of the POC dated 08/27/2021 through 10/25/2021, showed the following: - The patient was admitted to the agency on 08/27/2021; - Diagnosis included hemiplegia (total paralysis on one side of the body only) and hemiparesis (type of paralysis on one side of the body only following cerebral infarction (blood supply cut off due to blockage of a blood vessel) affecting right dominant side, dysphasia (difficulty swallowing), peripheral vascular disease (condition of the blood vessels that supply the legs and the feet. It leads to narrowing and hardening of the arteries, causing decreased blood flow, which can injure nerves and other tissues), chronic obstructive pulmonary disease (obstruction of airflow/difficulty breathing) and atherosclerotic heart disease (narrowing of the blood vessel) of native coronary artery (blood vessel that supply the heart); - Functional limitations: endurance, ambulation and dependent on activities of daily living (ADLs); - Safety measures: ambulation transfer assistive device safety and fall precautions; - Physical therapy and occupational therapy to evaluate and treat; and - Skilled nurse to review and reinforce home exercise program and educate patient/caregiver on fall prevention. Review of a physical therapy visit note, dated 09/08/2021, showed the physical therapy assistant documented in the comments: Family member states he/she found patient on the floor during the night last night. Patient slid out of bed trying to get to bed side toilet. No injury noted. Family member stated that he/she has asked for hospital bed for the patient and a trapeze bar to assist patient. Patient has single bed now and the bed and mattress slide when patient tries to get into bed and this increased patient's fall risk. There was no documentation that the physician was notified of the patient sliding out of his/her bed. Review of a skilled nursing note, dated 09/09/2021, showed the nurse documented the patient slid out of bed onto knees, no injuries reported. There was no documentation that the physician was notified of the patient sliding out of his/her bed. During an interview on 09/15/2021 at 11:04 AM, the clinical manager stated the patient's physician should have been notified at the time of the visit about the patient's fall. RECORD/PATIENT #5: Review of the POC dated 03/25/2021 through 05/23/2021, showed the following: - The patient was admitted to the agency on 03/25/2021; - Diagnosis included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) with hyperglycemia (elevated blood sugar); - Lantus (long-acting) insulin 100 units/ml (milliliter) subcutaneous (under the skin) pen - give 55 units two times daily subcutaneous; - Metformin (anti-diabetic medication used to treat type 2 diabetes); - Notify physician if fasting blood sugar (FSBG) is greater than 400 or less than 60; - The order failed to show how often to do blood sugar testing; and - Problem included falls. Review of a skilled nursing (SN) visit, dated 04/07/2021 at 12:05 PM, showed the following: - The FSBG was 537 and the patient had no signs or symptoms; - The patient was advised to go to the emergency room, by the skilled nurse; - The patient had a new abrasion to his/her right knee from a reported fall; - The patient was unstable with ambulation, the skilled nurse recommended the patient use a cane, but was unsure if the patient would comply; - Medications managed by the patient with no noted issues. No changes to the current medications; and - The narrative failed to show the physician was notified at the time of the visit of the out of range FSBG and the fall. Review of a SN visit, dated 04/22/2021 at 9:11 AM, showed the SN had filled the pill planner during the last skilled visit and the patient had missed Friday, Saturday, Tuesday, and Wednesday AM doses and Thursday, Saturday, Sunday, Monday, and Wednesday bedtime doses. The SN encouraged the importance of taking medications daily and insulin as ordered. The patient and/or the caregiver did not pick up the medications that were called into the pharmacy the last week. The patient was alert, but forgetful at times. He/she had impaired decision making. There was no documentation the physician was notified of the patient not taking his/her medications as ordered. During an interview on 09/15/2021 at 9:58 AM, the clinical manager stated the patient's physician should have been notified at the time of the visits about the fall, the elevated blood sugar, and the missed medications.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure coordination of patient care delivery in one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Care Coordination," dated revised 12/2017, showed in part the following: - Timely and ongoing communication is the responsibility of each team member, will be appropriate to the needs and abilities of the patient, and will be relevant to the care provided. The clinicians will be responsible for facilitating communications about changes in the patient's status among the assigned personnel; - Written evidence of care coordination will be recorded during the case conference and repeated in skilled nursing visit reports in the patient's clinical records; - The case manager/skilled nurse will coordinate care and communication with all physicians involved in the plan of care who give orders related to home health services and integrate orders from all physicians involved in the plan of care to assure coordination of all services and interventions provided to the patient; - Care coordination will include, but not be limited to: regularly occurring telephone or e-mail communication among team members, planned face to face conference, timely documentation of coordination of care activities, and proper communication upon "hand-off" of patient, including the opportunity for questions between the giver and receiver of patient information; - Organization personnel will communicate changes in a timely manner via telephone, one-to-one meetings, case conference and a home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication; - Written evidence of care coordination may be found in the plan of care, case conference summary forms, or clinical notes in the patient's clinical record; and - The transmission of patient care information will be timely, accurate, and standardized, whenever possible. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to the agency on 03/25/2021 with type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) with hyperglycemia (elevated blood sugar). The plan of care dated 03/25/2021 through 05/23/2021 ordered skilled nursing one time weekly for five weeks. The plan of care directed the skilled nurse (SN) to assess and monitor blood sugar with visit and instruct patient/ caregiver (Cg) in regards to blood glucose readings, and to notify the physician if fasting sugar blood glucose (FSBG) is greater than 400 or less than 60. Review of the clinical record showed the patient had no skilled nurse visit the 2nd week of service (03/28/2021 through 04/03/2021). The clinical record failed to show documentation or evidence that the missed visit was communicated with the team. SN visit on 04/07/2021 showed FSBG was 537 . The SN failed to report out of range FSBG to the physician as ordered and instead advised the patient to go to the emergency room. Review of the clinical record failed to show documentation or evidence that the patient went to the emergency room as advised by the skilled nurse, or that the physician was notified of the elevated blood sugar reading of 537. Review of the clinical record showed an office note dated 04/08/2021, from the patient's attending physician, that was faxed to the agency on 04/08/2021, showed the following: - The patient presented 2 hours early, unaccompanied. The patient stated that he/she felt "terrible" but had no specific complaints. The patient does not know what his/her blood sugars were and does not know where his/her glucometer was; - The physician stated that he/she could not attest that the patient was getting his/her meds; and - The Plan: Increase Lantus (long-acting insulin, used to treat elevated blood glucose levels) to 65 units subcutaneous (under the skin) twice daily. Review of the clinical record showed no communication notes: - That the fax with the new order to increase the insulin was communicated with the team, until 04/15/2021(8 days after the FSBG was 537); and - That there was a new order written to increase the Lantus to 65 units subcutaneous twice daily. During an interview on 09/15/2021 at 9:58 AM, the clinical manager stated the following: - The agency staff discuss every patient once a week; - The nurse that was over the patient never said anything about the FSBG being out of parameter and he/she should have shared that information; - The physician should have been alerted immediately to that out of range FSBG; and - The patient had a special insurance that only allowed five visits, but if the agency had known about FSBG issue, the agency could have called the insurance and requested additional visits.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of the patient rights left in the home admission folder, home visit observation, and interview, the agency failed to provide a written visit schedule that included disciplines that would visit and the frequency of visits in one (Record/Patient #3) of three home visit observations performed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the Center for Medicare and Medicaid Services Conditions of Participation: Patient's Rights 484.50 (c) (4) found in the admission folder left in patient's homes at the time of admission to service showed: - The patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to, (but not limited to) the disciplines that will furnish care and the frequency of visits. RECORD/PATIENT #3: Review of the plan of care (POC) dated 07/21/2021 through 09/18/2021 showed: - Principal diagnosis was anemia (a disorder in which the blood has fewer than the normal number of red blood cells); - Skilled nurse (SN) one time weekly for eight weeks beginning week of 07/25/2021; - SN draw complete blood count (CBC) and blood bank (BB) hold tube weekly on Mondays and per physician orders; and - May draw per venipuncture (puncture a vein with a needle, to obtain a blood sample for testing) as needed (PRN) port malfunction. A home visit observation on 09/14/2021 at 11:00 AM showed no monthly calendar in the home admission folder and no discipline visits were recorded. The patient stated he/she waited all day yesterday (Monday) for the home health nurse to come and draw his/her blood and was told at 3:00 PM that the nurse would not be there to draw his/her blood that day. The record review findings were presented to the clinical manager on 09/15/2021 at 11:04 AM and he/she stated a calendar should be in the home and it should be completed. He/she stated that the lab work was not obtained on Monday the weeks of 09/06 and 09/13 because he/she was gone on vacation and there was no staff to go and draw the patient's blood.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, home visit observation, and interview, the agency staff failed to follow accepted standards of practice/infection control measures during a home visit observation for one (Record/Patient #1) of three home visits conducted. This deficient practice has the potential to impact the infection control needs for all agency patients. Findings included: Review of the agency's policy titled, "Clean versus Aseptic (free from infecting organisms) technique", dated March, 2001, directed staff to use infection control strategies to reduce the number of microorganisms and or prevent the transmissions of microorganisms from one person to another. RECORD/PATIENT #1: Review of the plan of care dated 08/16/21 through 10/14/21 directed skilled nursing to perform wound care to the patient's right (upper and middle) leg wounds three times a week. During a home visit observation on 09/13/21 beginning at 2:45 PM, the Licensed Practical Nurse (LPN) performed wound care to the patient's right leg. The LPN applied gloves, removed the soiled wound dressing, removed gloves, performed hand hygiene and reapplied gloves. During the wound care, the LPN was observed cleaning the wound with a back and forth motion, using the same contaminated gauze (instead of moving from the least contaminated area to the most contaminated area, and using a clean gauze pad for each wipe). Observation showed the LPN failed to maintain infection control standards when he/she failed to obtain clean gauze pad for each wipe. During an interview immediately following the patient home visit, the LPN agreed that using a clean gauze pad for each wipe would be appropriate.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with one Condition of Participation: §484.60-Care planning, Coordination of Services and Quality of Care, the agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 09/15/2023.

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 agency policy, clinical record review, and interview, the agency failed to ensure that the aide provided services that were included in the plan of care in one (Record/Patient #4) of two applicable records. This deficient practice has the potential to affect the aide services for all patients served by the agency. Findings included: Review of the agency policy "Home Health Aide Plan of Care," dated revised 06/2018, showed in part the following: - Each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide; - The home health aide (HHA) plan of care will be individualized to the specific patient and will include at least: - Type of services/procedures to be provided; - Frequency of visits; - Diagnoses/prognosis if relevant to care; - Functional limitations; - Patient's mental status; - Activities permitted; - Nutritional requirements; - Specific procedure (s) to be performed, including amount, frequency, and duration; - Safety measures, including use of specific equipment; - Instructions for completion of documentation; - Reporting changes in patient's condition and needs; - Allergies (if indicated); - The case manager will review the home health aide plan of care (POC) with the aide assigned to the case; - A current copy of the HHA POC will be maintained in the patient's home; and - HH Aide will document on the HHA note which will consist of vital signs, nutritional services, personal care, elimination, homemaking, activity, monitoring of skin conditions. The patient and aide will sign off with the time and date documented. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency on 08/27/2021 with cardiovascular accident (CVA - stroke) with right side hemiplegia (total paralysis on one side of the body only). Review of the plan of care dated 08/27/2021 through 10/25/2021 showed: - Admit to home health for home health aide visits one time weekly for eight weeks; and - Home health aide to encourage fluids every visit, assist to bathroom every visit and assist with ambulation every visit. Review of the Home health aide care plan dated 08/27/2021 to present, showed he/she were to encourage fluids every visit, assist to bathroom every visit and ambulation assist every visit. Review of the clinical record showed: - The home health aide visit on 08/30/2021 failed to show documentation to encourage fluids, assist to the bathroom, ambulate with assist and skin care as ordered on the POC for every visit and did not have a patient signature; and - The home health aide visit on 09/13/2021 failed to show documentation to encourage fluids, assist to the bathroom and ambulate with assist as ordered on the POC for every visit. During an interview on 09/15/2021 at 11:04 AM, the clinical manager stated that the home health aide should document on everything that is ordered every visit.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to ensure that the clinical manager assured that patient needs were continually assessed in two (Records/Patients #3 & #5) of five full record reviews. The deficient practice has the potential to affect all agency patients. Findings included: Review of the agency policy titled, "Clinical Manager/Director of Nursing (CM/DON)," dated revised 11/2017, showed in part, the following: - The agency employs a clinical manager who has appropriate education, experience and skills to oversee the professional activities of the agency; - The clinical manager ensures care delivery meets the needs of the patients and follows professional standards of practice. To accomplish this, the clinical manager: Participates in all activities relevant to service delivery and professional services furnished. Observes, supervises, counsels, and disciplines staff effectively. Monitors compliance with: applicable Federal, State, and local laws; Professional standards and principles; Established policies and procedures; and the plan of care. Ensures that services are available. Recommends resources needed to provide care; - The clinical manager or a qualified alternate is readily available at all times during operating hours. In the absence of the clinical manager, a nurse case manager as designated by the Administrator assumes these responsibilities; and - The clinical manager participates in all activities relevant to services furnished under arrangement or contract, including development of qualifications, assignment, coordination and integrity of care, supervision, and evaluation. RECORD/PATIENT #3: Review of the plan of care (POC) dated 07/21/2021 through 09/18/2021 showed: - Principal diagnosis was anemia (a disorder in which the blood has fewer than the normal number of red blood cells); - Skilled nurse (SN) one time weekly for eight weeks beginning week of 07/252021; - SN draw complete blood count (CBC) and blood bank (BB) hold tube weekly on Mondays and per physician orders; and - May draw per venipuncture (puncture a vein with a needle, to obtain a blood sample for testing) as needed (PRN) port malfunction. An interview on a home visit observation on 09/14/2021 at 11:00 AM showed the patient stated that he/she had waited all day yesterday (Monday) for the home health nurse to come and draw his/her blood and was told at 3:00 PM that the nurse would not be there to draw his/her blood that day. The record review findings were presented to the clinical manager on 09/15/2021 at 11:04 AM he/she stated that the lab work was not obtained on Mondays the weeks of 09/06 and 09/13 because he/she was gone on vacation and there was no staff to go and draw the patient's blood. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to the agency on 03/25/2021 with type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) with hyperglycemia (elevated blood sugar). The POC dated 03/25/2021 through 05/23/2021 ordered SN one time weekly for five weeks. The POC directed the SN to assess and monitor blood sugar with each visit and instruct patient/ caregiver (Cg) in regards to blood glucose readings, and to notify the physician if fasting sugar blood glucose (FSBG) is greater than 400 or less than 60. Review of the clinical record showed the patient had no SN visit the 2nd week of service (03/28/2021 through 04/03/2021). The clinical record failed to show documentation or evidence that the missed visit was communicated with the team, including the clinical manager. SN visit on 04/07/2021 showed Registered Nurse (RN) A documented the patient's FSBG was 537. RN A failed to report the out of range FSBG to the physician or to the clinical manager, RN A instead advised the patient to go to the emergency room. Review of the clinical record failed to show documentation or evidence that the patient went to the emergency room as advised by the RN A. Review of the clinical record showed an office note dated 04/08/2021, from the patient's attending physician, that was faxed to the agency on 04/08/2021, showed the following: -The patient presented 2 hours early, unaccompanied. The patient stated that he/she felt "terrible" but had no specific complaints. The patient does not know what his/her blood sugars were and does not know where his/her glucometer was; - The physician stated that he/she could not attest that the patient was getting his/her meds; and - The Plan: Increase Lantus (long-acting insulin, used to treat elevated blood glucose levels) to 65 units subcutaneous (under the skin) twice daily. Review of the clinical record showed no communication notes: - That the fax with the new order to increase the insulin was communicated with the team, until 04/15/2021(8 days after the FSBG was 537); and - That there was a new order written to increase the Lantus to 65 units subcutaneous twice daily. During an interview on 09/15/2021 at 9:58 AM, the clinical manager stated the following: - The agency staff discuss every patient once a week, but does not document the discussion; - RN A should have reported the patient #5's FSBG, but RN A did not share that information; - RN A would not ever say much about his/her patient's; and - He/she as the clinical manager was pulled to do skilled visits frequently as the agency did not have enough staff to cover the visits.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on current survey findings, policy review, and interview, the agency failed to assure that the clinical manager (CM)/director of nursing (DON) has effectively assumed responsibility for overall supervision and direction of skilled professional services and actively participated in all activities relevant to the professional services furnished, including assuring the development, implementation, and updates to the individualized plan of care. The deficient practice has the potential to affect all agency patients. Findings include: Review of the agency policy titled, "Clinical Manager (CM/DON)," dated revised 11/2017, showed in part, the following: - The agency employs a clinical manager who has appropriate education, experience and skills to oversee the professional activities of the agency; - The clinical manager ensures care delivery meets the needs of the patients and follows professional standards of practice. To accomplish this, the clinical manager: Participates in all activities relevant to service delivery and professional services furnished. Observes, supervises, counsels, and disciplines staff effectively. Monitors compliance with: applicable Federal, State, and local laws; Professional standards and principles; Established policies and procedures; and the plan of care. Ensures that services are available. Recommends resources needed to provide care; - The clinical manager or a qualified alternate is readily available at all times during operating hours. In the absence of the clinical manager, a nurse case manager as designated by the Administrator assumes these responsibilities; and - The clinical manager participates in all activities relevant to services furnished under arrangement or contract, including development of qualifications, assignment, coordination and integrity of care, supervision, and evaluation. Current survey findings showed, the CM/DON failed to: - Assure initial assessments were completed within 48 hours of referral or within 48 hours after the patients return home; - Assure reconciliation of medications were accurate; - Assure the comprehensive assessment was complete to include the patient's primary caregiver (s), if any, and other available supports, including their willingness and ability to provide care; - Assure all physician's orders were followed and all home visits were made as ordered; - Assure physicians were promptly notified of changes in the patient's condition; - Assure coordination of patient care was delivered to meet the patient's needs; - Assure acceptable standards of practice/infection control measures was being practiced; - Assure that the aide provided services that were included in the plan of care; and - Assure discharge summaries were sent to the patient's attending physician within five business days of the patient's discharge. During an interview on 09/15/2021 at 11:00 AM, the CM, stated that the agency was short staffed and therefore, he/she was having to go and do home visits and was not able to spend as much time on his/her duties.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to provide a discharge summary that included all necessary components was sent to the primary care physician after discharge within five business days of the patient's discharge in one (Record/Patient #6) of two discharge records reviewed. This deficient practice has the potential to adversely affect the post discharge care of all patients served by the agency. Findings included: Review of the agency policy, titled, "Discharge Summary," revised 12/2017, showed in part the following: -Each clinician who provided care will complete a discharge summary at the time his/her discipline is discharged, which may include, as appropriate: Admission date and date of discharge, including the date the physician and the patient were informed of the discharge. Physician responsible for the home health plan of care. Reason for admission to home health. The reason for discharge. Type of services provided and frequency of services. Laboratory data. Medications the patient is on at the time of discharge. Medical status at discharge, including continuing symptom management needs. The overall status of the patient and patient outcomes in meeting the goals in the plan of care. Patient and family post-discharge instructions; - The discharge summary and other relevant clinical record documents will be completed and submitted by the clinician within 72 hours from the date of the order for discharge from service; and - A copy of the discharge summary will be provided to the responsible physician or other health care professional who will be responsible for providing care and services after discharge from the agency within 5 business days of the patient's discharge. RECORD/PATIENT #6: Review of the clinical record showed that the patient was admitted to the agency on 06/30/2021 with a diagnosis of disruption of external operation (surgical) wound, with orders for skilled nursing and physical therapy. On 08/02/2021 the patient called the agency and requested no further visits from skilled nursing or physical therapy. Review of the discharge list the agency provided, showed the patient was discharged on 08/02/2021. Review of the discharge summary, dated 08/27/2021 (25 days after patient request for discharge), showed the patient was admitted on 06/30/2021 after a hospital stay where he/she had an exacerbation of CHF (congestive heart failure - chronic condition in which the heart doesn't pump blood as well as it should) and a right 5th toe amputation (surgical removal of). Skilled nurse provided assessment, wound care, and education on signs and symptoms of infection, falls prevention, diabetes and medication regimen and CHF. The patient's spouse was a nurse and performed wound care and foot care as ordered. The patient reported no pain while on service and no falls. Physical therapy evaluated and performed therapeutic exercise and activities to enhance patient strength to reduce fall risk. The patient improved so that he/she could be up ambulating with no assistive devices independently with increased gait and distance. The patient called the agency to request discharge with no further visits on 08/02/2021 with wound healed and independence reached. The discharge summary failed to include the medications the patient was on. Review of the fax status report showed two pages were sent to the patient's physician on 08/27/2021. The agency failed to send discharge summary within 5 business days of date of discharge. During an interview on 09/15/2021 at 10:25 AM, the clinical manager stated that the discharge summary was not sent in a timely manner to the patient's physician as he/she was busy and did not have time to complete and send the discharge summary.