Medical Home Care Professionals

“Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This Standard is not met as evidenced by: Based on interview, and record review, this agency failed to ensure two of 17 sampled patients (Patient 6, and Patient 13), were assessed by a registered nurse within 48-hours of their referral for home health care, and notify the physician when there was a delayed in their start of care (admission to agency). These failures could result in changes to care without physician knowledge or approval, and a lack of adequate physician oversight leading to potential negative clinical outcomes. A review of Patient 13’s “Plan of Care,” dated 8/22/23, indicated Patient 13 was admitted to the agency on 8/22/23 with the diagnosis of hypotension (low blood pressure) and encounter for fitting and adjustment of urinary device (Foley catheter, a tube that went from the bladder to a bag that collected urine). During a concurrent interview and record review on 2/23/24 at 3:13 pm, with DPS, Patient 13’s referral packet to home health was reviewed. DPS stated, the referral packet included a “Face-to-Face Encounter,” dated 8/17/23, that indicted Patient 13 required home health services from skilled nursing and physical therapy. DPS stated the agency had 48-hours from the referral date to open a patent to home health services and confirmed Patient 13 was opened to home health on 8/22/23, two days late. Findings: The agency’s policy titled, “Initial and Comprehensive Assessment,” dated 2017, was reviewed and indicated, that an initial assessment visit must be performed either within 48-hours of the referral, 48-hours of the patient’s return home, on the start of care date ordered by the physician, or at the patient/family request with the approval of the physician. During a review of Patient 6’s clinical record, Patient 6 was admitted to the home health agency with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a progressive disease of damaged lungs), a cerebrovascular accident (stroke), and left foot wound (any disruption of the intact skin with underlying damage to the tissues). Patient 6 was referred to home health for skilled nursing for wound care for an open wound to the left foot. During a review, of Patient 6’s visit documentation, it was noted that Patient 6 was referred to services on 11/8/23, but the start of care (initial comprehensive assessment) date was 11/14/23 (6 days later). There was no documentation, that the physician had been notified of this delay in the start of care. During a concurrent record review, and interview, on 2/20/24 at 11:20 am, the Director of Patient Services confirmed there was no documentation of a reason for the delay of the start of care, and no update sent to the physician to notify that services were delayed for wound care. During an interview on 2/20/24 at 11:30 am, the Administrator confirmed, that it was the expectation and policy of this agency, as well as a Federal regulation, to open all patients to service within 48-hours of their referral date, and to notify the physician if there was a delay.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on interview, and record review, the agency failed to obtain verbal or written physician orders for Plans of Care for one out of 17 sampled patients, (Patient 6) in a timely manner after the patients were admitted for home health services. This failure could lead to a delay in coordination to the physician, and timely notifications of patient needs which could lead to potential negative clinical outcomes. The agency’s policy titled, “Physician Participation in Plan of Care,” dated 1/18, indicated, that the patient’s medical care will be provided only under a current plan of care approved by the attending/primary care physician. This agency’s policy indicated the attending physician’s verbal orders will be obtained at the time the plan of care is established. A physician will direct the care of every home health patient admitted to services. The agency’s policy titled, “Verification of Physician Orders,” dated 1/20/23, indicated, that the purpose of this agency’s policy is to ensure that accurate physician (or allowed practitioners) orders and prescriptions are obtained in accordance with state and federal law and regulation. This agency’s policy also indicated orders will be obtained from a licensed physician (or allowed practitioner) for care and services to be provided to home health patients. Patient 6’s clinical record was reviewed. Patient 6 was admitted to the home health agency on 11/14/23, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a progressive disease of damaged lungs), a cerebrovascular accident (stroke), and left foot wound (any disruption of the intact skin with underlying damage to the tissues). During a concurrent interview, and record review, on 2/21/24 at 4:35 pm, the Clinical Supervisor (CS), and Administrator (Admin) confirmed, that there was no physician approval, or supplemental verbal order for the Plan of Care for Patient 6 skilled nursing until the POC was signed by the physician on 12/4/23, 20 days after the start of care visit. During an interview, on 2/21/24 at 4:45 pm, the CS, and Admin, confirmed, that the referrals are not physician orders and are from the hospitalist, who do not follow patients, or sign orders after discharges to home, and they do not sign any home health orders. Both CS, and Admin confirmed, that this delay for the physician signature resulted in no current physician orders for Patient 3, and Patient 6 for home health services at the start of care date. During a follow up interview, on 2/23/24 at 10:55 am, the DPS, and Admin confirmed moving forward they are educating the SOC nurses to make sure to obtain a physician order before waiting on a signature for the POC, which causes a delay in physician orders needed at the SOC visit.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure infection control practices (prevention of the spread of infection) were followed for two out of 17 patients (Patient 11, and Patient 12) when: 1. Licensed Vocational Nurse (LVN) H did not disinfect vital sign equipment (blood pressure cuff, thermometer, pulse oximeter, and stethoscope) according to manufacture recommendations prior to placing the vital sign equipment into LVN H’s equipment bag, that contained clean supplies for other patients. 2. Registered Nurse (RN) E did not review hospital documentation that identified the bacteria in Patient 12’s wound. RN E did not place Patient 12 on contact precautions (a means to prevent transmission of infectious agents by use of gloves, gowns, and shoe covers), did not disinfect vital sign equipment according to manufacture recommendations prior to placing vistal sign equipment into RN E’s equipment bag that contained supplies for other patients, and did not follow manufacture recommendations for cleaning and disinfecting contaminated scissors. These failures had the potential to spread infection to other patients and agency staff, which could lead to negative clinical outcomes. Findings: A review, of the facility’s undated policy titled, “Isolation Precautions Contact Precautions,” indicated, that the purpose of the policy was to assure that transmission-based Contact Precautions are implemented to prevent the spread of communicable disease through direct and indirect contact. The policy indicated, that the agency would implement Contact Precautions when caring for a patient with a confirmed or suspected infection or evidence of a syndrome that represents an increased risk for transmission. The policy indicated, that Contact Precautions would be implemented when caring for a patient with confirmed or suspected Staphylococcal Disease (S. aureus), skin wound or burn (Staphylococcal Disease also called staph, an infection that was challenging to treat, and was resistant to most antibiotics). A review of Patient 11’s Plan of Care, dated 2/2/24, indicated, that Patient 11 was admitted to the agency with the diagnoses of gastrointestinal hemorrhage (a bleed in the digestive tract), and myocardial infarction (heart attack caused by low oxygen levels in the heart). During an observation, on 2/21/24 at 10:55 am, located in Patient 11’s home, during a home visit with LVN H. LVN H was observed disinfecting vital sign equipment after obtaining Patient 11’s vital signs (blood pressure, heart rate, temperature). LVN H used a disinfecting wipe with the brand name “Sani-Cloth,” to wipe down the vital sign equipment. LVN H did not wear gloves while cleaning the vital sign equipment, and immediately placed the vital sign equipment into LVN H’s clean equipment bag while the vital sign equipment was still wet from the disinfectant. During an interview, on 2/22/24 at 3:05 pm, LVN H confirmed not wearing gloves while using the “Sani-Cloth,” to clean the vital sign equipment after taking Patient 11’s vital signs. LVN H stated, that they never use gloves while disinfecting vital sign equipment. LVN H stated, items cleansed with “Sani-Wipes” required a two-to-three-minute wet time (the amount of time the surface must remain wet and allowed to dry before being considered decontaminated/clean). LVN H confirmed, that they had immediately placed the wet vital sign equipment into their equipment bag after wiping with the “Sani-Wipe.” LVN H confirmed, that this practice could lead to infection control issues. A review, of Patient 12’s Plan of Care, dated 9/23/23, with the Certification Period (Certification period is a date range that a patient received home health services) date of 1/21/24 through 3/20/24, indicated, that Patient 12 was admitted to the agency on 9/23/23. The Plan of Care indicated on 1/19/24, that Patient 12 was diagnosed with: “dehiscence” (surgical site that was once closed and has reopened and created a wound) “of amputation stump,” (after having right below the knee amputation (removal of the leg, below the knee) the remaining portion of the leg was sewn up, resulting in what was called a stump). The diagnosis list did not indicate Patient 12’s wound was infected. During a concurrent observation, and interview, on 2/21/24 at 3:40 pm, located in Patient 12’s home, during a home visit with RN E. RN E was observed disinfecting vital sign equipment after obtaining Patient 11’s vital signs. RN E used a disinfecting wipe with the brand name “Sani-Cloth,” to wipe down the vital sign equipment. RN E did not wear gloves while cleaning the vital sign equipment, and immediately placed the vital sign equipment into thier clean equipment bag while the vital sign equipment was still wet from the disinfectant. RN E stated no dirty equipment or supplies were stored in their equipment bag. RN E stated only clean supplies and equipment were stored in their equipment bag. RN E was observed performing wound care to Patient 11’s right lower extremity stump. RN E placed a barrier on the floor, and placed wound care dressings (bandages, tape) and supplies (measuring device and scissors) on the barrier. The barrier wound care dressing and supplies were positioned directly under Patient 12’s stump. RN E removed Patient 12’s dressing and the wound to Patient 12’s stump was dripping drainage on to the bandage scissors. RN E was observed using the contaminated scissors to cut a sterile (clean, without bacteria) dressing that was placed directly onto Patient 12’s wounds. When RN E completed Patient 12’s dressing change, RN E wiped the scissors with a “Sani-Wipe” and immediately placed the wet scissors in the container that Patient 12’s clean, unused wound care supplies were located. During an interview, on 2/22/24 at 2:31 pm, RN E confirmed not wearing gloves while using the “Sani-Cloth,” to clean the vital sign equipment after taking Patient 12’s vital signs. RN E confirmed placing the wet vital sign equipment into the clean equipment bag. RN E stated unawareness of drainage dripping off Patient 12’s stump wound on to the scissors and confirmed use of scissors to cut the sterile dressing that was used on Patient 12’s wounds. RN E confirmed the remaining dressing was set aside to be used later. RN E stated using the dirty scissors on the sterile dressing would render the remaining dressing as no longer sterile and unusable. RN E confirmed using one “Sani-Cloth,” to wipe the scissors and immediately placed the wet scissors in the container that Patient 12’s clean, unused wound care supplies were located. RN E stated unawareness of Patient 12’s wounds, which required Patient 12 to be on contact precautions. During a concurrent interview, and record review, on 2/22/24 at 3:23 pm, with Director of Patient Services (DPS), the “Sani-Cloth” manufacture recommendations and instructions for use, printed on the “Sani-Cloth” package was reviewed. DPS stated the “Sani-Cloth” package indicated a two-minute wet and dry time was required for the “Sani-Wipe” to be considered effective at killing bacteria. DPS stated, the vital sign equipment should have been allowed to completely dry, prior to being placed into the equipment bag. DPS confirmed the “Sani-Cloth,” package instructions indicated gloves were to be worn while using “Sani-Cloth,” and confirmed inadequate use of “Sani-Wipes,” could lead to infection control issues. DPS stated, that a resumption of care home visit was performed on Patient 12, after Patient 12 returned home from the hospital. DPS reviewed, the medical records the hospital faxed to the agency and stated, that Patient 12’s “Consultation Report,” dated 1/31/24, indicated, that Patient 12 had been seen by an infectious disease doctor (healthcare professional who specialized in diagnosing and treating conditions caused by bacteria) while in the hospital. DPS stated, that the “Consultation Report,” indicated, that Patient 12 had diagnostic testing that revealed Patient 12 had ESBL Klebsiella (a multi-drug resistant bacteria that was difficult to treat, caused serious infections, could be easily spread), and Staphylococcus pseudointermedius (a bacteria that is typically found in animals) growing in Patient 12’s wound. DPS stated, that the RN was expected to review all the medical records that the hospital faxed to the agency, prior to conducting a resumption of care home visit. DPS stated, the hospital records guided the RN with the development of the patient’s plan of care and provided an opportunity for the RN to identify what type of care the patient required. The DPS reviewed, the agency’s undated P&P titled, “Isolation Precautions Contact Precautions,” and stated, that the policy indicated, that a patient who was diagnosed with Staphylococcal disease (S. aureus), and ESBL type infections, are required to be placed on contact precautions. DPS reviewed Patient 12’s Plan of Care, dated 9/23/23, with the Certification Period date of 1/21/24 through 3/20/24. The DPS confirmed, that the Plan of Care did not indicate, that Patient 12 had been placed on contact precautions and should have.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to review and document all medications in the home for two out of 17 patients, (Patients 10, and Patient 11) during the initial assessment to include in the clinical record and for the physician to review for interactions. This failure had the potential to cause unrecognized medication interactions to go unnoticed, and cause potential negative clinical outcome. During a review of Patient 11’s “Plan of Care,” dated 2/2/24, indicated Patient 2 was admitted to the agency with the diagnoses of gastrointestinal hemorrhage (a bleed in the digestive tract), and myocardial infarction type 2 (heart attack caused by low oxygen levels in the heart). During a concurrent observation and interview on 2/21/24 at 11:48 am, during a home visit, located in Patient 11’s home, LVN H was observed completing a home visit. During the entirety of the home visit, LVN H did not review Patient 11’s medication list for completeness or for accuracy. Prior to leaving Patient 11’s home, a bottle of Tylenol (mild pain reliever), Ibuprofen (Mild pain reliever), Zinc (vitamin, supplement), and Dayquil (cold and cough syrup) were observed sitting on the counter. Patient 11 stated unawareness of who the bottles of medication belonged to and stated, inability to recall if Patient 11 ever took any of “those medications.” During a concurrent interview and record review on 2/21/24 at 6:05 pm, with Patient 11’s family member (FM) Start of Care, “Plan of Care,” dated 2/2/24, was reviewed. The section titled “Medications,” indicated, at the time of Patient 11’s Start of Care, Patient 11 was taking the following medications: Lisinopril (medication that treated high blood pressure) oral 40 milligrams (unit of measure, mg) 1 tab daily, Lipitor (treated high cholesterol) oral 40 mg 1 tab daily, alfuzosin HCL ER (treated an overgrowth of tissue that pushed on the bladder) oral 10 mg 1 tab daily, Protonix (treated stomach acid) oral 40 mg1 tab twice daily, and amlodipine besylate (treated high blood pressure) oral 5 mg 1 tab daily. FM confirmed the medication that was observed on the counter during the home visit belonged to FM and not Patient 11. FM stated the medications listed on Patient 11’s “Plan of Care” was not a complete list and during the start of care home visit, FM provided a complete list of medications to the nurse, that included: carvedilol (treated high blood pressure) 6.25 mg 1 tab twice a day, multivitamin (a supplement) 1 tab a day, and baby aspirin (a blood thinner) 81 mg 1 tab a day. FM stated Patient 11’s medication was only reviewed at the start of care visit, nurses never asked if Patient 11 was taking new medication, and nurses only asked if there was anything new. Findings: The agency’s policy titled, “Medication Profile,” approved June 2019, indicated the purpose of this policy is to define the use of the medication profile in evaluating a patient’s medication regimen. This agency’s policy also indicated all patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. The agency’s policy titled, “Initial and Comprehensive Assessment,” approved 2017, indicated the initial comprehensive assessment must include a review of the medication history, as applicable to care and service and current medication use, including prescription, over the counter medications, and herbal medications, and identify significant drug interactions, duplicative drug therapy, potential adverse effects and drug reactions, ineffective drug therapy, significant side effects and noncompliance with therapy. During a review of Patient 10’s clinical record, Patient 10 was admitted to the home health agency on 2/9/24, with diagnoses that included encounter for colostomy (an opening called a stoma is formed between the large intestine and abdominal wall that drains stool wastes from the body), surgical abdominal incision, high blood pressure, and diabetes (a chronic disease with too much sugar in the blood). During an observation, and concurrent interview with a medication record review, on 12/21/24 at 9:50 am, with Licensed Nurse (LN) B, the medications in the home did not match the medication profile created on 2/9/24 from the Registered Nurse (RN) initial start of care (SOC) visit. LN B confirmed the medications had not been checked in the home compared to the medication profile dated 2/9/24, at the last home visit that was completed on 2/18/24 by LN B. LN B stated, “We normally just ask if any medications have changed and then we update the medication list.” During an interview on 2/21/24 at 10:00 am, Patient 10 confirmed the medications in her home had not been reviewed with any nurses until 2/21/24. Patient 10 stated, “I know my medications, but no one has reviewed the medications with me or asked me about them. I take one medication I order from Canada for leg cramps.” During a review, of Patient 10’s visit documentation dated 2/21/24, it was noted that Patient 10’s medication profile had been updated with four medications in the home that were not on the medication profile dated 2/9/24 and the plan of care (POC) dated 2/9/24. The following medications were added to Patient 10’s medication profile on 2/21/24: Quinine (a medication for leg spasms) sulfate 324 milligrams, (mg, a unit of measure), 1 tablet by mouth (PO) at night. Cetirizine HCL (a medication for allergies) 10 mg, 1 tablet PO daily. Probiotic Product supplement 1 tablet PO daily. Rosuvastatin Calcium (a medication for high cholesterol) 5 mg, 1 tablet daily. During a concurrent record review and interview on 2/22/24 at 2:37 pm, the Director of Patient Services (DPS) confirmed Patient 10’s plan of care and medication profile dated 2/9/24 did not have all the medications that were in the home and taken daily by Patient 10. The DPS confirmed all over the counter medications, supplements, and any discontinued or new medications should be checked at every home visit. DPS confirmed the expectation is all nurses check the medication profile and compare to the Patient’s medications in the home for safety and per policy and update the physician with an updated list as needed with every home visit. During an interview on 2/22/24 at 2:40 pm, the Administrator confirmed the medication profile and POC was not accurate and up to date for Patient 10. The admin stated. “I confirm the start of care nurses need to make sure all medications in the home are on the medication profile and POC for accuracy and safety for the physician to review and sign, and this is my expectation per our policy.””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to include all treatments, pertinent diagnoses, and psychosocial status as relevant to the plan of care for three out of 17 sampled patients, (Patients 8, Patient 10, and Patient 16). This failure had the potential for unidentified problems, risk for hospitalizations and negative clinical outcomes to occur. A review of Patient 16’s “Plan of Care,” dated 2/7/24, indicated Patient 16 was admitted to the agency on 2/7/24 with the diagnoses of an infected wound, acute kidney failure (the kidneys filtered waste from the body and were not working), hypertension (high blood pressure), depression (a sad mood), and anxiety (feelings of fear, dread, or uneasiness). During a concurrent interview and record review on 2/23/24 at 8:15 am with DPS, Patient 16’s “Plan of Care,” dated 2/7/24 was reviewed. DPS stated the “Plan of Care” indicated Patient 16 had an infected wound that required use of a wound vac (continuous vacuum therapy that assisted with closure of a wound) and confirmed Patient 16’s “Plan of Care” did not include wound care interventions or orders (a physician’s order that described how often wound care would be performed, what type of wound care supplies would be used, how to clean the wound, and who would perform wound care) that described the management and care of Patient 16’s infected wound and should have. DPS stated Patient 16’s “Plan of Care” indicated Patient 16 had a diagnosis of hypertension. DPS confirmed Patient 16’s “Plan of Care” did not include interventions that described management of hypertension. DPS stated there were no interventions that described education on the disease process or medications Patient 16 was taking to control hypertension and should have. DPS stated Patient 16’s “Plan of Care” included the diagnoses of depression and anxiety. DPS confirmed Patient 16’s “Plan of Care” did not include interventions that described education or management of depression or anxiety and should have. DPS stated Patient 16’s “Plan of Care” did not include vital sign parameters (vital signs are a group of medical signs that describe the body’s function and included the blood pressure, temperature, pulse, oxygen level, pain level, or respiration rate. The parameters described when to notify the physician based on a vital sign that was was too high or too low) and should have. Findings: The agency’s policy titled, “Physician Participation in Plan of Care,” dated 01/2018 indicated the plan of care (physician orders) will be individualized, based on patient’s needs, and include patient diagnosis, treatments and procedures needed, medications to be monitored, related supplies, and a description of any medical, physical, psychosocial, or environmental precautions, or limitations, and activities permitted. The agency’s policy titled, “Initial and Comprehensive Assessment,” dated 2017, was reviewed and indicated the initial assessment will be patient-specific and comprehensive to include the patient’s need for home health care. This agency’s policy also indicated the patient’s medical and psychosocial (all aspects of a person’s life that can affect their mental state) history including pertinent diagnoses and prognosis. During a review of Patient 8’s clinical record, Patient 8 was admitted to the home health agency on 2/5/24 with diagnoses that included congestive heart failure (a long-term condition in which your heart cannot pump blood well enough to meet the body’s needs), heart attack, and pulmonary embolism (a blood clot that travels to the lungs, suddenly forms a blockage). During a review of Patient 8’s Plan of Care (POC, helps nurses and other team members organize aspects of patient care with a timeline) dated 2/5/24, a weight vital sign was not included with a parameter to notify the physician for a measurement of CHF to assess and monitor for weight gain, and exacerbations to prevent hospitalizations. During a concurrent record review and interview on 2/22/24 at 4:50 pm, the Director of Patient Services (DPS) confirmed the POC was not individualized for Patient 8 and should have included a weight parameter to notify the physician if indicated. DPS stated, “I confirm [Patient 8] should be monitored for weight gain for CHF, and we have a weight pathway that could have been easily added. I will continue to educate for all the clinicians to add to the POC.” During a review of Patient 10’s clinical record, Patient 10 was admitted to the home health agency on 2/9/24 with diagnoses that included encounter for colostomy (an opening called a stoma is formed between the large intestine and abdominal wall that drains stool wastes from the body), surgical abdominal incision, high blood pressure, and diabetes (a chronic disease with too much sugar in the blood). During a review of Patient 10’s POC, dated 2/9/24, psychosocial status was not identified or addressed related to a new colostomy, bowel incontinence, new surgical abdominal incision, and loss of independence. Patient 10 was totally independent before an emergent surgery and a new colostomy. During a review of Patient 10’s start of care, Oasis Outcome and Assessment Information Set (Oasis) dated 2/9/24, D0700 question indicated Patient 10 does feel lonely and isolated from those around you as “sometimes” but this problem was not added to the POC to assess and monitor with bi-weekly home visits. During a concurrent record review and interview on 2/22/24 at 4:30 pm, the DPS confirmed the POC was not individualized for Patient 10 and should have included the psychosocial effect of a new colostomy and loss of independence. DPS stated, “I confirm [Patient 10] should be monitored for signs and symptoms of depression and poor body image. [Patient 10] has been through a lot of new changes including bowel incontinence.””

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on interview and record review the agency failed to provide care that meet the needs for one out of 17 sampled patients (Patient 2) when: 1. The agency accepted a patient onto services when agency staff did not have the skills (the ability to do something competently) or competencies (the knowledge, skills, and ability to provide specific care) needed to manage a patient with a Pleurex Cath (a chest tube) system. 2. There was not an individualized plan of care (a document that described physician orders of the care to be provided in the form of interventions and goals) that outlined the care, treatment, and education required for the management of Patient 2’s Pleurex drainage system. 3. Pleurex Cath Drainage kit drainage kit (a disposable, vacuum sealed bottle that connected to a chest tube and allowed for fluid to be removed from the lung) and split gauze (a dressing that was in the shape of a square and split in the center, it wrapped around the chest tube and rested against the skin) supplies were not made available to Patient 2 in a timely manner. These failures had the potential to cause negative patient outcomes and negatively impact Patient 2’s psychosocial well-being. Findings: 1. During a review of the agency’s policy titled, “Admission Criteria and Process,” revised 10/1/12, indicated patients will be accepted for care based on the adequacy and suitability of organization personnel. The policy indicated, that assignment of appropriate clinical personnel to conduct the initial assessment of patients eligibility for admission will be based on organization personnel’s special training and their competence to meet patient needs. During a review, of the agency’s policy titled, “Intake Process,” revised 4/1/19, indicated, that the organization will accept only those patients whose needs can be met by the services it provides. Patient 2’s clincial record was reviewed. Patient 2 was admitted to the agency on 12/23/23, with the diagnoses of pleural effusion (a buildup of fluid in the chest), and liver cell carcinoma (liver cancer). During a concurrent interview, and record review, on 2/22/24 at 9:22 am, with Director of Patient Services (DPS), and Administrator (Admin), Patient 2’s Home Health Consult, dated 12/20/23, was reviewed. DPS stated, the Home Health Consult (the home health consult was a request, faxed to a home health agency prior to a patient being discharged from the hospital, that explained what care a patient needed in the home) indicated, that Patient 2 required skilled nursing services for, “Pleurex monitoring,” and “assessment.” DPS reviewed, the untitled record dated 12/20/23, and stated the untitled record indicated, that the agency accepted Patient 2 onto services, and confirmed Patient 2 was admitted to the agency on 12/23/23. A request was made to review staff competencies, and the skills check list for care of the Pleurex chest tube system. The DPS, and Admin, stated that there were no records to support that staff had been provided training or education for the care of Patient 2’s Pleurex chest tube system. DPS, and Admin confirmed, that agency staff was not provided with training and did not have the skills or competencies needed for monitoring or caring for Patient 2’s Pleurex drainage system. During an interview, on 2/27/24, at 1:13 pm, Patient 2’s Caregiver (CG) stated, every time an agency nurse came to Patient 2’s home, CG would ask a question regarding Patient 2’s Pleurex Drainage system. CG stated the agency nurse’s did not seem to know the answer to any questions, and told CG to call Patient 2’s doctor for answers to CG questions. 2. During a review, of the agency’s policy titled, “Initial and Comprehensive Assessment,” dated 11/1/17, indicated, that the comprehensive assessment shall reflect and determine. Plan of care, including type of services, frequency, and duration. During a concurrent interview, and record review, on 2/22/24 at 9:22 am, with DPS, Patient 2’s “OASIS-E Start of Care,” dated 12/23/23 was reviewed. DPS stated the “OASIS-E Start of Care,” (also known as the 485) included an individualized plan of care that served as the physician orders. DPS stated the 485 indicated, “Patient and CG” (CG, caregiver) “will demonstrate proper care of pleural drain tube by end of episode.” DPS confirmed this goal was not individualized, and stated the goal should have included, education to the CG regarding how often the plural drain tube (Pleurex drainage system) should be drained, how many milliliters of fluid should be drained from Patient 2’s lungs, and to monitor for signs and symptoms of infection at the pleural drain tube insertion site (where the tube entered the body). DPS stated the 485 did not include interventions that discussed how often the insertion site should be cleansed, or how often the split gauze dressing should be changed, and should have. DPS stated the 485 included an intervention of: “SN to instruct on disease process, treatments, sign and symptoms exacerbations to report.” DPS confirmed the intervention did not include a specific disease process, a specific treatment, and did not include specific symptoms that required reporting. The intervention did not indicate who was to be notified. DPS confirmed Patient 2’s 485 was not specific or individualized to care that would be provided or what education was needed. 3. A review of the document titled “Protocol,” dated, 1/30/23, indicated, “Admitting clinicians turn in completed Supply Order Form with the patient information, supply description, supply reference number, etc. to the billing office.” During a concurrent interview, and record review, on 2/22/24 at 8:50 am, with Licensed Vocational Nurse (LVN) A, Patient 2’s “Skilled Nursing Visit,” dated 12/27/23, was reviewed during a phone interview. LVN A confirmed, Patient 2’s “Skilled Nursing Visit,” indicated, that Patient 2’s care giver was concerned about not having enough supplies to care for Patient 2’s Pleurex drainage system. LVN A stated, that Patient 2’s care giver stated, they needed more of the Pleurex drainage kits (a disposable vacuum bottle that connected to the Pleurex drainage system where fluid from the lungs could be collected into), and split gauze. LVN A stated, providing Patient 2’s care giver with split gauze, and stated LVN A stated collaborating with Registered Nurse (RN) F, and Clinical Supervisor (CS) via use of electronic messages, and leaving a voice mail to request Pleurex drainage kits to be ordered. During a concurrent interview, and record review, on 2/22/24, with DPS and Admin, DPS confirmed, that LVN A sent a message to RN F regarding a need for Patient 2’s supplies to be ordered. DPS stated there was a concern the agency would not be able to provide Patient 2 with the Pleurex drainage kit, and confirmed the agency should have determined that prior to admitting Patient 2 to home health services. DPS reviewed, “Patient Communication,” dated 1/2/24 was reviewed. DPS stated the “Patient Communication” indicated, that Patient 2’s family called the agency and spoke to the Intake Coordinator to discuss supplies that were needed. DPS reviewed, “Patient Communication,” dated 1/12/24 with a contact date of 1/2/24, and stated, the “Patient Communication” indicated Patient 2’s caregiver called the agency and was “upset regarding supplies,” and was not able to drain fluid from Patient 2’s chest daily, as ordered by Patient 2’s physician. DPS stated the contact date of 1/2/24, indicated the date Patient 2’s care giver called the agency and stated the agency did not have the correct item number and was not able to order the Pleurex drainage kit. DPS stated the care giver had provided the agency with the correct item number. DPS, and Admin confirmed, Patient 2’s care giver first requested more Pleurex drainage kits on 12/27/23, and did not receive Pleurex drainage kits until nine days later, on 1/5/24. A review, of the untitled supply order request from the agency’s supply company, indicated that Patient 2’s Pleurex drainage kits were ordered on 1/3/24, seven days after the first request for supplies was made. During a concurrent interview, and record review, on 2/22/24 at 12 pm, with Admin, “Employee/Patient/Family Grievance and Complaint Report,” (Grievance Form) with multiple dates was reviewed. Admin stated the Grievance Form was completed after a phone call with Patient 2’s caregiver on 1/12/24. Admin stated, that Patient 2’s caregiver was not happy with the care Patient 2 had received from the agency, and stated the Grievance Form indicated the caregiver was originally unhappy due to the lack of needed supplies. Admin confirmed, that the nine-day delay in obtaining supplies for Patient 2’s care, and stated there was a break down in communication on all levels and from all agency staff involved in ordering supplies for Patient 2. During an interview, on 2/27/24 at 1:13 pm, Patient 2’s Caregiver (CG) confirmed, LVN A supplied Patient 2 with split gauze during LVN A’s home visit on 12/27/23, and stated CG was given two individual packs of split gauze. CG stated having to purchase split gauze from the store due to the agency not providing them. CG stated, due to the agency not providing the Pleurex drainage system, CG was not able to drain fluid off Patient 2’s lungs daily per the physician’s request.”