Community Home Health Care

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the EP Communication Plan included the physician’s name and contact information for each patient for 1 of 1 agency. Findings include: A review of the agency EP Communication Plan in binder included a list of agency patients that failed to evidence the names and contact information of each patients’ physician. During an interview on 11/12/24 at 3:50 PM, when asked to see the physician’s name and contact information for each patient in the EP, the alternate administrator indicated it was missing for most patients.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure initial EP policy and procedure training was completed at hire by all employees for 2 of 6 employee inservice records reviewed (Employee E, F). Findings include: 1.Record review of an agency document titled “Annual Re-Training In-Service Verification Form” included Emergency Preparedness Plan as an employee in-service to be completed annually. 2.Review of an agency report titled “Caregiver Inservice Details Report” for Employee E, with hire date of 06/30/2022, indicated completion of Annual Retraining Inservices on 12/04/2022 which was five months after date of hire. Documentation failed to evidence initial EP policy and procedure training was completed by Employee E. During an interview on 11/12/2024 at 1:35 PM, when asked to see the record of initial EP training for Employee E, the business operations manager indicated initial training was not done. 3.Personnel record review of Employee F, with hire date of 01/17/2023, evidenced an agency document titled “Inservice Verification Form” for the EP policy and procedure training inservice. Review included an agency document titled “EP Plan Inservice Test” that failed to evidence Employee F completed the inservice. During an interview on 11/12/2024 at 1:35 PM, when asked to see the record of initial EP training for Employee F, the business operations manager indicated Employee F did not finish the training.”

“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 record review and interview, the home health agency failed to document the agency’s response following actual emergency events for 1 of 1 agency. Findings include: 1.Review of an agency policy titled “Emergency Preparedness Plan” indicated responses are the activities taken by the agency immediately before, during, and after an emergency/disaster to address the immediate and short-term effects of the emergency event. 2.Review of the agency EP binder identified the agency initiated the EP plan for the following actual natural disasters: 01/22/2024 – 01/23/2024 for a Winter weather advisory, 01/24/2023 fora Winter Storm Warning, and 06/14/2024 -06/16/2024 for a Derecho (a widespread, long-lived windstorm). Documentation failed to evidence the outcome of emergency interventions put in place during each natural disaster. During an interview on 11/12/2024 at 3:50 PM, when asked to see the agency documentation of the outcome of the emergency interventions put into place for emergency events, the alternate administrator indicated calls to patients were documented in client logging. When asked to see the agency’s response of the actions put into place during an emergency event, the alternate administrator did not answer.”

“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 record review and interview, the agency failed to ensure the POC included medication orders that included the route, dose, frequency, and included the location of application for 2 of 5 active records reviewed (Patient #3, 5) and for 1 of 2 discharged records reviewed (Patient #6). Findings include: Review of an agency policy titled “Client Plan of Care” indicated the POC is established by the agency and reviewed by the physician to ensure the appropriate application of the services to the patient’s condition and the POC will include the Patient’s medications. 2. Review of the clinical record of Patient #3 included a POC for certification period 07/29/2024 – 09/26/2024 signed by RN 2 that included a narrative for the initial assessment that indicated the patient was taking Jardiance (used to lower blood sugar levels in individuals with type 2 diabetes) and Acetaminophen (used for mild to moderate pain). The POC failed to evidence the dose, route, and frequency for taking the medications. During an interview on 11/08/2024 at 3:14 PM, when asked where to find the dose, route, and frequency for Jardiance and Acetaminophen, RN 2 indicated the dose, route, and frequency were not in the POC. Review of the POC of Patient #3 for certification period 09/27/2024 – 11/25/2024 signed by RN 1 included a narrative in the 60-day summary that indicated the patient was taking Jardiance and Acetaminophen. The POC failed to evidence the dose, route, and frequency for taking the medications. During an interview on 11/08/2024 at 4:35 PM, when asked where to find the dose, route, and frequency for Jardiance and Acetaminophen, RN 1 indicated was not in the POC. 3. Review of the clinical record of Patient #5 included a POC for certification period 09/16/2024 – 11/14/2024 signed by RN 1 that included topical (apply to skin) medications but were not limited to, Collagenase (breaks down collagen in damaged tissue to help healthy tissue grow), Promogran Matrix (wound dressing to assist with wound healing), and Sodium Hypochlorite (antiseptic used for wound care). The POC included duplicate medications but were not limited to, Gentamicin (antibiotic to treat a skin infection) applied topically, Ferrous Sulfate (iron supplement), and Albuterol Sulfate (used to prevent and treat wheezing and shortness of breath). The POC failed to evidence the location for the application of the topical medications and failed to evidence which duplicate medication was to be used by the patient. During an interview on 11/08/2024 at 4:35 PM, when asked where in the POC for Patient #5 the following topical medications, Collagenase, Promogran Matrix, and Sodium Hypochlorite, were to be applied, RN 1 indicated the locations were missing. When asked why Ferrous Sulfate, Albuterol, and Gentamicin were entered into the POC in duplicate, RN 1 indicated they should not have been entered as duplicates. 4. Review of the clinical record of Patient #6 included a POC for certification period 08/03/2024 – 10/01/2024 that included a narrative of the 60-day summary that indicated the patient was taking Ozempic for weight management control. The POC failed to evidence the dose, route, and frequency of the medication. During an interview on 11/12/2024 at 12:15 PM, when asked where in Patient #6’s POC was the dose, route, and frequency of Ozempic, the alternate clinical supervisor indicated should have discontinued the order in the POC. IAC 17-13-1 (a)1(D)(ix)”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on record review and interview, the RN failed to ensure the ongoing interdisciplinary assessment included the staging of wounds for 1 of 3 active records reviewed of patients with wounds (Patient #2) and failed to include a pain assessment for 1 of 4 active records reviewed of patients taking scheduled pain medications (Patient #5). Findings include: Review of an agency policy titled “Comprehensive Client Assessment” indicated the comprehensive assessment must accurately reflect the patient’s current health status. 2. Review of the clinical record of Patient #2 indicated a diagnosis, but not limited to, quadriplegia (paralysis below the neck, including both arms and legs). Review included a recertification assessment completed on 08/29/2024 by RN 3 that identified pressure ulcers (skin injury caused by pressure on an area of the body and staged based on how deep the wound) to the right and left ischial (bony part of buttocks) areas. Review indicated the wounds were observed and the appearance of both wound beds was bone and indicated the staging for both wounds was not applicable. Documentation failed to evidence the staging of both pressure ulcers. During an interview on 11/08/2024 at 4:00 PM, when asked where to find the documentation of pressure ulcer staging in the recertification assessment, RN 3 indicated if the wound is documented as observed then the stage should be entered. 3. Review of the clinical record of Patient #5 indicated a diagnosis, but not limited to, chronic pain syndrome, and indicated patient takes Oxycontin (used to manage severe pain) every 8 hours for pain. Review included a recertification assessment completed on 09/11/2024 by RN 1 that included a pain assessment that indicated present level of pain was 0. Documentation of pain assessment failed to identify characteristics of pain which include the following: location, onset, how pain numbers were collected, worst pain gets on a 0-10 scale (0 is no pain and 10 is the worst), description, frequency, pattern, duration, and actions that make pain worse and better. During an interview on 11/08/2024 at 4:35 PM, when asked where to find the pain assessment in the recertification assessment of Patient #5, RN 1 indicated entered the pain score told by the patient at the visit. When asked if a thorough pain assessment should be completed and documented at a recertification assessment and for a patient who takes pain medications around the clock, RN 1 indicated yes. IAC 17-14-1(a)(1)(B)”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the SN failed to ensure orders were obtained for all services provided for 1 of 3 active records reviewed of patients with wounds (Patient #2). Findings include: Review of an agency policy titled “Physician Orders” indicated physician orders are required for all patient services including medical treatments. 2. Review of an agency job description for LPNs indicated the LPN provides nursing care that reflects the patients POC. 3. Review of the clinical record of Patient #2 included a POC for certification period 09/03/2024 – 11/01/2024 that included a diagnosis, but not limited to, quadriplegia (paralysis below the neck, including both arms and legs). The POC included wound care orders for the right ischial wound. Review of records included a recertification assessment completed on 08/29/2024 by RN 3 that identified pressure ulcers (skin injury caused by pressure on an area of the body) to the right and left ischial (bony part of buttocks) areas. Review of nursing flow sheets completed by LPN 1 on 09/13/2024, 09/20/2024, 10/18/2024, and 10/28/2024 indicated wound measurements for right and left ischial wounds, and application of wound dressing, Aquacel Ag (antimicrobial wound dressing) and dry sterile dressing, to both wounds. During an interview on 11/08/2024 at 4:00 PM, when asked where to find the wound care orders for the left pressure ulcer of Patient #2, RN 3 indicated the wound care order for the left pressure ulcer was not identified in the POC.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the HHA provided services included in the HHA POC and provided services consistent with home health aide training for 1 of 1 home visit observations of HHA providing care (Patient 3). Findings include: 1. During a home visit observation on 11/08/2024 beginning at 8:30 AM with HHA 1 and alternate clinical supervisor present, HHA 1 reminded Patient #3 to test his/her blood sugar. Observed Patient #3 stuck their finger with a lancet (small needle used to prick the skin to obtain a blood sample for testing blood sugar levels) and HHA 1 held glucometer (medical device to determine the concentration of glucose in the blood) with test strip (small, disposable plastic strip that measures blood sugar levels with a glucometer) and touched test strip to blood on patients’ finger. HHA reminded Patient #3 to take medications. Observed HHA 1 remove medications from the pillbox with a gloved hand and placed medications on a plate in front of the patient. During an interview on 11/08/2024 at 9:15 AM, when asked what a HHA can do regarding the use of the glucometer, the alternate clinical supervisor indicated hand-over hand (physically guiding individuals’ hands by placing their own hands over theirs to assist them with completing a task) actions by a HHA are alright. When asked what an HHA can do regarding medications, the alternate clinical supervisor indicated if a patient needs more assistance, the HHA can do a hand-over-hand assist such as pulling medications from the pillbox and placing them on patients’ plate. Review of the HHA Assignment Sheet for Patient #3 included the task, medication reminder. Documentation failed to evidence the HHA task to physically pick up patients’ medications and place them in front of the patient. 3. Review of the agency HHA Competency Checklist completed by HHA 1 on 07/22/2024 failed to evidence HHA competency task for use of the glucometer and test strips to check patients’ blood sugar.”