Icare Home Health Agency LLC

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on interviews and record review the agency failed to complete an updated and revised comprehensive assessment as the patients condition warranted for an improvement in health status in 1 of 1 discharged patients reviewed who received skilled nursing (SN), physical therapy (PT) and occupational therapy (OT) services (Patient #3). Findings Include: AGENCY POLICY According to an agency policy, dated 2019, and titled, Patient Assessments / Plan Of Care, (read in pertinent parts): “Written policies and procedures are established that describe the process for assessment, and the development of the plan of care. Agency staff provides efficient, and effective, case management, according to home health care agency policies and procedures. P&P describe, at a minimum -A comprehensive assessment is completed in a timely manner, consistent with the patient’s immediate needs.” 1. The clinical record for Patient #3 was reviewed on 12/17/24. The plan of care for the period dated 09/30/24 to 11/28/24, revealed a start of care date of 9/30/24; diagnosis included disorder of the skin and subcutaneous tissue, unspecified and Non-pressure chronic ulcer of other part of left foot with unspecified severity. Plan of care orders included SN visits once a week for 17 weeks for wound care. Further review of the plan of care revealed Registered Nurse (RN) Case Manager #3 documented under the system’s assessment for skin “stasis ulcer to left foot.” Documented goals included patient wound status on the left foot will exhibit objective signs of healing without complication within the certification period. a. The agency failed to ensure an updated and revised comprehensive assessment was completed as warranted due to an improvement in Patient #3’s health status. Specifically, the RN Case Manager failed to perform a comprehensive assessment to address the change in condition presented by Licensed Practical Nurse (LPN) #4 on 10/1/24 until 10/30/24. Review of the start of care comprehensive assessment revealed on 9/30/24, RN Case Manager #3 documented Patient #3 had a wound present, specifically one observable stasis ulcer that was not healing. Record Review revealed LPN #4’s visit note dated 10/1/24 included assessment notes in which they documented the patient reported having a wound of her left foot however upon inspection they did not observe any wounds. Record review revealed care coordination documentation dated 10/1/24 at 3:10 p.m., in which LPN #4 brought attention to the care team including RN Case Manager #3 questioning what SN services were needed for Patient #3. Response given by RN Case Manager #3 on 10/1/24 at 3:14 p.m., stated “Her wound care. We are treating a patient with major health issues. Once you go see her, you will figure it out.” Record review revealed on 10/1/24 RN Case Manager #3 received verbal orders for an alternate dressing while waiting for the ordered dressing. Record review revealed LPN notes dated between 10/1/24 to 10/30/24 included documentation which stated the skin assessment was performed and no observable wounds were present. Record Review revealed on 10/30/24, RN Case Manager #3 completed a comprehensive assessment. Documentation stated under skin assessment the skin was within normal limits and a new wound had not developed. Further review revealed under assessment notes, RN #3 documented “Wound care to right foot closed. Dry dressing placed.” 2. During an interview on 12/18/24 at 10:53 a.m., the administrator stated if the LPN noticed a change in a patient’s condition the RN was to re-evaluate the patient as soon as possible when questioned about the assessment process for a patient’s change in condition. During an interview on 12/18/24 at 11:18 a.m., RN Case Manager #3 stated there was a wound present at the time of the start of care Oasis assessment and wound care was indicated based on the wound care orders and the start of care assessment. RN Case Manager #3 was unable to recall the exact date she was made aware by the LPN there was no wound present. The administrator confirmed LPN #4 documented 10/1/24 no wound was present on her assessment. RN Case Manager #3 was not able to recall the date she completed the comprehensive re-assessment; however recalled documentation of wound care was completed during the visit. The administrator confirmed 10/30/24 RN Case Manager #3 completed the comprehensive assessment and documented the wound was healed. During an interview on 12/18/24 at 1:20 p.m., the administrator stated that she was looking into the situation regarding the assessment for RN #3 and inquiring about “why it was done so late” and continued to state it would be discussed at the upcoming Quality Assurance and Performance Improvement meeting.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to provide emergency preparedness training to staff at least annually. Findings include: AGENCY POLICY According to an agency policy dated 2019 and titled, “Emergency Preparedness Training and Testing.” “-Initial training in emergency preparedness policies and procedures, to all new and existing Agency staff, volunteers, and individuals providing services under arrangement, consistent with their expected roles. -Demonstrate staff knowledge of emergency procedures. -Provide emergency preparedness training at least annually. -Maintain documentation of all emergency preparedness training.” 1. Review of the emergency preparedness meeting minutes dated 1/3/23 showed the administrator and director of nursing (DON) attended the agency’s annual emergency preparedness training. Review of Employee #5’s, date of hire 1/17/22, and Employee #9’s, date of hire 12/26/22, personnel records failed to show documentation of annual emergency preparedness training. The meeting minutes failed to show other staff members were present at the agency’s 2023 emergency preparedness training. Review of the emergency preparedness meeting minutes dated 1/3/24 showed the administrator and the vice president of the agency attended the agency’s annual emergency preparedness training. The meeting minutes failed to show other staff members were present at the agency’s 2024 emergency preparedness training. During an interview on 4/30/24 at 2:50 p.m., Employee #9 stated the only emergency preparedness training she received from the agency was upon hire. During an interview on 4/30/24 at 11:00 a.m., the administrator and DON stated employees receive emergency preparedness training at hire, but not annually as regulation required. During an interview on 5/2/24 at 2:41 p.m., the administrator stated she was unaware all staff were to receive emergency preparedness training annually. The administrator stated she would work to correct this deficiency by incorporating training for staff on issues identified in the agency’s risk assessment for emergencies.”

“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 facility failed to conduct exercises to test the emergency plan annually for emergent issues which would potentially impact patient’s of the agency. Specifically, the facility failed to conduct a full-scale exercise that was community based annually and conduct an additional exercise annually. Findings include: AGENCY POLICY According to an agency policy dated 2019 and titled, Emergency Preparedness Training and Testing, (read in pertinent parts): “The Agency must develop, and maintain, an emergency preparedness training and testing, program that is based on the emergency plan, risk assessment, policies and procedures, and the communication plan. The training and testing program must be reviewed, and updated, at least every two years. Agency must participate in a full-scale exercise that is community-based or, when a community-base exercise is not accessible, conduct an individual, facility-based functional exercise every two years; or if the Agency experiences an actual natural, or man-made, emergency that requires activation of the emergency plan, the Agency is exempt from engaging in its next required full-scale community-based, or individual, facility-based, every two years, following the onset of the actual event. Conduct an additional exercise every two years, opposite the year the full-scale or functional exercise is conducted, that may include, but is not limited to the following: -A second full-scale exercise that is community-based or individual facility based functional exercise; or -A mock disaster drill; or -A tabletop exercise or workshop that is lead 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 Analyze the Agency’s response to, and maintain documentation of, of all drills, tabletop exercises, and emergency events, and revise the Agency’s emergency plan as needed.” 1. Review of the agency’s emergency preparedness documentation showed the agency’s policies and procedures for emergency preparedness, along with the agency annual safety meetings. Further review of the annual safety meetings for 2021, 2022, 2023 and 2024 showed two office staff members were present for the meeting. At each meeting, the safety committee completed the following: reviewed the agency’s safety manual, including waste disposal and hazardous medical device reporting; reviewed exits for the office building where the agency office was located; reviewed the location of the fire extinguishers located in the office and ensured the fire extinguishers were working and not expired; checked the agency supplies and disposed of all expired supplies; ensured the agency had personal protective equipment supplies; tested the agency’s telephone tree which the agency would use in an emergency; and conducted a fire drill for office staff. There was no documentation to show the agency had conducted a community-based full scale exercise or facility-based full scale exercise, if a community-based exercise was not available, or a second exercise (either another community-based/facility-base exercise or a tabletop exercise) each year that pertained to emergent issues the agency patient’s might experience as required by regulation. During an interview on 4/30/24 at approximately 11:00 a.m., the administrator stated the agency had conducted a risk assessment for the agency each year and had determined the top three emergency risks their patients might face included: an emergency related to a winter storm, an emergency related to hail, or an emergency related to Covid-19. The administrator acknowledged the emergency preparedness testing the agency had completed in 2021, 2022, 2023, and 2024 had been to conduct a fire drill with office members present on the day of the testing. The administrator acknowledged, the annual fire drills conducted with office staff was not a valid test to ensure the emergency procedures the agency had put in place would be effective for the three main identified risks the agency patient’s might encounter. During an interview on 5/2/24 at 2:41 p.m., the administrator stated the reason the agency continued to do fire drills each year as their exercise to test their emergency preparedness procedures was a fire drill was the exercise the administrator was familiar with executing. The administrator again acknowledged a fire drill conducted with office staff did not meet the regulation, as the agency was not testing the agency’s emergency preparedness procedures to ensure their procedures would be effective in assisting the agency to help their patients with emergencies the patient might encounter. The administrator stated she planned to discuss ways her agency could meet this regulation with the consultant she took her annual administrator training from to assist the agency with being compliant with this regulation.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and record review of the Centers for Medicare and Medicaid Services (CMS) Outcome and Assessment Information Set (OASIS) Error Detail report, the agency failed to electronically transmit current and accurate data regarding each beneficiary with respect to which information was required to be transmitted within 30 days of completing the assessment of the beneficiary for 45 patients who received an assessment from 4/1/23 through 4/30/24. Findings include: 1. Review of the OASIS Error detail report from 4/1/23 through 4/31/24 revealed 66 assessments, which pertained to 45 different patients, were submitted more than 30 days after the “M0090” date, which was the last date information used to complete the comprehensive assessment and determine the OASIS coding gathered by the assessing clinician. Review of the OASIS validation report for 4/1/23 through 4/31/24 revealed Patient A had her OASIS submitted on 1/30/24, for an assessment that had been completed on 11/30/23, approximately 62 days after the completion of the assessment. Review of the OASIS validation report for 4/1/23 through 4/31/24 revealed Patient B had his OASIS submitted on 2/24/24, for an assessment that had been completed on 12/28/23, approximately 59 days after the completion of the assessment. Review of the OASIS validation report for 4/1/23 through 4/31/24 revealed Patient C had her OASIS assessment submitted on 1/30/24, for an assessment that had been completed on 12/12/23, 49 days after the completion of the assessment. Similar findings of the agency failing to submit accurate OASIS assessments within the 30 day timeframe required by regulation was found for assessments submitted for the other 42 patients reviewed on the agency’s OASIS validation report from 4/1/23 to 4/30/24. 2. During an interview on 5/2/24 at 1:05 p.m., the administrator acknowledged the agency was late sending OASIS reports. The administrator stated one of the issues in 2023 was the agency had an OASIS coordinator who was responsible for transmitting OASIS data. The administrator stated she terminated the OASIS coordinator when she realized the OASIS coordinator was transmitting many OASIS assessments late. Additionally, the administrator stated the current issue the agency faced, which resulted in late transmission of OASIS assessments, was the tardiness of clinicians in completing their comprehensive assessments and plans of care. The administrator stated if the clinician failed to complete their comprehensive assessments and plans of care in a timely manner, she was unable to transmit the OASIS with accurate information within the 30 day window required by regulation. The administrator stated she continued to educate her clinicians on the importance of completing and documenting their assessments accurately and timely to try to reduce this issue.”

“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 interview and record review, the agency failed to ensure an initial assessment was provided within 48 hours of referral by a physician for 1 of 8 active patients reviewed who received physical therapy (PT) (Patient #7). Findings include: According to an agency policy, dated 2019, and titled, Initial Assessment Requirements, (read in pertinent parts): “All patients, referred for services, have an initial assessment. The initial assessment is conducted within 48 hours of referral, and/or within 48 hours of the patient’s return home, or on the physician’s ordered start of care date.” 1. The clinical record for Patient #7 was reviewed on 4/29/24. The plan of care for the certification period dated 1/7/24 to 3/6/24 revealed a start of care date of 1/7/24; diagnoses included obstructive sleep apnea, congestive heart failure, chronic obstructive pulmonary disease, unsteadiness on feet, age-related physical debility, hypertension and dependence on other enabling machines and devices. Plan of care orders included PT visits two times a week for six weeks, three times a week for two weeks and two times a week for three weeks for therapeutic exercises, fall safety, gait training, home safety, and dynamic balance training starting 1/7/24; and speech therapy (ST) visits one time a week for one week starting 1/17/24 (no further information was provided). a) The agency failed to complete a comprehensive assessment within 48 hours of receipt of the referral for Patient #7. Specifically, the agency completed the assessment 18 days after receipt of the referral and failed to obtain a delayed start of care order until 16 days after the receipt of the referral for Patient #7. Review of referral documentation showed on 12/21/23 at 9:42 a.m., the agency received a fax from Patient #7’s primary care physician (PCP) ordering PT for Patient #7 due to Patient #7 feeling weak after stopping therapy. Review of the clinical record showed PT #12 completed a start of care visit with Patient #7 on 1/7/24, 18 days after the agency received the referral order from Patient #7’s PCP. Review of Patient #7’s journal notes from 12/26/23 through 4/28/24 showed on 12/27/23 at 2:15 p.m., Scheduler #13 documented he spoke to Patient #7 and she had an appointment on Friday. Scheduler #13 documented he was unable to speak further with Patient #7 as she hung up the phone. Review Patient #7’s record showed text messages between agency employees from 12/21/23 through 1/26/24. On 12/25/23 at 9:03 a.m., Scheduler #13 documented he tried to call Patient #7 for pre-admission information and had to leave a voice message as Patient #7 did not answer her phone. Scheduler #13 also documented he texted Patient #7. On 12/25/23 at 3:37 p.m., Scheduler #13 documented Patient #7 requested the agency call her on 12/26/23 to discuss pre-admission questions as she did not want to answer any questions on Christmas Day. On 1/2/24 at 8:16 a.m., Scheduler #13 documented he called Patient #7 to see if she was available at 10 a.m., but he had to leave a voice message and he also left a text message for Patient #7. On 1/2/24 at 8:26 a.m., Scheduler #13 documented Patient #7 requested a visit at 12:00 p.m. or later. On 1/2/24 at 3:07 p.m., Scheduler #13 documented Patient #7 was informed the agency did not have a therapist to complete a visit at 12:00 p.m. or later in the afternoon on 1/2/24, and Patient #7 stated she was available anytime the week of 12/31/23 through 1/6/24. On 1/2/24 at 4:26 p.m., Intake Coordinator #14 documented Patient #7 agreed to a visit from an agency PT on 1/3/24 at 10:45 a.m. On 1/3/24 at 11:05 a.m., PT #12 documented she arrived at Patient #7’s apartment to complete the initial visit and Patient #7 was not home. On 1/7/24 at 9:28 a.m., PT #12 documented she was scheduled to see Patient #7 at 1:30 p.m. Review of supplemental orders for Patient #7, showed on 1/5/24 PT #12 spoke with Patient #7’s PCP office and a verbal order was approved for a delayed start of care. Patient #7’s PCP signed this verbal order on 2/5/24. This order was obtained 15 days after the agency received the referral order and Patient #7’s record failed to show documentation of any other delayed start of care orders for Patient #7. During an interview on 5/1/24 at 10:44 a.m., PT #12 stated she suffered a head injury in January 2024 and did not recall seeing a patient in January 2024. Upon further interview, PT #12 stated she did remember completing a start of care visit for Patient #7. PT #12 stated when she received orders for a start of care, she would attempt to complete this visit within 24 to 48 hours after the referral was sent to the agency. PT #12 stated she remembered Patient #7 had several scheduling issues. PT #12 stated she thought some of the scheduling issues revolved around issues with insurance approval or receiving information back from Patient #7’s PCP. PT #12 stated she went to see Patient #7 to complete the start of care visit (Wednesday 1/3/24), but Patient #7 was not home. PT #12 stated she only worked on weekends, so another PT attempted to complete the start of care visit with Patient #7, but was unsuccessful. PT #12 stated Case Managers #11 or #15 were typically responsible for calling a patient’s PCP to obtain delayed start of care orders. During an interview on 5/2/24 at 11:37 a.m., Case Manager #11 reviewed Patient #7’s record and confirmed the only delayed start of care order the agency received for Patient #7 was obtained on 1/5/24, 15 days after the agency received the order. Case Manager #11 stated the agency should have communicated to Patient #7’s PCP about the delay and attempted to receive a delayed start of care order by 12/23/23. Case Manager #11 stated the agency needed to improve their process to obtain and document orders. During an interview on 5/2/24 at 3:06 p.m., the administrator stated she appreciated the survey process as the agency always learned so much through the process. The administrator stated the agency strived to provide good care to their patients and would work to correct the deficient practice cited during this survey.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure an accurate comprehensive assessment was completed in 1 of 3 patients reviewed who had their comprehensive assessments completed by a therapist (Patient #3). Findings include: AGENCY POLICY According to an agency policy, dated 2019, and titled, Comprehensive Assessment Requirements, (read in pertinent parts): “Each patient must receive, and an Agency must provide, a patient-specific, comprehensive assessment. A registered nurse must complete the comprehensive assessment, unless physical therapy, speech-language pathology, or occupational therapy is the only service ordered, by the physician. The comprehensive assessment must address, at least the following items: -The physical health component: -Diagnosis -Identification of additional health problems, or pertinent health history -Review of medications -Special nutritional needs, or dietary requirements, and weight loss -Other needed information that could impact the level of services required to meet the patient , and family, needs.” 1. The clinical record for Patient #3 was reviewed on 4/29/24. The plan of care for the certification period dated 1/19/24 to 3/18/24, revealed a start of care date of 1/19/24; diagnoses included hypothyroidism, hypertension, stage 4 chronic kidney disease, gout, polyneuropathy, malaise and history of falling. Plan of care orders included physical therapy (PT) visits one time a week for one week, two times a week for three weeks and one time a week for four weeks starting on 1/19/24 for strengthening, transfer training, gait training, endurance training, and fall risk assessment and education; occupational therapy (OT) visits one time a week for one week starting 1/21/24 for evaluation and treatment. Review of the plan of care for the certification period dated 3/19/24 to 5/19/24, revealed a start of care date of 1/19/24; diagnoses included: hypothyroidism, hypertension, type 2 diabetes mellitus, stage 4 chronic kidney disease, acute respiratory failure with hypoxia, acute embolism and thrombosis of bilateral lower extremities, pulmonary embolism with acute cor pulmonale, polyneuropathy, malaise, hyperlipidemia, difficulty walking, gastro-esophageal reflux disease, gout and cognitive communication deficit. Plan of care orders included PT visits one time a week for nine weeks starting 3/19/24 for gait training, endurance training and fall risk management; and OT to evaluate and treat. a) The agency failed to ensure on 1/19/24, an accurate start of care comprehensive assessment was completed for Patient #3. Specifically, the director of rehab (DOR) failed to list all of Patient #3’s diagnosis appropriate to this episode of care and failed to accurately assess Patient #3’s endocrine system. Review of the start of care comprehensive assessment revealed, on 1/19/24, the DOR inaccurately completed the diagnosis section of the assessment. Specifically, the DOR documented Patient #3’s primary diagnosis for the initiation of this home care episode was hypothyroidism and other diagnoses included hypertension, stage 4 chronic kidney disease, gout, polyneuropathy, and other malaise. The DOR failed to document the diagnosis found on Patient #3’s referral documentation. Review of referral documentation sent to the agency on 1/17/24, by Patient #3’s primary care physician’s (PCP) office, showed Patient #3 had a PCP visit completed on 1/16/24 and had the following diagnoses listed: Stage 4 chronic kidney disease, gout, hypertension, and type 2 diabetes mellitus. The 1/17/24 referral paperwork showed Patient #3 was referred for PT and OT due to physical deconditioning. Review of the initial comprehensive assessment completed on 1/19/24, showed the DOR inaccurate assessed Patient #3’s endocrine system. Specifically, the DOR documented Patient #3 had no problems identified in her endocrine system, failing to identify Patient #3’s diagnosis of type 2 diabetes mellitus and to assess how Patient #3 managed her type 2 diabetes mellitus. b) The agency failed to ensure an accurate resumption of care comprehensive assessment was completed for Patient #3. Specifically, the DOR failed to list all of Patient #3’s diagnosis appropriate to this episode of care and failed to accurately assess Patient #3’s endocrine system and cardiac status. Review of the resumption of care comprehensive assessment completed on 2/26/24, showed the DOR inaccurately completed the diagnosis section of the assessment. Specifically, the DOR documented Patient #3’s primary diagnosis for the initiation of this home care episode was hypothyroidism and other diagnoses included hypertension, stage 4 chronic kidney disease, gout, polyneuropathy, and other malaise. The DOR failed to document the diagnosis found on Patient #3’s referral documentation after her hospitalization. Review of referral documentation sent to the agency on 2/19/24, by the skilled nursing facility (SNF) who cared for Patient #3 from 1/27/24 through 2/22/24 (Patient #3 was hospitalized from 1/23/24 through 1/27/24), showed Patient #3’s was assessed by a physician at the SNF on 2/9/24. The physician at the SNF documented Patient #3 had been admitted to the hospital with Influenza A, a pulmonary embolism (blood clot in her lung) and bilateral lower extremity deep vein thrombosis (blood clots in her legs), and acute respiratory failure with hypoxia (low blood oxygen). The physician at the SNF listed Patient #3’s pertinent medical history included: hypertension, type 2 diabetes mellitus controlled with diet, gastroesophageal reflux, stage 4 chronic kidney disease, gout, hyperlipidemia, unspecified glaucoma, muscle weakness and multiple orthopedic issues. Additionally, the referral documentation listed the medication Patient #3 was taking, which included the anticoagulant (blood thinner) Apixaban 5 milligrams by mouth daily. c) The agency failed to ensure on 3/16/24, an accurate recertification comprehensive assessment was completed for Patient #3. Specifically, the DOR failed to accurately assess Patient #3’s endocrine system and cardiac status. Review of the resumption of care comprehensive assessment completed on 3/16/24, showed the DOR inaccurately assessed Patient #3’s endocrine system. Specifically, the DOR documented Patient #3 had no problems identified in her endocrine system, failing to identify Patient #3’s diagnosis of type 2 diabetes mellitus and to assess how Patient #3 managed her type 2 diabetes mellitus. Review of the resumption of care comprehensive assessment completed on 3/16/24, showed the DOR inaccurately assessed Patient #3’s cardiac status. Specifically, the DOR documented Patient #3 was not taking an anticoagulant medication, failing to identify Patient #3 was taking the anticoagulant medication Apixaban. 2. During an interview on 5/1/24 at 10:26 a.m., Patient #3 stated her current diagnoses were: type 2 diabetes, hypertension, gout, chronic kidney disease, high cholesterol, and gastric reflux. Patient #3 stated her kidney doctor was currently running tests to see if she was suffering from hypothyroidism, but she did not have a current diagnosis of hypothyroidism. Patient #3 stated she took several medications daily which included: lasix (a diuretic) for her kidney issues, omeprazole for her gastric reflux, latanoprost eye drops to prevent glaucoma, high blood pressure medicine, high cholesterol medication, Vitamins C, D, and E, and Eliquis (the brand name for Apixaban) to prevent her from getting any more blood clots. Patient #3 stated she had been taking Eliquis since the end of February 2024 when she discharged home from the SNF. During an interview on 5/2/24 at 9:57 a.m., the DOR acknowledged she completed Patient #3’s start of care comprehensive assessment on 1/19/24, her resumption of care comprehensive assessment on 2/26/24 and her recertification comprehensive assessment on 3/16/24. The DOR stated Case Managers #11 and #15 were responsible for documenting a patient’s diagnoses on a patient’s comprehensive assessment. The DOR stated she could not recall the reason Patient #3 was hospitalized in January of 2024 and required a resumption of care comprehensive assessment on 2/26/24 as it was too many months ago. The DOR stated she was out of the country on vacation and could not access the agency’s electronic medical record (EMR) system to be able to review the documentation to assist her with her recall of events. The DOR stated her practice when she completed any comprehensive assessment was to review the referral documentation sent to the agency. Additionally she would review a patient’s medication list and compare this to the medications the patient had in their home. If there was any discrepancies in the medication list compared to the medication the patient had in the home, she would notify the patient’s physician and the agency management staff to get the discrepancies corrected. During an interview on 5/2/24 at 10:22 a.m., Case Manager #11 reviewed Patient #3’s comprehensive assessments and referral documentation and agreed the primary diagnosis of hypothyroidism was inaccurate. Case Manager #11 stated per the initial referral documentation sent to the agency on 1/17/24 the primary diagnosis listed should have been hypertension. The director of nursing (DON) reviewed the 1/17/24 referral information and the comprehensive assessments and stated due to Patient #3’s type 2 diabetes, the DOR should not have marked no problem identified on the endocrine section of the assessment. The DON stated the DOR should have marked Patient #3 had type 2 diabetes mellitus and completed the assessment questions related to this diagnosis. The DON also reviewed the referral information sent to the agency on 2/19/24, the resumption of care comprehensive assessment completed on 2/26/24, and the recertification comprehensive assessment completed on 3/16/24 by the DOR and stated the DOR should have checked Patient #3 was taking an anticoagulant medication. During continued interview, Case Manager #11 stated the agency had noted when a therapist completed a comprehensive assessment they tended to focus primarily on the issues the therapist would address for the patient and sometimes failed to complete a full comprehensive assessment for the patient. Case Manager #11 stated the agency had started to ask physician’s on a therapy only case if a registered nurse could have orders to complete the initial assessment, to ensure the patient received a complete comprehensive assessment.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview and record review the agency failed to ensure drugs, services and treatments were administered only as ordered by a physician or allowed practitioner for 4 of 9 active patient records reviewed (Patients #3, #4, #5, and #8). Findings include: AGENCY POLICY According to an agency policy, dated 2019, and titled, Patient Assessments/ Plan of Care, (read in pertinent parts): “Physician’s orders are established, and documented, for the health care services the agency provides to those patients who: -Are being actively treated, by a physician, for a diagnosed health care problem. -Have a health care need, or change[,] in physical status, requiring medical intervention. - Are Home Health Aide patients of a certified Home Health Agency.” “Any changes in the physician’s plan of treatment shall be made, in writing, and signed, timed, and dated by the physician, or by the registered nurse [on] the staff of the Agency, pursuant to the verbal orders of the physician, which will be mailed to him for his signature and place in the chart, within 30 days.” 1. The clinical record for Patient #5 was reviewed on 4/30/24. The plan of care for the certification period dated 3/13/24 to 5/11/24, and signed by Patient #5’s primary care physician (PCP) on 4/22/24, revealed a start of care date of 3/13/24; diagnoses included: stage 4 pressure ulcers of right and left heels and other site, stage 3 pressure ulcer of right ankle, unstageable pressure ulcer of the left ankle, osteomyelitis of right ankle and foot, alcohol abuse, alcoholic polyneuropathy, nicotine dependence, esophagitis, and anemia. Plan of care orders included skilled nurse (SN) visits two times a week for one week and three times a week for eight weeks for wound care; and physical therapy (PT) to evaluate and treat. a) The agency failed to obtain orders for the SN care provided to Patient #5 from 3/15/24 through 3/26/24, a total of four SN visits. Review of a referral order sent to the agency on 3/13/23 at 1:13 p.m., showed an order for home health for wound care evaluation and treatment. Review of Patient #5’s supplemental orders showed on 3/13/24, registered nurse (RN) #16 documented Patient #5’s start of care (SOC) assessment was completed. RN #16 requested SN visits two times a week for one week and three times a week for eight weeks for wound care. RN #16 requested the specific wound care she recommended the agency’s SN perform with Patient #5 was as follows: clean areas with wound cleanser; pat dry; apply medi-honey (a wound gel that provides a moist wound environment and autolytic debridement of a wound) to the wound bed; cover the area with calcium alginate (a type of wound dressing used to promote new cell formation); cover with a non-stick dressing and secure with kerlix (a type of rolled gauze). RN #16 requested orders for PT to eval and treat on 3/25/24. By the time of the survey exit, this order had not been signed by Patient #5’s PCP. Review of Patient #5’s journal notes from 3/13/24 through 4/25/24 showed on 3/14/24 at 9:14 a.m. Case Manager #11 documented she tried to call Patient #5’s PCP office to obtain verbal orders to continue Patient #5’s care based on RN #16 recommendations. Case Manager #11 documented she was only able to leave a voicemail requesting a call back. Review of a journal note written on 3/14/24 at 10:11 a.m. by Intake Coordinator #14 showed Patient #5’s PCP returned the agency’s phone call. Patient #5’s PCP declined to provide a verbal order for Patient #5. Intake Coordinator #14 stated Patient #5’s PCP’s office stated Patient #5 was scheduled for a visit with the PCP on 3/25/24. Intake Coordinator #14 documented Patient #5 could call her PCP to try to get her visit moved up from 3/25/24. Review of a journal note written on 3/14/24 at 10:52 a.m., showed Case Manager #11 attempted to reach Patient #5 and her spouse, but neither Patient #5 or her husband answered the telephone. Case Manager #11 documented she left a voice message requesting Patient #5 call the agency back regarding her 3/25/24 PCP appointment. Review of a text communication between agency employees regarding Patient #5 showed on 3/14/24 at 11:18 a.m., Intake Coordinator #14 documented Patient #5 received the message from the agency regarding Patient #5’s PCP declining to give a verbal order until Patient #5 was seen by her PCP. Intake Coordinator #14 documented Patient #5 stated she would contact her PCP right away. Review of a text communication between agency employees regarding Patient #5 showed on 3/14/24 at 2:59 p.m., Intake Coordinator #14 documented Patient #5 was scheduled to see a colleague of her PCP (her PCP was on vacation) on Monday (3/18/24) instead of Monday 3/25/24 and the agency could call again on Monday (3/18/24) to obtain a verbal order for continued SN visits and the specific wound care to perform for Patient #5. Review of text communications between agency employees regarding Patient #5 showed on 3/15/24, licensed practical nurse (LPN) #17 requested information from agency management regarding what the specific wound care orders were for Patient #5. RN #16 documented there were no wound care orders as Patient #5 needed to follow up with her PCP to obtain orders. Case Manager #11 asked if RN #16 could recommend any wound care and asked if RN #16 called Patient #5’s PCP. RN #16 documented Patient #5 needed to see her PCP first, but LPN #17 could do medi-honey and calcium alginate and cover with non-stick dressing and wrap with kerlix. Case Manager #11 requested RN #16 create a verbal order for her wound care recommendations. Review of a text communication between agency employees regarding Patient #5 on 3/18/24 at 10:04 a.m. showed Intake Coordinator #14 documented Patient #5’s PCP still could not provide the verbal order for continued SN care and the specific wound care orders requested by the agency, as Patient #5 failed to show up for her scheduled appointment. Patient #5’s PCP office stated Patient #5 still had an appointment with her PCP on 3/25/24. Review of a text communication between agency employees regarding Patient #5 showed on 3/26/24, Case Manager #11 received an order for wound care for Patient #5 and requested RN #16 add this order to Patient #5’s interventions by creating a change order. Review of the 3/25/24 wound care order received by the agency on 3/26/24 at 2:03 p.m., showed Patient #5 was to receive home health SN for wound care three times a week and home health PT. Review of SN notes from 3/13/24 to 4/29/24, showed LPN #17 provided Patient #5 with SN care including wound care on 3/15/24, 3/18/24, 3/20/24 and 3/22/24: all four visits were provided without orders. During a home visit on 5/1/24 at 12:40 p.m., LPN #17 acknowledged her first visit with Patient #5 was on 3/15/24. LPN #17 stated Patient #5 had five wounds and LPN #17 measured all five wounds, documented the measurements of Patient #5’s five wounds in the agency’s EMR and provided wound care as indicated in the intervention section of the EMR. LPN #17 acknowledged she provided Patient #5 care on 3/18/24, 3/20/24, and 3/22,25 as well. During an interview on 5/2/24 at 8:59 a.m., RN #16 stated she called Patient #5’s PCP office on 3/13/24 and attempted to receive a verbal order to continue care of Patient #5 and to receive specific orders for wound care as the referral order the agency received was for wound care evaluation and treatment. RN #16 stated Patient #5’s PCP refused to provide verbal orders for Patient #5 until the PCP saw Patient #5. RN #16 stated Patient #5 had an appointment with her PCP on 3/25/24, and the agency was provided orders to proceed with SN three week for wound care with specific instructions provided for Patient #5’s left and right foot and leg wounds on 3/26/24.. RN #16 stated she did not know why LPN #17 was scheduled to provide visits from 3/15/24 through 3/22/24 as the agency did not have orders for that care. During an interview on 5/2/24 at 11:26 a.m., the director of nursing (DON) and Case Manager #11 both acknowledged the agency provided Patient #5 with wound care on 3/15/24, 3/18/24, 3/20/24 and 3/22/24 without having orders. The DON and Case manager #11 stated the administrator directed Case Manager #11 to schedule LPN #17 to provide the care for Patient #5 without orders on those four days as Patient #5’s PCP would not provide them with verbal orders until Patient #5 was seen by the PCP. The DON and Case Manager #11 stated the administrator was worried about Patient #5 potentially developing an infection if she was not provided any wound care until she was seen by her PCP, thus the administrator decided to have LPN #17 continue to provide Patient #5 with wound care; and follow the wound care orders Patient #5 was provided in the long-term acute care hospital prior to discharging home. During an interview on 5/2/24 at 2:42 p.m., the administrator acknowledged she advised the DON and Case Manager #11 to have LPN #17 provide Patient #5 with wound care without orders on 3/15/24, 3/18/24, 3/20/24 and 3/22/24. The administrator stated she directed her management staff to make this decision as she was worried about the health consequences Patient #5 might face if the wound care was not provided. The administrator stated she recently had another patient whose PCP would not provide verbal orders for wound care and the agency did not provide that patient wound care until the orders were received. The administrator stated the patient developed an infection in her wound. The administrator acknowledged regulation required the agency to have physician orders for all care provided. b. The agency failed to ensure LPN #17 followed wound care orders for treatment provided to Patient #5 from 3/27/24 through 5/1/24, a total of 13 visits. Further review of the 3/25/24 wound care order received at the agency on 3/26/24 for Patient #5 showed Patient #5’s right heel wound was to be cleansed with saljet (a bullet of saline used to cleanse wounds), gauze, and wound cleanser and dressed with Sureprep to periwound (a product used on skin around a wound to create a protective barrier), alginate, foam and offload, conforming gauze and Coban (a type of self stick bandage). Patient #5’s left heel and left lateral wound were to be: cleansed with gauze and wound cleanser; dressed with Sureprep to the periwound; allevyn (a type of wound dressing that provides a barrier to bacteria and helps prevent fluid from leaking) with one large allevyn for Patient #5’s heel and a small one for her lateral wound; and wrapped in conforming gauze and Coban. Review of SN notes from 3/27/24 through 4/29/24 showed LPN #17 documented she provided Patient #5 with wound care as ordered on the 3/25/24 wound care order. During a home visit on 5/1/24 at 12:11 p.m., LPN #17 was observed to provide Patient #5’s Left and Right heels and left lateral leg wound with the following wound care: removal of the old dressing; cleansed each wound with wound cleanser and gauze; applied skin prep to the periwound of each wound; applied an alginate dressing with medi-honey on the alginate cut to the size of each of the three wounds; assisted the alginate dressings to stay in place by wrapping both Patient #5’s right and left foot and lower leg with kerlix, and then secured the kerlix with Coban. LPN #17 failed to follow the wound care orders for Patient #5’s Left and right lower extremity wounds provided to the agency on 3/26/24. During an interview on 5/1/24 at 12:40 p.m., LPN #17 showed the surveyors in the agency’s electronic medical record (EMR) where she looked to see what wound care orders to provide a patient. LPN #17 showed the surveyors the wound care request order entered into the agency EMR on 3/13/24 by RN #16. LPN #17 stated the wound care the surveyors observed LPN #17 provide Patient #5 on 5/1/24, was the wound care she had provided to Patient #5 since she began caring for her on 3/15/24. LPN #17 stated she was not aware Patient #5’s wound care orders had changed on 3/26/24, thus she failed to provide the wound care as ordered for all 13 visits she provided Patient #5 from 3/27/24 through 5/1/24. LPN #17 stated she failed to see the 3/26/24 wound care order in the system. During an interview on 5/2/24 at 8:59 a.m., RN #16 stated the change in Patient #5’s wound care order on 3/26/24 was communicated to all SNs who provided Patient #5 care, including LPN #17, in the text communication chain the agency used to communicate regarding Patient #5. Additionally, RN #16 stated she completed a change order in the system to update the interventions for the wound care to provide Patient #5 on 3/26/24, and LPN #17 would be able to see updated wound care interventions in the agency’s EMR. RN #16 could not state why LPN #17 had not seen the wound care order changes on 3/26/24 or why she did not follow the new orders. During an interview on 5/2/24 at approximately 3:00 p.m., the administrator and DON stated they were not aware LPN #17 was not following the wound care orders provided to the agency on 3/26/24 and instead 3/15/24 through 5/1/24 had provided Patient #5 with the wound care order requested by RN #16 on 3/13/24. The administrator stated LPN #17 should have followed the 3/25/24 order received by the agency on 3/26/24 and updated in the agency’s EMR by RN #16 on 3/26/24. 2. The clinical record for Patient #3 was reviewed on 4/29/24. The plan of care for the certification period dated 1/19/24 to 3/18/24, revealed a start of care date of 1/19/24; diagnoses included: hypothyroidism, hypertension, stage 4 chronic kidney disease, gout, polyneuropathy, malaise and history of falling. Plan of care orders included PT visits one time a week for one week, two times a week for three weeks and one time a week for four weeks starting on 1/19/24 for strengthening, transfer training, gait training, endurance training, and fall risk assessment and education; occupational therapy (OT) one time a week for one week starting 1/21/24 for evaluation and treatment. a) The agency failed to obtain a delayed resumption of care (ROC) order for Patient #3 when she returned home from the hospital on 2/22/24. Review of Patient #3’s record revealed the director of rehab (DOR), PT #5, completed a transfer to inpatient facility (TIF) OASIS on 1/23/24 for Patient #3 which stated Patient #3 was admitted to the hospital on 1/23/24 for an unknown reason. Review of discharge paperwork, faxed to the agency on 2/19/24, from the skilled nursing facility Patient #3 was admitted to from the hospital on 1/27/24, showed Patient #3 was discharged home to her new living environment, a senior living facility, on 2/22/24. The paperwork showed the agency was ordered to provide home health PT and OT to Patient #3. Review of Patient #3’s record showed text communications between employees for Patient #3 from 2/19/24 to 2/26/24. On 2/21/24, Scheduler #13 documented Patient #3 wanted to move her ROC comprehensive assessment scheduled for 2/23/24 and the address of Patient #3’s new senior living facility. Scheduler #13 failed to document further information regarding what day Patient #3 requested to move her ROC comprehensive assessment appointment to. On 2/22/24 at 8:01 a.m., Scheduler #13 documented Patient #3 wanted her ROC comprehensive assessment appointment to be on Monday, 2/26/24, and Scheduler #13 included a screenshot of a text sent to him by Patient #3 on 2/21/24 at 6:27 p.m., in which Patient #3 texted she wanted to wait until Monday, 2/26/24 for her ROC comprehensive assessment. On 2/22/24 at 8:02 a.m., Scheduler #13 documented he would call to obtain a delayed ROC order. On 2/22/24 at 11:55 a.m., Scheduler #13 documented he spoke with an employee at Patient #3’s PCP office and requested a delayed ROC order. Scheduler #13 documented he expected a call back on 2/23/24 to receive the delayed ROC order. Review of Patient #3’s record revealed the DOR completed Patient #3’s ROC OASIS/comprehensive assessment on 2/26/24. Review of Patient #3’s record failed to reveal the agency had obtained a verbal or written order to delay completing Patient #3’s ROC comprehensive assessment within 48 hours of her return home from the hospital as required by regulation. During an interview on 5/2/24 at 9:52 a.m., the DOR stated the agency’s expectation was ROC comprehensive assessments would be completed within 48 hours of a patient returning home from the hospital unless a delayed ROC order was obtained. The DOR stated she was out of the country on a vacation and could not access the agency’s EMR system. The DOR stated she could not recall why Patient #3’s ROC comprehensive assessment in February 2024 was delayed or if a delayed ROC order was obtained. During an interview on 5/2/24 at 10:33 a.m., the DON and Case Manager #11 reviewed Patient #3’s record and acknowledged the agency failed to obtain a delayed ROC order for Patient #3. Case Manager #11 stated typically the clinician going out to complete the ROC was responsible for obtaining the delayed ROC order for a patient. Case Manager #11 stated Scheduler #13 called to request a delayed ROC order, but failed to document if he received approval from Patient #3’s PCP for the agency to delay Patient #3’s ROC. Case Manager #11 reviewed the text messages agency employees had regarding Patient #3 and stated could she could not say why the agency failed to obtain the delayed ROC order for Patient #3. 3. The clinical record for Patient #4 was reviewed on 4/30/24. The plan of care for the certification period dated 4/6/24 to 6/4/24, revealed a start of care date of 4/6/24; diagnoses included: malignant neoplasm of the unspecified bronchus or lung, stage 1 pressure ulcer of the sacral region; chronic pain, hypertension, chronic obstructive pulmonary disease, muscle weakness, obstructive sleep apnea, disorders of psychological development, constipation, nausea and vomiting, repeated falls, anxiety, and history of a femur fracture. Plan of care orders included SN visits five times a week for eight weeks for assessment and wound care starting from 4/15/24; and home health aide (HHA) visits three times a week for nine weeks for assistance with bathing and grooming starting 4/8/24. Review of Patient #4’s supplemental orders revealed a verbal order for daily SN visits for daily sacral wound dressing changes for Patient #4’s coccyx wound and HHA visits three times a week to assist with showering and grooming written by RN #10 on 4/8/24 and signed by Patient #3’s PCP on 4/25/24. a) The agency failed to ensure SN visits were completed as ordered. Review of Patient #4’s clinical record revealed from 4/6/24 through 4/29/24 Patient #4 received 15 SN visits on the following days: 4/6/24, 4/10/24, 4/11/24, 4/15/24 - 4/19/24, 4/21/24, 4/22/24, 4/24/24 - 4/26/24, 4/28/24 and 4/29/24. Patient #4 had documented missed SN visits sent to his PCP on 4/9/24, 4/12/24, and 4/23/24. Further record review failed to show why Patient #4 did not receive SN visits on the following five days: 4/8/24, 4/13/24, 4/14/24, 4/20/24, and 4/27/24. During a home visit on 4/30/24 at 8:41 a.m., Patient #4 stated RN #10 provided him SN care five or six days a week for wound care. Patient #4 stated he typically received SN visits Monday through Friday and sometimes on Sunday. Patient #4 stated he did not know why he didn’t receive SN visits on Saturdays and why he only sometimes received SN visits on Sundays. During an interview on 5/1/24 at 3:35 p.m., RN #10 confirmed she was Patient #4’s primary nurse. RN #10 stated she provided Patient #4 with assessment and wound care Monday through Fridays and as needed (PRN) visits on the weekends. RN #10 reviewed the verbal order she obtained on 4/8/24 from Patient #4’s PCP in which she documented Patient #4’s PCP provided her with an order for daily SN visits for wound care. RN #10 stated daily meant seven days a week. RN #10 stated she could not recall exactly what she requested from Patient #4’s PCP for a SN frequency. RN #10 stated what she wanted to request and should have documented was SN visits Monday through Friday with PRN visits on Saturdays and Sundays. RN #10 acknowledged the verbal order she documented and was signed by Patient #4’s PCP was for daily SN visits. RN #10 stated the she had failed to comply with this order as Patient #4 did not receive SN visits for five days from 4/8/24 through 4/29/24. During an interview on 5/2/24 at 11:11 a.m., Case Manager #11 stated part of her job responsibility was to ensure SN visits were scheduled as ordered to ensure visits were not missed. Case Manager #11 stated the start of care order for Patient #4 was for SN visits five times a week and she scheduled SN visits for five times a week. Case Manager #11 stated she had just recently seen RN #10 had obtained a verbal order for daily SN visits, and by that point, Patient #4 had not received the five missed visits. Case Manager #11 stated she educated RN #10 on the importance of ensuring her frequency of visits matched her order. Case Manager #10 also stated she re-educated RN #10 on the importance of remembering to update the text communication thread agency employees used to discuss patients, including scheduling issues, to ensure all agency employees were informed of changes with a patient. 4. Similar findings of the agency failing ensure SN visits were completed as ordered was found for Patient #8. 5. During an interview on 5/2/24 at 11:49 a.m., Case Manager #11 stated the agency needed to improve their process of having clinicians verify the agency received an order when a member of the team requested an order from a physician prior to the clinician providing the care. During an interview on 5/2/24 at 3:06 p.m., the administrator stated she appreciated the survey process as the agency always learned so much through the process. The administrator stated the agency strived to provide good care to their patients and would work to correct the deficient practice cited during this survey.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure verbal orders were documented in the patient’s record by the skilled nurse (SN) who received the order for 2 of 9 active patients records reviewed (Patients #4 and #7). Findings include: AGENCY POLICY According to an agency policy, dated 2019, and titled, Verbal Orders, (read in pertinent parts): “Physician’s orders, which are signed, timed, and dated by the physician, are required for all services rendered by the Agency. All verbal, or telephone, orders will be received by licensed personnel, i.e., RN [registered nurse], PT [physical therapist], ST [speech therapist], OT [occupational therapist], etc. All Plans of Care/Treatment and verbal, or telephone, orders will be countersigned, by the physician, within thirty (30) days. Verbal orders are to be recorded in the patient’s clinical record, by the professional receiving them and must include date, time, and signature.” 1. During an interview on 4/29/24 at 10:19 a.m., the administrator stated the clinician who received a verbal order from the patient’s physician was responsible for documenting the verbal order in the patient’s record. The administrator stated the clinician was to document the order, the name of the person at the physician’s office who provided the order, the time and date the order was received; and the clinician was to sign the order. The administrator stated agency personnel who worked in the office were responsible for sending all verbal orders to the physician who provided the order to the physician to authenticate, sign and date the verbal order. 2. The clinical record for Patient #4 was reviewed on 4/30/24. The plan of care for the certification period dated 4/6/24 to 6/4/24, revealed a start of care date of 4/6/24; diagnoses included: malignant neoplasm of the unspecified bronchus or lung, stage 1 pressure ulcer of the sacral region; chronic pain, hypertension, chronic obstructive pulmonary disease, muscle weakness, obstructive sleep apnea, disorders of psychological development, constipation, nausea and vomiting, repeated falls, anxiety, and history of a femur fracture. Plan of care orders included SN visits five times a week for eight weeks for assessment and wound care starting from 4/15/24; and home health aide (HHA) visits three times a week for nine weeks for assistance with bathing and grooming starting 4/8/24. Further review of the plan of care showed SNs were to apply calmoseptine cream (a multipurpose moisture barrier that protects and helps heal skin irritations) to Patient #4’s coccyx wound and to cover the wound with a mepilex border foam dressing (a conformable antimicrobial foam dressing that absorbs drainage and maintains a moist wound environment). a. The agency failed to ensure registered nurse (RN) #10 documented all verbal orders received for Patient #4’s wound care. Review of Patient #4’s 4/6/24 start of care outcome and assessment information set (OASIS)/comprehensive assessment showed RN #10 assessed Patient #4 to have one stage 1 pressure ulcer on his coccyx. Review of Patient #4’s wound care assessment in the agency’s electronic medical record (EMR) showed on 4/6/24, RN #10 assessed Patient #4 to have a stage 1 pressure ulcer to his coccyx which RN #10 labeled Site 1. On 4/16/24, RN #10 assessed Patient #4 to have an additional stage 1 pressure ulcer at his gluteal fold, which she labeled Site 2. On 4/29/24, RN #10 assessed Patient #4 to have a stage 1 pressure ulcer on his sacrum, which she labeled Site 3 and she documented Patient #4’s Site 1 wound was healed. Review of a SN note dated 4/16/24, showed RN #10 documented, in the today’s notes section of the note, she discovered Patient #4 had a new open area. RN #10 documented she updated Patient #4’s wound care assessment. RN #10 stated she contacted a medical doctor (MD), the note failed to state which MD, and received a verbal order to treat the new wound (Site 2) with the same treatment (cover the wound with caloseptime cream and a mepilex dressing) as Patient #4’s Site 1 wound. Patient #4’s record failed to show RN #10 documented the verbal order she received on 4/16/24 that included: the name of physician and/or the physician representative she received the verbal order from, the date and time she received the verbal order and her signature. Review of Patient #4’s wound care assessment documentation from 4/16/24 to 4/28/24 showed RN #10 documented she provided wound care as ordered to Patient #4’s Site 1 and 2 wounds. Review of a SN note dated 4/29/24, showed RN #10 documented, in the today’s notes section of the note, she discovered Patient #4 had developed a new open area to his sacrum area (labeled Site 3 on the wound care assessment) below the coccyx and Patient #4’s coccyx wound was healed. RN #10 documented a MD (RN#10 failed to document the name of the MD she spoke to) recommended the same treatment for the new open area. Patient #4’s record failed to show RN #10 documented the verbal order she received on 4/29/24 to treat Patient #4’s new sacral wound that included: the name of physician and/or the physician representative she received the verbal order from, the date and time she received the verbal order and her signature. During an interview on 5/1/24 at 3:03 p.m., RN #10 confirmed she was the SN who completed Patient #4’s start of care assessment and provided him with SN visits most days. RN #10 stated on 4/16/24 and 4/29/24 she called Patient #4’s primary care physician (PCP) to inform the PCP that Patient #4 had developed a new wound each of those days. RN #10 stated the PCP provided her with a verbal order to provide the same wound care treatment of cover the wound with caloseptime cream and a mepilex dressing as provided for Patient #4’s initial coccyx wound on 4/6/24, but she failed to document the verbal orders she received on 4/16/24 and 4/29/24. RN #10 stated the agency expectation was all verbal orders received were to be documented in the patient’s record as a verbal order. RN #10 stated she forgot to document the verbal orders she received on 4/16/24 and 4/29/24. RN #10 stated she was still learning how to use the agency’s EMR. RN #10 also stated she often forgot to document; and was working on improving her documentation as she was aware of how important it was to document. During an interview on 5/2/24 at Case Manager #11 acknowledged RN #10 failed to document the 4/16/24 and 4/29/24 verbal orders she received for wound care for Patient #4’s Site 2 and 3 wounds respectively. Case Manager #11 stated part of her responsibilities at the agency was to complete quality assurance reviews of patient’s records which included, but was not limited to, ensuring SNs and/or therapists documented all verbal orders received. Case Manager #11 stated she noted RN #10 had failed to document the verbal order she received for wound care to Patient #4’s Site 2 wound on 4/16/24 and had reminded RN #10 to document the verbal order. Case Manager #11 acknowledged as of 5/2/24, RN #10 had failed to document the 4/16/24 verbal order and Case Manager #11 had failed to follow up and ensure RN #10 completed this task. 3. Similar findings of the agency failing to ensure SNs documented all verbal orders received was found for Patient #7. 4. During an interview on 5/2/24 at 3:06 p.m., the administrator stated she appreciated the survey process as the agency always learned so much through the process. The administrator stated the agency strived to provide good care to their patients and would work to correct the deficient practice cited during this survey.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on interview and record review the agency failed to ensure the home health aide (HHA)/certified nursing assistant (CNA) provided services as ordered by the physician, included in the plan of care and permitted under State Law for 1 of 4 active patient records reviewed receiving HHA services (Patient #1). Findings include: AGENCY POLICY According to an agency policy dated 2019 and titled, Home Health Aide Service, (read in pertinent parts): “A Home Health Aide provides services that are: -Ordered by the physician; -Included in the plan of care; -Permitted to be performed under state law; and -Consistent with the home health aide training.” 1. The clinical record for Patient #1 was reviewed on 4/29/24. The plan of care for the certification period dated 3/14/24 to 5/12/24, revealed a start of care date of 3/20/23; diagnoses included: type 2 diabetes mellitus, chronic obstructive pulmonary disease, hypertension, glaucoma, benign prostatic hyperplasia, disorders of pituitary gland, insomnia, anxiety, alcohol abuse, gastro-esophageal reflux, tremor, amnesia and essential tremor. Plan of care orders included: skilled nurse (SN) visits two times a week for nine weeks for medication management, set up, and compliance; oxygen safety checks; assessment; and disease management; and HHA visits two times a week for nine weeks for grooming and showering assistance. a) The agency failed to ensure HHA #7 only provided services as ordered by the physician, included in the plan of care and permitted under state law. Specifically, the agency failed to ensure HHA #7 did not cut Patient #1’s fingernails or toenails. Review of the HHA care plan dated 3/14/24 to 5/12/24 revealed the HHA #7 was assigned to assist Patient #1 with shampooing and showering without a frequency provided. Review of HHA visit notes from 3/14/24 to 4/30/24 revealed HHA #7 provided Patient #1 with care nine times (3/18/24, 3/22/24, 3/25/24, 3/28/24, 4/1/24, 4/8/24, 4/22/24, 4/30/24). During an interview on 4/30/24 at 4:16 p.m., HHA #7 stated she reviewed a patient’s plan of care when she first began to provide a patient care, in order to know what tasks to assist the patient with. HHA #7 stated she confirmed the information she reviewed on the plan of care with the patient prior to starting services. During a home visit on 4/30/24 at 12:24 p.m., Patient #1 and HHA #7 confirmed she was Patient #1’s HHA and provided Patient #1 with care two times a week for grooming and hygiene. HHA #7 specifically stated she assisted Patient #1 to shower and she assisted Patient #1 with cutting his fingernails and toenails as needed, a task not ordered by the physician, care planned or permitted under state law due to Patient #1 being diabetic. HHA #7 stated she used large clippers to cut Patient #1’s toenails as he had thick toenails and it took her awhile to cut his nails. HHA #7 stated she was not aware Patient #1 suffered from type 2 diabetes. During an interview on 5/2/24 at 11:55 a.m., the director of nursing (DON) stated she was unaware HHA #7 was cutting Patient #1’s fingernails and toenails. The DON stated this task was not ordered by Patient #1’s physician for the HHA to perform, care planned or permitted under state law due to Patient #1’s type 2 diabetes. The DON stated fingernail and toenail trimming was not a care planned task or permitted under state law for a HHA to perform on a patient with diabetes because if the HHA were to accidentally cut the patient’s skin with the nail clippers, the patient could develop a wound. The DON stated this would be a potential issue for a patient with diabetes as diabetes can impede a patient’s ability to heal a wound. The DON stated HHA #7 had access to Patient #1’s plan of care which stated Patient #1 had type 2 diabetes, thus HHA #7 should have been aware Patient #1 had type 2 diabetes. The DON stated the agency educated all HHA that fingernail and toenail trimming was not a HHA permitted task for patients with diabetes. The DON also stated, HHA #7 should only provide patients assistance with care planned tasks. The DON stated she would re-educate HHA #7 on the importance of reviewing a patient’s diagnosis and only providing care planned and permitted tasks with patients. 2. During an interview on 5/2/24 at 3:06 p.m., the administrator stated she appreciated the survey process as the agency always learned so much through the process. The administrator stated the agency strived to provide good care to their patients and would work to correct the deficient practice cited during this survey.”