Sunrise Home Health Care

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the emergency preparedness plan and training for staff were done in an annual basis. This failure had the potential for the staffs to lack the knowledge to respond effectively during an emergency situation. During a review of the emergency preparedness plan of the HHA on 11/11/23, at 12:30 p.m., the HHA did not have evidence of Emergency Preparedness training/disaster drill for all staffs and did not have evidence of emergency plan annual review. During an interview with the director of patient care services (DPCS) on 11/11/23, at 1 p.m., she confirmed that two of their CHHA (certified home health aide) have not received Emergency Preparedness/Disaster training and they should be included in their annual drills and training. She also stated that the emergency preparedness plan had not been reviewed. There was no documented evidence the governing body reviewed the policy annually on Emergency Preparedness/Disaster. The HHA’s undated policy and procedure titled “Emergency/Disaster Plan” indicated the purpose was to outline a planned, coordinated strategy to promote the safety and continuation of care and/or services to agency patients in the event of a disaster.”

“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 observation, interview and record review, the agency staff failed to ensure care followed the written plan of care for two of seven sampled patients (Patient 2 and 5). For Patient 2, the staff failed to manage the patient’s pain by not assessing effectiveness of the pain intervention. This deficient practice placed the patient at risk for ineffective pain relief causing patient’s discomfort and distress. For Patient 5, the visiting nurse failed to provide continuous education and teaching for pacemaker care. This deficient practice resulted in the patient’s lack of knowledge to manage the safe and effective use of the pacemaker (an artificial device stimulating the heart muscle and regulating its contractions). A joint home visit was conducted on 11/10/23 at 1:00 p.m., at Patient 5’s (P5) residence with Licensed Vocational Nurse 1 (LVN 1). Observed that the patient is living in a separate dwelling unit at the back of the daughter’s home with a live-in 24 hour caregiver. P5 is awake , sitting in a recliner watching spanish telenovela, not in any respiratory distress. Caregiver present beside her. A review of Patient 5’s (P5) “ Face Sheet” indicated that a Start of Care (SOC) date of 10/25/23 with the certification period reviewed on 10/25/23 to 12/23/23 with a diagnosis of unspecified atrial fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow) and heart failure (chronic condition in which the heart doesn’t pump blood as well as it should). P5 also had a history of pacemaker replacement twice. Skilled nursing visits once a week for nine weeks to do skilled assessment and observation of vital signs (blood pressure, pulse rate, respirations and oxygen level) of all bodily systems, heart palpitation, fatigue, shortness of breath, bleeding tendencies, high and low blood pressure, heart rate irregularities and rhythm and signs and symptoms of pacemaker dysfunction, increasing confusion, reduced concentration and loss of ability to do everyday tasks. A review of P5’s “Home Health Certification and Plan of Care” for the benefit period of 10/25/23 to 12/23/23 indicated that the Goals/Rehabilitation potential/Discharge plan is for patient to to have a stable cardiopulmonary status as evidenced by no irregular heart rate less than 50 per minute or greater than 100 per minute, no edema, no signs and symptoms of pacemaker malfunction, no chest pain and signs and symptoms of bleeding. Skilled nursing to perform, monitor and teach to patient/patient caregiver (PCG) pacemaker malfunction such as palpitations, dizziness, syncope, slow heart rate, prolonged hiccupping, reportable signs and symptoms of chest pain, shortness of breath, irregular heartbeat, headache. Notify MD immediately or call 911 if above symptoms occurs. During the joint home visit on 11/10/23 at 1:00 p.m., with the Licensed Vocational Nurse 1 (LVN1), when asked how she assess for P5’s pacemaker, LVN 1 stated on the plan of care it is listed to monitor heart rate and call physician if its less than 50 and more than 100 beats per minute. On concurrent interview with the 24 hour live-in caregiver , she stated that she uses the blood pressure machine on the left arm and whatever the results on the blood pressure machine that is how she measures the heart rate. Caregiver also stated that when the patient complaints of chest palpitations, she gives the patient water and have her lie down. During the interview with the Director of Patient Care Services (DPCS) on 11/11/23 at 11:00 a.m., DPCS stated that she admitted the patient on 10/25/23. DPCS stated that she took the picture of the pacemaker card but did not upload the details of the pacemaker in the patients electronic medical record. DPCS also confirmed that she did not confirm the settings of the pacemaker with the patient’s cardiologist. DPCS stated that the expectation for the nurse is to monitor for irregular heartbeat, palpitations, dizziness and syncope and report to the DPCS and doctor. DPCS stated it is significant to add it in the record so whoever will visit the patient will be knowledgeable when it was inserted and how to monitor for changes. DPCS stated that we need to communicate with the doctor for the specific settings of the pacemaker and should be included in the care plan. A review of the HHA’s undated policy titled “Entries into the Clinical Record” indicated a clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum, pertinent medical history, physician’s orders and evidence of physician oversight activities, changes in the plan of c are, dates, times and types of interventions, assessments and coordination of care. Entries in the clinical record will be clear, concise, and specific statements of fact. A review of the HHA’s policy titled “ Initial and Comprehensive Assessment” dated 2009, indicated that the assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social and discharge planning needs. This assessment will measure patient outcomes from data collected at the start of care. A plan of care will be developed from the information gathered during the initial and comprehensive assessment. The patient’s physician is consulted for approval if additions or modifications to the plan of care are required after the assessment is completed. a. During a review of Patient 2’s Patient Information indicated, a start of care (SOC) date of 8/18/23, with diagnosis that included atherosclerosis heart disease (build up of fats cholesterol and other substances in and on the artery walls). During a review of Patient 2’s Plan of Care (POC) indicated a certification period from 10/17/23 to 12/15/23. It also included an order for skilled nurse (SN) to visit of once a week for nine weeks, to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication knowledge and compliance. Instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). One of the skilled nursing intervention was to assess pain level and effectiveness of current pain management. On 11/10/23, at 11:30 a.m., a home visit was conducted at Patient 2’s residence with LVN 1. Patient 2 was observed sitting on a chair with bilateral plus 2 pitting edema on both lower extremities. A review of Patient 2’s Nursing Progress Notes dated 10/17 and 10/25/23, indicated the patient had pain scale level of 5 achy, intermittent pain on back area. However, there was no documented evidence of a post pain assessment and pain relief measures being provided by the visiting nurse. On 11/11/23, at 1:30 p.m., during an interview with the DPCS (director of nursing services) , she stated the visiting nurse should do a post pain assessment and provide pain relief measures when Patient 3 has pain during visits. A review of the agency’s undated policy of “Pain Management “ indicated when the patient or the clinician identifies pain, pain assessment information will be obtained including present pain management regimen and effectiveness.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on observation, interview and record review, the HHA failed to provide services by skilled professionals who practice according to the HHA’s policies and procedures for 3 out of 7 sampled residents. (Patients 5, 6, and 7). This deficient practice had the potential in the delay to identify the patients’ care needs affecting their health status and well-being. Findings: a. A review of Patient 5’s “ Face Sheet” indicated a Start of Care (SOC) date of 10/25/2023. A review of the certification period from 10/25/23 to 12/23/23 included a diagnosis of unspecified atrial fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow) and heart failure (chronic condition in which the heart doesn’t pump blood as well as it should). Patient 5 also had a history of pacemaker replacement twice. The POC included skilled nursing visits once a week for nine weeks to do skilled assessment and observation of vital signs (blood pressure, pulse rate, respirations and oxygen level) of all bodily systems, heart palpitation, fatigue, shortness of breath, bleeding tendencies, high and low blood pressure, heart rate irregularities and rhythm and signs and symptoms of pacemaker dysfunction, increasing confusion, reduced concentration and loss of ability to do everyday tasks. A review of Patient 5’s “Home Health Certification and Plan of Care” for the benefit period of 10/25/23 to 12/23/23 indicated that the Goals/Rehabilitation potential/Discharge plan was for patient to have a stable cardiopulmonary status as evidenced by no irregular heart rate less than 50 per minute or greater than 100 per minute, no edema, no signs and symptoms of pacemaker malfunction, no chest pain and signs and symptoms of bleeding. Skilled nursing to perform, monitor and teach to patient/patient caregiver (PCG) pacemaker malfunction such as palpitations, dizziness, syncope, slow heart rate, prolonged hiccupping, reportable signs and symptoms of chest pain, shortness of breath, irregular heartbeat, headache. Notify MD immediately or call 911 if above symptoms occur. A review of Patient 5’s electronic medical record on 11/10/23 revealed that the “Initial Case Conference” was conducted on 10/25/2023 electronically signed by the licensed vocational nurse 1/case manager (LVN1/CM). LVN1/CM also documented and signed for the supervisory visits for the LVN and home health aide (HHA). b. A review of Patient 6’s “ Face Sheet” indicated a Start of Care (SOC) date of 7/25/23 with the certification period reviewed on 9/23/23 to 11/21/23. The diagnosis included type 2 diabetes (non-insulin dependent type of diabetes- inability of the body to process sugars) and fitting for urinary device (a medical equipment that helps the patient urinate). The POC included Skilled nursing (SN) visits once a week for nine weeks to do skilled assessment and observation of vital signs (blood pressure, pulse rate, respirations and oxygen level) of all bodily systems, inspect catheter insertion site for any signs of redness, swelling, or discharge. SN to monitor blood glucose level, proper glucometer care, compliance with patient/caregiver in correct blood sugar monitoring with observation of aseptic techniques and proper disposal of sharps.SN to change foley catheter every month and as needed for leaking. A review of Patient 6’s “Home Health Certification and Plan of Care” for the benefit period of 10/25/23 to 12/23/23 indicated that the Goals/Rehabilitation potential/Discharge plan was for patient will not manifest signs and symptoms of UTI during the certification period. Urinary elimination will be within normal limits and foley catheter will remain patent with absence of infections by 4-6 weeks. Patient/PCG will be knowledgeable on the disease processes, signs and symptoms, preventive measures, complications, disease management, and medication management: dose, route and schedule/actions, interactions and contraindications, side effects and its sign and symptoms to report; compliance adherence to diet impacting disease in 2-4 weeks. A review of the HHA’s document titled “Supervisory Visits for Home health care staff” dated 9/25/23 and 10/25/23 for the second benefit period indicated that the same LVN1/CM conducted the supervisory home visit for the home health aide. No case conference was done for the second benefit period for this patient noted in the medical record. A review of the HHA document titled “LVN Supervisory Note” dated 7/27/23 showed the same LVN1/CM conducted and signed the LVN supervisory home visit. c. A review of Patient 7’s “ Face Sheet” indicated that a Start of Care (SOC) date of 6/29/2023. The certification period from 10/27/2023 to 12/25/2023 included diagnoses of chronic venous hypertension (Improper functioning of the vein valves in the leg, causing swelling and skin changes) and none pressure chronic ulcer (areas on the legs, ankles or feet where underlying tissue damage, or a trauma, has caused skin loss, leaving a raw wound that takes a long time to heal) of both lower legs. The POC included SN visits for once a week for one week and three times a week for eight weeks to do skilled assessment and observation of: vital signs and all body systems; assess/monitor for signs and symptoms of COVID- 19 every visit including fever, dry cough, difficulty breathing, headache, muscle aches, diarrhea with emphasis on: integumentary status: pressure ulcer wound, appearance, size, drainage, color, surrounding tissue, skin integrity, signs and symptoms of infections, healing process. SN to instruct patient/caregiver on disease process of stage 4 pressure ulcer on Right lower posterior leg and stasis ulcers on Right posterior ankle, left medial ankle- lower and upper, proper wound care, appropriate measures to minimize and manage infections, good diet and nutrition to improve circulation and promote healing process; measures to prevent skin breakdown. Disease processes of Essential (primary) hypertension, instruct activity modification and measures to prevent complications, importance of proper diet/hydration, medication purpose, dosage, frequency, adverse reactions, edema, signs and symptoms of high or low blood pressure, reportable signs and symptoms such as chest pain, shortness of breath or dyspnea, irregular heartbeat, headache and dizziness. Notify MD immediately or call 911 if above signs and symptoms occurs. A review of Patient 7’s “Home Health Certification and Plan of Care” for the benefit period of 10/27/23 to 12/25/23 indicated that the Goals/Rehabilitation potential/Discharge plan was for patient to Wash all wounds & skin with warm water, pat dry, Cleanse wound with Normal saline, spray/cleanse with Anasept spray, apply hydrogel cover wound bed with woven gauze, cut silicone foam dressing according to wound size, cover with dry gauze, wrap with gauze roll, secured with tape, wrap with Coban until healed observing aseptic technique, universal precautions and proper disposal of soiled materials. A review of the HHA’s document titled “LVN Supervisory Note” dated 10/19/23 indicated that there was only one supervisory visit conducted for this patient during his care by the same LVN1/CM. During an interview with the Director of Patient Care services (DPCS) on 11/11/23 at 11:45 a.m., DPCS state that the case summary participants are all clinicians or staff that is involved in the care of the patient like the case manager, home health aide, social worker, medical director or attending physician, administrator and the DPCS, and if they have physical therapy, speech therapy and other ancillary services. DPCS stated “only the case managers are able to sign the case conferences in the electronic medical record”. During an interview with the DPCS, at 12:08 p.m., DPCS stated that she should have signed the review for the supervisory visit as specified in the electronic medical record. DPCS stated that the registered nurse was expected to conduct the supervisory home visits for the LVN and HHA. During an interview with the DPCS on 11/11/23, at 12:38 p.m., stated that the policy stated that in the case summary all staff should be present during the case conference. DPCS stated that the staff who attended the case conference should sign in the electronic medical record. DPCS further agreed with the statement “If it is not signed, it is not done.” A review of the HHA’s policy titled “Care/Service Coordination” dated 2009 indicated A case conference/progress summary, written by the appropriate discipline(s) seeing the patient, will be placed in the patient’s clinical record after each case conference meeting. A copy will be sent to the attending physician. A record will be kept indicating who participated in the meeting and which patients were discussed. The record will list patients by name and clinical record number. A review of the HHA’s policy titled “Case Conference progress Summary” dated 2009 indicated Case conferences will be held at the start of care and at least every 60 days to review and discuss all multidisciplinary cases. Items of discussion will include, but will not be limited to, the type and frequency of service by each discipline involved, changes in the patient’s overall status, problems, possible resolutions, progress towards goals, and any necessary revisions in the plan of care. Case conferences will include utilization review; therefore, all clinicians-both direct and contract personnel-working with patients will participate in case conferences. A review of the HHA’s undated policy titled “ Skill Nurse Supervisory Visits” indicated The registered nurse or therapist (when there is not a nurse assigned to the patient) must conduct supervisory visits to the patient’s residence at regular intervals. The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted at least every two (2) weeks. The registered nurse and/or appropriate therapist will be responsible for: A. Supervision of all services provided for in the plan of care. B. Specific training in personal care skills and other procedures related to the care of the patient. C. Regular consultations (i.e., case conferences) with the home health aide. D. Documentation of all pertinent clinical notes which may include observations made by the Skill Nurse. E. Annual skill competency evaluations and supervisory reports. 4. Supervisory visits and overall supervision will be documented in the clinical record. A. Supervisory visits will be documented on a supervisory visit form. B. Ongoing supervision will be documented within the plan of care, Skill Nurse assignment sheet, and clinical notes. A review of the HHA’s undated policy titled “Supervision” indicated Sunrise Home Health Care verifies that supervisory staff understand and have the clinical and supervisory experience in all the care, treatment and services that they are required to supervise. Sunrise Home Health Care verifies that supervisory staff understand the staff responsibilities associated with the level of care provided by the staff they supervise. When a Clinical Supervisor/Nursing Supervisor does not have experience related to the clinical specialty area, he/she will consult with the Clinical Director, Executive Director/Administrator or an appropriate supervisory consultant to provide the supervision.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on observation, interview, and record review, the governing body failed to assume full legal authority and responsibility for the overall management and operation of the HHA. This deficient practice has the potential risk to result in the provision of a substandard quality of care that could affect the health and safety of the patients. Findings: During the recertification survey on 11/9/23 to 11/11/23, the Administrator was not available during the survey process. The governing body minutes was requested from the Director of Patient Care Services (DPCS) but unable to provide the documented evidence to indicate the governing body addressed the functioning hospice operations and its quality assessment and performance improvement (QAPI) program. During an interview with the DPCS on 11/11/23, at 12:50 p.m., the DPCS stated that the Administrator was on vacation and was not available. During a review of the HHA’s governing Body Minutes for 2023 indicated the governing body conducted a “General Meeting” on 10/20/2023 at 10:30 a.m., however, the DPCS could not provide the written agenda of the meeting and attendance sheet of the members that attended the general meeting. A review of the HHA’s undated policy titled “ Governing Body Minutes” indicated that the Organization will organize, manage and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patients plan of care. The organization will assure administrative and supervisory functions are not delegated to another agency or organization and all services not furnished directly are monitored and controlled. Governing Body will assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement (QAPI) program. The governing body will review the agency’s by laws at least annually. The governing body will appoint a professional advisory committee to review and develop official policies and procedures and assist in identifying goals and measuring accomplishments of the organizations operations.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to provide written notice of patients’ rights in written and spoken language made available to one of 7 sampled patients ( Patient 5). This failure resulted for Patient 5 not to have written notice of patient’s rights available in her patient handbook for her and her 24 hour caregiver who has limited English reading and writing proficiency which both required to understand the patient’s plan of care. A joint home visit was conducted on 11/10/2023, at 1 p.m., at Patient 5’s residence with Licensed Vocational Nurse 1 (LVN 1). Patient 5 was observed living in a separate dwelling unit at the back of the daughter’s home with a live-in 24-hour caregiver. Patient 5 was awake, not in any respiratory distress sitting in a recliner watching Spanish telenovela. Patient 5’s caregiver was present beside her. A review of Patient 5’s “ Face Sheet” indicated a Start of Care (SOC) date of 10/25/2023 with the certification period reviewed from 10/25/2023 to 12/23/2023, with a diagnosis of unspecified atrial fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow) and heart failure (chronic condition in which the heart doesn’t pump blood as well as it should). Patient 5 also had a history of pacemaker replacement twice. Skilled nursing visits once a week for nine weeks to do skilled assessment and observation of vital signs (blood pressure, pulse rate, respirations and oxygen level) of all bodily systems, heart palpitation, fatigue, shortness of breath, bleeding tendencies, high and low blood pressure, heart rate irregularities and rhythm and signs and symptoms of pacemaker dysfunction, increasing confusion, reduced concentration and loss of ability to do everyday tasks. A review of Patient 5’s “Home Health Certification and Plan of Care” for the benefit period of 10/25/2023 to 12/23/2023 indicated the Goals/Rehabilitation potential/Discharge plan included for the patient to have a stable cardiopulmonary status as evidenced by no irregular heart rate less than 50 per minute or greater than 100 per minute, no edema, no signs and symptoms of pacemaker malfunction, no chest pain and signs and symptoms of bleeding. Skilled nursing to perform, monitor and teach to patient/patient caregiver (PCG) pacemaker malfunction such as [palpitations, dizziness, syncope, slow heart rate, prolonged hiccupping, reportable signs and symptoms of chest pain, shortness of breath, irregular heartbeat, headache. Notify MD immediately or call 911 if above symptoms occur. During the joint home visit on 11/10/2023, at 1 p.m., with the Licensed Vocational Nurse 1 (LVN1) noted that Patient 5 and her 24 hour caregiver only speak and understand “Spanish”. There was no patients’ rights available in “Spanish” inside the patients handbook. During an interview with Patient 5’s caregiver on the same date, stated that she was unable to read the book because it was in English. Caregiver stated that if she has questions, she calls and notifies the daughter. When asked if in case the daughter was out for grocery shopping or market, caregiver stated that she would still call the daughter before calling 911 for emergency or any other situations with the patient. During an interview with the patient’s family member (daughter) during the home visit, daughter stated that she gave instructions to the caregiver to call her in case of emergency because the 24-hour live-in caregiver cannot read and write and speak in English. During an interview with the Director of Patient Care Services (DPCS) on 11/11/2023, at 11 a.m., stated that the population they serve include Hispanics and they make it a point to assign them to a staff that speaks their language. DPCS stated that from now on they needed to provide them a handbook with their language translation so they will know their plan of care. A review of the HHA’s policy titled “Patient Education Process” dated 2009 indicated that the patient and family/caregivers will receive education in verbal, visual and written format as appropriate. The scope of teaching will be determined by assessing the needs, abilities, learning preferences, and readiness to learn of the patient and family/caregiver, as well as by plan of care, goals and established outcomes. Education will be the responsibility of each clinician.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on observation, interview, and record review, the facility failed to advice two of seven patients (Patients 1 and 2) the toll-free home health telephone hot line to its purpose, lodge complaints, and other concerns regarding care services furnished by the agency. This failure has the potential to result in home health complaints or concerns not being reported by patients and will not be resolved by the agency. Findings: a. During a review of Patient 1’s Patient Information indicated, a start of care (SOC) date of 10/20/23, with diagnosis that included atherosclerosis heart disease (build up of fats cholesterol and other substances in and on the artery walls). During a review of Patient 1’s Plan of Care (POC), dated 10/20/23, the POC indicated, a certification period from 10/20/23 to 12/18/23. It also included an order for skilled nurse (SN) to visit of once a week for one week, twice a week for two weeks, once a week for six weeks, to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication knowledge and compliance. Instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). On 11/10/23, at 1 p.m., a home visit was conducted at Patient 1 residence. Patient 1 was observed sitting on the couch in the living room with LVN 2 and FM 1 (family member) beside the patient. During an interview on 11/10/23, at 1:15 p.m., when FAM 1 was asked thy were told regarding the State hotline number written in the agency folder to call in case if they have a complaint against the agency, she stated they were not aware of it. During an interview on 11/10/23, at 1:15 p.m., during an interview with LVN 2, she stated she was unable to locate the HH toll-free hotline number in the agency folder. b. During a review of Patient 2’s Patient Information indicated, a start of care (SOC) date of 8/18/23, with diagnosis that included atherosclerosis heart disease (buildup of fats cholesterol and other substances in and on the artery walls). During a review of Patient 2’s Plan of Care (POC) indicated a certification period from 10/17/23 to 12/15/23. It also included an order for skilled nurse (SN) to visit of once a week for nine weeks, to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication knowledge and compliance. Instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). On 11/10/23, at 11:30 a.m., a home visit was conducted at Patient 2’s residence with LVN 1. Patient 2 was observed sitting on a chair with bilateral 2+ pitting edema (excess fluid causing swelling, when pressure is applied to the swollen area, a “pit” leaves an indentation of 3-4 mm that will rebound in 15 seconds) on both lower extremities. During an interview on 11/10/23, at 11: 45 a.m., when Patient 2 was asked if he was aware of a State hotline number written in the agency folder for him to call for grievance against the agency, he stated no one told him about it. On 11/11/23, at 1 p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should mention the State hotline number to their patients and should be written in their agency folder.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on observation, interview and record review, the physical therapist (PT) failed to provide initial PT services within 48 hours as ordered for one out of seven sample patients (Patient 1). This deficient practice placed the patient at risk to slow down rehabilitation process. Findings: During a review of Patient 1’s “Patient Information” indicated a start of care (SOC) date of 10/20/23, with diagnosis that included atherosclerosis heart disease (buildup of fats cholesterol and other substances in and on the artery walls). During a review of Patient 1’s Plan of Care (POC), dated 10/20/23, the POC indicated for certification period from 10/20/23 to 12/18/23, included an order for a PT evaluation and treatment. On 11/10/23, at 1 p.m., a home visit was conducted at Patient 1 residence. Patient 1 was observed sitting on the couch in the living room with LVN 2 and FM 1 (family member) beside the patient. A review of Patient 1’s PT evaluation and Plan of Care dated 10/24/23, indicated the PT provided the initial visit 4 days after the PT order date. A further review of Patient 1’s clinical record indicated no communication note to justify the reason why the PT visit was 4 days late. On 11/11/23, at 1 p.m., at 1 p.m., during an interview with the director of patient care services (DPCS) stated that there should have been documentation why PT initial assessment/evaluation was 4 days late after it was initially ordered. A review of the policy “ Admission Process” indicated that each client referred to the agency shall be evaluated by a registered nurse/therapist and the initial assessment will be completed within 48 hours of referral or on the physician ordered start of care date.”

“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 home health agency (HHA) staff failed to review all the medications and verified with the physician regarding discrepancy of the medication administration for one of seven patients (Patient 2). This failure has the potential to result in putting the patient at risk for medication errors and adverse (harmful) drug reactions. Findings: During a review of Patient 2’s Patient Information indicated a start of care (SOC) date of 8/18/23, with diagnosis that included atherosclerosis heart disease (buildup of fats cholesterol and other substances in and on the artery walls). During a review of Patient 2’s Plan of Care (POC) indicated a certification period from 10/17/23 to 12/15/23, included an order for skilled nurse (SN) to visit of once a week for nine weeks, to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication knowledge and compliance. Instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). A physician’s order indicated in the POC included to administer Potassium Chloride 20 milliequivalents one tablet by mouth daily. On 11/10/23, at 11:30 a.m., a home visit was conducted at Patient 2’s residence with LVN 1. Patient 2 was observed sitting on a chair with bilateral 2+ pitting edema on both lower extremities. On 11/10/23, at 12 p.m., during a medication review of Patient 2’s medication, there was one bottle of Potassium Chloride 20 milliequivalents one tablet by mouth twice daily. On 11/10/23, at 12:15 p.m., during an interview with Patient 2 stated, he takes the Potassium medication one tab twice daily for two months now. On 11/11/23, at 2 p.m., during an interview with the DPCS stated, the visiting nurse should always check the actual medication bottles and verify with the patient if taking correct dosages during their visits. A review of the agency’s undated policy “ Medication Administration”, indicated when there is a discrepancy in the medications, the nurse will contact the physician by telephone as soon as possible to verify the medication regimen. The nurse will instruct the patient and family in the correct medication regimen. The nurse will document all telephone conversations and instructions given to the patient and/or family in the patient clinical record.”