Every finding on record at Wings Home Health Services LLC

Purpose of Visit: To conduct Re-Certification and Re-Licensure survey On 01/23/23 at 1:42 p.m., Surveyor conducted an unannounced visit, and an entrance conference was conducted with the Alt Adm. Census: Licensed & Certified- 0 Licensed Home Health Services - 0 Personal Assistance Services – 245 Adm-Administrator Alt-Alternate POC- Plan of Care TAC- Texas Administrative Code An exit conference was conducted on 01/27/23 at 4:10 p.m., with the Adm, Alt Adm, and Secretary. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Written instructions were provided for submitting a Plan of Correction within 10 days of receipt of the Statement of Deficiencies.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on record review and interview, the Agency's written emergency preparedness and response plan failed to include a continuity of operation business plan that addressed essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible for 2020,2021 and 2022.. This failure could place the agency’s active clients at risk of harm from the possibility of the agency being unable to function following a disaster. The Findings Included: Review of the Agency's Emergency Preparedness & Response Plan Manual included an agency form titled "Emergency Preparedness Policy Plan" which consisted of 31 pages identified by the Alt Adm as the agency’s Emergency Preparedness Plan. Continued review of the Emergency Preparedness & Response Plan Manual revealed a form titled "Business Continuity and Disaster Preparedness Plan" which consisted of 11 pages identified by the Alt Adm as the agency’s “Business Continuity Plan.” Review of the agency's Business Continuity and Disaster Preparedness Plan failed to reveal documentation of a continuity of operations business plan that addressed essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible for 2020,2021, and 2022. During an interview on 01/27/23 at 2:00 p.m. with the Adm and Alt Adm, Surveyor read Federal Regulation 484.102(a) and asked if the agency's Business Continuity and Disaster Preparedness Plan addressed essential functions for client services, critical personnel, and how to return to normal operations as quickly as possible for 2020,2021 and 2022. After review of the Business Continuity and Disaster Preparedness Plan, the Adm stated, “no, it’s not here.” Review of the agency's policy manual included a policy titled "Emergency Preparedness Policy and Plan” EC.8 dated 12/16/21. The policy revealed, in part: “…6. Agency leaders will develop the Business Continuity and Disaster Preparedness Plan which will be maintained in the Emergency Preparedness and Response Plan Manual to address the following: … c. Essential functions for patient services; d. Critical personnel, roles and responsibilities…h. How to return to normal operations as quickly as possible." …

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency's emergency preparedness and response plan failed to include current names and contact information for staff, other entities providing services under arrangement and patients' physicians. This failure could place the agency's patients at risk of harm from the possibility of the patient not having continuity of care in the event of a disaster. The findings included: Review of the agency’s Emergency Preparedness Policy and Plan read in Part: “E. Emergency Preparedness Planning for Natural and Manmade Disasters: …4. A Communication Plan will be developed and kept accurate and current that includes all of the following: a. Names and contact information for the following: i. Staff (updated with new and terminated staff throughout the year, contacts for staff and family members); ii. Entities identified providing services under arrangement; iii. Patient’s physicians or allowed practitioners involved in POC…” Further review of the agency’s Emergency Preparedness Policy and Plan failed to include names and contact information for staff, entities providing services under arrangement and patients' physicians. During an interview on 01/27/23 at 2:00 p.m. with the Adm and Alt Adm, Surveyor read Federal Regulation TAC 484.102(c) and asked if the agency’s Emergency Preparedness Policy and Plan included current names and contact information for staff, other entities providing services under arrangement and patients' physicians. After review of agency’s Emergency Preparedness Policy and Plan, the Adm stated, “I don’t see it here.”

Purpose of Visit: To conduct Re-Certification and a follow-up to survey dated 02/13/20 On 01/23/23 at 1:42 p.m., Surveyor conducted an unannounced visit, and an entrance conference was conducted with the Alt Adm. Census: Licensed & Certified- 0 Licensed Home Health Services - 0 Personal Assistance Services – 245 An exit conference was conducted on 01/27/23 at 4:10 p.m., with the Adm, Alt Adm, and Secretary. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Written instructions were provided for submitting a Plan of Correction within 10 days of receipt of the Statement of Deficiencies. Adm- Administrator Alt- Alternate Bid- twice a day Bpm-beats per minute DON- Director of Nurses ER- extended release H- hour Hcl-Hydrocholoride Hrs- hours LVN- Licensed Vocational Nurse Mg- milligrams (M0104)- identifier for the date of a referral on the OASIS o/a- observation and assessment OASIS- Outcome and Assessment Information Set otc- Over the counter PAM-Pamoate Po- by mouth POC- Plan of Care PRN- as needed Pt- patient Q/q- every RN- Registered Nurse Soc- Start of Care SN- Skilled Nurse Tab(s)- tablet(s) U-unchanged x- times

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: (This is a continuing deficiency previously cited at G-514 on 02/13/20.) Based on record review and interview, the agency failed to perform an initial assessment visit within 48 hours of referral for 2 of 7 discharged patients (#7 & #11) whose records were reviewed. This failure could potential to place the agency's active patients of the agency at risk for failure to have adequate care that is essential to the patient' health provided in a timely manner. The Findings Include: 1. Review of discharged Patient # 7's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 06/02/20 for the certification period of 06/02/20-07/31/20, that was signed and dated by Ex-Employee on 06/02/20. Discharged Patient #7's clinical record revealed a form titled, “[Agency Name] Referral and Face to Face Encounter Documentation” that revealed the patient was referred to agency on 05/29/20. Continued review of Discharged Patient # 7's clinical record revealed a document titled, "OASIS-D1 Start of Care" that revealed on section (M0104) Date of Referral: 05/29/20 which was signed and dated by Ex-Employee on 06/02/20. Review of Discharged Patient #7’s clinical record revealed no Initial Assessment documenting evidence that the patient was admitted within 48 hours of receiving the referral. During an interview concurrent with record review on 01/26/23 at 3:10 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if the patient was admitted within 48 hours of receiving the referral. DON stated, “no.” 2. Review of discharged Patient # 11’s clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 06/02/20 for the certification period of 06/02/20-07/31/20, that was signed and dated by Ex-Employee on 06/02/20. Review of Discharged Patient # 11's clinical record revealed a document titled, "OASIS-D1 Start of Care" that revealed on section (M0104) Date of Referral: 05/29/20 which was signed and dated by Ex-Employee on 06/02/20. Review of Discharged Patient #11’s clinical record revealed no Initial Assessment documenting evidence that the patient was admitted within 48 hours of receiving the referral. During an interview concurrent with record review on 01/26/23 at 3:50 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if the patient was admitted within 48 hours of receiving the referral. DON stated, “no.” Surveyor asked DON when the referral was received. DON stated, “05/29/20.” Review of the agency's policy manual included a policy titled "Initial Patient Comprehensive Assessment” PE. 3 dated 05/04/07. The policy revealed, in part: “…2. The initial visit will be conducted within 48 hours of referral or on the physician or allowed practitioner ordered star of care date.…”

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 clinical record review and interview, the agency failed to ensure the patient's received the services that were written in their individualized plans of care for 3 of 7 Discharged Patients (#6, #8 and #10) patient's whose records were reviewed. 1. LVN N did not perform fingerstick for blood glucose analysis q visit on Discharged Patient #6 as ordered on the POC. 2. LVN N did not instruct Discharged Patient #8 and/or caregiver as ordered on the POC. 3. LVN M and LVN N did not perform fingerstick for blood glucose analysis q visit on Discharged Patient #10 as ordered on the POC. Failure of the agency's skilled nurses to follow the plan of care placed the agency's patients at risk of receiving inadequate care and services and could have placed the patients at risk of negative outcomes. The findings included: 1. Review of Discharged Patient # 6's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 07/10/20 for the certification period of 07/10/20-09/07/20, that listed the principal diagnosis of Type 2 diabetes mellitus without complications (condition where the insulin your pancreas makes can’t work properly or can’t make enough insulin, causing high blood sugar levels). The POC listed a SN visit frequency of one time a week for one week, three times a week for one week and one time a week for six weeks. Review of Discharged Patient #6's POC included an order for the SN to perform fingerstick for blood glucose analysis q visit. Review of Discharged Patient # 6's clinical record revealed an SN visit note signed and dated by LVN N on 08/10/20 that did not include documentation of who performed a fingerstick for blood glucose analysis. Continued review of Discharged Patient #6’s clinical record revealed an SN visit note signed and dated by LVN N on 08/21/20 that revealed in part, “…Endocrine/Hematologic” section “Diabetes: Blood Sugars Performed By Caregiver, SN…” Discharged Patient #6’s clinical record did not include documented evidence that LVN N performed a fingerstick for blood glucose analysis q visit as per POC on SN visits dated 08/10/20 and on 08/21/20. During an interview concurrent with record review on 01/26/23 at 2:52 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if there was documentation of who checked the patient’s blood sugar on 08/10/20. DON stated, “no.” Surveyor then asked DON if there was documentation of who checked the patient’s blood sugar on 08/21/20. DON stated, “no.” Surveyor asked DON if the POC was being followed. DON stated, “no.” 2. Review of Discharged Patient # 8's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 08/16/19 for the certification period of 04/12/20-06/09/20, that listed the principal diagnosis of Unilateral primary osteoarthritis, left knee (a common form of arthritis that causes constant pain to the left knee only). The POC listed a SN visit frequency of two times a week for two weeks, and one time a week for seven weeks. Review of Discharged Patient # 8's POC included an order for the SN to instruct patient/caregiver on self- management of Hypertension, Osteoarthritis, and Hypothyroidism. Review of Discharged Patient # 8's clinical record revealed an SN visit note signed and dated by LVN N on 05/21/20 revealed in part, “… Interventions… S.N. instructed patient and caregiver on[RG(1] Hypertension…” Discharged Patient #8’s clinical record did not include documented evidence that LVN N instructed on self-management, signs or symptoms, or disease process of Hypertension for SN visit note dated 05/21/20. During an interview concurrent with record review on 01/26/23 at 3:24 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if there was documentation of teaching as per the POC for SN note dated 05/21/20. DON stated, “no.” 3. Review of Discharged Patient # 10's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 02/19/20 for the certification period of 06/18/20-08/16/20, that listed the principal diagnosis of Essential (primary) hypertension (abnormally high blood pressure often due to poor diet, obesity or family history). The POC listed a SN visit frequency of one time a week for nine weeks. LVN M and LVN N did not perform fingerstick for blood glucose analysis q visit on Discharged Patient #10 as ordered on the POC. Review of Discharged Patient #10’s clinical record revealed an SN noted signed and dated by LVN M on 06/22/20 that revealed in part, “…Endocrine/Hematologic” section “Diabetes: Blood Sugars Performed By Caregiver…” Continued review of Discharged Patient #10’s clinical record revealed an SN noted signed and dated by LVN N on 07/01/20 that revealed in part, “…Endocrine/Hematologic” section “Diabetes: Blood Sugars Performed By Caregiver…” Discharged Patient #10’s clinical record did not include documented evidence that LVN M and LVN N performed fingerstick for blood glucose analysis every visit as per POC for SN visit notes dated 06/22/20 and 07/01/20. During an interview concurrent with record review on 01/26/23 at 3:38 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if there was documentation that the SN checked the blood sugar every visit. Don stated, “no.” Review of the agency's policy manual included a policy titled "Responsibilities of the Director of Home Health" LD.6 and dated 05/04/07. The policy revealed, in part: “…9. Ensuring that a patient's Plan of Care is executed as written;” …

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: (This is a continuing deficiency previously cited at G-574 on 02/13/20.) Based on record review and interview, the agency failed to establish a written plan of care (POC) that included the required elements for 2 of 7 Discharged Patients (#6 and #11) whose records were reviewed in that: - The update to the POC failed to reveal orders for SN to observe and assess incision site every visit and report abnormal findings to MD/RN for Discharged Patient #6. - The update to the POC failed to reveal orders for patient-specific interventions and education regarding pain management and reporting pain >5 to RN/MD for Discharged Patient #6. - The POC failed to reveal orders for patient-specific interventions and education regarding pain management and reporting pain >5 to RN/MD for Discharged Patient #11. This failure placed all agency patients at risk of receiving inadequate care and services and could place the patients at risk of negative outcomes. The findings included: 1. Review of Discharged Patient # 6's clinical record revealed a form titled, "Home Health Certification and Plan of Care (Resumption of Care Following Hospital Stay" that revealed a start of care date as 07/10/20 for the certification period of 07/10/20-09/07/20, that listed the principal diagnosis of Type 2 diabetes mellitus without complications (condition where the insulin your pancreas makes can’t work properly or can’t make enough insulin, causing high blood sugar levels). The POC listed a SN visit frequency of one time a week for one week, three times a week for one week and one time a week for six weeks. Review of Discharged Patient #6’s clinical record revealed a form titled, “OASIS-D1 Resumption of Care” comprehensive assessment signed and dated by Ex-Employee on 07/17/20 that read in part: "Patient is post hospital status. Incision site clean and dry with no complications noted and no wound care to be performed. SN to o/a incision site and report any abnormal findings to MD/RN… Sn to o/a system q visit.” … Continued review of Discharged Patient #6’s “OASIS-D1 Resumption of Care” comprehensive assessment read in part: “Pain Assessment; Does patient have pain that interferes with activity? Yes; … Current Pain Intensity 5- Very distressing… Pain relief measures Massage, Medication Meditation, Reposition, and Rest… Pain status; Frequency of Pain interfering with patient’s activity movement: Less often than daily” … Review of the updated POC did not include documented evidence for SN to observe and assess incision site every visit and report abnormal findings to MD/RN for Discharged Patient #6. Continued review of the updated POC did not include documented evidence of orders for patient-specific interventions and education regarding pain management and reporting pain >5 to RN/MD for Discharged Patient #6. During an interview concurrent with record review on 01/26/23 at 2:52 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if there was an order on the POC to O/A incision site effective 07/17/20. DON stated, “I don’t see it here.” Surveyor then asked DON if there was an order for pain assessment and teaching. DON stated, “no.” 2. Review of Discharged Patient # 11's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 06/02/20 for the certification period of 06/02/20-07/31/20, that was signed and dated by Ex-Employee on 06/02/20. Review of Discharged Patient #11’s clinical record revealed a form titled, “OASIS-D1” comprehensive assessment signed and dated by Ex-Employee on 06/02/20 that read in part: “Pain Assessment; Does patient have pain that interferes with activity? Yes; ... Current Pain Intensity 4- Distressing… Pain relief measures Cold, Meditation, and Reposition… Pain status; Frequency of Pain interfering with patient’s activity movement: Daily, but not constantly” … Review of Discharged Patient #11's POC did not include documented evidence of orders for patient-specific interventions and education regarding pain management and reporting pain >5 to RN/MD. During an interview concurrent with record review on 01/26/23 at 3:50 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if the POC included teaching on pain. DON stated, “no.”

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal orders were documented in the patient's clinical record with signature, date and time order was written for 1 of 7 Discharged Patients (#10) whose records were reviewed. This failure could place the agency's patients at risk of receiving inadequate care and services and result in negative outcomes. The findings included: Review of Discharged Patient # 10's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 02/19/20 for the certification period of 06/18/20-08/16/20, that listed the principal diagnosis of Essential (primary) hypertension (abnormally high blood pressure often due to poor diet, obesity or family history). The POC listed a SN visit frequency of one time a week for nine weeks. Review of Discharged Patient #10’s clinical record revealed an SN noted signed and dated by LVN K on 07/14/20 revealed in the “Gastrointestinal” section “Last BM 07/11/2020; Abnormal bowel Stool: Constipation” Comment section revealed: “increase clear liquids, as per Dr. Y ordered otc stool softener.” Continued review of Discharged Patient #10’s clinical record revealed a form titled, “[Agency Name] Communication Note” noted signed and dated by LVN K on 07/14/20 that revealed in part, “…SN spoke to Identifier 50 from DR. Y’s office. DR Y ordered over the counter stool softener 3 x a day…” Continued review of Discharged Patient #10’s clinical record did not include documented evidence that LVN K submitted a telephone order regarding the verbal order given for the patient to take over the counter stool softener 3 x a day effective 10/14/20. During an interview concurrent with record review on 01/26/23 at 3:38 p.m. with DON, Surveyor and DON reviewed the above findings. Surveyor asked DON if there was documentation of an order effective 07/14/20 for otc stool softener 3 x a day. Don stated, “no.” Review of the agency's policy manual included a policy titled "Physician Orders" TX.5 and dated 09/17/18. The policy revealed, in part: “…H. All telephone or verbal orders will be written down, signed and dated with the date of receipt by a licensed nurse…” …

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure the patient’s medication list was updated to assure that all the drugs were indicated to identify ineffective drug therapy, drug side effects, actual or potential drug interactions, and duplicate drug therapy for 4 of 7 Discharged Patients (#7, #9, #,10 and #11) whose records were reviewed. This failure could place the agency's patients at risk for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy. The findings included: 1. Review of Discharged Patient # 7's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 06/02/20 for the certification period of 06/02/20-07/31/20, that was signed and dated by Ex-Employee on 06/02/20. Continued review of the “Home Health Certification and Plan of Care” revealed in part, “…Medications, There was no data for this section” … Review of Discharged Patient # 7's clinical record revealed a document titled, "OASIS-D1 Start of Care" that revealed a section titled, “Medication Status” that showed “Medications reconciled” was checked off. Continued review of Discharged Patient # 7's "OASIS-D1 Start of Care" revealed a section titled, “(M20001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? 0-No- No issues found during review” was checked off. Review of Discharged Patient #7’s clinical record revealed a medication profile that was not signed nor dated that include the following medications: -Seroquel (to treat certain mental/mood disorders) 400 mg oral tablet 1 tablet at bedtime by mouth (PO) - Quetiapine (for major depression/ bipolar disorder) 400 mg Extended Release 1 tablet at bedtime by mouth (PO) - Hydroxyzine Pamoate (helps with itching caused by allergies/ anxiety) 50 mg oral capsule 1 capsule at bedtime by mouth (PO) -Divalproex Sodium (for seizures/ mental/mood conditions) Extended Release 500 mg 1 tablet twice a day by mouth (PO) -Rexulti (for depression/mood/behavior) 4 mg oral tablet 1 tablet once daily by mouth (PO) Review of Discharged Patient #7’s clinical record revealed a medication profile that was signed and dated by LVN N on 07/01/20. Discharged Patient #7's clinical record did not include documented evidence that Ex-Employee updated the Medication Profile effective 06/02/20 to include medications patient was currently taking as listed in the 07/01/20 medication profile. During an interview concurrent with record review on 01/26/23 at 3:21 p.m. with DON and Alt Adm, surveyor and DON reviewed the above findings. The Alt Adm presented a medication profile that was not signed nor dated stating that Ex-Employee included the medications the patient was taking but did not sign the medication profile. The Alt Adm stated, “I believe what happened was that Ex-Employee didn’t sign the medication profile initially, then LVN N signed it on 07/01/20. Surveyor asked the DON if the POC dated 06/02/20- 07/31/20 included medications the patient was taking. DON stated, “no.” 2. Review of discharged Patient # 9's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 06/02/20 for the certification period of 06/02/20-07/31/20, that was signed and dated by Ex-Employee on 06/02/20. Continued review of the “Home Health Certification and Plan of Care” revealed in part, “…Medications - Aspirin 81 mg 1 tab daily by mouth (PO) Tylenol 500 mg oral tablet 1-2 tabs q 6H PRN Pain by mouth (PO)” Review of Discharged Patient #9’s clinical record revealed a form titled, “[software X] Medication Profile; List of Patient Medication Logs” that included the following: “User Name [sic]: Ex-Employee, Action Description: Medication Added for Patient Date: 07/05/20 at 5:44 PM and then updated again at 5:47 PM.” Discharged Patient #9's clinical record did not include documented evidence that Ex-Employee updated the Medication Profile effective 06/02/20 that included the following medications: Aspirin 81 mg 1 tab daily by mouth (PO) and Tylenol 500 mg oral tablet 1-2 tabs q 6H PRN Pain by mouth (PO) that the patient was currently taking. During an interview concurrent with record review on 01/26/23 at 3:28 p.m. with DON and Alt Adm , surveyor and DON reviewed the above findings. Alt Adm presented a medication profile log that included dates and times of medication entries. Surveyor asked DON if there was documentation of a signed Medication Profile on SOC that included medications the patient was currently taking. DON stated, “no.” 3. Review of discharged Patient # 10's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 02/19/20 for the certification period of 06/18/20-08/16/20, that was signed and dated by Ex-Employee on 06/15/20. Continued review of the "Home Health Certification and Plan of Care” for the certification period of 06/18/20-08/16/20 revealed the patient was taking the following medications: “Gabapentin (for pain) 300 mg Oral Capsule 1 tab bid by mouth (PO), Lisinopril (for high blood pressure)40 mg Oral Tablet 1 tab daily by mouth (PO), Metformin (for diabetes) 500 mg Oral Tablet 1tab bid by mouth (PO), Glimepiride (for diabetes) 4 mg Oral Tablet 1 tab bid by mouth (PO), Aspirin (this blood) 81mg 1 tab daily by mouth (PO), and Atorvastatin (lowers bad cholesterol) 10 mg Oral Tablet 1 tab 1 tab po [sic]” Review of Discharged Patient #10’s clinical record revealed an SN noted signed and dated by LVN N that revealed medications were reviewed and reconciled but did not mention any new medications noted at time of visit. Review of Discharged Patient #10’s clinical record revealed a form titled, “[Agency Name] Medication Profile” that was signed and dated by LVN N on 07/01/20 that included: “Gabapentin (for pain) 300 mg Oral Capsule 1 tab bid by mouth (PO), Lisinopril (for high blood pressure)40 mg Oral Tablet 1 tab daily by mouth (PO), Metformin (for diabetes) 500 mg Oral Tablet 1tab bid by mouth (PO), Glimepiride (for diabetes) 4 mg Oral Tablet 1 tab bid by mouth (PO), Aspirin (thins blood) 81 mg 1 tab daily by mouth (PO), Atorvastatin (lowers bad cholesterol) 10 mg Oral Tablet 1 tab 1 tab po [sic], Hydrocodone-Acetaminophen (for pain) 10 mg-325 mg oral tablet 10-325 mg 1 or 2 Q 8 hrs or PRN by mouth, Divalproex Sodium (for seizures or bipolar disorder) 500 mg oral delayed release tablet 1 tablet at bedtime by mouth (PO) and, Quetiapine Fumarate (for mental or mood conditions) 40 mg 1 Tablet twice a day by mouth (PO).” Continued review of Discharged Patient #10’s clinical record revealed an SN noted signed and dated by LVN K on 07/10/20 the revealed medications reconciled; Comment section included: “Hydrocodone-Acetaminophen (for pain) 10 mg-325 mg. 1- or 2-tab(s) Q 8 hrs as needed, Divalproex Sodium (for seizures or bipolar disorder) 500 mg. 1 tab at bedtime and, Quetiapine Fumarate (for mental or mood conditions) 40 mg. 1 tab twice a day” Continued review of Discharged Patient #10’s clinical record revealed an SN noted signed and dated by LVN K on 07/14/20 revealed in the “Gastrointestinal” section “Last BM 07/11/2020; Abnormal bowel Stool: Constipation” Comment section revealed: “increase clear liquids, as per Dr. Y ordered otc stool softener.” Further review of the SN noted signed and dated by LVN K on 07/14/20 revealed in the “Health Management” section “medication profile was reviewed, medications reconciled, and that there was New/Changed Medications in the home. Comment section included: Discovered Meds: 1) Hydrocodone-Acetaminophen 10-325 mg1 or 2 tablets Q 8 hrs or PRN. 2) Divalproex Sodium 500 mg 1 tablet at bedtime 3) Quetiapine Fumarate 400 mg 1 tablet twice a day” Discharged Patient #10’s clinical record did not include documented evidence that LVN K updated the Medication Profile effective 07/14/20 to include medications patient was currently taking. During an interview concurrent with record review on 01/26/23 at 3:38 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if there is documentation of an updated, signed Medication Profile on 07/14/20. DON stated, “no.” 4. Review of Discharged Patient # 11's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 06/02/20 for the certification period of 06/02/20-07/31/20, that was signed and dated by Ex-Employee on 06/02/20. Continued review of the “Home Health Certification and Plan of Care” revealed in part, “…Medications: Lisinopril 10 mg oral tablet 1 tablet daily by mouth (PO) U, Nexium 40 mg oral delayed release capsule 1 Cap daily by mouth (PO) U, and Naproxen 500 mg oral tablet 1 tablet twice daily 1- PO by mouth U.” Discharged Patient #11's clinical record did not include documented evidence that Ex-Employee updated the Medication Profile effective 06/02/20 to include medications patient was currently taking as per POC. During an interview concurrent with record review on 01/26/23 at 3:50 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if there was a signed medication profile on SOC. DON stated, “no.” Review of the agency's policy manual included a policy titled "Medication List and Monitoring” TX.16 dated 05/04/07. The policy revealed, in part: “…I. the Agency will maintain a current, accurate list of all prescription and over-the-counter medications taken by the client (Medication Profile) …”

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency assured communication with the physician’s involved in the care of a patient for 2 of 7 Discharged Patients (#7 and #9) whose records were reviewed. 1. SN failed to report Discharged Patient #7 with new medications found in the home. 2. SN failed to report Discharged Patient # 9’ heart rate > (greater than) 100 to the physician as ordered. This failure could place the agency's patients at risk for a delay in receiving care and could impede the effectiveness of the patients' plans of care and cause negative health outcomes. The findings included: Review of Discharged Patient # 7's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 06/02/20 for the certification period of 06/02/20-07/31/20, that was signed and dated by Ex-Employee on 06/02/20. Continued review of the “Home Health Certification and Plan of Care” revealed in part, “…Medications, There was not data for this section” … Review of Discharged Patient #7’s clinical record revealed an SN visit note signed and dated by LVN K on 07/14/20 read in part: “… Health Management; Review Medication Profile and Medications Reconciled; Comment section: Pt is currently taking the following medications: 1) Quetiapine 400 mg. ER 1 tablet at bedtime, 2) Hydroxzine [sic] PAM 500mg. 1 capsule at bedtime, 3) Divalproex sodium ER 500 mg. 1 tablet twice a day, 4) Rexulti 4mg. 1 tablet by mouth once daily.” Discharged Patient #7's clinical record did not include documented evidence that LVN K coordinated with the MD nor the RN to report new medications found in the home. During an interview concurrent with record review on 01/26/23 at 3:10 p.m. with DON, Surveyor and DON reviewed the above findings. Surveyor asked DON if there was documentation of coordination with the MD and RN. DON stated, “no.” 2. Review of discharged Patient # 9's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 06/02/20 for the certification period of 06/02/20-07/31/20, that was signed and dated by Ex-Employee on 06/02/20. Continued review of the “Home Health Certification and Plan of Care” revealed in part, “…Medications - Aspirin 81 mg 1 tab daily by mouth (PO) Tylenol 500 mg oral tablet 1-2 tabs q 6H PRN Pain by mouth (PO)” Review of Discharged Patient #9’s clinical record revealed a SN noted signed and dated by LVN K on 07/14/20 that included patient’s pulse rate of 103 bpm. Continued review of Discharged Patient #9’s SN noted signed and dated by LVN K on 07/14/20 that read in part: “… Health Management; Review Medication Profile; Medications Reconciled; and New/Changed Medications in the Home. Comment section: 1)Metformin HCL (for diabetes) 500 mg 1 tablet daily 2) Prazosin (for high blood pressure) 2 mg 1 tablet daily 3) Methylphenidate (for impulse control) 10 mg 1 tablet daily 4) Cyclobenzaprine (for pain and stiffness) 10 mg 1 tablet twice a day as needed for muscle spasms 5) Meloxicam (for pain and swelling) 15 mg 1 tablet daily 6) Lisinopril (for high blood pressure) 20 mg 1 tablet daily Discharged Patient #9's clinical record did not include documented evidence of coordination hat LVN K reported the pulse rate of 103 bpm and the new medications found at the patient’s home to the MD or RN. During an interview concurrent with record review on 01/26/23 at 3:28 p.m. with DON and Alt Adm, surveyor and DON reviewed the above findings. Surveyor asked DON if there is documentation of coordination with the MD and RN regarding the elevated heartrate of 103. DON stated, “no.” Surveyor then asked DON if there is documentation of coordination with MD and RN regarding the new medications found in the home. DON stated, “no.” Review of the agency's policy manual included a policy titled "Coordination of Care" TX.8 and dated 09/24/18. The policy revealed, in part: “…B. Agency will exchange information, report to and coordinate patient services among: 1. All agency personnel providing care and services… 2. All physicians involved in the POC… C…. This will be documented in the clinical record or on a communication note to serve as coordination of care…”

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: (This is a continuing deficiency previously cited at G-710 on 02/13/20.) Based on clinical record review and interview, the agency’s skilled nurses failed to provide services as ordered by the physician in the patient's POC for 3 of 7 Discharged Patients (#6, #8 and #10) patient's whose records were reviewed. 1. LVN N did not perform fingerstick for blood glucose analysis q visit on Discharged Patient #6 as ordered on the POC. 2. LVN N did not instruct Discharged Patient #8 and/or caregiver as ordered on the POC. 3. LVN M and LVN N did not perform fingerstick for blood glucose analysis q visit on Discharged Patient #10 as ordered on the POC. Failure of the agency's skilled nurses to follow the plan of care placed the agency's patients at risk of receiving inadequate care and services and could have placed the patients at risk of negative outcomes. The Findings Included: 1. Review of Discharged Patient # 6's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 07/10/20 for the certification period of 07/10/20-09/07/20, that listed the principal diagnosis of Type 2 diabetes mellitus without complications (condition where the insulin your pancreas makes can’t work properly or can’t make enough insulin, causing high blood sugar levels). The POC listed a SN visit frequency of one time a week for one week, three times a week for one week and one time a week for six weeks. Review of Discharged Patient #6's POC included an order for the SN to perform fingerstick for blood glucose analysis q visit. Review of Discharged Patient # 6's clinical record revealed an SN visit note signed and dated by LVN N on 08/10/20 that did not include documentation of who performed a fingerstick for blood glucose analysis. Continued review of Discharged Patient #6’s clinical record revealed an SN visit note signed and dated by LVN N on 08/21/20 that revealed in part, “…Endocrine/Hematologic” section “Diabetes: Blood Sugars Performed By Caregiver, SN…” Discharged Patient #6’s clinical record did not include documented evidence that LVN N performed a fingerstick for blood glucose analysis q visit as per POC on SN visits dated 08/10/20 and on 08/21/20. During an interview concurrent with record review on 01/26/23 at 2:52 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if there was documentation of who checked the patient’s blood sugar on 08/10/20. DON stated, “no.” Surveyor then asked DON if there was documentation of who checked the patient’s blood sugar on 08/21/20. DON stated, “no.” Surveyor asked DON if the POC was being followed. DON stated, “no.” 2. Review of Discharged Patient # 8's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 08/16/19 for the certification period of 04/12/20-06/09/20, that listed the principal diagnosis of Unilateral primary osteoarthritis, left knee (a common form of arthritis that causes constant pain to the left knee only). The POC listed a SN visit frequency of two times a week for two weeks, and one time a week for seven weeks. Review of Discharged Patient # 8's POC included an order for the SN to instruct patient/caregiver on self- management of Hypertension, Osteoarthritis, and Hypothyroidism. Review of Discharged Patient # 8's clinical record revealed an SN visit note signed and dated by LVN N on 05/21/20 revealed in part, “… Interventions… S.N. instructed patient and caregiver on Hypertension…” Discharged Patient #8’s clinical record did not include documented evidence that LVN N instructed on self-management, signs or symptoms, or the disease process of Hypertension for SN visit note dated 05/21/20. During an interview concurrent with record review on 01/26/23 at 3:24 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if there was documentation of teaching as per the POC for SN note dated 05/21/20. DON stated, “no.” 3. Review of Discharged Patient # 10's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 02/19/20 for the certification period of 06/18/20-08/16/20, that listed the principal diagnosis of Essential (primary) hypertension (abnormally high blood pressure often due to poor diet, obesity or family history). The POC listed a SN visit frequency of one time a week for nine weeks. LVN M and LVN N did not perform fingerstick for blood glucose analysis q visit on Discharged Patient #10 as ordered on the POC. Review of Discharged Patient #10’s clinical record revealed an SN noted signed and dated by LVN M on 06/22/20 that revealed in part, “…Endocrine/Hematologic” section “Diabetes: Blood Sugars Performed By Caregiver…” Continued review of Discharged Patient #10’s clinical record revealed an SN noted signed and dated by LVN N on 07/01/20 that revealed in part, “…Endocrine/Hematologic” section “Diabetes: Blood Sugars Performed By Caregiver…” Discharged Patient #10’s clinical record did not include documented evidence that LVN M and LVN N performed fingerstick for blood glucose analysis every visit as per POC for SN visit notes dated 06/22/20 and 07/01/20. During an interview concurrent with record review on 01/26/23 at 3:38 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if there was documentation that the SN checked the blood sugar every visit. Don stated, “no.” Review of the agency's policy manual included a policy titled "Plan of Care" TX.6 and dated 08/22/17. The policy revealed, in part: “…E. Services are to be furnished according to a written plan of treatment…”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals prepared clinical notes for 3 of 7 Discharged Patients (#6, #7and #9) patient's whose records were reviewed. This failure prevents the agency from ensuring patient services are provided and the needs are met and could place all agency patients as risk of harm. The findings included: 1. Review of Discharged Patient # 6's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 07/10/20 for the certification period of 07/10/20-09/07/20, that listed the principal diagnosis of Type 2 diabetes mellitus without complications (condition where the insulin your pancreas makes can’t work properly or can’t make enough insulin, causing high blood sugar levels). The POC listed a SN visit frequency of one time a week for one week, three times a week for one week and one time a week for six weeks. Review of Discharged Patient # 6's clinical record revealed the following incomplete note dated 07/20/20 that included a section titled, “Time in and Time” which was assigned to LVN L. Continued review of Discharged Patient # 6's clinical record revealed a from titled, “Software X” that included a scheduled visit dated 07/20/20 for LVN L that read, “Reopened (note was opened and sent back to SN to complete visit note).” Further review of Discharged Patient # 6's clinical record revealed the following note dated 07/24/20 which was assigned to LVN L. Continued review of Discharged Patient # 6's clinical record revealed a from titled, “Software X” that included a scheduled visit dated 07/24/20 for LVN L that read, “Returned for Review (note was sent back to SN to complete visit note).” Review of clinical record failed to reveal documented evidence the SN notes dated 07/20/20 and 07/24/20 were accurate, complete, and in the patient’s record within 14 days as required by the agency policy. During an interview concurrent with record review on 01/26/23 at 2:52 p.m. with DON, surveyor and DON reviewed the above findings. Surveyor asked DON if the SN note dated 07/20/20 was accurate and complete. DON stated, “no.” Surveyor then asked DON if the SN note dated 07/24/20 was complete and in the record within 14 days. DON stated, “no.” 2. Review of Discharged Patient # 7's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 06/02/20 for the certification period of 06/02/20-07/31/20, that was signed and dated by Ex-Employee on 06/02/20. Review of Discharged Patient # 7's clinical record revealed the following notes dated, 06/04/20,06/08/20, 06/12/20 and 06/22/20 which were scheduled for LVN M. Continued review of Discharged Patient # 7's clinical record revealed a from titled, “Software X” that included scheduled visits dated 06/04/20,06/08/20, 06/12/20 and 06/22/20 for LVN M that read, “Not Yet Started (notes were never started by visiting nurse).” Review of the record failed to reveal documented evidence that SN notes dated 06/04/20,06/08/20, 06/12/20 and 06/22/20 were completed and in the clinical record within 14 days as required by agency policy. Continued review of Discharged Patient # 7's clinical record revealed a from titled, “Software X” that included scheduled LVN/LPN Supervisory visits dated 07/02/20 and 07/27/20 which were assigned to Ex-Employee that read, “Submitted with Signature (note was submitted to agency, but it was not approved to show it was completed and in the record within 14 days).” Review of the record failed to reveal documented evidence that LVN/LPN Supervisory visit notes dated 07/02/20 and 07/27/20 were completed and in the clinical record within 14 days as required by agency policy. During an interview concurrent with record review on 01/26/23 at 3:10 p.m. with DON, Surveyor and DON reviewed the above findings. Surveyor asked DON if notes dated 06/04/20,06/08/20, 06/12/20 and 06/22/20 were completed and in the clinical record within 14 days. DON stated, “no.” Surveyor then asked DON if the Supervisory visit notes dated 07/02/20 and 07/27/20 were completed and in the clinical record within 14 days. DON stated, “no.” 3. Review of discharged Patient # 9's clinical record revealed a form titled, "Home Health Certification and Plan of Care" that revealed a start of care date as 06/02/20 for the certification period of 06/02/20-07/31/20, that was signed and dated by Ex-Employee on 06/02/20. Review of Discharged Patient # 9's clinical record revealed the following notes dated, 06/04/20,06/08/20, 06/12/20 and 06/22/20 which were scheduled for LVN M. Continued review of Discharged Patient # 9's clinical record revealed a from titled, “Software X” that included scheduled visits dated 06/04/20,06/08/20, 06/15/20 and 06/22/20 for LVN M that read, “Not Yet Started (notes were never started by visiting nurse).” Review of the record failed to reveal documented evidence that SN notes dated 06/04/20,06/08/20, 06/12/20 and 06/22/20 were completed and in the clinical record within 14 days. Continued review of Discharged Patient # 9's clinical record revealed a from titled, “Software X” that included scheduled LVN/LPN Supervisory visits dated 07/02/20 and 07/27/20 which were assigned to Ex-Employee that read, “Submitted with Signature (note was submitted to agency, but it was not approved to show it was completed and in the record within 14 days).” Review of the record failed to reveal documented evidence that LVN/LPN Supervisory visit notes dated 07/02/20 and 07/27/20 were completed and in the clinical record within 14 days. During an interview concurrent with record review on 01/26/23 at 3:28 p.m. with DON, Surveyor and DON reviewed the above findings. Surveyor asked DON if notes dated 06/04/20, 06/08/20, 06/12/20 and 06/22/20 were completed and in the clinical record within 14 days. DON stated, “no.” Surveyor then asked DON if the Supervisory visit notes dated 07/02/20 and 07/27/20 were completed and in the clinical record within 14 days. DON stated, “no.” Review of the agency's policy manual included a policy titled "Medical Record Content” IM.8 dated 12/30/12. The policy revealed, in part: “…A. Agency will retain an accurate and complete medical record for each patient receiving care…” … Review of the agency's policy manual included a policy titled "Timelines” IM.10 dated of 06/12/19. The policy revealed, in part: “…F. All clinical record information will be incorporated into the patient’s medical record within 14 business days.” …