Centerwell Home Health

“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 record reviews, interviews, and data report reviews, the agency failed to ensure that the Outcome and Assessment Information Set (OASIS) assessment was transmitted to the CMS system within 30 days of the M0090 (date assessment completed) to allow an outside contractor to complete a review of the OASIS data for 4 (#2, #4, #15, #17) of 17 sampled Medicare/Medicare Advantage patients, . The findings included: A review of the agency policy titled 03-05 Initial and Comprehensive Assessments Policy reviewed on Review: 04/2023 and a revision date of revised: 04/2023 revealed: • Assessments will be performed by a qualified Clinical Associate who has demonstrated verbal/written knowledge of the specific skills needed to perform assessments, including specialty assessment OASIS Data Collection The Home Health agency will: Collect information, including OASIS data items for each agency patient receiving skilled care to be billed to Medicare/Medicaid as primary or secondary payers according to Company procedures. Encode the OASIS data for Medicare/Medicaid patients receiving skilled care (including maternity patients whose care will be billed to Medicare and those under a managed care or Medicaid waiver program) as specified in Company procedures. Maternity patients whose care will be billed to Medicare as a primary or secondary payer will have selected OASIS indicators assessed performed to establish the Home Health Resource Group (HHRG). OASIS data will not be transmitted to the state. The OASIS form will be maintained in such patients’ medical records. OASIS data items will be encoded and transmitted within 30 calendar days of the completion of the OASIS assessment. A review of the Internet Quality Improvement Evaluation System (IQIES) Home Health Agency (HHA) Error Summary report for the year to date 01/14/2024-06/14/2024 indicated an error rate of 32.21% for the error code 3330, Record Submitted Late (error 3330). In total, 3139 assessments were processed with 1011 errors, noted as error 3330, and the record was submitted late. Reviewing the OASIS Agency Final Validation Reports dated 06/14/2024 indicated that 4 of 19 transmitted OASIS had error message 3330. According to the Centers for Medicare and Medicaid Services (CMS) OASIS Error Message User Guide dated January 18, 2023, the OASIS Provider Final Validation report is automatically generated within 24 hours of successfully submitting a file. All warning errors should be reviewed and corrected, if appropriate, to ensure the data uploaded is accurate and complete. Error 3330 message is “Record submitted late: The submission date is more than 30 days after M0090 on this new record. The potential cause is the assessment was not submitted within CMS timing guidelines. The submission date minus M0090 (date assessment completed) should be no more than 30 days.” CMS suggested actions include “review the assessment timing schedule in the Current OASIS Guidance Manual and verify that all assessments are submitted in a timely manner.” During an interview with the administrator on 06/14/2024 at 11:55 AM, she confirmed she was aware of the reporting errors. “We knew we would be tagged for that.” For Patient #2, the RN OASIS admission assessment was completed on 1/12/2023 (M0090 date). However, the agency did not transmit this assessment until 2/27/2024, 46 days after its completion. For Patient #4, the RN OASIS admission assessment was completed on 3/14/2024 (M0090 date). However, the agency did not transmit this assessment until 4/16/2024, 33 days after completion. For Patient #15, the RN OASIS admission assessment was completed on 4/12/2024 (M0090 date). However, the agency did not transmit this assessment until 5/13/2024, 32 days after its completion. For Patient #17, the RN OASIS admission assessment was completed on 12/30/2023 (M0090 date). However, the agency did not transmit this assessment until 1/30/2024, 32 days after its completion.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observations, interviews, records, and policy reviews, the agency failed to follow its policy and procedure for standard precautions during wound care for 1 (#12) patient out of 1 wound care observation and 2. The agency also failed to ensure staff followed their policy and procedure for handwashing and use of gloves for 2 (#12, #15) patients out of 7 home visits conducted. The findings included: The survey team requested a hand-washing policy several times. The administrator instructed that it was part of the policy titled Bag technique, home care, with a revised date of May 22, 2023. The policy only addressed hand hygiene when disinfecting/cleaning nursing bags. A review of the medical record for patient #12 revealed an admission date of 9/09/2023 and a current certification period of 5/06/2023 to 7/04/2024. The primary diagnosis listed is a pressure ulcer of the sacral region stage 4 and a pressure ulcer of the right buttock stage 4 With a pertinent diagnosis of paraplegia. On line 21 of the plan of care (POC), the orders for disciplines and treatments read SN (skilled nurse) 2 week 9. With Orders of discipline and Treatments: Sn to perform pressure ulcer care to the sacral coccyx and the right buttock, cleanse with normal saline solution and Dakin’s, apply skin prep to peri-wound Apply Mupirocin 2% ointment to the wound bed apply collagen AG (alginate) and calcium AG, cover with bordered foam and secure with tape using clean technique Change dressing every day and PRN soiling/dislodgement.” “Sacral coccyx wound cleansing and peri-wound skin care, clean wound with normal Saline and Dakin’s or wound cleanser and apply skin prep peri-wound and apply Mupirocin 2% ointment to wound bed apply collagen AG or parasol calcium alginate cover with ADB pad or bordered dressing 3 times per week Continue home health 2 times per week on Monday’s and Wednesday’s Nurse Practitioner to see the patient on Friday’s Durable medical equipment (DME) listed on the POC Dakin’s solution, dressing ABD, dressing alginate /hydrofiber, dring collagen, dressing cotton tp applicator, dressing foam dressing gauze, dressing hydrocolloid, skin protectant, tape and wound cleanser. Reviewing the agency policy for wound measurements revealed that the nurse will measure wounds on Mondays. A home visit was conducted for Patient #12 with Staff AA, Licensed Practical Nurse (LPN) on 6/17/224 at noon. Patient #12 was in bed and could roll on his left side. Staff LPN put his nursing bag on a barrier, sanitized his hands, and donned gloves. Staff AA LPN removed wound care supplies from a plastic container in the patient’s room and placed them on the bed beside the patient. Then, staff AA put a barrier down near the patient. Staff AA then removed the wound dressing from the patient’s right ischium, removed the dressing from the patient’s coccyx area, and placed it in a plastic bag on the floor. Staff LPN then cleaned the right ischium with saline-moistened gauze. The LPN cleaned the inside of the wound, folded the gauze over, wiped it around the wound, and swiped it back across the open ischium wound. The LPN then applied a foam-padded dressing to the wound. The LPN did not measure the wound. With the same gloves, the LPN performed wound care to the coccyx using saline-moistened gauze. The LPN cleaned into the deepest area of the wound, rotating the gauze in a circular motion. Then, the LPN wiped around the wound, folded the gauze over, and went back into the wound. The LPN then applied a foam-padded dressing. Staff AA did not measure the wound. The LPN then cleaned his scissors with an alcohol pad, gathered up all of the used supplies and packaging, and placed them in a plastic bag on the floor. Staff AA LPN then removed his gloves. During an interview with staff AA on 6/17/2024 at 12:28 PM, he stated he had not changed his gloves. A second interview was conducted with Staff AA on 6/182024 at 1:15 PM. Staff AA stated that he had not used Dakin’s solution but wound cleanser instead for the wounds on patient #12 on 6/17/2023. A review of the visit note written by Staff AA, LPN, revealed documentation that he had measured the wounds during the home care observation conducted on 6/17/2024 Documented that the sacral wound as #1 that measurements taken were 5.8 x 5.6 x 3 with a surface area of 32.48 The visit note documented that the wound care provided was: Skilled nurse performed pressure ulcer care to the sacral coccyx and the right buttock cleansed with normal saline solution and Dakin’s, applied skin-prep to periwound, applied mupirocin 2% ointment to the wound bed applied collagen ag and calcium alginate, covered with bordered foam secured with tape using clean technique The visit note documented wound #2 #2 - LOW BUTTOCK, RT, PU STAGE IV and measured 5.1 X 3.3 X 2.9 Wound care provided Skilled nurse performed pressure ulcer care to the sacral coccyx and the right buttock cleansed with normal saline solution and Dakin’s,applied skin-prep to peri-wound, applied mupirocin 2% ointment to the wound bed, applied collagen ag and calcium alginate, and covered with bordered foam secured with tape using clean technique. The visit note dated 6/17/2024 for patient #12, documented by Staff AA, LPN, was reviewed with the administrator on 6/18/2024 at 2:50 PM. The administrator confirmed that Staff AA should have changed his gloves and sanitized his hands between removing the old dressing and putting a new dressing on and between the two wounds. During an interview with the administrator on 6/19/2024 at 10:00 AM, she stated that we had addressed the wound care performed by Staff AA, LPN, with him. An observation was conducted during a home visit on 6/19/2024 at 12:30 PM with Staff BB, a Physical Therapy Assistant (PTA) for Patient #15. Staff BB entered the patient’s home wearing gloves. Once he was in the house, he set up his equipment. Then, Staff BB, PTA checked the patient’s vital signs; he used hand sanitizer with his gloves on and then proceeded to start the patient’s therapeutic exercises. During an interview with the administrator on 6/19/2024 at 10:00 AM, she stated that we had addressed this with Staff BB, PTA, stating, “I have never heard of anyone using hand sanitizer with gloves on.””

“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 observations, interviews, and record reviews, the agency failed to document in writing the frequencies of the services to be provided for 5 (#4, #6, #10, #13, and #14) patients out of 17 patient records sampled. The findings included: Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, concerning-- (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. A review of the Home Care Consent for patient #4 revealed that it was signed by the patient and agency representative on 3/14/2024. The consent did not document the expected physical or occupational therapy frequencies and duration. A review of the plan of care (POC) revealed an admission date of 3/14/2024 and a certification period of 3/14/2024 to 5/12/2024. It was documented on the POC for Frequency/duration of Visits skilled nursing (SN) 1 wk1, physical therapy (PT) 1 wk1, 3 wk1, 1 wk1, and occupational therapy (OT) effective 3/17/2024 1 wk 2. The medical record revealed no documentation that PT or OT notified the patient or caregiver of the frequencies to be provided. A review of the Home Care Consent for patient #6 revealed that it was signed by the patient and agency representative on 4/25/2024. The consent form did not document the expected frequencies and duration of PT, OT, or speech therapy(ST). A review of the plan of care (POC) revealed an admission date of 4/25/2024 and a certification period of 4/25/2024 to 6/23/2024. The PC Documented for Frequency/duration of Visits skilled nursing (SN) 1 wk3, PT effective 4/28/2024 1 wk1, OT effective 4/28/2024 effective 4/28/224 1 wk1 and ST 1 wk1, 2wk4, 1wk4. Reviewing the Client Scheduling Report revealed that ST provided services for 1 wk1 and was scheduled for 2 x wk 8 through the end of the certification period. OT was scheduled 0wk 1 and 1 wk 5. The medical record revealed no documentation that the patient or caregiver was notified of the frequencies to be provided by ST or OT or that the patient agreed with the POC. A review of the Home Care Consent for patient #10 revealed that it was signed by the patient and agency representative on 6/11/2024. The consent did not document the expected frequencies and duration for SN. A review of the plan of care (POC) revealed an admission date of 6/11/2024 and a certification period of 6/11/2024 to 8/09/2024. Documented on the POC for frequency/duration of visits to skilled nursing (SN) 2 wk1, 1 wk 3. The medical record revealed no documentation that the patient or caregiver was notified of the frequencies to be provided by SN or that the patient agreed with the POC. A review of the Home Care Consent for patient #13 revealed that it was signed by the patient and agency representative on 3/28/2024. The consent did not document the expected frequencies and duration for SN. A review of the POC revealed an admission date of 3/28/2024 and a current certification period of 5/27/2024 to 7/25/2024. Documented for Frequency/duration of Visits SN 1 wk9. The medical record revealed no documentation that the patient nor caregiver was notified of the frequencies to be provided by SN or that the patient agreed with the POC. A review of the Home Care Consent for patient #14 revealed that it was signed by the patient and agency representative on 4/13/2024. The consent document included the expected frequencies and duration for PT, OT, and ST 1 w 1 (evaluation). A review of the plan of care (POC) revealed an admission date of 4/13/2024 and a certification period of 6/12/2024 to 8/10/2024. Documented for Frequency/duration of Visits SN effective 6/16/2024 1 wk4, PT 1 wk1, 2wk1, 1 wk3, 2wk1, 1wk2, OT effective 6/15/2024 1wk1, 1 every 2wk2, 1 wk3 and ST 1wk3, 1 every 2wk2, 1 wk4.The medical record revealed no documentation that the patient or caregiver was notified of the frequencies provided by PT, OT, or ST or that the patient agreed with the POC. During an interview with the administrator on 6/19/2924 at 11:40 AM, she said that the consent forms should be filled out, and if there are changes, the patient should be notified.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on record review and interview the Home Health Agency failed to ensure that for 4 of 17 (#3, #5, #8, #9) patients sampled, that they received all services per their plan of care. Findings included 1. Review of Patient Number 3’s record revealed that this patient had a Start of Care (SOC) date of 11/11/23 with a certification period of 11/11/23-1/9/24. The patient had diagnosis that included: Fracture of the neck of the femur, Essential Hypertension, and Gastro-Esophageal Reflux. Review of the clients plan of care revealed that the client had the following frequencies: “SN 1WK1, 3WK8, 1WK1 PT EFF 11/12/23 3WK1, 2WK1 OT EFF 11/12/23 1WK6 HHA EFF 11/12/23 1WK6” Review of the patients calendar and coordination notes revealed that there was a missed Occupational Therapy (OT) visit for the week of 11/19/23. The calendar and coordination notes revealed that efforts were not made to ensure that this visit was completed at anytime during this week. Interview with Administrator on 6/19/24 at 1:12 PM revealed that there was no documentation that would reflect that efforts were made by the OT to reschedule Patient #3’s visit. 2. Review of Patient Number 5’s record revealed that this patient had a Start of Care (SOC) date of 4/5/24 with a certification period of 4/5/24-6/3/24. The patient had diagnosis that included: Essential Hypertension, Morbid Obesity, and Hyperlipidemia. Review of the clients plan of care revealed that the client had the following frequencies: -SN 1WK1, 2WK2 Review of the patient record revealed that this patient signed a consent for services on 4/5/14. Review of the patients coordination notes revealed the following: -“Authorization update 4/3/24- PER PORTAL BRANCH IS NOT AN ACTIVE BRANCH WE CANNOT SUBMIT AUTHORIZATION REQUEST AT THIS TIME UNABLE TO ACCEPT PATIENTS HOME HEALTH SERVICES.” -“Authorization update 4/4/24- BRANCH B72 IS NOT AN ACTIVE BRANCH/OON WITH TRICARE EAST SO WE ARE UNABLE TO SUBMIT/OBTAIN AUTHORIZATION AT THIS TIME WE ARE WORKING TO RESOLVE THIS ISSUE BUT NO RESOLUTION TIME.” -“Authorization update 4/8/24- B72 IS NOT AN ACTIVE BRANCH/OON WITH TRICARE EAST SO WE ARE UNABLE TO SUBMIT/OBTAIN AUTHORIZATION AT THIS TIME WE ARE WORKING TO RESOLVE THIS ISSUE BUT NO RESOLUTION TIME.” Review of the patient visit calendar and visit note revealed that on 4/5/24 the Registered nurse (RN) completed an Oasis admission visit. Additional review of the calendar revealed that the RN completed a discharge on 4/5/24 with no visit. Continued review of the patients coordination noted revealed a note dated 4/10/24 indicating “CALLED AND SPOKE WITH PT TO INFORMED THEM THAT WE ARE NO LONGER CONTACTED WITH INSURANCE VENDOR AND REFERRED PT TO ALTERNATE HOME HEALTH.” Interview with admin 6/19/24 1:45 PM reported that she will obtain info on coordination of services for d/c when client still needed services. Interview with Administrator on 6/19/24 at 1:45 PM revealed that at the time the Home Health Agency was unable to provide services for the patients due to being cancelled by their insurance company. She reported that there should have been coordination of services for the discharge and confirmed that there was no documentation in the record that would reflect that there was no lapse in service for Patient #5 when services were still needed. 3. Review of Patient Number 8’s record revealed that this patient had a Start of Care (SOC) date of 5/29/24 with a certification period of 5/29/24-7/27/24. The patient had diagnosis that included: Hemiplegia following a Cerebral Infraction Affecting Left Side, Type 2 Diabetes, and Atrial Fibrillation. Review of the clients plan of care revealed that the client had the following frequencies: “SN 1WK5, 1EVERY2WK4 PT 1WK1, 2WK3, 1WK3” Review of the physician order date 5/24/24 revealed that OT services were ordered with the frequency of 3 visits a week for 4 weeks. Review of the patients visit notes, calendar and coordination notes revealed that there was a missed OT initial visit on 6/7/24. the documentation indicated “OT-Schedule conflict- visit needs moved to next week.” Review of the Physician order dated 6/7/24 indicated that “Reschedule visit for initial eval for week of June 10 for OT.” Continued review of the patient visit notes, calendar and coordination notes revealed that there was no documentation that would indicate that the initial OT visit for an evaluation was completed. Interview on 6/19/24 at 11:20 AM with the Administrator revealed that the patient was admitted with orders for OT and was unsure if the visit was made. She confirmed that there was no documentation that would indicate that the visit was completed. 4. Review of Patient Number 9’s record revealed that this patient had a Start of Care (SOC) date of 4/29/24 with a certification period of 4/29/24-6/27/24. The patient had diagnosis that included: Laceration of Right Forearm, Fracture of the left femur, and Chronic Obstructive Pulmonary Disease. Review of the clients plan of care revealed that the client had the following frequencies: “SN 2WK1, 1WK2; EFF 5/23/24 sn TO CONTINUE FOR WOUND CARE. SN 1WK2 eff wk of 5/27 PT 1WK4 OT EFF 5/5/24 1WK1, 1WK5” Review of the patients visit calendar, visit notes and coordination notes revealed that Skilled Nursing (SN missed visits for the weeks of 5/12/24, 5/26/24 and 6/2/24. Review of the record also revealed that there were missed OT visits for the weeks of 5/26/24 and 6/9/24. The Visit calendar, visit notes and coordination notes revealed that efforts were not made to ensure that these visits was completed at anytime during the scheduled weeks. Interview with administrator on 6/19/24 at 1:46PM revealed that there was no documentation that would reflect that efforts were made by the SN and OT to reschedule Patient #9’s visits. A request for a policy related to following the plan of care and missed visits was requested from the agency on 6/19/24 at 1:50 PM, but not provided.”

“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, interviews, and record reviews, the agency failed to ensure staff followed the physician-ordered plan of care for wound care for 1 (#12) patient out of 1 patient observed with wound care. The findings included: A review of the agency policy titled 03-51 Wound Care Assessment and Clinical Oversight documented Policy: For all wound/post-operative care/dressings, a physician /allowed practitioner order will be obtained as part of the patient plan of care. Physician/allowed practitioner orders will specify the cleansing agent, products/treatments, specific sites/locations, outer dressings to be applied, treatment frequency, and individual to perform the treatment. Wound care supplies are to be included in the patient’s care plan. The licensed practical nurse (LPN) will execute interventions according to the plan of care and collect data on wound status and documents in the patient record. A review of the medical record for patient #12 revealed an admission date of 9/09/2023 and a current certification period of 5/06/2023 to 7/04/2024. The primary diagnosis listed is a pressure ulcer of the sacral region stage 4 and a pressure ulcer of the right buttock stage 4, with a pertinent diagnosis of paraplegia. On line 21 of the plan of care (POC), the orders for disciplines and treatments read SN (skilled nurse) 2 week 9. With Orders of Discipline and Treatments: SN is to perform pressure ulcer care to the sacral coccyx and the right buttock, cleanse with normal saline solution and Dakin’s, and apply skin prep to peri-wound. Apply Mupirocin 2% ointment to the wound bed. Apply collagen AG (alginate) and calcium AG, cover with bordered foam, and secure with tape using clean technique. Change dressing every day and PRN soiling/dislodgement.” “Sacral coccyx wound cleansing and peri-wound skin care, clean wound with normal Saline and Dakin’s or wound cleanser and apply skin prep peri-wound and apply Mupirocin 2% ointment to wound bed apply collagen AG or parasol calcium alginate cover with ADB pad or bordered dressing 3 times per week. Continue home health 2 times per week on Mondays and Wednesdays. The nurse practitioner will see the patient on Fridays. Durable medical equipment (DME) listed on the POC Dakin’s solution, dressing ABD, dressing alginate /hydrofiber, dring collagen, dressing cotton tp applicators, dressing foam dressing gauze, dressing hydrocolloid, skin protectant, tape, and wound cleanser. A home visit was conducted for Patient #12 with Staff AA, Licensed Practical Nurse (LPN), on 6/17/224 at noon. Patient #12 was in bed and could roll on his left side. Staff AA LPN put his nursing bag on a barrier, sanitized his hands, and donned gloves. Staff AA LPN removed wound care supplies from a plastic container in the patient’s room and placed them on the bed beside the patient. Then, staff AA put a barrier down near the patient. Staff AA then removed the wound dressing from the patient’s right ischium, then removed the dressing to the patient’s coccyx area and placed them in a plastic bag on the floor. Staff AA, LPN then cleaned the right ischium with saline-moistened gauze. The LPN cleaned the inside of the wound, folded the gauze, then wiped it around the wound and swiped it back across the open ischium wound. The LPN cut a small piece of calcium alginate for each wound with scissors. Staff AA first applied the calcium alginate to the ischial wound and then covered it with a foam-padded dressing. Staff AA applied the alginate to the sacral wound and covered it with a foam-padded dressing. Staff AA did not use skin prep, clean the wounds with Dakin’s solution, or apply Mupirocin 2% ointment as ordered on the POC. Staff AA LPN did not measure the wound before wound care. With the same gloves, the LPN performed wound care to the coccyx using saline-moistened gauze. The LPN cleaned into the deepest area of the wound, rotating the gauze in a circular motion. Then, the LPN wiped around the wound, folded the gauze over, and went back into the wound. The LPN then applied a foam-padded dressing. Staff AA did not measure the wound. The LPN then cleaned his scissors with alcohol, gathered up all of the used supplies and packaging, and placed them in a plastic bag on the floor. Staff AA LPN then removed his gloves. A second interview was conducted with Staff AA on 6/18/2024 at 1:15 PM. Staff AA stated that he had not used Dakin’s solution on the wounds during wound care for patient #12 on 6/17/2024, “No, it was saline.” Reviewing the visit note written by Staff AA, LPN, revealed that he documented he had measured the wounds during the home care observation conducted on 6/17/2024. He documented that the sacral wound was #1, and the measurements taken were 5.8 x 5.6 x 3 with a surface area of 32.48. The visit noted that the wound care provided was as follows: A skilled nurse performed pressure ulcer care on the sacral coccyx and the right buttock. cleansed with normal saline solution and Dakin’s, applied skin-prep to peri-wound, applied mupirocin 2% ointment to the wound bed, applied collagen ag and calcium alginate, and covered with bordered foam secured with tape using clean technique. The visit note documented wound #2 #2 - LOW BUTTOCK, RT, PU STAGE IV and measured 5.1 X 3.3 X 2.9. The nurse provided wound care and performed pressure ulcer care on the sacral coccyx and the right buttock. Cleansed with normal saline solution and Dakin’s, applied skin-prep to peri-wound, applied mupirocin 2% ointment to the wound bed, applied collagen ag and calcium alginate, and covered with bordered foam secured with tape using clean technique. A review of the visit note dated 6/17/2024 with the administrator on 6/18/2024 at 2:50 PM. “The care should have been provided as ordered.””

“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 observations, interviews, and record reviews, the agency failed to notify the physician of a change in condition for 1 (#13) patient out of 7 home care visits. Regulation Text 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. An agency-specific policy was requested but not received. An observation was conducted during a home visit on 6/18/2024 with Staff CC, Registered Nurse (RN), during a home visit for patient #13. During the assessment, patient #13 stated she was experiencing increased shortness of breath (SOB), “More than usual.” Staff CC RN did not address this or educate the patient on using her oxygen or what and when to report if symptoms worsened or did not improve with medication or the use of oxygen. A review of the visit note dated 6/18/2024 completed by Staff CC, R.N., revealed that there was no documentation that Staff CC notified the physician that patient #13 reported an increase in SOB. The administrator was interviewed on 6/19/2024 at 11:40 AM. She said that the nurse should have notified the physician.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to provide a written visit schedule for each discipline providing services for 7 (#11, #12, #13, #14, #15, #16, and #17) patients out of 7 patients sampled during home care visits. The findings included: A review of the agency policy title 03-09 Patient Rights/Notice of Privacy Practices with a revised date of 4/2022. Patient Communication: The patient will be encouraged to participate in planning care both at the beginning of services and throughout the course of care to the extent that the patient chooses to participate. Where the patient is not able to exercise their rights due to physical or mental impairments, family members and/or significant others who are authorized representatives may exercise the rights on the patient’s behalf. As a patient of the company, Patients have the right to 8. Participate in and be informed in advance about treatment, including the completion of assessments to determine care needs; decisions about the care to be provided or revisions to the care plan; the name and title of staff who will perform or supervise their care; the frequency of visits; expected outcomes and goals; and any factors that could impact the effectiveness of their treatment. A home care observation on 6/17/2024 at 11:30 AM for patient # 11 revealed the home care admission pack contained blank scheduling calendars. An interview was conducted with patient #11’s caregiver on 6/17/2024 at 11:30 AM. The caregiver said that when they admitted patient #11 over the weekend, they did not tell me the days they would be coming. “So far, they have called me to tell me when they were coming.” A home care observation was conducted on 6/17/2024 at 12:15 PM for patient # 12, which revealed that there was no home care folder in the home. Staff AA, Licensed Practical Nurse (LPN), said that patient #12 had been with the home care agency for a while and would need another home folder. An interview was conducted with patient #12 on 6/17/2024 at 12:25 PM. Patient #12 said that staff usually call him the night before or when they are on their way. During a home care observation conducted on 6/18/2024 at 10:00 AM with patient # 13, a review of the home care admission pack revealed scheduling calendars that were not filled out. Patient #13 was interviewed on 6/18/2024 at 10:13 AM. Her staff called to let her know what days and times they were coming. During a home care observation conducted on 6/182024 at 11:03 AM for patient # 14, a review of the home care admission pack revealed scheduling calendars that were not filled out. Patient #14 was interviewed on 6/18/2024 at 10:13 AM. Patient #14 stated that the staff called her to tell her what days and times they were coming. During a home care observation conducted on 6/18/2024 at noon for patient # 15, a home care admission pack review revealed incomplete scheduling calendars. An interview was conducted with patient #15 on 6/18/2024 at 12:05 PM. Patient #15 said the staff called him and told me when they were coming. “They know I prefer morning visits.” During a home care observation conducted on 6/18/2024 at 12:30 PM for patient # 16, the caregiver stated they did not feel like visiting Calebder; they just called and let me know when they would be here. During a home care observation conducted on patient # 17, an attempt was made to review the patient’s home care folder, and the spouse stated that it was locked up in a file cabinet. The home care admission pack, “If they need it, they can just ask me for it,” The patient’s spouse added that they do not fill out calendars for their visits but call or text her to let her know when they are coming. “Sometimes they call the night before or the day of the visit to let me know what time.” During an interview on 6/19/2024 at 11:45 AM, the administrator said staff should fill out the calendars in the patients’ home folders.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to provide the patient and caregiver with a written medication schedule for 6 (#11, #12, #14, #15, #16, and #17) patients out of 7 sampled during home visits. The findings included: A home care observation on 6/17/2024 at 11:30 AM for patient # 11 revealed that the home care admission pack did not include a written medication profile. A home care observation was conducted on 6/17/2024 at 12:15 PM for patient # 12, which revealed that there was no home care folder or written medication profile for the patient in his home. During a home care observation conducted on 6/182024 at 11:03 AM for patient # 14, a home care admission pack review did not include a written medication profile. During a home care observation conducted on 6/18/2024 at noon for patient # 15, a home care admission pack did not include a written medication profile. During a home care observation conducted on patient # 17, an attempt was made to review the patient’s home care folder, and the spouse stated that it was locked up in a file cabinet. The home care admission pack said, “If they need it, they can just ask me for it.” The patient’s spouse added that there was no updated medication profile in the folder. During an interview on 6/19/2024 at 11:45 AM, the administrator confirmed that the admitting nurse should reconcile the medications and leave a copy of the meds with instructions in the home folder for the patient and/or the caregiver.”