Every finding on record at Zion Rock Services LLC

An Emergency Preparedness Survey was initiated with the Administrator on 09/12/2024 at 12:00 PM. Census: Licensed and Certified- 4 Licensed Home Health- 2 Personal Assistance Services- 3 An exit conference was conducted with the Administrator on 09/16/2024 at 2:45 PM. The preliminary findings were discussed. The agency was given an opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Acronyms used: ERPREP- Emergency Preparedness

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct exercises and test the emergency plan annually when it was not tested during an actual emergency response for three of three years reviewed (2021, 2022 and 2023). This failure did not allow for the agency to determine the effectiveness and appropriateness of its ERPREP Plan if an emergency occurred that affected agency operations and client care outcomes. FINDINGS INCLUDE: A review of the ERPREP binder and documents provided to the surveyor on 09/16/2024 revealed a drill dated 01/31/2024 for an annual fire drill exercise for the agency office. The drill included, “… Reason Implemented: Annual Fire Drill Exercise … Nature of Events: Disaster Coordinator explained the importance of safety and emergency preparedness when all was in order. Employees were asked to return to office. Evaluation: The annual fire drill exercise was a success because all employees cooperated, … Completed by: (Alternate Administrator), dated 1/31/2024.” The fire drill was not community-based or individual facility based and did not contain information that would affect client care outcomes. No additional drills were found to review in the ERPREP binder. In an interview with the Administrator on 09/16/2024 at 2:22 PM, the surveyor asked if there were any ERPREP drills performed for 2021, 2022 and 2023. The Administrator looked in the ERPREP binder and could not find any more drill. The surveyor asked why the agency failed to make sure it conducted a drill which was patient centered for 2021, 2022 and 2023. The Administrator stated, “It was missed.” The surveyor asked how it affected patient care outcomes if the ERPREP drill were not conducted. The Administrator stated, “The patients may not be safe in case of an emergency.” Agency policy, dated 01/13/18, quoted in part, “EMERGENCY PREPAREDNESS AND RESPONSE PLAN, ED.8, … III. Preparedness, A. Administrative staff responsibilities … 2. Training and testing … e. The agency will conduct two (2) exercised to test the emergency plan at least annually. The agency will do the following: (1) Participate in a full-scale exercise that is community-based. If a community-based exercise is not accessible, an individual, facility-based exercise will be conducted….”

A Recertification Survey was initiated with the Administrator on 09/12/2024 at 12:00 PM. Census: Licensed and Certified- 4 Licensed Home Health- 2 Personal Assistance Services- 3 An exit conference was conducted with the Administrator on 09/16/2024 at 2:45 PM. The preliminary findings were discussed. The agency was given an opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Acronyms used: Pt.- Patient POC- Plan of Care SN- Skilled Nurse RBS- Random Blood Sugar DON- Director of Nurses SNV- Skilled Nurse 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 record review and interview, the agency failed to ensure that a patient received home health services as ordered in the individualized POC for 1 (Patient #1) of 7 patient records reviewed. Out of parameter range blood sugar readings were not reported to the physician for Patient #1. This failure potentially placed patients at risk of not receiving life sustaining interventions when needed to prevent complications, and a decline in the patients’ health status. FINDINGS: Patient #1: Review of the record revealed a POC dated 07/15/2024 to 09/12/2024 with a SOC date 07/15/2024. The POC listed the following diagnoses: Diabetes Mellitus 2 with hyperglycemia (high blood sugar); Hypertension; Infection of the skin; Anxiety and Chronic pain. The POC listed physician orders for SN visits once a week for one week, then twice a week for eight weeks. The SN was to notify the physician of a Random Blood Sugar reading greater than 140 or less than 70. Record review revealed the following SN visits conducted by the DON included RBS readings above 140: 07/24/24—178 07/30/24—175 08/01/24—154 08/05/24—149 08/12/24—189 08/15/24—160 08/22/24—145 08/26/24—147 08/29/24—187 09/05/24—158 In an interview with the DON on 09/16/2024 at 1:45 PM, the surveyor asked if the supervising nurse was the primary nurse providing care for Patient #1. The DON stated, “yes.” The surveyor asked who set the patient’s blood sugar parameters. The DON stated, “I did.” The surveyor asked if the physician was consulted on the parameters prior to the POC. The DON said, “No.” The surveyor reviewed the referral orders with the DON and the physician did not specify any RBS parameters. The surveyor asked if the physician was notified when the RBS results breached the parameters during the SN visits. The DON stated, “No, because the patient looked okay and I was thinking it wasn’t too high yet. I missed calling the doctor.” The surveyor asked how it might affect patient care and outcomes if the doctor was not notified of changes in the patient’s condition. The DON stated, “It could jeopardize the patient’s care and outcomes.”

A Recertification survey entrance conference was conducted on 08/25/2021 with the Adm at 10:00 AM. Written information regarding "What to Expect During Your Agency's Survey" was provided. Census L&CHHS: 28 PAS: 14 An exit conference was conducted on 09/03/2021 with the Adm and Alternate Adm/PAS Supervisor at 3:00 PM. The preliminary findings were discussed. The agency was found in compliance with 42 CFR Part 484.22 Medicare Conditions of Participation and no deficiencies were cited. ABBREVIATIONS: Adm - Administrator CFR - Code of Federal Regulations L&CHHS - Licensed and Certified Home Health PAS - Personal Assistance Services

A Recertification survey entrance conference was conducted on 08/25/2021 with the Adm at 10:00 AM. Written information regarding "What to Expect During Your Agency's Survey" was provided. Census L&CHHS: 28 PAS: 14 An exit conference was conducted on 09/03/2021 with the Adm and Alternate Adm/PAS Supervisor at 3:00 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. ABBREVIATIONS: Adm - Administrator CFR - Code of Federal Regulations CMS - Centers for Medicare and Medicaid Services D/C - discharge Dc'd - discharged Dr - Doctor d/t - due to DON - Director of Nurses EMR: electronic medical record FSBS- finger stick blood sugar HHA - Home Health Agency HMO - Health Maintenance Organization L&CHHS - Licensed and Certified Home Health Services MD- Medical Doctor NOMNC - Notice of Medicare Non-Coverage OASIS- Outcome and Assessment Information Set OSHA - Occupational Safety and Health Administration PAS- Personal Assistance Services PAD - Peripheral Arterial Disease POC - plan of care PVD - Peripheral Vascular Disease QIO - Quality Improvement Organization RN - registered nurse SN - skilled nurse UTI - Urinary Tract Infection

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care, in three of three (Patients 5, 6 and 7) DC'd patient records reviewed whose reason for DC was goals met. The agency failed to provide the completed CMS form titled, "Notice of Medicare Non-Coverage". The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-DC needs and could prevent the patients from exercising the right to appeal the DC decision, if desired. FINDINGS INCLUDE: A patient DC list with DC reason was given to the surveyor by the Adm on 08/25/2021. The DC list included the DC date of 01/29/2021 for Patient 5, 04/01/2021 for Patient 6 and 05/19/2021 for Patient 7. The DC list included the reason for DC as goals met for Patient 5, 6 and 7. Patient 5: Record review of the EMR included a POC dated 01/07/2021 to 03/07/2021 that was electronically signed by RN A on 01/07/2021. The record contained a DC OASIS visit that was electronically signed by RN A on 01/29/2021 with the reason for DC as goals met. The EMR did not show that Patient 5 received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 01/29/2021. The record did not include a written NOMNC. During an interview with the Adm and RN A (via telephone) on 09/03/2021 at approximately 12:45 PM, the surveyor asked why the agency had not provided written notice of the intent to discharge with the completed NOMNC form no later than two days in advance of terminating on-going care for Patient 5. RN A stated that all she could think of was the agency was unable to contact Patient 5 because he was transient with his living arrangements. Patient 6: Record review of the EMR included a POC dated 02/01/2021 to 04/01/2021 that was electronically signed by RN B on 02/01/2021. The record contained a DC OASIS visit that was electronically signed by RN B on 04/01/2021 with the reason for DC as goals met. The EMR did not show that Patient 6 received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 04/01/2021. The record did not include a written NOMNC. During an interview with the Adm and RN B (via telephone) on 09/03/2021 at approximately 12:00 PM, the surveyor asked why the agency had not provided written notice of the intent to discharge with the completed NOMNC form no later than two days in advance of terminating on-going care for Patient 6. The Adm stated the Medicare HMO only approved four visits and the NOMNC was not given because of the insurance denying additional visits. Patient 7: Record review of the EMR included a POC dated 05/21/2021 to 07/19/2021 that was electronically signed by the RN B on 05/20/2021. The record contained a DC OASIS visit that was electronically signed by RN B on 07/19/2021 with the reason for DC as goals met. The record contained a written NOMNC that read in part, " ...The effective date coverage of your current home health services will end: ..." The date was blank and did not indicate the effective date the current home health services were ending. The NOMNC was signed and dated by Patient 7 on 07/19/2021, the same day of DC. The EMR did not show that Patient 7 received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 07/19/2021. During an interview with the Adm and RN B (via telephone) on 09/03/2021 at approximately 1:06 PM, the surveyor asked if Patient 7 was DC'd on 05/19/2021 per the agency DC list or on 07/19/2021. The Adm stated 07/19/2021. The surveyor asked why the agency had not provided written notice of the intent to discharge with the completed NOMNC form no later than two days in advance of terminating on-going care for Patient 7. RN B stated she did not have the form with her when Patient 7 was notified of the upcoming DC. Agency policy titled, "PATIENT/CLIENT TRANSFER AND DC NOTICES PE.6" with a revision date of 01/13/2018 read in part, " ... PURPOSE To provide guidance on completion of the required ...discharge notices... POLICY I. Prior to ...discharging a patient/client, the Agency will provide written notification to the patient/client or the patient's/client's parent, family, spouse, significant other or legal representative ...Notification will be provided in accordance with state and federal regulations ...III. The Agency will deliver the Notice of Medicare Non-Coverage ...to the patient/client (or authorized representative), at least two (2) calendar days before Medicare covered services end ...C. The Agency will keep the following in the patient's/client's file: 1. A copy of the written notification provided to the patient/client or their parent, family, spouse, significant other, or legal representative ... II. Notice of Medicare Non-Coverage (NOMNC) ... A. Agency staff will provide valid delivery notice (involves both delivery and completion) of the NOMNC to the patient/client (or their representative) when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. B. At least two (2) calendar days before Medicare covered services end...the Agency representative will provide the NOMNC to the patient/client ...C. If the Agency fails to give valid notice, patient/client coverage continues for at least two (2) days after the notice is received ...I. The Agency will have the patient/client (or their representative) complete and sign the NOMNC. The patient/client or representative should sign and date two copies, keep one, and return a copy to the Agency ..." Regulation: July 1, 2005, the new Medicare regulations, Benefits Improvement and Protection Act gave beneficiaries access to the new expedited determination process when their home health agency services were ending. There were two notices required by these regulations. The first was a generic notice called a Notice of Medicare Provider Non-coverage labeled "FORM No. CMS 10123" that the provider would be delivered at least two days prior to when a beneficiary's Medicare coverage of services was ending. The telephone number for the QIO was to be included in the notice. The second was a detailed notice, called a Detailed Explanation of Provider Non-Coverage that the provider would deliver to the beneficiary and the appropriate QIO only if the beneficiary requested an expedited review by the QIO of the decision that coverage for items and/or services should end.

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 record review and interview, the agency failed to develop a POC that covered all required elements for all patients. In one of one (Patient 1) record reviewed where the patient had a pressure ulcer and suprapubic urinary catheter, the POC failed to include: orders for the nurse to assess the pressure ulcer and suprapubic catheter site for signs and symptoms of infection and complications; the wound care clinic where the patient received wound care; the patient's wound care physician; and safety measures to protect against injury to the pressure ulcer and suprapubic catheter site. In one of one (Patient 2) record reviewed where the patient had a diagnosis of chronic pain, the POC failed to include unacceptable pain levels to report to the physician. In one of one (Patient 3) record reviewed where the patient had a diagnosis of diabetes mellitus, the POC failed to include orders for the nurse to assess the patient's blood sugar by performing a FSBS and to include all pertinent diagnoses. In one of one (Patient 4), the POC failed to include goals identified by the HHA. The failure of the agency to ensure that the POC included all patient-specific orders resulted in patients being placed at risk of harm for failure of agency staff to address the patients' risk factors and type of services needed for appropriate care. Findings Include: Definitions: Pressure Ulcer: injuries to skin and underlying tissue resulting from prolonged pressure on the skin that most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone. [also called bedsores / decubitus ulcers]. Suprapubic urinary catheter: A catheter that permits direct urinary drainage from the bladder through the lower abdominal wall from a surgically fashioned opening located just above the pubic symphysis. Patient 1: Record review of the EMR included a POC dated 06/08/21 to 08/06/2021 electronically signed by RN A on 06/07/2021 that included a diagnosis of pressure ulcer to heel and encounter for attention to artificial opening of urinary tract. The POC did not include: orders for the nurse to assess the pressure ulcer and suprapubic catheter site for signs and symptoms of infection and complications; the wound care clinic where the patient received wound care; the patient's wound care physician; and safety measures to protect against injury to the pressure ulcer and suprapubic catheter site. During an interview with the Adm and RN A (via telephone) on 09/03/2021 at approximately 12:35 PM, the surveyor asked why the POC did not include orders for the nurse to assess the pressure ulcer and suprapubic catheter site for signs and symptoms of infection and complications and safety measures to protect against injury to the pressure ulcer and suprapubic catheter site. RN A stated she forgot to include pressure ulcer and suprapubic catheter information and interventions on the POC. The surveyor asked why the POC did not include the wound care clinic where the patient received wound care and the patient's wound care physician. RN A stated Patient 1 was supposed to follow-up with the wound care clinic but had not been compliant with making appointments and that Patient 1's spouse had cancelled several wound care clinic appointments. Patient 2: Record review of the EMR included a POC dated 05/26/21 to 07/24/2021 electronically signed by RN B on 05/26/2021 that included a diagnosis of multiple sclerosis and chronic pain. The POC did not include unacceptable pain levels to report to the physician. The record included a start of care assessment conducted by RN B on 05/26/2021 that read in part, " ...Frequency of Pain Interfering with patient's activity or movement ...Daily, but not constantly ... Location of Pain: back ...Intensity of pain: 5 ... Medication effectiveness: minimal ... Frequency of Pain Interfering with patient's activity or movement ...Daily ..." During an interview with the Adm, the DON and RN B (via phone) on 09/03/2021 at approximately 12:00 PM, the surveyor asked why the POC did not include unacceptable pain levels to report to the physician. RN B stated Patient 2 received only therapy services. The Adm stated it was a therapy case only. Patient 3: Record review of the EMR included a POC dated 06/25/2021 to 08/23/2021 electronically signed by RN B on 06/25/2021 that included diagnoses of: Morbid obesity due to excess calories, Lymphedema, Type 2 diabetes mellitus, Long term use of insulin, and hypertension. The record included a start of care assessment conducted by RN B on 06/25/2021 that read in part, " ...(M1028) Active Diagnoses ...Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD) ... Blood Sugar 136 ...Blood sugar checked by: SN ..." The record included a nurse note signed by RN B for a visit conducted on 07/02/2021 that read in part, " ...FSBS obtained via left 3rd finger in aseptic manner. Sharps disposed PER osha Guideline and patient tolerated procedure well ..." The record included nurse notes signed by RN B for visits conducted on 07/02/2021, 07/07/2021, 07/14/2021, 07/21/2021, 07/28/2021, 08/04/2021 and 08/11/2021 that read in part, " ... edema to bilateral ankle with cellulitis ..." The record included a nurse note signed by RN B for a visit conducted on 08/11/2021 that read in part, " ...Patient cellulitis getting worst (sic) again. Dr ...notified ..." The record included a communication note sent to the physician signed by RN B on 08/11/2021 that read in part, " ...visited patient today ...Upon assessment SN noted her lower legs (sic) cellulitis is coming back... May we get order or any new recommendation to manage cellulitis to bilateral lower leg ..." The record included a recertification assessment conducted by RN B on 08/20/2021 that read in part, " ...Blood Sugar 152 ...Blood sugar checked by: SN ... Patients bilateral ankle looks red again, MD was notified. MD started patient on Bactrim DS and amoxicillin ..." The POC failed to include orders for the nurse to assess the patient's blood sugar by performing a FSBS and to include a diagnosis cellulitis. During an interview with the Adm, the DON and RN B (via telephone) on 09/03/2021 at approximately 11:00 AM, the surveyor reviewed the start of care assessment conducted on 06/25/2021 and asked why PVD or PAD were not included as a diagnosis on the POC. RN B stated that Patient 3 had cellulitis, not PVD. The surveyor asked why cellulitis was not included as a diagnosis on the POC. RN B stated, "I know I put that diagnosis in, but I don't know what happened ..." The surveyor asked why the POC did not include orders for the nurse to assess the patient's blood sugar by performing a FSBS. RN B stated Patient 3 checked the blood sugar in front of RN B and then RN B documented the result. The surveyor asked if RN B performed a FSBS on any SN visit. RN B stated she assisted Patient 3 in checking the blood sugar. Patient 4: Record review of the EMR included a POC dated 06/04/21 to 08/02/2021 electronically signed by RN B on 06/01/2021. The POC did not include measurable outcomes and goals identified by the HHA and the patient. During an interview with the Adm, the DON and RN B (via telephone) on 09/03/2021 at approximately 11:40 AM, the surveyor asked why the POC did not include measurable outcomes and goals identified by the HHA and the patient. RN B stated she was only starting the long-term care program for Patient 4. The Adm stated Patient 4 was a therapy only patient. Agency Policy titled, "PLAN OF CARE PC.8" with a revision date of 11/02/2020, read in part, "PURPOSE To ensure that care provided is appropriately planned in a timely manner to meet the patient's/client's specific needs and problems ...PROCEDURE III. Each patient/client 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/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care..The individualized plan of care must include the following: 1. All pertinent diagnoses ... 3. The types of services, supplies, and equipment required ... 10. All medications and treatments ... 11. Safety measures to protect against injury ... 14. Patient/client-specific interventions ... 15. Measurable outcomes and goals identified by the Agency and the patient/client..."

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 record review and interview, the agency failed to complete and send completed DC and transfer summaries. In three of three (Patient 5, 6 and 7)) records reviewed, a discharge summary was not sent to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after DC within 5 business days. In one of one (Patient 1) record reviewed, a transfer summary was not completed and sent to the hospital within two business days after becoming aware of an unplanned transfer and hospital admission. The failure placed patients at risk of negative outcomes, patient/caregiver receiving post-DC instructions, and the physician and hospital from ensuring patient services were provided and patient needs were met. FINDINGS INCLUDE: Patient 1: Record review of the EMR included a POC dated 06/08/21 to 08/06/2021 electronically signed by RN A on 06/07/2021. The EMR included a Communication Note electronically signed and dated by RN A on 07/04/2021 that read in part, " ...The patient's wife informed SN that the patient has been admitted to the hospital d/t Suprapubic catheter malfunction with UTI ..." The EMR included an OASIS form titled, "Transfer Inpatient Facility" that included Patient 1 had an unplanned transfer and hospital admission on 07/04/2021 due to an UTI. The record did not include a transfer summary. During an interview with the Adm and RN A (via telephone) on 09/03/2021 at approximately 12:35 PM, the surveyor asked why a transfer summary was not completed and sent to the hospital within two business days after becoming aware of the unplanned transfer and hospital admission. RN A stated at times the agency does not know a patient transferred to the hospital and it is difficult to keep up with what the patients are doing from day to day. Patient 5: Record review of the EMR included a POC dated 01/07/2021 to 03/07/2021 that was electronically signed by RN A on 01/07/2021. The record contained a DC OASIS that was electronically signed by RN A on 01/29/2021 that included a DC Summary that read in part, " ...Discharge from Home Health Service ..." The DC Summary did not indicate the form was sent to the physician. Patient 6: Record review of the EMR included a POC dated 02/01/2021 to 04/01/2021 that was electronically signed by RN B on 02/01/2021. The record contained a DC OASIS visit that was electronically signed by RN B on 04/01/2021 that included a DC Summary that read in part, " ...Discharge from Home Health Service ..." The DC Summary did not indicate the form was sent to the physician. Patient 7: Record review of the EMR included a POC dated 05/21/2021 to 07/19/2021 that was electronically signed by the RN B on 05/20/2021. The record contained a DC OASIS visit that was electronically signed by RN B on 07/19/2021 that included a DC Summary that read in part, " ...Discharge from Home Health Service ..." The DC Summary did not indicate the form was sent to the physician. During an interview with the Adm on 09/03/2021 at approximately 12:00 PM, the surveyor asked why the agency did not send the DC Summary for Patient 5, 6 and 7 to the physician. The Adm stated the agency sent orders, but not the DC summary. Agency policy titled, "PATIENT/CLIENT TRANSFER, DISCHARGE AND AGENCY DISSOLUTION PE.5" with a revision date of 01/13/2018 read in part, "... PROCEDURE ...I. Transfer or Transfer and Discharge ...H. The Agency will provide the receiving agency or facility with a transfer summary ...II. Discharge ... J. A completed discharge summary will be sent to the primary care physician or other health care professional who will be responsible for providing care and services to the patient/client after discharge from the Agency ...within (5) business days of the patient's/client's discharge ..."