Palo Alto Community Health

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on clinical record review, personnel file review and agency policy review, the agency failed to ensure 2 of 2 sampled home health aides (Staff E and Staff F) had documented evidence of competency in the application of a pain patch, which exceeded the level of basic home health aide skills, in the presence of a registered nurse prior to being assigned to perform the task independently for 1 of 2 sampled patients with extra skills (Patient #2). The agency provided home health aide services to 20 patients at the time of the survey and employed 2 home health aides. Failure to ensure home health aides have a competent ability to perform all skills above and beyond basic home health skills increased the risk for patients to receive inadequate or inappropriate care. Findings include: The Medicare Conditions of Participation require home health agencies to determine competence of home health aides in those skills which exceed the general basic home health aide skills areas prior to assigning the home health aide to a patient who would require the task be performed. According to the agency policy titled Home Care Aide Supervision and Home Care Aide Duties, dated 2/2024, the Registered Nurse (RN) supervises the home care aide and evaluates the aides performance and competency with tasks and provides education when indicated. Patient #2 had a start of care date of 4/3/23. Clinical record review revealed: a. The aide care plan included RN instructions to the aide to apply a pain patch to the patient’s right shoulder per patient request. b. Review of the clinical record showed Staff E and Staff F, Home Health Aides, provided aide services independently for Patient #2. c. Staff E, Home Health Aide, had a hire date of 6/24/11. Staff E’s personnel file lacked any documentation verifying that an RN had observed and evaluated the home health aide to confirm competence in application of a pain patch. d. Staff F, Home Health Aide, had a hire date of 9/3/19. Staff F’s personnel file lacked any documentation verifying that an RN had observed and evaluated the home health aide to confirm competence in application of a pain patch. The agency failed to ensure home health aides successfully completed a competency evaluation in assigned extra skills prior to performing the extra skills. The above findings were reviewed with the Administrator/Clinical Manager.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on clinical record review, agency policy review, patient/caregiver interview and agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 2 of 3 sampled patients receiving home health aide services (Patients #1 and #6). The agency reported 20 patients received care provided by a home health aide. Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency’s home health aides for each patient increased the risk agency patients would receive inappropriate or inconsistent home health aide services. Findings include: 2. Patient #6 had a start of care date of 6/2/25 and a discharge date of 8/12/25. Clinical record review revealed: a. The POC, dated 8/1/25 to 9/29/25, identified the patient had a primary diagnosis of cerebral infarction and included orders for skilled nurse and home health aide services. b. The aide care plan, dated 8/1/25, included aide instructions to assist family to transfer patient per patient/family request. The assignment failed to include specific instructions on what assistive devices were needed to transfer the patient. The home health RN failed to include specific instructions to the aide on what assistive devices were needed to transfer the patient. The above findings were reviewed with the Administrator. According to the policy, titled Plan of Care and Care Management, last revised 2/2026, if home health aide services are ordered, the primary nurse/therapist assigns the home health aide by completing the home health aide plan of care. 1. Patient #1 had a start of care date of 1/31/24. Clinical record review revealed: a. The Plan of Care (POC), dated 7/19/26 to 9/16/26, included primary diagnosis of psychomotor deficit post cerebral infarction and physician orders for skilled nursing and home health aide services. b. The aide care plan, dated 1/31/24, included task: apply lotion. c. The aide visit notes, dated 8/24, 8/27, 8/31/26 and 9/3/26, the task apply lotion completed. The aide care plan failed to include all necessary specific tasks for the aide to complete.”

“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 agency staff interviews, clinical record reviews, and policy review, the home health agency failed to ensure the drug regimen review identified at a minimum the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and/or patient compliance with medications for 3 of 3 sampled patients with observation home visits (Patient #1, #2 and #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings include: 3. Patient #2 had a start of care date of 4/3/23. Clinical record review revealed: a. The POC, dated 7/16/26 to 9/13/26, identified the patient had a primary diagnosis of muscular dystrophy and included physician orders for medication set up and skilled nursing services. b. The skilled nurse comprehensive assessment, dated 7/14/26, completed by Staff D, RN, identified the RN reviewed the patient’s medications with the patient and the medication list was updated. c. During a home observation visit on 9/8/26 at 9:00 AM, Staff D, RN, completed a recertification visit and medication set up. During this same visit, the surveyor identified the patient’s bottle of nitroglycerin 0.4 mg sublingual tablets expired on 6/2026. The RN failed to identify the expired nitroglycerin tablets during the DRR on 7/14/26 and during the skilled nurse comprehensive assessment and medication set up on 9/8/26. The above findings were reviewed with the Administrator. According to the agency policy, titled Drug Regimen Review, dated 5/2022, the drug regimen consists of a complete assessment of all current drugs including over the counter drugs and as needed drugs such as pain medications, laxatives, antacids and vitamins. During an interview on 9/9/26 at 12:00 PM the Administrator/Clinical Manager stated the Registered nurse whe completes the drug regimen reviewduring the patinet assessment on admission, recertification, resumption of care and with medication changes. 1. Patient #1 had a start of care date of 1/31/24. Clinical record review revealed: a. The Plan of Care (POC), dated 7/19/26 to 9/16/26, included primary diagnosis of psychomotor deficit post cerebral infarction and physician orders for medications and skilled nurse services to perform medication set up. b. The skilled nurse visit completed at recertification, dated 7/16/26, Staff D, Registered Nurse (RN) documented a drug regimen review (DRR) completed. c. The medication profile, dated 9/8/26, included orders for the following medications: 1) Lidocaine 4% topical patch, 1 to 4 times a day. 2) Magnesium citrate 1.745 grams (gm)296 milliliters (ml) oraly, daily as needed for constipation. d. During an observational home visit on 9/8/26 at 9:15 AM with the Administrator, the patient stated no longer using lidocaine patch and had not used for years and had never taken magnesium citrate. The registered nurse failed to complete a drug regimen review at the time of the recertification comprehensive assessment to identify accurate current medications as regulated. 2. Patient #3 had a start of care date of 11/13/23. Clinical record review revealed: a. The POC, dated 8/29/26 to 10/27/26, included primary diagnosis of sequelae of cerebral infarction and physician orders for medications and skilled nurse services to perform medication set up. b. The skilled nurse visit at recertification, dated 8/6/26, Staff C, RN, documented a DRR completed. c. The medication profile, dated 9/8/26, included orders for the following medications: 1) Miralax 17 gms 3 times a day orally, as needed for constipation. 2) Guaifinesin 400 milligrams (mg) orally, take 1 tablet oral every 4 hours. d. During a observational home visit on 9/9/26 at 9:15 AM with Staff B, RN, the surveyor observed the RN set up the medication guaifinesin 3 times a day. The patient’s spouse stated the medication miralax administered one time daily. The registered nurse failed to complete a drug regimen review at the time of the recertification comprehensive assessment to identify accurate current medications as regulated.”

“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 home observation visits, patient interviews, clinical record reviews and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all medical equipment/supplies, all medications and all treatments for 4 of 7 sampled patients (Patients #2, #3, #6 and #7). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, supplies, medications and/or treatments according to assessed needs and physician orders. Findings include: 3. Patient #3 had a start of care date of 11/13/23. Clinical record review revealed: a. The POC dated 8/29/26 to 10/27/26, identified the patient had a primary diagnosis of sequelae of cerebral infarction and included orders for medical supplies and equipment used by the patient. The POC included the following medical supplies and equipment used by the patient: overbed table, raised toilet seat, wheelvchair, bedside commode, rolling walker, reacher, hand-held shower, grab bars/safety rails, adjustable bed and continuous positive airway pressure (CPAP) machine. b. During a home observation visit on 9/8/26 at 9:00 AM with Staff B, RN, the surveyor observed the patient had a pill splitter, lift chair, incontinent products, spirometer and shower chair. The patient’s spouse stated the lift chair since the several months and all other products for several years. The agency failed to include all medical equipment and supplies on the patient’s POC, including pill splitter, lift chair, incontinent products, spirometer and shower chair. 4. Patient #7 had a start of care date of 1/13/26. Clinical record review revealed: a. The POC dated 1/13/26 to 3/9/26, identified the patient had a primary diagnosis of osteomyelitis of the right ankle/foot and included orders for medical supplies and equipment used by the patient. b. The POC included orders for a central venous catheter and flush the catheter before and afer lab draw or infusion with saline. The order lacked specific instructions for the amount of saline flush. The agency failed to include all medication and treatments on the patient’s POC, including patient specific intruction for saline flush. The above findings reviewed with the Administrator/Clinical Manager. According to the agency policy titled Plan of Care and Management, dated 2/2026, the Plan of Care (POC) is based on problems/needs identified through a comprehensive assessment of the patient. The POC includes the patient diagnoses, severity rating of each condition and supplies provided by the agency. 1.Patient #2 had a start of care date of 4/3/23. Clinical record review revealed: a. The POC, dated 7/16/26 to 9/13/26, identified the patient had a primary diagnosis of muscular dystrophy and included orders for medical supplies and equipment used by the patient. The POC included the following medical supplies and equipment used by the patient: overbed table, electric wheelchair, raised toilet seat, shower bench, rolling walker, bed rails, hand held shower, grab bars, safety rails and medication boxes. b. During a home observation visit on 9/8/26 at 9:00 AM with Staff D, Registered Nurse (RN), the surveyor observed the patient had a life alert button, lift chair and a reach extender device. The patient stated they wear the life alert button at bedtime and have had this for about two years. The patient identified having the lift chair and reach extender device for a long time. The agency failed to include all medical equipment and supplies on the patient’s POC, including life alert button, lift chair and reach extender device. 2. Patient #6 had a start of care date of 6/2/25 and a discharge date of 8/12/25. Clinical record review revealed: a. The POC dated 8/1/25 to 9/29/25, identified the patient had a primary diagnosis of cerebral infarction and included orders for medical supplies and equipment used by the patient. The POC included the following medical supplies and equipment used by the patient: overbed table, raised toilet seat, crutches, walker, wheelchair, bedside commode, gait belt, bed rails, quad cane, incontinence products, wound supplies, handles over toilet, scale, blood glucose machine, insulin pen, sharps container, medication box, pill crusher and pill splitter. b. The skilled nurse visit note, dated 6/18/25, completed by Staff G, RN, identified the patient had a new lift chair. The agency failed to include all medical equipment and supplies on the patient’s updated POC, including life chair.”

“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 staff interview, clinical record review and agency policy review, the agency failed to provide a complete wound assessment on a weekly basis per agency policy for 1 of 3 sampled patients with a wound (Patient #6). Failure to accurately and thoroughly complete wound assessments put patients at an increased risk of unidentified condition changes. Findings include: According to the agency’s policy titled Wound Care, dated 2/2025, wounds should be measured at a minimum of once a week by the home care nurse and documented in the electronic medical record. On 9/9/26 at 12:00 PM, the Administrator stated wounds are to be measured each week (length, width, depth) and documented in the clinical record. Patient #6 had a start of care date of 6/2/25 and a discharge date of 8/12/25. Clinical record review revealed: a. The Plan of Care (POC), dated 6/2/25 to 7/31/25, identified the patient had a primary diagnosis of cerebral infarction and included physician orders for skilled nursing services 1-2 times a week to assess for skin excoriation, breakdown, friction, shearing or pressure areas. b. The skilled nurse visit note, dated 7/15/25, completed by Staff B, Registered Nurse (RN), identified the patient continues to have an open wound to midline buttocks coccyx but failed to include measurements of the wound. The agency nurse failed to obtain complete a weekly wound assessment and measurements of the patient’s wound per agency policy. The above findings were reviewed with the Administrator/Clinical Manager.”

“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 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 2 of 3 sampled patients (Patient #1 and #3) with home visits. 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: 2. Patient #1 had a start of care date of 9/25/23 and received services from the agency. The surveyor accompanied Staff D, Registered Nurse (RN), to a home visit on 11/29/23 at 9:00 AM Staff D. Staff D placed vital sign equipment directly into the nursing bag. The equipment was not sanitized after use in the patient’s home. In an interview with Staff D, she reported that she has a dirty pocket in her bag and she places the equipment there and will sanitize the equipment at the office. Staff D reported that if she is using her car, she has an area to sanitize her equipment there. The patient’s clinical record revealed a Wound Care Progress Note dated 11/28/23 noted by Staff C, RN, on 11/28/23 that the patient was MRSA + (Methicillin-resistant Staphylococcus aureus infection). The above findings were reviewed with the agency Administrator/Clinical Coordinator, Staff B, RN, Staff C, and Staff D. The agency provided no additional information prior to the end of the survey. According to the agency policy titled Hand Hygiene, dated 2/2023, hand hygiene is performed: before and after contact with patient or patient environment, after contact with patient environment/especially frequently touched surfaces, after removing sterile or non-sterile gloves and any time hands are visibly soiled. According to the agency policy titled Home Care Bag, dated 2/2023, each field staff employee will carry the Home Care Bag into the patient’s home on every visit unless one or more of the following conditions exists: there is a resistant organism. Technique to be used with the Home Care Bag: when all clean items have been returned to the proper section of the home care bag, the hag shall be zippered securely and the staff member shall wash his/her hands. According to the agency policy titled Multidrug-Resistant Organisms Infection Control Guidelines, dated 2/2023, dedicate reusable items (such as blood pressure cuffs, stethoscopes, wheelchairs, thermometers, commodes, etc) then possible, and leave in patient room until discharged. Multiple use items that need to be used on another patient are wiped down with an approved disinfectant per manufactures recommendation before use on another patient. 1. Patient #3 had a start of care dated of 6/28/23. The surveyor accompanied Staff C, Registered Nurse (RN), to a home visit on 11/29/23 at 10:00 AM Staff C failed to complete hand hygiene at start of visit with gloves put on. She then took out her Blood Pressure cuff and placed it on a barrier, got the pill planner out, got patient a glass of water from the kitchen, opened the glucometer case and took the glucometer out. Staff C checked the patient’s capillary blood glucose level with the glucometer, moved the patient’s scale from the bedroom floor to the bathroom floor before she took the gloves off. No hand hygiene was performed. Staff C then put the glucometer back in its case, went outside the patient’s front door and retrieved a bag that was on the door handle. She opened a vital sign equipment bag and placed equipment on a barrier, when she took the hand sanitizer out, she used it. She took the patient’s vital signs and placed the used equipment on the barrier, she then cleaned the equipment. After she cleaned the equipment, she placed the equipment on the same barrier. The vital sign equipment was put back in its cases. She took out a computer, used it, did not sanitize it, and placed it back in its case. No hand hygiene was performed at the end of the visit. The agency failed to ensure infection control standards followed during patient care.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to wound assessments for 2 of 3 sampled patients with wounds (Patients #4 and #7). The agency reported a current patient census of 32 patients. Failure to accurately and thoroughly complete wound assessments placed patients at an increased risk of unidentified condition changes. 2. Patient #4 had a start of care date of 10/30/23. Clinical record review revealed the following: a. The POC, dated 10/30/23 to 12/28/23, included orders for skilled nurse services. b. The skilled nurse visit note, dated 11/20/23 identified the patient had 4 surgical laparotomy stab wounds well approximated with sutures and dermabond. The note failed to include documentation of measurements of the surgical wounds. The agency failed to document complete assessment with measurements of the patient’s surgical stab wounds. The above stated finding were presented to the Administrator/Clinical Manager and Staff B, RN, Staff C, RN and Staff D, RN. No further information provided prior to the end of the survey. Findings include: According to the agency’s undated policy, Wound Care, in pertinent part: Wounds should be measured at a minimum of once a week by the home care nurse and documented in the electronic medical record. Wound assessments should contain the following components in the medical record: a. Location of wound. b. Length, width, and depth measurements recorded in centimeters. c. Direction and length of tunneling or undermining. d. Appearance of the wound base. e. Type of tissue in the wound. f. Drainage amount and characteristics; including color, consistency, and odor. g. Appearance of wound edges. h. Description of the peri-wound condition or evaluation of the skin adjacent to the wound. On 11/30/23 at 9:00 AM, when asked about wound assessments, the Administrator did not report any information. 1. Patient #7 had a start of care date of 3/12/23 and was discharged from home health services on 4/13/23. Clinical record review revealed the following: Referral information from a nursing home with a care plan intervention dated 2/3/23 that the patient had a pressure ulcer to his right buttock due to lack of mobility. The start of care assessment dated 3/12/23 revealed that the patient had no pressure ulcers. The skilled nurse visit note on 3/16/23 revealed the patient had erythema (redness) to the skin on his upper coccyx (tailbone). The clinical record lacked any further assessments of the upper coccyx area. The skilled visit note for the patient’s home health discharge on 4/13/23 revealed that the patient reported to the nurse that he had an open wound to his left buttock. The wound was assessed at a stage 2 pressure ulcer (partial thickness skin loss).”

“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 agency policy review, clinical record review and agency staff interview, the agency failed to complete a drug regimen review with all of the required components and patient specific for each patient for 7 of 7 sampled patients requiring drug regime reviews (Patients #1, #2, #3, #4, #5, #6 and #7 ). The agency reported a current patient census of 32 patients. Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. 3. Patient #2 had an admission date of 3/14/22. Review of the clinical record revealed the following: a. The POC, dated 9/5/23 to 11/3/23 and 11/4/23 to 1/2/24, included orders for skilled nursing services and orders for medications. The medication orders included medications with duplicate therapies including Cinnamon, Vitamin B 12 and Vitamin D3 for supplements. b. The comprehensive assessment completed by the RN, dated 3/14/22, included the following documentation related to the DRR: “multiple duplicates.” c. The comprehensive assessment completed by the RN, dated 11/2/23, included the following documentation related to the DRR: “multiple duplicates.” The agency staff failed to identify individual patient outcomes of the DRR. 4. Patient #3 had an admission date of 6/28/23. Review of the clinical record revealed the following: a. The POC, dated 9/5/23 to 10/22/23 and 10/23/23 to 12/23/23, included orders for skilled nursing services and orders for medications. The medication orders included medications with duplicate therapies including Biscodyl, Docusate sodium, Magnesium hydroxide and Polyethylene glycol for bowel medications. b. The comprehensive assessment completed by the RN, dated 6/13/23, included the following documentation related to the DRR: “multiple duplicates.” c. The comprehensive assessment completed by the RN, dated 10/4/23, included the following documentation related to the DRR: “multiple duplicates.” The agency staff failed to identify individual patient outcomes of the DRR. 5. Patient #4 had an admission date of 10/30/23. Review of the clinical record revealed the following: a. The POC, dated 10/30/23 to 12/28/23, included orders for skilled nursing services and orders for medications. The medication orders included medications with duplicate therapies including Acetaminophen and Advil for pain. b. The comprehensive assessment completed by the RN, dated 10/30/23, included the following documentation related to the DRR: “no issues.” The agency staff failed to identify individual patient outcomes of the DRR. 6. Patient #5 had an admission date of 11/13/23. Review of the clinical record revealed the following: a. The POC, dated 11/13/23 to 1/11/24, included orders for skilled nursing services and orders for medications. The medication orders included medications with duplicate therapies including Docusate sodium and Polyethylene glycol for bowels, Albuterol and Albuterol-ipratropium for respiratory and aripiprazole, buspar for psychiatric medications. The medications orders also included medications with potential adverse interactions which included aripiprazole, buspar and trazodone. b. The comprehensive assessment completed by the RN, dated 11/13/23, included the following documentation related to the DRR: “no issues found.” The agency staff failed to identify individual patient outcomes of the DRR. The above stated finding were presented to the Administrator/Clinical Manager and Staff B, RN, Staff C, RN and Staff D, RN. No further information provided prior to the end of the survey. Findings Include: According to the agency policy, titled Drug Regimen Review dated 5/22, in pertinent part: 1. The drug regimen review consists of a review of all drugs the client is currently using in order to identify: a. Potential adverse effects and drug reactions b. Ineffective drug therapy c. Significant side effects d. Drug interactions e. Drug allergies/reaction f. Duplicate drug therapy g. Non-compliance with drug therapy h. Drug Omissions and Errors i. Drug Discrepancies j. Knowledge related to drug therapy 2. Significant findings from the drug regimen review are instructed to the client/caregiver(s) and reported to the patient’s physician (see procedure). Significant findings include, but are not limited to, duplications, potential adverse effects, drug reactions, significant interactions and side effects. During an agency staff interview on 11/30/23 at 9:00 AM, the Administrator/Clinical Manager reported that the comprehensive drug regime review could be identified in the patient’s clinical record. Subsequent review of patient clinical records lacked further specific comprehensive components of the drug regime review. 1. Patient #1 had an admission date of 9/25/23. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 9/25/23 to 11/23/23 and 11/24/23 to 1/22/24, included orders for skilled nursing services and orders for medications. The medication orders included medications with duplicate therapies including Centrum Silver Therapeutic Multiple Vitamins with Minerals, ferrous sulfate, and Vitamin B12 for supplements. b. The comprehensive assessments completed by the Registered Nurse (RN), dated 9/25/23 and 11/20/23, included the following documentation related to the DRR: “multiple duplicates.” The agency staff failed to identify individual patient outcomes of the Drug Regime Review (DRR). 2. Patient #6 had an admission date of 4/8/23. Review of the clinical record revealed the following: a. The POC, dated 4/8/23 to 6/6/23, included orders for skilled nursing services and medications. The medications with duplicate therapies included furosemide and spironolactone for diuretic medications. b. The comprehensive assessment completed by an RN, dated 4/8/23, included the following documentation related to the DRR: “multiple duplicates.” The agency staff failed to identify individual patient outcomes of the DRR. c. Patient #7 had an admission date of 3/12/23. Review of the clinical record revealed the following: a. The POC, dated 3/12/23 to 5/10/23, included orders for skilled nursing services and medications. The medications with duplicate therapies included algoliptin, glipizide, and metformin for anti-diabetic medications. b. The comprehensive assessment completed by an RN, dated 3/12/23, included the following documentation related to the DRR: “multiple duplicates.” The agency staff failed to identify individual patient outcomes of the DRR.”

“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 agency policy review, clinical record review, home visit observation and patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 3 sampled patients with surveyor home visit observation(Patients #2, #3 and #6). 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: 4. Patient #6 had a start of care date of 4/8/23 and was discharged from home health services on 4/24/23. Clinical record review revealed the following: The start of care assessment on 4/8/23 revealed that the patient: Was incontinent and used disposable briefs. The patient had a long history of pulmonary fibrosis and had already been on home oxygen. The Plan of Care dated 4/8/23 to 6/6/23 lacked: Disposable briefs as durable medical equipment. Did not list oxygen on the medication list. The above findings were reviewed with the agency Administrator/Clinical Manager and Staff . The agency provided no additional information prior to the end of the survey. According to the agency policy titled Plan of Care and Care Management, dated 11/2023, the plan of care is based on problems/needs identified through a comprehensive assessment of the patient. It also includes supplies that the agency will furnish. Agency staff review medications including oxygen and over the counter medications. 1. Patient #2 had a start of care date of 3/14/22. Clinical record review revealed the following: a. The Plan of Care (POC), dated 9/5/23 to 11/3/23 and 11/4/23 to 1/2/24, identified Durable Medical Equipment (DME) the patient utilized including: overbed table, raised toilet seat, shoe/sock aids, hand-held shower, grab bars/safety rails, handles over toilet, scale, pill splitter, thermometer, med boxes and safety alarms. The POC also included the patient’s current medications. b. During an observation home visit on 11/29/23 at 1:30 PM with Staff B, RN the surveyor identified a blood pressure cuff. During an interview with the patient during the same home visit the patient stated the blood pressure cuff used daily for blood pressure readings and started taking blood pressures for a long time. The observation also included Staff B set up the patient’s medications. The patient had a bottle of ibuprofen. The patient reported he/she started the medication about 2 months prior and took it for 3 to 4 days and also took the medication the night before. The POC failed to include DME incontinent briefs and the medication ibuprofen required by the patient. 2. Patient #3 had a start of care date of 6/28/23 . Clinical record review revealed the following: a. The Plan of Care (POC), dated 8/5/23 to 10/3/23 and 10/4/23 to 12/2/23, identified Durable Medical Equipment (DME) the patient utilized including: raise toilet seat, cane, shower chair, hand-held shower, grab bars/safety rails, scale, compression socks, large screen phone, nebulizer machine, blood sugar machine, thermometer, lift chair and 4 wheeled walker. b. The skilled nurse recertification assessment note, dated 10/4/23, identified the patient incontinent and required incontinent briefs. The POC failed to include DME incontinent briefs required by the patient.”

“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 agency policy review, clinical record review and agency staff interview, the agency failed to provide medications, treatments or services only as ordered by the physician for 1 of 1 sampled patients with coumadin ordered and 1 of 4 sampled patients with physical therapy (PT) Patient #1. The agency reported a current patient census of 32 patients. Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to agency policy in pertinent part, titled Plan of Care and Care Management with a retrieval date 11/23, the therapist writes and signs verbal orders in the electronic medical record (as necessary) that is faxed to the physician for signature. In an interview on 11/30/23 at 9:00 AM, the Administrator reported that PT did not contact the physician when the visits did not take place as ordered. The Administrator did not provide any information about the issue with coumadin management by the agency or provide a policy related to coumadin management. Patient #1 had a start of care date of 2/18/2020. Review of the clinical record revealed the following: 1. An order for warfarin(coumadin) 1 mg (milligram) oral tablet; Take 1.5 tab(s) (tablet(s)) oral every Sunday, Monday, Wednesday, Friday, and Saturday. 2. An order for warfarin 3 mg oral tablet; take 1 tab(s) oral every Tuesday and Thursday. 3. An order for INR (lab to monitor coumadin level in the blood) to be drawn on 9/28/23. 4. An order for PT; 2 times per week for 4 weeks; beginning during week of 9/25/2023 - ending on 10/21/2023. The Clinical Record lacked: 1. An order for INR to be drawn on 9/28/23 was performed. 2. Subsequent INR lab orders. 3. Whether the agency or the patient would manage coumadin therapy including labs and medication adjustments. 4. PT visits for the fourth week of the order for PT. 5. Physician notification that PT visits did not occur for the fourth week of the order for PT. The above findings were reviewed with the agency Administrator/Clinical Coordinator, Staff B, Registered Nurse (RN), Staff C, RN, and Staff D, RN. The agency provided no additional information prior to the end of the survey.”

“Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This Element is not met as evidenced by: Based on observation, agency policy review, clinical record review and agency staff interview, the agency failed to provide copies of paperwork signed by the patient identifying the treatments to be administered by the agency for 2 of 3 patients with home visits ( Patients #1 and #3). The agency reported a current patient census of 32 patients. Failure to ensure patients had information in their home for their treatments places patients at risk for the patient’s rights being violated. 2. Patient #3 had a start of care date of 6/28/23. a. The Plan of Care (POC), dated 10/4/23 to 12/2/23, included orders for skilled nursing and home health services. b. On 11/29/23 at 10:00 AM, the surveyor accompanied Staff C, Registered Nurse (RN), to the patient’s home for an observation home visit. During the home visit, the surveyor requested review of the agency’s folder kept by the patient. During review of the folder, which included all paper work given to the patient by the agency, the surveyor found no documentation identifying the treatments to be administered by the home health agency personnel and personnel acting on behalf of the agency. The above findings shared with the Administrator/Clinical Manager and Staff B, RN, Staff C, RN and Staff D, RN. No further information provided prior to the end of the survey. Findings include: In an interview on 11/30/23 at 9:00 AM, the Administrator reported that all of the information patients sign at home health admission are in their clinical records and that the agency does not have a policy related to copies of information that is provided to patients at admission. 1. Patient #1 had a start of care date of 9/25/23. a. The POCs, dated 9/25/23 to 11/23/23 and 11/24/23 to 1/22/24, included orders for skilled nursing and physical therapy. b. On 11/29/23 at 9:00 AM, the surveyor accompanied Staff D, RN, to the patient’s home for an observation visit. During the home visit, the surveyor requested review of the agency’s folder kept by the patient. During review of the folder, which included all paperwork given to the patient by the agency, the surveyor found no documentation identifying the treatments to be administered by the home health agency personnel and personnel acting on behalf of the agency.”