Cedar County Public Health Nursing Services

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits as originally ordered on the Plan for Care for 2 of 7 sampled patients. (Patients #3 and #4) Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient’s health care needs. Findings: 1.Patient #3 had a start of care date of 7/16/26. Clinical record review revealed:a. The physical therapy plan of care (POC), dated 7/24/26, included a primary diagnosis of quadriplegia and provider orders for physical therapy visits 2 times per week from 7/24/26 to 8/21/26. b. Clinical record review lacked documentation of a second physical therapy visit during the week of 8/16/26 to 8/22/26. During an interview on 9/10/26 at 8:3 AM, the Clinical Manager reported that the provider notification of the missed physical therapy visit is not scanned in yet because the agency is waiting on the provider to sign the notification and return it. The agency failed to notify the provider of a missed physical therapy visit. 2.Patient #4 had a start of care date of 7/20/26. Clinical record review revealed: a. The update to the POC, dated 8/11/26, identified a primary diagnosis of unspecified open wound of unspecified buttock and physician orders for 4-5 skilled nursing visits per week. b. Clinical record review lacked documentation of a fourth skilled nursing visit the week of 8/30/26 to 9/5/26. The agency failed to notify the provider of a missed skilled nursing visit. The above findings were reviewed with the Administrator, Clinical Manager, Business/Quality Manager and Staff D, RN. Agency policy, titled Plans of Care, dated 11/2023, identified the plan of care includes the types of services required and the frequency and duration of visits to be made.”

“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 clinical record review, agency policy review, agency staff interview and home visit observation, the agency failed to ensure staff provided care in accordance with accepted infection control standards of practice observed during a home visit for 1 of 3 sampled patients with home visits. (Patient #3) Failure to follow accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. Findings include: Patient #3 had a start of care date of 7/16/26. Clinical record review revealed: a. The plan of care, dated 7/16/26 to 9/13/26, identified the patient had diagnoses of quadriplegia and stage 4 pressure ulcer to the sacral region and included physician orders for weekly skilled nursing services for assessment of wound and measurements. b. During a home observation visit on 9/10/26 at 11:10 AM with Staff D, Registered Nurse (RN), Staff D performed assessment of the patient’s sacral pressure ulcer. During assessment, Staff D cleansed the patient’s buttocks. Staff D then removed their right glove and failed to complete hand hygiene before putting on a new right glove. Staff D then applied a hydrophilic dressing paste to the patient’s buttocks. Staff D, RN failed to failed to complete hand hygiene per agency policy and accepted standards of practice. The above finding was reviewed with the Administrator, Clinical Manager, Business/Quality Manager and Staff D. Agency policy, titled Hand Hygiene, dated 09/2026, identified staff wash hands with an alcohol-based hand sanitizer before and after contact with a patient, before and after changing of gloves, and after contact with inanimate objects in the immediate vicinity of the patient.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on staff interview, clinical record reviews and agency policy review, the agency failed to provide a complete comprehensive assessment for patients with wounds for 1 of 4 sampled patients with wounds (Patient #3). Failure to accurately and thoroughly complete wound assessments or provide a comprehensive assessment placed patients at an increased risk of unidentified condition changes. Findings include: According to agency policy titled Wound Care, dated November 2023, measurements of wounds shall be performed by a registered nurse (RN) and recorded in centimeters. Measurements taken will be length, width, depth and measured at the greatest point. Tunneling or undermining will be assessed when measuring the wound. It is important that the measuring procedures are consistent in order to determine improvement of the wound. Wound measurements must occur at a minimum weekly and orders for measurement frequency reflected in the patient’s plan of care (POC). All documentation will be recorded in the patient’s electronic medical record (EMR). During an interview on 9/9/26 at 8:54 AM, the Clinical Manager reported that wounds are measured weekly to include length, width and depth along with other assessment components such as drainage. Patient #3 had a start of care date of 7/16/26. Clinical record review revealed: a. The POC, dated 7/16/25 to 12/31/26, included diagnoses of quadriplegia and stage 4 pressure ulcer of sacral region and physician orders for weekly skilled nursing services for assessment of wound and measurements. b. The comprehensive assessment completed at start of care, dated 7/16/26, completed by Staff D, RN, included documentation of an unhealed stage 2 pressure ulcer. The assessment lacked documentation of a comprehensive wound assessment per agency policy. c. The skilled nurse visit note, dated 8/26/26, completed by Staff D included documentation that the pressure ulcer was healed. Review of the clinical record failed to include weekly comprehensive wound assessments starting from the start of care assessment throughout the time that the patient had an unhealed pressure ulcer. The nurse failed to document a weekly comprehensive wound assessment per agency policy. The above finding was reviewed with the Administrator, Clinical Manager, Business/Quality Manager and Staff D, RN.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to perform complete drug regimen reviews with corresponding comprehensive assessments for 3 of 7 sampled patients (Patients #3, #4 and #7). Failure to perform a complete drug regimen review places the patient at risk for delayed identification of medication concerns. Findings include: According to agency policy titled Drug Regimen Review (DRR) and Medication Reconciliation, dated July 2026, the purpose of the policy is to identify clinically significant medication issues which could lead to reduced re-hospitalization, reduced adverse events related to medications/drugs and improved health outcomes and to have a proactive, systemic and effective approach to monitoring, reporting and acting upon the effects, risk and adverse consequences of medications. The definition of a DRR is a review of all medications the client is currently using in order to identify any potential adverse effects and drug interaction, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy. All clients will have a DRR completed whenever comprehensive assessments are completed. A DRR will be completed and documented on clients receiving skilled care at completion of the start of care comprehensive assessment and subsequent comprehensive assessments at 60-day recertification. During an interview on 9/9/26 at 8:54 AM, the Clinical Manager reported that a DRR completed by the skilled nurse at admission, recertification, resumption of care, discharge, transfer and change in status. 1.Patient #3 had a start of care date of 7/16/26. Clinical record review revealed:a. The plan of care (POC), dated 7/16/25 to 12/31/26, included a primary diagnosis of quadriplegia and physician orders for skilled nursing services. b. The comprehensive assessment completed at start of care, dated 7/16/26, completed by Staff D, Registered Nurse (RN), lacked documentation of a complete drug regimen review. The review lacked assessment of ineffective drug therapy. 2.Patient #4 had a start of care date of 7/20/26. Clinical record review revealed: a. The POC, dated 7/20/26 to 9/17/26, identified a primary diagnosis of unspecified open wound of unspecified buttock and physician order for skilled nursing services. b. The comprehensive assessment completed at start of care, dated 7/20/26, completed by Staff D, RN, lacked documentation of a complete drug regimen review. The review lacked assessment of ineffective drug therapy. 3. Patient #7 had a start of care date of 3/5/26 and a discharge date of 5/18/26. Clinical record review revealed: a. The POC, dated 3/5/26 to 5/3/26, identified a primary diagnosis of parkinsonism and physician orders for skilled nursing services. b. The comprehensive assessment completed at start of care, dated 3/5/26, completed by Staff C, RN, lacked documentation of a complete drug regimen review. The review lacked assessment of ineffective drug therapy. c. The comprehensive assessment completed at recertification, dated 4/20/26, completed by Staff C, lacked documentation of a complete drug regimen review. The review lacked assessment of ineffective drug therapy. The above findings were reviewed with the Administrator, Clinical Manager, Business/Quality Manager and Staff D, RN.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on, patient and staff interview, home visit observation and clinical record review, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient to meet their needs, an accurate list of the patient’s current medications and wound care orders for 4 of 7 sampled patients (Patients #1, #3, #4 and #7). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: 2.Patient #3 had a start of care date of 7/16/26. Clinical record review revealed: a. The plan of care (POC), dated 7/16/25 to 12/31/26, included a primary diagnosis of quadriplegia and the following medications: aspirin, bumetanide, Eliquis, fluoxetine, gentamicin, iron, miconazole, potassium chloride, senna, trazodone hydrochloride and vitamin c and the following supplies and equipment: glasses, BiPap, wound care supplies, chux pads, lift chair, hospital bed, wash basin, cell phone, mechanical lift, walk in shower, handheld shower handle, positioning wedges, external urinary catheter and supplies, alternating air pressure mattress and transfer sheet. The POC did not include orders for wound treatments. b.The comprehensive skilled nurse assessment, dated 7/16/26, completed by Staff D, Registered Nurse (RN), included that the patient and caregiver reported that oxycodone available in the home but the patient did not like to take it and that Staff D reviewed alternating acetaminophen and ibuprofen as needed for pain. c. The skilled nurse visit note, dated 8/26/26, completed by Staff D, included that the patient’s wound was healed. d.During a home visit observation on 9/9/26 at 11:10 AM with Staff D review of the patient’s medications, supplies and equipment and wound care treatment took place with the patient’s caregiver as follows: hydrophilic wound cream has been used since the start of home health care, that zinc oxide has been used on the wound since it has healed, that gentamicin is no longer used as the wound is healed, the patient takes 2 doses of acetaminophen per week for left knee pain, the patient stopped taking aspirin a few weeks ago, iron was changed to every other day a month ago, miconazole powder is now used once per day as the patient’s skin cleared up a few weeks ago, senna was changed to every other day 2-3 weeks ago, he has used a urinal, pill planner and compression stockings before he started with home health care, started using a left knee brace a month ago and has a pulley system. During an interview on 9/9/26 at 11:10 AM, the patient’s caregiver reported that she manages the patient’s medications. The caregiver reported that wound treatment was provided by the caregiver as directed during the patient’s hospitalization, that the agency did not provide wound treatment orders. The agency failed to include all medication, changes to medication, all supplies and equipment and treatments on the POC. 3.Patient #4 had a start of care date of 7/20/26. Clinical record review revealed: a. The POC, dated 7/20/26 to 9/17/26, identified a primary diagnosis of unspecified open wound of unspecified buttock and the following medications: acetaminophen, sodium hypochlorite, estradiol, exemestane, levothyroxine, loperamide, loratadine, oxycodone, pantoprazole, senna, Verzenio, vitamin D3-vitamin k2. b.The comprehensive skilled nursing assessment, dated 4/20/26, completed by Staff D, included that the patient alternates acetaminophen and ibuprofen. The agency failed to include ibuprofen on the POC. 4. Patient #7 had a start of care date of 3/5/26 and a discharge date of 5/18/26. Clinical record review revealed: a. The POCs, dated 3/5/26 to 5/3/26 and 5/4/26 to 7/2/26, identified a primary diagnosis of parkinsonism and the following medications: acetaminophen, acyclovir, amlodipine, calcium acetate, carbidopa/levodopa, cetirizine, clopidogrel, compazine, hydrocortisone cream, diphenhydramide hydrochloride, dorzolamide hydrochloride, escitalopram, ferrous sulfate, gabapentin, gentamicin, imipramine hydrochloride, insulin glargine, isosorbide mononitrate, multivitamin, metoprolol, primidone and hydrophilic wound cream. b. The comprehensive skilled nursing assessment, dated 4/30/26, completed by Staff C, RN, included that the patient took melatonin for sleep. The agency failed to include melatonin on the POC. The above findings were reviewed with the Administrator, Clinical Manager, Business/Quality Manager and Staff D, RN. Agency policy, titled Plans of Care, dated 11/2023, identified the plan of care includes the types of services, supplies, equipment required and all medications and treatments. 1. Patient #1 had a start of care date of 3/21/16. Clinical record review revealed: a. Plan of Care, dated 7/27/26 to 9/24/26, included primary diagnosis of hemiplegia (medical condition causing partial or total paralysis on one side of body) and medical equipment: 4 wheeled walker, canes, bath bench, bath mat, CPAP (continuous positive airway pressure machine), bedside table to hold CPAP machine, glasses, med planners, pill splitter, walk in shower, adjustable shower head, grabber, scale, hospital bed, lift chair, lifeline, bed rail, dentures/denture cleaner, wheelchair, depends, cloth and paper chux, urintal, exercise pedals, heating pad, flashlight by bed, automatic blood pressure cuff, oximeter and thermometer. b. During a home visit observation, on 9/8/26 at 1:00 PM, with Staff C, RN (registered nurse), the surveyor observed a chair cushion in the wheelchair by the window. Patient #1 reported getting the cushion about a year ago for comfort. c. During an interview on 9/8/26 at 1:00 PM, Staff C, RN, reported she missed adding the cushion to the plan of care. Plan of Care failed to include all equipment used by the patient.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on agency staff interview and clinical record review, the agency failed to update the Plan of Care with all new physician orders for 3 of 7 sampled patients with interim orders. (Patients #1, #4 and #7). Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: 2. Patient #4 had a start of care date of 7/20/26. Clinical record review revealed:a. The POC, dated 7/20/26 to 9/17/26, identified a primary diagnosis of unspecified open wound of unspecified buttock and physician order for skilled nursing services for wound care 4-5 times per week starting the week of 7/26/26. b. The medical excuse document, dated 7/22/26, signed by a nurse practitioner, included orders for wound care 3 times per week using rolled gauze soaked with sodium hypochlorite solution, cover with an abdominal (ABD) pad and secure with tape. The agency failed to update the POC with the provider order for wound care orders and frequency. c. The clinical visit note, dated 8/10/26, signed by a nurse practitioner, included orders for the wound to be covered with either am ABD or silicone foam dressing, to take ondansetron 8 mg every 8 hours as needed to stop docusate 100 milligram (mg) capsule. The patient’s medication list in her clinical record failed to include docusate. The agency failed to update the POC with wound orders and medication changes. d. The physician order, dated 8/27/26, included wound care to the coccyx to include daily dressing changes to place iodoform gauze packing strip, cover with woven gauze sponge and secure with tape. The agency failed to update the POC with the wound order. e. The physician order, dated 9/3/26, included wound care to the coccyx to include negative pressure wound therapy and to cleanse the wound with hypochlorous acid. f. The updated POC, dated 9/9/26, completed by Staff D, Registered Nurse (RN) included to cleanse the coccyx wound with saline. The agency failed to update the POC with correct wound care orders. 3. Patient #7 had a start of care date of 3/5/26 and a discharge date of 5/18/26. Clinical record review revealed: a. The POC, dated 3/5/26 to 5/3/26, identified a primary diagnosis of parkinsonism and provider orders for skilled nursing services and for PT to evaluate and treat, their POC to follow separately. b. The PT Initial Evaluation and POC, dated 3/10/26, included provider orders for 2 PT visits per week from 3/10/26 to 4/7/26. The agency failed to update the POC with the provider order for the PT visit frequency. During an interview on 9/9/26 at 7:56 AM, the Clinical Manager reported that the POC, dated 3/5/26 to 5/3/26, was expected to contain the updated physical therapy (PT) service frequency, but it was missed. c.The Physician Order, dated 4/17/26, included to admit the patient to home health care for once a week dressing changes to the right calcaneus and to clean the wound with normal saline, then apply iodine prep solution and cover with a silicone foam dressing. The agency failed to update the POC with the physician order for weekly dressing changes. The above findings were reviewed with the Administrator, Clinical Manager, Business/Quality Manager and Staff D, RN. Agency policy, titled Plans of Care, dated 11/2023, identified the plan will be revised to reflect any verbal order received during the 60-day certification period so that all agency staff are working from a current plan. The plan will be revised after a therapy plan of care has been received to integrate therapy orders, frequencies, and duration of services. 1. Patient #1 had a start of care date of 3/21/16. Clinical record review revealed: a. Plan of Care (POC), dated 7/27/26 to 9/24/26, included primary diagnosis of hemiplegia (medical condition causing partial or total paralysis on one side of body) and physician orders for skilled nurse and home health aide services. b. Physical Therapy (PT) faxed consult, dated 8/3/26, included documentation for agency to obtain a PT evaluation and treatment due to a recent fall. c. PT evaluation, dated 8/11/26, completed by Staff E, PT, included documentation evaluation was completed and further services would be provided. During an interview on 9/10/26 at 8:18 AM, Staff F, Business/Quality Manager, confirmed chart was reviewed and no order entered in clinical record for PT evaluation and no updated POC to reflect the PT evaluation. The agency failed to update the Plan of Care with the physician order for the PT evaluation.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure the clinical record included a complete clinical record for 3 of 7 sampled patients (Patients #3, #4 and #6). Failure of the agency to ensure the clinical record included all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders placed agency patients at risk to receive care or not receive care meeting the needs of the patient. Findings include: According to agency policy titled Medical Records, dated May 2026, the home health agency maintains a clinical record for each client which includes the documentation of services provided as well as those services provided through arrangements with another agency. The record contains pertinent past and current medical, nursing, social and other therapeutic information, including the plan of care. Contents include discharge, general notes, scanned documentation and client activities. According to agency policy titled Home Therapy Services, dated March 2026, all therapy documentation will be sent to the agency by the therapist to be incorporated into the patient’s EMR within the required time frame as specified in the written contract. According to the therapy contract, dated 12/29/20, patient documentation shall be part of the provider charts. Documentation shall be the responsibility of the contractor. Provider agrees that all services provided by assigned personnel hereunder shall be at its discretion and under its supervision, and accordingly, accepts full responsibility for ensuring that all services comply with the applicable federal, state and local law, rules and/or regulations. The provider will distribute policies and procedures to the contractor that are related to the appropriate administration of patient care. The contractor shall be responsible for all policies, procedures and regulatory compliances related to their agency disciplines. 1.Patient #3 had a start of care date of 7/16/26. Clinical record review revealed:a. The plan of care (POC), dated 7/16/25 to 12/31/26, included a primary diagnosis of quadriplegia and physician orders for skilled nursing services. b. Review of the clinical record included that a physical therapy visit occurred on 8/20/26. The clinical record failed to include the physical therapy visit note. During an interview on 9/10/26 at 8:3 AM, the Clinical Manager reported that the physical therapy visit note from 8/20/26 is not scanned in because the agency is waiting for the physician sign it. Physical therapy visit notes that require a physician signature are not scanned in to the electronic medical record (EMR) until they return back from the physician. 2.Patient #4 had a start of care date of 7/20/26. Clinical record review revealed: a. The POC, dated 7/20/26 to 9/17/26, identified a primary diagnosis of unspecified open wound of unspecified buttock and physician order for skilled nursing services. b. The discharge instructions, dated 7/20/26, identified that photos of the wound should be sent to the burn unit every Tuesday. c. The clinical record failed to include documentation that photos of the wound were sent to the burn unit as ordered. During an interview on 9/10/26 at 8:16 AM, the Business Manager reported that the photos were sent via electronic mail (email) and showed that the emails were sent to the burn unit. The Business Manager reported that no photos of the wound were sent to the burn unit the week of 8/12/26. 3.Patient #6 had a start of care dated of 4/18/25 and a discharge date of 8/10/26. Clinical record review revealed: a. The POC, dated 6/12/26 to 8/10/26, identified a primary diagnosis of spinal stenosis of the cervical region and physician orders for skilled nursing services. b. The facsimile (fax), dated 8/10/26 at 2:17 PM, completed by Staff D, Registered Nurse (RN), identified the patient was discharged from home health services and to see the attached discharge summary. c. The EMR failed to include the discharge summary or the medication list that was sent to the patient’s provider at discharge. During an interview on 9/10/26 at 8:11 AM, the Business Manager reported that only the first page is scanned into the EMR and that the discharge summary and discharge medication list is not scanned into the EMR. The above findings were reviewed with the Administrator, Clinical Manager, Business/Quality Manager and Staff D, RN.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to complete a drug regimen review with each comprehensive assessment and identify patient specific medication issues for 5 of 7 sampled patients (Patients #1, #2, #3, #5 and #6). Failure to complete a drug regimen review with each comprehensive assessment placed the patient at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy, titled Drug Regimen Review and Medication Reconciliation, dated July 2023, all patients will have a drug regimen review completed whenever comprehensive assessments are completed. Drug regimen review will be completed and documented on patients receiving skilled care at the following times: Start of Care comprehensive assessment, subsequent comprehensive assessments at 60-day recertification, following a major decline or improvement in the patient’s health status, resumption of care, and at time of discharge. During an interview on 11/2/23 at 1:42 PM, the Clinical Manager reported drug regimen reviews are completed with comprehensive assessments at Start of Care, Resumption of Care, Recertification and Discharge assessments. The completed drug regimen review will be documented on the skilled nursing comprehensive assessment visit note. 1. Patient #3 had a start of care date of 12/16/22. Clinical record review revealed the following: a. Plan of Care, dated 12/16/22 to 2/13/23, included orders for lactulose, Clear Lax and Senexon-S (bowel meds); and ferrous gluconate, folic acid, Therems-H (multivitamin), Vitamin B1 and Vitamin D3 (vitamins). b. Start of Care comprehensive assessment visit note, dated 12/16/22, included documentation a drug regimen review had been completed and identified duplicate medications: yes. The note lacked documentation of the duplicate bowel meds and vitamins. c. Plans of Care, dated 8/13/23 to 10/11/23 and 10/12/23 to 12/10/23, included orders for bisacodyl, lactulose, Clear Lax and Senexon-S (bowel meds); acetaminophen and ibuprofen (pain meds); and ferrous gluconate, folic acid, Therems-H (multivitamin), Vitamin B1 and Vitamin D3 (vitamins). d. Recertification comprehensive assessment visit note, dated 8/8/23, included documentation a drug regimen review had been completed, identified patient demonstrated non-compliance with medications: yes and duplicate medications: yes. The note lacked documentation of the duplicate bowel meds, pain meds and vitamins, and the non-compliance patient demonstrated. e. Recertification comprehensive assessment visit note, dated 10/10/23, lacked documentation a drug regimen review had been completed. The agency failed to complete drug regimen reviews with all comprehensive assessments and completed drug regimen reviews failed to identify the duplicate medications the patient was taking and the patient’s non-compliance. 2. Patient #5 had a start of care date of 11/18/22. Clinical record review revealed the following: a. Plan of Care, dated 11/18/22 to 1/16/23, included orders for warfarin and aspirin (blood thinners) (potential interactions); ferrous sulfate, oyster shell calcium, Vitamin D3, and magnesium (vitamins), and omeprazole (potential interaction with warfarin). b. Start of Care comprehensive assessment visit note, dated 11/18/22, included documentation a drug regimen review had been completed, identified potential drug interactions: yes and duplicate medications: yes. The note lacked documentation of the duplicate vitamins and blood thinners and the potential interaction between warfarin and aspirin and omeprazole. c. Plan of Care, dated 9/14/23 to 11/12/23, included orders for warfarin and aspirin (blood thinners) (potential interactions); ferrous sulfate, oyster shell calcium, Vitamin D3, and magnesium (vitamins), and omeprazole (proton pump inhibitor for stomach acid), naproxen (nonsteroidal anti-inflammatory med) and Diflucan (antifungal med) (potential interaction with warfarin). d. Recertification comprehensive assessment visit note, dated 9/11/23, included documentation a drug regimen review had been completed and identified duplicate medications: yes and potential drug interactions: no. The note lacked documentation of the duplicate blood thinners and vitamins, and the potential drug interactions between warfarin and aspirin, omeprazole, naproxen and diflucan. The completed drug regimen reviews failed to identify the duplicate medications the patient was taking and the potential drug interactions. 3. Patient #6 had a start of care date of 4/28/23 and a discharge date of 5/25/23. Clinical record review revealed the following: a. Plan of Care, dated 4/28/23 to 6/28/23, included orders for Tylenol and ibuprofen (pain meds) and magnesium, Vitamin B12 and Vitamin D3 (vitamins). b. Start of Care comprehensive assessment visit note, dated 4/28/23, included documentation a drug regimen review had been completed and identified duplicate medications: no. The note failed to identify the duplicate vitamins and pain medications the patient was taking. c. Discharge comprehensive assessment visit note, dated 5/25/23, failed to include documentation a drug regimen review had been completed. The agency failed to complete a drug regimen review with the discharge comprehensive assessment and completed drug regimen review failed to identify the duplicate medications the patient was taking. 4. Patient #1 had a start of care date of 3/21/16. Clinical record review revealed the following: a. Plans of Care, dated 6/13/23 to 8/11/23 and 8/12/23 to 10/10/23, included orders for Colace and Imodium (bowel meds); potassium chloride and Vitamin B12 (vitamins); and Icy Hot, Salonpas lidocaine pain relieving liquid, and Tylenol (pain medications). b. Plan of Care, dated 10/11/23 to 12/9/23, included orders for Colace and Imodium (bowel meds); potassium chloride and Vitamin B12 (vitamins); and Icy Hot, Salonpas lidocaine pain relieving liquid, Tylenol, Aspercreme with lidocaine topical patch, and equate pain relief patch (pain medications). c. Recertification comprehensive assessment visit notes, dated 6/12/23, 8/7/23 and 10/9/23 included documentation a drug regimen review had been completed and identified duplicate medications: yes, telephone call to primary care physician review with review of patient condition and medications/possible duplicates for review. The note lacked documentation of the duplicate bowel meds, vitamins and pain meds. Completed drug regimen reviews failed to identify the duplicate medications the patient was taking. 5. Patient #2 had a start of care date of 5/25/22. Clinical record review revealed the following: a. Plans of Care, dated 5/20/23 to 7/18/23, 7/19/23 to 9/16/23 and 9/17/23 to 11/15/23, included orders for multivitamin, Vitamin C and Vitamin D3 (vitamins). b. Recertification comprehensive assessment visit notes, dated 5/18/23, 7/18/23 and 9/14/23, included documentation a drug regimen review had been completed and identified duplicate medications: yes. The note lacked documentation of the duplicate vitamins. Completed drug regimen reviews failed to identify the duplicate medications the patient was taking. The above stated findings were reviewed with the Administrator, Clinical Manager and Business and Quality Manager and the agency provided no additional information prior to the end of the survey.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to update the Plan of Care with all new physician orders for 4 of 5 sampled patients with interim physician orders. (Patients #3, #4, #5 and #7). Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: According to the agency policy, titled Plans of Care, dated November 2020, the plan will be revised to reflect any verbal order received during the 60-day certification period so that all agency staff are working form a current plan. the plan of care is updated to reflect all current ongoing orders including any verbal orders received during the 60-day period. During an interview on 11/2/23 at 1:42 PM, Clinical Manager, reported the updated Plan of Care is in the electronic medical record system under episode tab and then the Plan of Care section will have the plans of care listed by date. 1. Patient #1 had a start of care date of 12/16/22. Clinical record review revealed the following: a. Plans of Care, dated 6/14/23 to 8/12/23 and 8/13/23 to 10/11/23, included orders for skilled nursing services. b. Interim physician order, dated 6/27/23, for new medications: lamotrigine and risperidone and discontinue Quetiapine. c. Interim physician order, dated 7/10/23, for medication changes: bisacodyl, melatonin and finasteride. d. Interim physician order, dated 7/19/23, for medication update: increased risperidone. e. Interim physician order, dated 9/12/23, for new medication: skin, hair, nails gummy and patient has stopped taking lactulose. The clinical record lacked documentation of Plan of Care updates for the interim physician orders. 2. Patient #4 had a start of care date of 10/24/23. Clinical record review revealed the following: a. Plan of Care, dated 10/24/23 to 12/22/23, included orders for skilled nursing services. b. Interim physician order, dated 10/24/23, for laboratory bloodwork to be drawn. c. Interim physician order, dated 10/27/23, for laboratory bloodwork to be drawn. d. Interim physician order, dated 11/3/23, for patient to hold Bactrim. The clinical record lacked documentation of Plan of Care updates for the interim physician orders. 3. Patient #5 had a start of care date of 11/18/22. Clinical record review revealed the following: a. Plans of Care, dated 7/16/23 to 9/13/23 and 9/14/23 to 11/12/23, included orders for skilled nursing and home health aide services. b. Interim physician order, dated 8/23/23, for the addition of paste, powder and ointment for skin healing. c. Interim physician order, dated 10/23/23, for change in wound care. The clinical record lacked documentation of Plan of Care updates for the interim physician orders. 4. Patient #7 had a start of care date of 6/27/23 and a discharge date of 7/27/23. Clinical record review revealed the following: a. Plan of Care, dated 6/27/23 to 8/12/23 and 8/25/23, included orders for skilled nursing, home health aide services and physical therapy evaluation. b. Interim physician order, dated 6/29/23, for physical therapy services 2 times a week for 4 weeks. The clinical record lacked documentation of a Plan of Care update for the interim physician order. The above stated findings were reviewed with the Administrator, Clinical Manager and Business and Quality Manager and the agency provided no additional information prior to the end of the survey.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights for 3 of 3 sampled patients receiving home health aide services (Patients #1, #5 and #7). Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients’ personal care needs. Findings include: During an interview on 11/2/23 at 1:42 PM, the Clinical Manager reported the aide supervision is documented in the skilled nursing visit note or on a separate supervision form under the episode tab in the electronic medical record. 1. Patient #1 had a start of care date of 3/21/16. Clinical record review revealed: a. The Plans of Care, dated 8/12/23 to 10/10/23 and 10/11/23 to 12/9/23, included orders for skilled nursing and home health aide services. b. Supervision report notes, dated 8/14/23 and 9/28/23, included documentation the home health aide was supervised by the skilled nurse for the required supervisory elements. c. Skilled nursing visit notes, dated 8/28/23, 9/11/23, 9/25/23, 10/10/23 and 10/23/23, included documentation the aide followed the plan of care but lacked documentation of the elements: maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights. The agency failed to complete home health aide supervision that included the required regulatory elements. 2. Patient #5 had a start of care date of 3/21/16. Clinical record review revealed: a. The Plan of Care, dated 9/14/23 to 11/12/23, included orders for skilled nursing and home health aide services. b. Skilled nursing visit notes, dated 9/22/23, 9/25/23, 9/28/23, 9/29/23, 10/2/23, 10/3/23, 10/6/23, 10/9/23, 10/12/23, 10/13/23, 10/16/23, 10/19/23, 10/20/23, 10/23/23, 10/27/23, 10/31/23 and 11/3/23, included documentation the aide followed the plan of care but lacked documentation of the elements: maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights. The agency failed to complete home health aide supervision that included the required regulatory elements. 3. Patient #7 had a start of care date of 6/27/23 and a discharge date of 7/27/23. Clinical record review revealed: a. The Plan of Care, dated 6/27/23 to 8/25/23, included orders for skilled nursing, home health aide and physical therapy services. b. Supervision report notes, dated 6/30/23, included documentation the home health aide was supervised by the skilled nurse for the required supervisory elements. c. Skilled nursing visit notes, dated 7/10/23 and 7/24/23, included documentation the aide followed the plan of care but lacked documentation of the elements: maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights. The agency failed to complete home health aide supervision that included the required regulatory elements. The above stated findings were reviewed with the Administrator, Clinical Manager and Business and Quality Manager and the agency provided no additional information prior to the end of the survey.”