One at Home - Broward

“Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This Element is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure the coordination of their patient’s referral for services to make sure the patient’s referring physician was notified of the HHA’s inability to assess the patient within the required timeframe for 1 of 4 sampled patients (Patient #2). The findings included: Review of Patient #2’s clinical record documents a referral from a local hospital dated 11/14/24 sent to the HHA’s “Intake Department” for the services of RN (Registered Nurse), Evaluation and Treat PT (Physical Therapy), OT (Occupational Therapy) and Home Health Aide. Review of Patient #2’s “Start of Care” reveals a date of 11/21/24, seven days later, with a physician’s Plan of Care Certification period from 11/21/24 to 01/19/25. Review of Patient #2’s electronic medical record lacks written evidence of documentation related to attempts to contact the patient between 11/14/24 through 11/20/24 to complete the “Start of Care.” On 12/04/24 at 2:03 PM, an interview and a side-by-side review of Patient #2’s clinical record was conducted with the HHA’s Director of Nursing (DON) who stated the patient’s referral was received on 11/14/24; the DON was asked who assigns the nurse to go out to perform the “Start of Care” and stated the Intake Department, and a nurse was assigned to conduct the “Start of Care” on 11/15/24; the DON was asked when Patient #2’s “Start of Care” was completed and stated it was done on 11/21/24; the DON was asked about the delay of over 48 hours to complete Patient #2’s “Start of Care” and to submit any written evidence of the HHA’s staff’s attempts to contact the patient from 11/14/24 thru 11/21/24; the DON stated the HHA’s internal messaging, dated 11/21/24 at 9:00 AM read that the call center received a call from the hospital Case Manager regarding a “Start of Care” and advised that Patient #2 was discharged on 11/17/24 and provided another contact telephone number for the patient; the DON stated the patient’s family called on 11/21/24 regarding coordination of the “Start of Care” and read the HHA’s internal messaging documentation by Staff A, RN/Case Manager (CM) dated 11/21/24, “as per the RN (Registered Nurse) no answer to phone and door today, will continue to follow up”. On 12/04/24 at 2:16 PM, a joint telephone interview was conducted with Staff A, RN/CM, the DON and the Acting Administrator. Staff A was asked when Patient #2’s referral was received and stated on 11/14/24; Staff A stated a nurse was scheduled to provide care and services to Patient #2 on 11/15/24 and did not get a response or communication from the nurse assigned; Staff A was asked for written documentation of the staff’s attempts to coordinate the “Start of Care” from 11/15/24 thru 11/21/24; Staff A was asked why it took so long to complete Patient #2’s “Start of Care” and stated they received a message from the RN that the patient was still hospitalized; Staff A, the Administrator and the DON were apprised the information was not on the patient’s electronic medical record for surveyor review; Staff A stated she did not have any written documentation/information regarding the field nurse’s contacts to the patient and added, “maybe she was calling” and stated she did not know what happened between 11/14/24 and 11/21/24; Staff A then added the nurse was calling the patient and the patient was not answering her calls; Staff A confirmed they received a call from the patient’s ... (family member) on 11/20/24 regarding the “Start of Care” not being done; the surveyor did not have access to the HHA’s internal messaging; Staff A was asked if she notified the referring physician regarding the HHA’s inability to coordinate Patient #2’s “Start of Care” from 11/14/24 through 11/20/24 and replied, “No, I did not;” Staff A stated a report was sent to the physician after the “Start of Care” was completed on 11/21/24; during the joint interview, the Administrator stated they (staff) need to communicate with the physician when unable to contact the patient. On 12/04/24 at 3:11 PM, a joint telephone interview was conducted with Staff B, Field RN, the DON and the Administrator; Staff B stated she clearly remembered Patient #2; stated she called the patient on 11/21/24 and got no answer, called every contact number they had and no answer; drove by and parked on the side of the patient’s house and stayed there for 30 minutes, no one came out or called back and as she was leaving, the patient’s spouse came out; Staff B was asked how she communicated her calls and contact attempts with Patient #2 to Staff A, CM and stated she wrote text messages; Staff B was asked if she entered any contact attempts or communication with the Staff B on the patient’s electronic medical record or the HHA’s internal messaging system and stated she did not remember; Staff B added she spoke to the intake person once and was unable to provide documentation to the surveyor; Staff B stated she did not get a message from the call center from the Patient #2’s ... (family member); during the joint telephone interview, Staff A, the DON and the Administrator were apprised of the lack of written documentation related to staff contacts with Patient #2 to coordinate the “Start of Care” visit and the lack of written documentation of physician notification related to the inability of the agency’s to coordinate between 11/14/24 to 11/20/24.”

“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 the Home Health Agency (HHA)’s Policy and Procedure review, record review and interview, the HHA failed to ensure their patients’ Plan of Care (POC) was followed as ordered for 2 of 3 sampled patients (Patient #1 and #2). The findings included: 1) Review of the HHA’s protocol titled, “Guidelines for Maintenance of Peripheral IV (Intravenous) sites and Central Lines,“ provided by the Director of Nursing documents,“…PICC (Peripherally Inserted Central Catheter) line: flush per SASH (method for flushing an IV catheter) protocol; first with 3-10 ml. (millimeters) of N.S. (Normal Saline), administer medication, then re-flush with 3-10 ml. of N.S., finish with Hep (Heparin) blood thinner) loc 3-5 ml. (100units/ml). When the catheter is not being used, the catheter can be flushed minimally 1/week…if you draw blood from the catheter, you must flush with 20 ml. N.S., then 3-5 ml Hep Loc sol (100uints/ml) …Midline: flush per SASH protocol…” Review of Patient #1’s record reveals a “Home Health Certification and Plan of Care (POC) certification period from 06/27/24 to 08/25/24 with diagnoses to include Unspecified Cirrhosis of Liver and Fever. The POC documents a physician’s orders for a Skilled Nurse (SN) visit daily until 07/06/24 to provide/ instruct patient/caregiver to reset CADD (an infusion device) pump every 24 hours to administer Ampicillin (antibiotic) 8 gram/500 millimeters (ml.) Normal Saline continuously at a rate of 20.8 ml./hour daily intravenous via midline by CADD pump…thru 07/06/2024. The POC documents a physician’s order for the SN to flush the Midline (IV catheter) with 10cc. (cubic centimeter). of Normal Saline solution 0.9% Pre/Post Infusion and to flush with Heparin 100 Units/ml 3-5 ml. after last (Normal) Saline flush as per protocol administer by SN”. Review of Staff A, RN/SN (Registered Nurse/Skilled Nurse)’s notes for Patient #1 dated 06/28/24, 06/29/24, 06/30/24, 07/01/24, 07/02/24, 07/03/24, 07/04/24, 07/05/24 and 07/06/24 documented. “…PICC Line flushed with 10 cc. of 0.9% flush before and after each use. Resistance felt while flushing”. Further review reveals the SN notes lacked written documentation of evidence of flushing the line with Heparin as per the physician’s order. Review of Staff A, RN/SN note for Patient #1 dated 07/01/24 documented, ““PICC LINE flushed with 10 cc of 0.9% flush before and after each use. Resistance felt while flushing…skilled instructions provided on how to flush catheter line…”. Further review reveals the lack of a modified physician’s order for Staff A to instruct Patient #1 to flush the PICC line. Review of Patient #1’s electronic medical record’s “Patient Communication,” dated 07/02/24 documents, “Please be advised as per SN report, last two days patient has 2-3 hours medication remaining in bag and last week Saturday 1/2 bag (219 ml.) due to machine beeping/high pressure. New pump and 1 additional bag of Ampicillin will be delivered tomorrow to be administered 7/6. Per patient’s ... (family member) request for missing doses. MD (physician) NOTIFIED”. Further review of Patient #1’s physician’s orders reveals the lack of a written modified physician’s order for the extra bag of the Ampicillin antibiotic requested. On 07/30/24 at 3:10 PM, a joint interview as conducted with the Director of Nursing (DON) and Staff B, RN/IV Team/Case Manager; the DON stated that Staff B manages patients receiving IV (Intravenous) infusion and injections; Staff B stated she had to request an extra “antibiotic bag” because something happened with the pump. Staff B and the DON were apprised that Staff A continued to document “resistance felt while flushing” the line from 06/28/24 until 07/05/24. On 07/31/24 at 8:25 AM, a telephone call was made to Staff A, RN, a voice recorded message was activated and a voice message was left to call back at the telephone number provided. As of 08/02/24, the surveyor had not received a call back from Staff A, RN. 2) Review of Patient #2’s record reveals a “Home Health Certification and Plan of Care (POC) certification period from 05/31/24 to 07/29/24 with diagnoses to include Sepsis (bloodstream infection). The POC documents physician’s orders for a Skilled Nurse (SN) visit daily until 06/24/2024, then once weekly until further orders. Skilled Nurse to administer Invanz (Antibiotic) 1gm (gram)/100 ml. Normal Saline over 30 minutes every 24 hours intravenous via right upper arm PICC line, by gravity, under universal precautions and sterile technique, 06/24/2024. SN to flush PICC line with 10cc. Normal Saline solution 0.9%. pre/post infusion. SN to perform PICC line site care every week or as needed. Review of Patient #2’s SN Start of Care (SOC) Assessment, dated 05/31/24 documented, “Invanz 1 gram to be administered over 30 minutes daily. First dose administered as ordered…”. Further review of the SOC Assessment lacks written evidence of documentation that Patient #2’s PICC line was flushed with 10 cc. of Normal Saline solution per and post infusion as per the POC. Review of Staff C, RN/SN (Registered Nurse/Skilled Nurse) notes for Patient #2 dated from 06/01/24 through 06/08/24 and 06/10/24 through 06/22/24 documented, “…SN administered Invanz 1gm./100 ml. Normal Saline over 30 minutes intravenous via right upper arm PICC line…”. Further review reveals the SN notes lacked written evidence of documentation of flushing the PICC line as per the physician’s order. Review of Staff C, RN/SN (Registered Nurse/Skilled Nurse) notes for Patient #2 dated 07/01/24 documented, “…SN administered Invanz 1gm./100 ml Normal Saline over 30 minutes intravenous via right upper arm PICC line…”. Further review reveals the SN’s notes lacked written evidence of documentation of flushing the PICC line as per the physician’s order. Further review reveals a lack of a written modified physician’s order to administer Invanz 1gm./100 ml. Normal Saline over 30 minutes intravenous via right upper arm PICC line on 07/01/24. Review of Staff C, RN/SN (Registered Nurse/Skilled Nurse) notes for Patient #2 dated 07/09/24 documented, “… SN to performed line site care as follows: removed old dressing and dispose, assessed insertion site…skilled nurse cleaned insertion site with alcohol swab sticks or Chloraprep (antiseptic solution) as available, applied haloguard (antimicrobial) disc dressing around PICC line, applied clear dressing (Tegaderm). date dressing and change injector cap…”. Further review revealed the SN’s note lacked written evidence of documentation of flushing the PICC line as per the HHA’s protocol. On 07/30/24 at 2:46 PM, a joint telephone call with the DON and Staff D was made to Staff C, RN for an interview. There was no answer to several rings, the DON left a message for Staff C to call back the DON. As of 08/02/24, the surveyor had not received a call back from Staff C, RN. On 07/30/24 at 3:45 PM, during an interview, the DON stated that when a patient’s “line” was not in use, the SN would do the “line” care and flush as per protocol weekly until the physician give an order to discontinue the line. On 07/31/24 at 8:23 AM, a telephone call was made to Staff C, RN for an interview, a voice message was left to call the surveyor back at the telephone number provided. As of 08/02/24, the surveyor had not received a call back from Staff C, RN.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on the Home Health Agency (HHA)’s Policy review, record review and interview, the HHA failed to ensure that the patient’s physician was promptly alerted regarding the patient’s Intravenous catheter line resistance to flushing after the antibiotic therapy for 1 of 3 sampled patients (Patient #1); failed to coordinate care and services with the physician related to the discontinuation of an intravenous catheter after the completion of the antibiotic therapy for 1 of 3 sampled patients (Patient #2) and failed to obtain a modified physician’s order to administer missed antibiotic therapy for 2 of 3 sampled patients (Patient #1 and #2). The findings included: 1) Review of the HHA’s Policy and Procedure titled, “Medication Administration” provided by the Director of Nursing revised on 02/2021 documented, “…any unresolved, significant concerns about medications will be discussed by the nurse with the patient’s physician/practitioner and appropriate staff.” Review of Patient #1’s record reveals a “Home Health Certification and Plan of Care (POC) certification period from 06/27/24 to 08/25/24 with diagnoses to include Unspecified Cirrhosis of Liver and Fever. The POC documents physician’s orders for a Skilled Nurse (SN) visit daily until 07/06/24 to provide/ instruct patient/caregiver to reset CADD (an infusion device) pump every 24 hours to administer Ampicillin (antibiotic) 8 gram/500 millimeters (ml) Normal Saline continuously at a rate of 20.8 ml./hour daily intravenous via midline by CADD pump (infusion device connected to an intravenous line) under universal precautions and sterile technique thru 07/06/2024. The POC documents a physician’s order for the SN to flush the Midline (type of Intravenous Catheter) with 10cc. (cubic centimeters) of Normal Saline solution 0.9% Pre/Post Infusion and to flush with Heparin (blood thinner) 100 Units/ml. 3-5 ml. after last (Normal) Saline flush as per protocol administer by SN. Review of Staff A, RN/SN (Registered Nurse/Skilled Nurse)’s notes for Patient #1 dated 06/28/24, 06/29/24, 06/30/24, 07/01/24 documented, “…PICC (Peripherally Inserted Central Catheter) Line flushed with 10 cc. of 0.9% flush before and after each use. Resistance felt while flushing.” Further review reveals the SN’s notes lacked written evidence of documentation of notifying the patient’s physician or communicating with the HHA’s IV (Intravenous) Team/Case Manager regarding having resistance while flushing the IV line from 06/28/24 until 07/01/24 and then 07/03/24 until 07/06/24. Review of Staff A, RN/SN’s note for Patient #1 dated 07/01/24 documented, ““PICC LINE flushed with 10 cc of 0.9% flush before and after each use. Resistance felt while flushing…skilled instructions provided on how to flush catheter line…”. Further review reveals the lack of a modified physician’s order for Staff A to instruct Patient #1 to flush the line. Review of Patient #1’s electronic medical record’s “Patient Communication” dated 07/02/24 documents, “Please be advised as per SN report, last two days, patient has 2-3 hours medication remaining in bag and last week Saturday 1/2 bag (219 ml.) due to machine beeping/high pressure. New pump and 1 additional bag of Ampicillin will be delivered tomorrow to be administered 7/6. Per patient’s ... (family member) request for missing doses. MD (physician) NOTIFIED”. On 07/30/24 at 3:10 PM, a joint interview as conducted with the Director of Nursing (DON) and Staff B, RN/IV Team/Case Manager; the DON stated that Staff B manages patients receiving IV (Intravenous) infusion and injections; Staff B stated Patient #1 was admitted for IV antibiotic (administration) from 06/27/24 to 07/07/24 and she had to request an extra “antibiotic bag” because something happened with the pump. Staff B stated that on 07/02/24, the patient’s CADD pump was beeping and the skilled nurse informed her and she then communicated with the physician and the pharmacy; Staff B was asked why the physician was not contacted prior to 07/02/24 and replied she had no control of what the nurses out in the field see or do; Staff B added that as soon as she received the message from the nurse, she contacted the pharmacy and a new pump and extra bag of Ampicillin was delivered next day. Staff B and the DON were apprised that Staff A documented “resistance felt while flushing” the line from 06/28/24 until 07/05/24. On 07/30/24 at 3:45 PM, during an interview, the DON submitted the “Medication Administration” policy and stated it “covers” for Coordination of Care related to not coordinating with the physician. On 07/31/24 at 8:25 AM, a telephone call was made to Staff A, RN for an interview, a voice recorded message was activated and a voice message was left to call the surveyor back at the telephone number provided. As of 08/02/24, the surveyor had not received a call back from Staff A, RN. 2) Review of Patient #2’s record reveals a “Home Health Certification and Plan of Care (POC) certification period from 05/31/24 to 07/29/24 with diagnoses to include Sepsis (bloodstream infection). The POC documents physician’s orders for a Skilled Nurse (SN) visit daily until 06/24/2024, then once weekly until further orders. “Skilled Nurse to administer Invanz (antibiotic) 1gm. (gram)/100 ml. Normal Saline over 30 minutes every 24 hours intravenous via right upper arm PICC line, by gravity.” ... “SN to flush PICC line with 10cc Normal Saline solution 0.9%. pre/post infusion. SN to perform PICC line site care every week or as needed”. Further review reveals a lack of a physician’s order and coordination of care for the PICC line removal after therapy completion. Review of Patient #2’s Patient communication to the admitting physician dated 06/21/24 documented, “PATIENT COMMUNICATION-The Registered Nurse will require an order from physician to remove IV line during the last visit. Please, forward order to remove IV line after treatment is completed. IV therapy EOT (End of Treatment) 06/24/2024. Please fax the order asap (as soon as possible). MD (physician) was notified.” Review of Patient #2’s “Patient communication to the Infectious Disease (ID) physician,” dated 06/27/24 documented, “PATIENT COMMUNICATION- Please review the email sent on 06/27/2024, 11:05 am, requesting the order for IV access removal. MD was notified.” Review of Patient #2’s “Patient communication,” dated 07/09/24 documented, – “Please note I spoke with (ID physician office) today 1:49 pm and request order to remove PICC line, Dr (Doctor). won’t be at office until tomorrow and will send order. I also explained patient caregiver is upset and requested PICC line to be removed ASAP. MD NOTIFIED.” Review of Patient #2’s clinical record documented a missed visit on 06/09/24 “Reason: Other (Specify), Comments: Administered by patient -patient was out of city”. Review of Patient #2’s clinical record documented a missed visit on 06/23/24 “Reason: Other (Specify) Comments: PATIENT IS NOT HOME”. Further review reveals a lack of written communication with Patient #2’s physician to coordinate the two missed antibiotic therapies not administered as ordered and the lack of a modified physician order. Review of Staff C, Registered Nurse (RN)’s visits notes from 06/18/24 through 07/09/24 lack written evidence of documentation of coordinating Patient #2’s care with the physicians, Admitting physician and Infectious Disease Physicians). On 07/30/24 at 1:33 PM, during an interview, the DON stated that the physician did not give the agency an order to discontinue Patient #2’s PICC line and the patient went to Emergency Room on 07/09/24 to have it removed. On 07/30/24 at 2:19 PM, a joint interview was conducted with Staff D, RN/IV Team Case Manager; Staff D stated that Patient #2 was admitted on 05/31/24 thru 06/24/24, and added the patient completed IV antibiotic therapy; Staff D stated the patient finished the treatment on 06/24/24 and on 06/21/24 she sent a patient “communication note” to the doctor and sent an e-mail to the physician’s office for an order to discontinue the patient’s IV line; Staff D stated that sometimes the agency will get the order for removal and if not they try to get an order three (3) days prior to the treatment is finished; Staff D added sometimes the physician asks the patient to go to their office, stated she received a (telephone) call, could not provide the date, from Staff C, Registered Nurse because Patient #2 asked for their IV line to be discontinued; A side-by-side review of Staff D’s “patient communication” reveals that it was sent to the patient’s other physician not the Infectious Disease physician on 06/21/24 to have an order to discontinue Patient #2’s IV line was conducted with Staff D and the DON. Staff D and the DON were apprised of the lack of follow through with the physicians to obtain the order; the DON was apprised that Patient #2 had an IV line in place that not been used from 06/24/23 through 07/09/24; the DON added that the patient’s line site care and flushes had been done; the DON was apprised of the lack of written evidence of documentation that Patient #2 received the IV line flushes as per order by Staff C, RN/SN; Staff D was asked regarding the patient’s missed visit, two times and stated the patient went out of the service area and the physician was notified. On 07/30/24 at 2:46 PM, a joint telephone call with the DON and Staff D was made to Staff C, RN for an interview; there was no answer to several rings, the DON left a message for Staff C to call back the DON. As of 08/02/24, the surveyor had not received a call back from Staff C, RN. On 07/30/24 at 3:45 PM, during an interview, the DON submitted a “Medication Administration” policy and stated, “it covers” for “Coordination of Care” related to not having an order to discontinue a Midline/PICC line; the DON stated the HHA needs an order from the physician who ordered the antibiotic therapy, usually from an Infectious Disease physician from a hospital. On 07/31/24 at 8:23 AM, a telephone call was made to Staff C, RN for an interview, a voice message was left to call the surveyor back at the telephone number provided. As of 08/02/24, the surveyor had not received a call back from Staff C, RN.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on the Home Health Agency (HHA)’s Policy and Procedure review, record review and interview and the HHA failed to ensure their patients participate in and be informed about any factors that could impact treatment effectiveness, and any changes in the care to be provided for 2 of 3 sampled patients (Patient #1 and #3). The findings included: 1) Review of the HHA’s Policy and Procedure titled, “Plan of Care-CMS #485 and Physician/Practitioners orders” revised on February 2022 documents, “…patients are accepted for treatment on reasonable expectation that Agency can meet the patient’s medical, nursing, rehabilitative…. needs… services must be furnished in accordance with the accepted standards of practice… the patient’s orders for treatment and services are the foundation of the plan of care. If the agency misses a visit…which results in any potential for clinical impact upon the patient, then the agency must notify the responsible physician…the physician/practitioner decided whether the treatment or services may be skipped or whether additional interventions is required by the agency… if the agency is unable to identify and address the reason for refusal, then the agency must communicate with the patient’s responsible physician/practitioner to discuss how to proceed with patient care…” Review of Patient #1’s physician’s referral for home health dated 11/20/23 documents a “Start of Care” on 11/29/23 and a Skilled Nurse (SN) request, “status post a total knee arthroplasty (a surgical procedure to resurface a knee damaged by arthritis) on 11/27/23. Registered Nurse (RN) to evaluate and treat. Do not remove Aquacel (Wound Dressing) until 7 days completely saturated. Remove Aquacel on Day 7 and perform daily dressing change once daily for 7 days using a dry dressing.” Review of Patient #1’s Home Health Certification and Plan of Care period, from 11/29/23 to 01/27/24 documents the patient’s diagnosis as Unilateral Primary Osteoarthritis of Left Knee. The Plan of Care orders document a Skilled Nurse to perform Left Knee incision wound care daily for seven days…after surgery. Skilled Nurse to remove Aquacel, then dry sterile dressing….” Review of Patient #1’s record reveals the lack of a Skilled Nurse visit performed on 12/04/23 to remove a surgical incision dressing as per the physician’s referral orders. Further review reveals the lack of written documentation of an attempt to visit Patient #1 on 12/04/23 or any communication related to a Skilled Visit on 12/04/23. Review of Patient #1’s “Skilled Nurse Visit calendar” documents a “missed visit” on 12/05/23 with comments written, “Patient’s daughter changed the dressing.” On 01/17/24 at 1:44 PM, a telephone interview was conducted with Staff A, Registered Nurse (RN)-Case Manager (CM) who stated that Patient #1’s surgical incision dressing should have been changed on 12/04/23; that the physician’s order said to change it on Day 7and confirmed that the patient did not have a Skilled Nurse visit on Day 7 (12/04/23). On 01/17/24 at 3:46 PM, during an interview and a side-by-side review of Patient #1’s clinical record conducted with the DON, the DON stated that the physician’s referral read that the Skilled Nurse goes (visits the patient) on Day 7th removes the dressing and then applies a regular dry dressing every day for 7 days after that; the DON stated that Day 7 would have been on 12/04/23; added that the Skilled Nurse documented on the “Start of Care” that the patient needed a visit on Monday (12/04/23) for dressing removal; the DON confirmed that Patient #1 had a “missed visit” on 12/05/23 due to the patient’s daughter performing the dressing change; the DON stated that the first Skilled Nurse visit, after the “Start of Care” was on 12/06/23 not on 12/04/23 as per (the physician’s) orders; the DON confirmed that the Skilled Nurse should have seen the patient on 12/04/23 to remove the surgical dressing and perform wound care. 2) Review of Patient 3’s Home Health Certification and Plan of Care period, from 11/17/23 to 01/15/24 reveals the Plan of Care documents a physician’s order for a Registered Physical Therapist to evaluate and treat, establish a home exercise program, and prepare the patient for Outpatient Physical Therapy. The Physical Therapist’s frequency was ordered as two times a week for two weeks effective on 12/03/23. Review of Patient #3’ clinical record documents three (3) Physical Therapy “missed visits” as follows: 12/07/23- PTA (Physical Therapist Assistant) missed visit documents under comments, “Patient requested to be seen by female therapist instead of a male therapist.” 12/11/23 PTA missed visit documents under comments, “Patient requested to be seen by a female therapist instead of a male therapist.” 12/13/23 PTA missed visit documents under comments, “Patient requested to be seen by a female therapist.” Further review revealed a lack of written documentation regarding Patient #3’s missed visits and discussion of any factors that could impact the patient’s treatment. On 01/17/24 at 2:29 PM, a telephone interview was conducted with Staff B, RN-CM who stated that Patient #3 requested a female therapist and the HHA did not have one in the patient’s area; stated that the staff is supposed to notify the physician and that she will call the doctor the same day the missed visit happened; Staff B was asked for written documentation of her communication with the physician regarding Patient #3’s request for a female therapist and the HHA has not been able to find the documentation; Staff B stated that the HHA’s “Therapy Coordinator” was handling that; stated she was supposed to be aware of the patient’s requesting a female therapist, but she does not have any documentation in the patient’s clinical record under the “communication tab;” Staff B added she did not get involved because the “Therapy Coordinator” was handling it. On 01/17/24 at 4:29 PM, a joint interview was conducted with Staff C, Therapy Coordinator and the Director of Nursing; Staff C stated that the HHA did not have a female therapist as requested by Patient #3; Staff C was asked if the HHA attempted to assign a female therapist from other area; she stated she was not sure; Staff C was asked if a contracted agency was contacted and she could not answer; during the interview, Staff C and the DON were apprised that Patient #3’s clinical record reveals no written documentation to demonstrate that the HHA made efforts to honor the patient’s right to request a female therapist. Staff C stated there was some communication documented in the HHA internal “K-email” system; the DON and Staff C were asked to submit a copy of those communications; during an interview. On 01/17/24 at 4:29 PM, the Vice President (VP) of the HHA’s Health Services stated that the agency has a policy that the K-email was part of the patient’s record; the Vice President was asked to submit K-e-mails with written evidence of the HHA’s efforts to honor the patients request and no records was submitted. The VP and the DON were asked if the HHA attempted to utilize a contracted agency therapist and there was no answer, they were asked if they assigned other area’s therapist to Patient #3’s area and stated the therapist from other areas did not want to go. Further review reveals that Patient #3 was transferred to a local hospital on 12/19/23 due to a fall.”

“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 the Home Health Agency (HHA)’s Policy and Procedure review, record review and interview, the HHA failed to ensure their patients’ Plan of Care was followed as ordered for 2 of 3 sampled patients (Patient #1 and #3). The findings included: 1) Review of the HHA’s policy and procedure titled “Plan of Care-CMS #485 and Physician/Practitioners orders” revised on February 2022 documents, “… patients are accepted for treatment on reasonable expectation that Agency can meet the patient’s medical, nursing, rehabilitative …. needs … services must be furnished in accordance with the accepted standards of practice…each patient must receive the home health services that are written in an individualized plan of care…if a physician/practitioner refers a patient under a plan if care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan… the patient’s orders for treatment and services are the foundation of the plan of care. If the agency misses a visit… which results in any potential for clinical impact upon the patient, then the agency must notify the responsible physician… the physician/practitioner decided whether the treatment or services may be skipped or whether additional interventions is required by the agency… if the agency is unable to identify and address the reason for refusal, then the agency must communicate with the patient’s responsible physician/practitioner to discuss how to proceed with patient care…” Review of Patient #1’s physician’s referral for home health dated 11/20/23 documents a “Start of Care” on 11/29/23 and a Skilled Nurse (SN) request, “status post a total knee arthroplasty (a surgical procedure to resurface a knee damaged by arthritis) on 11/27/23. Registered Nurse (RN) to evaluate and treat. Do not remove Aquacel (Wound Dressing) until 7 days completely saturated. Remove Aquacel on Day 7 and perform daily dressing change once daily for 7 days using a dry dressing.” Review of Patient #1’s Home Health Certification and Plan of Care period, from 11/29/23 to 01/27/24 documents the patient’s diagnosis as Unilateral Primary Osteoarthritis of Left Knee. The Plan of Care orders document a Skilled Nurse to perform Left Knee incision wound care daily for seven days…after surgery. Skilled Nurse to remove Aquacel, then dry sterile dressing….” Review of Patient #1’s record reveals the lack of a Skilled Nurse visit performed on 12/04/23 to remove a surgical incision dressing as per the physician’s referral orders. Review of Patient #1’s “Skilled Nurse Visit calendar” documents a “missed visit” on 12/05/23 with comments written, “Patient’s daughter changed the dressing.” On 01/17/24 at 1:44 PM, a telephone interview was conducted with Staff A, Registered Nurse (RN)-Case Manager (CM) who stated that Patient #1’s surgical incision dressing should have been changed on 12/04/23; that the physician’s order said to change it on Day 7and confirmed that the patient did not have a Skilled Nurse visit on Day 7 (12/04/23). On 01/17/24 at 3:46 PM, during an interview and a side-by-side review of Patient #1’s clinical record conducted with the DON, the DON stated that the physician’s referral read that the Skilled Nurse goes (visits the patient) on Day 7th removes the dressing and then applies a regular dry dressing every day for 7 days after that; the DON stated that Day 7 would have been on 12/04/23; added that the Skilled Nurse documented on the “Start of Care” that the patient needed a visit on Monday (12/04/23) for dressing removal; the DON confirmed that Patient #1 had a “missed visit” on 12/05/23 due to the patient’s daughter performing the dressing change; the DON stated that the first Skilled Nurse visit, after the “Start of Care” was on 12/06/23 not on 12/04/23 as per (the physician’s) orders; the DON confirmed that the Skilled Nurse should have seen the patient on 12/04/23 to remove the surgical dressing and perform wound care. 2) Review of Patient 3’s Home Health Certification and Plan of Care period, from 11/17/23 to 01/15/24 reveals the Plan of Care documents a physician’s order for a Registered Physical Therapist to evaluate and treat, establish a home exercise program, and prepare the patient for Outpatient Physical Therapy. The Physical Therapist’s frequency was ordered as two times a week for two weeks effective on 12/03/23. Review of Patient #3’ clinical record documents three (3) Physical Therapy “missed visits” as follows: 12/07/23- PTA (Physical Therapist Assistant) missed visit documents under comments, “Patient requested to be seen by female therapist instead of a male therapist.” 12/11/23 PTA missed visit documents under comments, “Patient requested to be seen by a female therapist instead of a male therapist.” 12/13/23 PTA missed visit documents under comments, “Patient requested to be seen by a female therapist.” On 01/17/24 at 2:29 PM, a telephone interview was conducted with Staff B, RN-CM who stated that Patient #3 requested a female therapist and the HHA did not have one in the patient’s area; stated that the staff is supposed to notify the physician and that she will call the doctor the same day the missed visit happened; Staff B was asked for written documentation of her communication with the physician regarding Patient #3’s request for a female therapist and the HHA has not been able to find the documentation; Staff B stated that the HHA’s “Therapy Coordinator” was handling that; stated she was supposed to be aware of the patient’s requesting a female therapist, but she does not have any documentation in the patient’s clinical record under the “communication tab;” Staff B added she did not get involved because the “Therapy Coordinator” was handling it. On 01/17/24 at 4:29 PM, a joint interview was conducted with Staff C, Therapy Coordinator and the Director of Nursing; Staff C stated that the HHA did not have a female therapist as requested by Patient #3; Staff C was asked if the HHA attempted to assign a female therapist from other area; she stated she was not sure; Staff C was asked if a contracted agency was contacted and she could not answer; during the interview, Staff C and the DON were apprised that Patient #3’s clinical record reveals no written documentation to demonstrate that the HHA made efforts to honor the patient’s right to request a female therapist. Staff C stated there was some communication documented in the HHA internal “K-email” system; the DON and Staff C were asked to submit a copy of those communications; during an interview. On 01/17/24 at 4:29 PM, the Vice President (VP) of the HHA’s Health Services stated that the agency has a policy that the K-email was part of the patient’s record; the Vice President was asked to submit K-e-mails with written evidence of the HHA’s efforts to honor the patients request and no records was submitted. The VP and the DON were asked if the HHA attempted to utilize a contracted agency therapist and there was no answer, they were asked if they assigned other area’s therapist to Patient #3’s area and stated the therapist from other areas did not want to go. Further review reveals that Patient #3 was transferred to a local hospital on 12/19/23 due to a fall.”