Home Sweet Home Care

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on review of the emergency preparedness plan and related policies and agency staff interview, the agency failed to complete a written emergency preparedness plan that included a process for cooperation and collaboration with local, state, and federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the agency’s efforts to contact such officials and of its participation in collaborative and cooperative planning efforts. Failure to have a process for cooperation and collaboration with local, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation potentially placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency’s Emergency Preparedness Plan and related policies, the agency failed to address the process for cooperation with state and federal emergency preparedness officials efforts to maintain an integrated response during a disaster or emergency situation. During an interview on 2/11/25 at 1:30 PM, the Assistant Administrator stated she acknowledged the Emergency Preparedness Program failed to address state and federal emergency preparedness officials. The agency failed to have a written policy and procedure for cooperation and collaboration with local, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The above findings reviewed with the Assistant Administrator.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on review of the agency emergency preparedness plan and related policies and agency staff interview, the agency failed to complete a written emergency preparedness plan that included procedures to inform State and local officials of any on duty staff they are unable to contact in the event of an interruption of services related to an emergency. Failure to have procedures in place to inform State and local officials of any on duty staff they are unable to contact in the event of an interruption of services related to an emergency placed agency staff and patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency’s Emergency Preparedness Plan and related policies identified a lack of procedures to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. During agency staff interview on 2/11/25 at 1:30 PM, the Assistant Administrator verified an inability to find language in the plan to include procedures to inform State officials of on duty staff they are unable to contact and to inform both local and State officials of patients they are unable to contact in the event of an interruption of services related to an emergency. The above findings were reviewed with Assistant Administrator.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on review of the agency facility emergency preparedness documentation and staff interview, the agency failed to provide documentation the agency developed and maintained an emergency plan that included primary and alternate means of communicating with the agency staff and federal, state, tribal, regional and local emergency management agencies. Failure to develop and maintain an emergency preparedness plan including primary and alternate means of communication with the agency staff and federal, state, tribal, regional and local emergency management agencies during a time of disaster or emergency which could lead to poor client outcomes in the event of an emergency/disaster. Findings include: Review of the agency’s Emergency Plan and related policies revealed the agency failed to include primary and alternate means of communicating with the agency staff and federal, state, tribal, regional and local emergency management agencies. On 2/11/25 at 1:30 PM, the Assistant Administrator acknowledged the agency’s communication plan failed to include documentation that the agency developed and maintained an emergency plan that included primary and alternate means of communicating with the agency staff and federal, state, tribal, regional and local emergency management agencies. The above findings were reviewed with the Assistant Administrator.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on agency staff interview, agency emergency preparedness plan policy review and review of emergency preparedness exercises conducted by the agency, the agency failed to ensure agency staff participated in at least one full scale community emergency preparedness exercise, or if a full scale community exercise was unavailable, then a facility based functional exercise in 2023 or 2024. Failure to conduct or participate in emergency preparedness exercises placed agency patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: Review of the agency’s emergency preparedness plan revealed the agency will conduct annual testing of the emergency preparedness program through exercising. Review of agency’s testing of the emergency preparedness plan for 2023 and 2024, revealed a lack of documentation of a full-scale community wide exercise, facility wide, mock disaster or table top drill or documentation of an actual event. On 2/11/25 at 1:30 PM, during an interview, the Assistant Administrator reported the agency did not complete any testing of the emergency preparedness plan for the years 2023 or 2024. The agency failed to maintain documentation of an after action report to either an actual event which triggered the activation of their emergency program or a community wide full-scale exercise, or facility wide if a community wide exercise was not available. The above findings reviewed with the Assistant Administrator.”

“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 home visit observation, clinical record review and agency policy review, 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 (Patient #2) with home visits. Failure to follow accepted standards of practice for infection control may put the patient at risk for receiving unsafe care or care that allows the spread of infection. Findings include: According to the agency policy titled Control of Infection Sources, dated 4/21/14, staff place bags taken into the home on a barrier. Equipment is cleaned prior to patient use, before returning to bag after patient use and stored in Ziplock bags in the nursing bag. Patient #2 had a start of care date of 1/24/25 and received services from the Clarinda office. 1.The Plan of Care (POC), dated 1/24/25 to 3/24/25 identified the patient had diagnoses of paraplegia, new ostomy and hypertension and included orders for skilled nursing services three times a week. 2.During a home visit observation on 2/10/25 at 2:00 PM, with Staff E, Registered Nurse (RN), the surveyor observed equipment for vital signs assessment placed on a clean barrier. Staff E assessed the patients vital signs. After use, Staff E placed the contaminated equipment back on the barrier and placed the thermometer in her scrub shirt pocket. Staff E set up a clean workspace to provide wound care in patient’s bedroom. Staff E utilized scissors to cut gauze, placed the scissors on clean barrier, used the scissors to cut another piece of gauze and placed scissors in her scrub shirt pocket. Staff E measured wound using a tape measure (not disposable) and placed tape measure in her scrub shirt pocket after use. At end of the visit, Staff E placed all blood pressure cuff, stethoscope, pulse oximeter (electronic device used to monitor blood oxygen saturation and heart rate) back in nursing bag without sanitizing the items. The tape measure, scissors and thermometer remained in Staff E’s pocket. Staff E, RN, failed to sanitize all contaminated items prior to returning them to nursing bag. The above findings were reviewed with the Administrator, Assistant Administrator and Clinical Manager.”

“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 during start of care, recertifications, resumption of care and discharge assessments for 1 of 2 sampled patients with wounds (Patient #7). 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 the agency policy titled Wound Policy, revised 8/23/2016, an initial wound assessment is completed when the area is first discovered and it includes measurements of length by width by depth in centimeters, description of wound bed, surrounding skin, wound edges, drainage, pain, odor and treatment. Follow up assessments are completed weekly and include description of the wound and measurements of length by width by depth in centimeters. During an interview on 2/11/25 at 12:15 PM, Staff C, Clinical Manager stated wounds are measured every skilled nurse visit and wound measurements include length by width by depth in centimeters. Patient #7 had a start of care date of 1/9/25 and a discharge date of 1/20/25. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/9/25 to 3/9/25, identified the patient had diagnoses of pyogenic arthritis, disruption of external operation and atrial fibrillation and included orders for skilled nursing services one time a week. b. The start of care comprehensive assessment, dated 1/9/25, completed by Staff C, Clinical Manager, identified she did not observe patient’s wound with new dressing intact. The skilled nurse failed to complete an initial assessment of patient’s wound. c. The skilled nurse visit note, dated 1/14/25, completed by Staff E, Registered Nurse (RN), included the following documentation of patient’s wound: Wound to right leg has area halfway down the length of the calf with bloody drainage, no odor. The area measures 5 centimeters (cm) by 13 cm. The measurements lacked depth measurement. The agency failed to include accurate and complete comprehensive assessments of wounds. The above findings reviewed with the Administrator, Assistant Administrator and Clinical Manager.”

“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 observations, patient interviews, staff interview, clinical record reviews and agency policy review, the agency failed to ensure the drug regimen review identified ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #6 and #7). 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 effects to the patients. Findings include: 4. Patient #3 had a start of care date of 10/8/2020. Clinical review revealed the following: a. The POCs, dated 11/16/24 to 1/14/25 and 1/15/25 to 3/15/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease. The POC included physician orders for medications and skilled nursing services. b. The start of care comprehensive assessment, dated 10/8/2020, completed by Staff F, Registered Nurse, included documentation a DRR was completed and patient demonstrated noncompliance with medication use, as prescribed by physician and potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications have been identified. The DRR failed to identify the findings. c. During an observational home visit on 2/10/25 at 3:45 PM with the Clinical Manager, the surveyor noted the patient had the following medications: An interview during the same home visit, the patient stated he/she had the medications an extended time. The identified medications not listed on the patient medication profile. 1.) Aspirin and Caffeine (pain medication) tablet 500 mg/32.5 mg as needed for pain, taken for 10 years. 2.) Rybelsus (diabetic medication) 14 mg 1 tablet daily , taken for 3 months. The agency failed to complete an accurate DRR to include all current medications and results of the adverse findings of the DRR. 5. Patient #4 had a start of care date of 12/18/23. Clinical review revealed the following: a. The POCs, dated 12/12/24 to 2/9/25 and 2/10/25 to 4/10/25, identified the patient had a diagnosis of cerebral palsy. The POC included physician orders for medications and skilled nursing services. b. The start of care comprehensive assessment, dated 12/18/23, completed by Staff C, Clinical Manager, included documentation a DRR was completed and patient demonstrate noncompliance with medication use, as prescribed by physician and potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications have been identified. The DRR failed to identify the findings. The agency failed to complete an accurate DRR to include the results of the findings of the DRR. 6. Patient #6 had a start of care date of 11/18/24 and was discharged from the agency on 1/13/25. Clinical review revealed the following: a. The POC, dated 11/18/24 to 1/16/25, identified the patient had a diagnosis of cerebral palsy. The POC included physician orders for medications and skilled nursing services. b. The start of care comprehensive assessment, dated 12/18/23, completed by the Clinical Manager, included documentation a DRR was completed and patient demonstrate noncompliance with medication use, as prescribed by physician and potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications have been identified. The DRR failed to identify the results of the findings. The agency failed to complete an accurate DRR to include the results of the adverse findings of the DRR. The above findings reviewed with the Administrator, Assistant Administrator and Clinical Manager. According to the agency policy titled Drug Regimen Review, dated 4/21/14, patient medications will be reviewed for potential adverse side effects and drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy. All medications, including over-the-counter medications will be ordered by a physician. During an interview on 2/11/25 at 12:15 PM, Staff C, Clinical Manger, reported drug regimen reviews (DRR) are completed at admission, recertification, resumption of care, discharge and when a new medication is added. 1.Patient #1 had a start of care date of 9/29/22. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/16/25 to 3/16/25, identified the patient had diagnoses of hypertension, gout and peripheral neuropathy and included physician orders for medications and skilled nursing services. b. The recertification comprehensive assessment, dated 1/15/25, completed by Staff C, Clinical Manager, included documentation a DRR was completed and potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications have been identified. c. During a home observation visit on 2/10/25 at 12:30 PM, Staff C, Clinical Manager, set up patient’s medications. The following medication discrepancies were identified: 1) The POC identified the patient takes Melatonin 10 milligrams (mg) orally at bedtime as needed for insomnia. The bottle in the home is Melatonin 5mg tablets. Patient reported he/she takes one tablet as needed for insomnia. 2) The POC identified the patient takes Tylenol 325 mg orally with instructions to take two tablets every 6 hours as needed for pain. The bottle in the home is Extra Strength Pain Relief 500 mg tablets. Patient reported taking two tablets as needed for pain. 3) The POC identified the patient takes Cyclobenzaprine 10 mg orally at bedtime as needed for back pain. The patient reported he/she does not have Cyclobenzaprine in the home and has not taken the medication for several months. The DRR failed to specify what issues were identified and failed to include an accurate list of all medications taken by the patient. 2.Patient #2 had a start of care date of 1/24/25. Clinical record review revealed the following: a. The POC, dated 1/24/25 to 3/24/25, identified the patient had diagnoses of paraplegia, new ostomy and hypertension and included physician orders for medications, skilled nursing services and home health aide services. b. The start of care comprehensive assessment, dated 1/24/25, completed by Staff E, Registered Nurse (RN), included documentation a DRR was completed and potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications have been identified. The DRR failed to specify what issues were identified. 3.Patient #7 had a start of care date of 1/9/25 and a discharge date of 1/20/25. Clinical record review revealed the following: a. The POC, dated 1/9/25 to 3/9/25, identified the patient had diagnoses of pyogenic arthritis, disruption of external operation and atrial fibrillation and included physician orders for medications and skilled nursing services. b. The start of care comprehensive assessment, dated 1/9/25, completed by Staff C, Clinical Manager, included documentation a DRR was completed and potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications have been identified. The DRR failed to specify what issues were identified.”

“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 supplies/equipment and all medications and treatments used by the patient for 5 of 7 sampled patients (Patients #1, #2, #4, #5 and #6). 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: 4. Patient #4 had a start of care date of 12/18/23. Clinical review revealed the following: a. The POCs, dated 12/12/24 to 2/9/25 and 2/10/25 to 4/10/25, identified the patient had a diagnosis of cerebral palsy. The POC included the following DME required by the patient: elevated toilet seat, grab bars and shower bench. b. The comprehensive assessment at start of care, dated 12/18/23, identified the patient required the use of a motorized scooter and medication planner. The agency failed to include all DME on the patient’s POC including a motorized scooter and medication planner required by the patient. 5. Patient #6 had a start of care date of 11/18/24 and discharged from the agency on 1/13/25. Clinical review revealed the following: a. The POC, dated 11/18/24 to 1/13/25, identified the patient had a diagnosis of diabetes mellitus. The POC included the following DME required by the patient: shower bench, diabetic supplies and suprapubic catheter supplies. b. The comprehensive assessment at start of care, dated 11/18/24, identified the patient required the use of an electric wheelchair and prosthetics. The assessment also identified the patient required the use of a suprapubic catheter. c. The skilled nurse visit note, dated 12/25/24, identified the patient had a #18 French suprapubic catheter in place. d. Review of the medical record lacked orders for the size and balloon size for the suprapubic catheter. The agency failed to include all DME and orders on the patient’s POC including an electric wheelchair and prosthetic and suprapubic catheter orders required by the patient. The above findings were reviewed with the Administrator, Assistant Administrator and Clinical Manager. According to the agency policy titled Plan of Care, dated 4/21/14, the plan of care developed in consultation with the physician and agency staff includes but is not limited to all pertinent diagnoses, types of services and equipment, medications and treatments, frequency of visits and functional limitations. Orders for each service must include specific procedures and modalities to be used and the frequency and duration of services. 1.Patient #1 had a start of care date of 9/29/22. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/16/25 to 3/16/25, identified the patient had diagnoses of hypertension, gout and peripheral neuropathy. The POC included the following durable medical equipment (DME) used by the patient: grab bars and shower bench. b. During a home observation visit on 2/10/25 at 12:30 PM with Staff C, Clinical Manager, the surveyor identified the following DME used by the patient: medication cassette, lift chair and glucometer. The patient stated during the same home visit that he/she had the medication cassette, lift chair and glucometer for greater than 3 months. The agency failed to include all DME on the patient’s POC including a medication cassette, lift chair and glucometer used by the patient. 2.Patient #2 had a start of care date of 1/24/25. Clinical record review revealed the following: a. The POC, dated 1/24/25 to 3/24/25, identified the patient had diagnoses of paraplegia, new ostomy and hypertension. The POC included the following DME used by the patient: manual wheelchair, motorized wheelchair, trapeze, hospital bed, gloves, drainage bag, catheter leg bag, elevated toilet seat, grab bars, shower bench and ostomy supplies. b. The start of care comprehensive assessment, dated 1/24/25, completed by Staff E, Registered Nurse (RN), identified the patient required use of a suprapubic catheter. c. During a home observation visit on 2/10/25 at 2:00 PM with Staff E, RN, the surveyor identified the following DME used by the patient: reacher device. d. Review of the medical record lacked orders for the size and balloon for the suprapubic catheter. The agency failed to include all DME and orders on the patient’s POC including a reacher device and suprapubic catheter orders required by the patient. 3.Patient #5 had a start of care date of 12/3/24. Clinical record review revealed the following: a. The POC, dated 2/1/25 to 4/1/25, identified the patient had diagnoses of chronic obstructive pulmonary disease (COPD), hypertension and non-insulin dependent diabetes mellitus (NIDDM). The POC included orders for medications, treatments, and the following DME used by the patient: medication cassette, cane and diabetic supplies. b. The skilled nurse visit note, dated 2/5/25, completed by Staff D, Licensed Practical Nurse (LPN), identified the patient uses oxygen at 2 liters per nasal cannula as needed. c. Review of the medical record lacked orders for patient’s use of oxygen. The agency failed to include all orders on the patient’s POC including oxygen orders 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 home visit observations, agency staff interview, clinical record reviews and agency policy review, the agency failed to follow physician orders for treatments for 4 of 7 sampled patients (Patients #2, #3, #4 and #5). Failure to ensure staff obtain and follow physician orders for treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: 3. Patient #3 had a start of care date of 10/8/2020. Clinical record review revealed the following: a. The POCs, dated 11/16/24 to 1/14/25 and 1/15/25 to 3/15/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included orders for skilled nursing visits one time a week. b. The POCs included physician orders for medications and treatments, which included orders to assess the patient’s use of glucose measuring and glucometer recordings. c. The skilled nurse visit notes, dated 12/17, 12/24/24, 1/21/25 and 2/6/25, lacked documentation of the patient’s glucometer recordings. Agency staff failed to document the glucometer readings every visit. 4. Patient #4 had a start of care date of 12/18/23. Clinical record review revealed the following: a. The POCs, dated 10/13/24 to 12/11/24,12/12/24 to 2/9/25 and 2/10/25 to 4/10/25, identified the patient had a diagnosis of cerebral palsy and included orders for skilled nursing visits two times a week. The POCs included the order for vitamin D supplement 5,000 units daily. b. The POCs included physician orders for medications and treatments, which included orders for the skilled nurse to set up the patients medications every week. The POCs included the order for vitamin D supplement 5,000 units daily. c. The verbal order, dated 10/2/24, included physician’s order to decrease the vitamin D3 from 50,000 units daily to 5,000 units daily. d. The verbal order, dated 1/20/25, identified physician notification the pharmacy continued to supply vitamin D3 50,000 units. The physician ordered vitamin D3 5,000 units and to draw a vitamin D3 level due to 6 weeks on the wrong vitamin D3 therapy. c. The verbal order, dated 1/30/25, identified physician notification the skilled nurse attempted the vitamin D3 level laboratory draw and unable due to patient not cooperating. The physician ordered the patient to have lab draw at the medical clinic. d. During an interview on 2/11/25 at 11:55 AM the Clinical Manager stated the patient had not gone to the medical clinic for a lab draw due to lack of transportation and weather caused the inability to use his/her motorized scooter. Agency staff failed to document the glucometer readings every visit. The above findings reviewed with the Administrator, Assistant Administrator and Clinical Manager. According to the agency policy titled Plan of Care, dated 4/21/14, the plan of care developed in consultation with the physician and agency staff includes but is not limited to all pertinent diagnoses, types of services and equipment, medications and treatments, frequency of visits and functional limitations. Orders for each service must include specific procedures and modalities to be used and the frequency and duration of services. 1.Patient #2 had a start of care date of 1/24/25. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/24/25 to 3/24/25 identified the patient had diagnoses of paraplegia, new ostomy and hypertension and included orders for skilled nursing services three times a week. b. The POC included physician orders for medications and treatments, which included the following wound care orders: complete wound care three times a week, moisten dry gauze with 1/4 strength vashe or dakins, pack into wound leaving tail for easy removal. Cover with abdominal pad and skin friendly tape. c. During on home observation visit on 2/10/25 at 2:00 PM, surveyor observed Staff E, Registered Nurse (RN) performing the following wound care: Staff E, RN irrigated patient’s wound with 6 cubic centimeters (cc) of normal saline, moistened gauze with vashe, applied calmoseptine, packed wound with dry gauze and left tail out, covered would with abdominal pad and secured with skin friendly tape. Agency staff failed to provide wound care only as ordered by the physician. 2.Patient #5 had a start of care date of 12/3/24. Clinical record review revealed the following: a. The POCs, dated 12/3/24 to 1/31/25 and 2/1/25 to 4/1/25 identified the patient had diagnoses of chronic obstructive pulmonary disease, hypertension and non-insulin dependent diabetes mellitus and included orders for skilled nursing visits two times a week. b. The POCs included physician orders for medications and treatments, which included orders to notify physician of systolic blood pressure greater than 140 or less than 100, diastolic blood pressure greater than 90 or less than 60 and blood glucose level greater than 145 or less than 70. c. The skilled nurse visit note, dated 12/9/24, completed by Staff D, Licensed Practical Nurse (LPN), included documentation the patient had a blood pressure (BP) of 142/80 but lacked documentation the physician was notified of the BP that fell outside parameters set. The skilled visit note lacked documentation of the patient’s blood glucose level. d. The skilled nurse visit notes, dated 12/12/24, 12/16/24 and 12/19/24, completed by Staff D, LPN, lacked documentation of the patient’s blood glucose level. e. The skilled nurse visit note, dated 12/23/24, completed by Staff D, LPN, included documentation the patient had a BP of 142/82 but lacked documentation the physician was notified of the BP that fell outside parameters set. The skilled nurse visit note lacked documentation of the patient’s blood glucose level. f. The skilled nurse visit note, dated 12/26/24 completed by Staff C, Clinical Manager, included documentation the patient had a BP of 163/90 but lacked documentation the physician was notified of the BP that fell outside parameters set. The skilled nurse visit note lacked documentation of the patient’s blood glucose level. g. The skilled nurse visit notes, dated 12/30/24 and 1/2/25, completed by Staff D, LPN, lacked documentation of the patient’s blood glucose level. h. The skilled nurse visit note, dated 1/5/25, completed by Staff D, LPN, included documentation the patient had a BP of 142/80 but lacked documentation the physician was notified of the BP that fell outside parameters set. The skilled nurse visit note lacked documentation of the patient’s blood glucose level. i. The skilled nurse visit notes, dated 1/9/25, 1/13/25, 1/16/25, 1/20/25, 1/23/25, 1/27/25 and 2/3/25, completed by Staff D, LPN, lacked documentation of the patient’s blood glucose level. The agency staff failed to notify the physician of vital sign readings that fell outside parameters set and failed to document patient’s blood glucose levels each visit.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to assure nurses taking verbal orders from a physician documented the orders in the clinical record (signed, dated and timed) sending the orders to the physician for authentication, including signature and date of signature for 1 of 7 sampled patients (Patients #6). Failure to document physician orders taken into patient clinical records placed the patient at risk for inappropriate, inadequate care resulting in potential injury or harm. Findings include: According to the agency policy, titled Interim (Verbal Orders), dated 4/21/14, when verbal orders for care are given by the patient’s physician, a record of the orders will be immediately written on the agency’s physician interim order form. The original will be sent to the physician for signature within 30 days and a copy will remain in the active chart. When the order is returned, the copy is removed and the original filed in the chart. During an interview on 2/11/25 at 12:15 PM the Clinical Manager stated interim physician orders are printed and put in the patient’s chart. If there is an update to the plan of care (POC), it is put in the computer on the POC, printed and put in the patient’s chart. Patient #6 had a start of care date of 11/18/24 and discharged from the agency on 1/13/25. Clinical record review revealed: a. The POC, dated 11/18/24 to 1/16/25, identified the patient had a diagnosis of Diabetes Mellitus. The POC included orders for skilled nursing services. b. The skilled nurse visit note, dated 11/25/24, Staff E, Registered Nurse, identified the patient started a new medication Cefadroxil (antibacterial) 500 milligrams 2 times a day for 7 days. c. Review of the clinical record lacked documentation of a verbal order for the medication Cefadroxil. The agency failed to include verbal orders for all medications required by the patient. The above findings reviewed with the Administrator, Assistant Administrator and Clinical Manager.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. 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 and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient’s transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 1 of 2 sampled patients with transfers/ discharges (Patient #6). Failure to send the physician and other health care professionals a summary of the patient’s care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: According to the agency policy titled, Transfer of Home Health Patients, last revised 4/21/14, when the overall medical condition or living situation of the patient dictates that the agency’s skills and services are no longer sufficient to provide the necessary care, the agency shall notify the attending physician of such. He and/or the responsible party shall make the final determination whether the patient should be transferred to a hospital or other home care facility. During an interview on 2/11/25 at 11:58 AM Staff C, Registered Nurse (RN) stated she generally filled out the transfer summary and it would be sent to the physician. She further stated she had not sent a transfer summary to the receiving facility. Patient #6 had a start of care date of 11/18/24 and discharged from the agency on 1/13/25. Clinical record review revealed: a. The POC, dated 11/18/24 to 1/16/25, identified the patient had a diagnosis of Diabetes Mellitus. The POC included orders for skilled nursing services. b. An interim physician’s order, dated 1/13/25, ordered to transfer the patient to a higher level of care (nursing home). c. A home health transfer summary completed by the Staff C, RN, dated 1/13/25, included identification the patient transferred to the hospital and the summary sent to the primary care physician. The agency failed to send the transfer summary and discharge summary to the receiving nursing home. The above findings reviewed with the Administrator, Assistant Administrator and Clinical Manager.”