Carefocus Corporation

“Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This Element is not met as evidenced by: Based on interview and record review the agency failed to prevent further potential violations, including retaliation while a complaint was being investigated for 1 of 1 patient (P2). P2 filed a complaint about missing money from a safe in his home. During the investigation the PCA and her mother (the agency scheduler) went to P2’s home and allegedly had verbal altercations with P2 and his wife. In addition, the facility was unable to provide documentation that an investigation was completed for the theft allegations. P2’s POC dated 9/9/24 – 11/7/24 indicated P2’s pertinent diagnoses included legal blindness, type 2 diabetes, and Meniere’s disease bilaterally (inner ear disease which causes dizziness). P2’s orders for discipline were skilled nursing weekly for medication management and compliance monitoring. Patient care assistant (PCA) up to 43.75 hours a week to assist with grooming, bathing, dressing, meal preparation, mobility, run errands and homemaking. Upon interview on 9/11/24 at 9:50 a.m. P2’s patient care assistant (PCA)-A stated P2’s family member (FM)-A called the PCA’s Mother, the agencies scheduler on 9/1/24 and accused PCA-A of taking $8000.00 from the safe in the home. PCA-A stated she then called P2’s wife and told her she didn’t take the money. She stated on 9/2/24 her and her mother went to P2’s house to discuss the missing money. FM-A wouldn’t stop accusing PCA-A about the missing money, stating the only three people who knew of the safe where P2, FM-A and PCA-A. She stated FM-A was yelling at her mother and her and PCA and her mother did not raise their voices back at FM-A. PCA-A stated she refused to see P2 following the allegations. She was unaware of a facility investigation regarding the allegations. Upon interview on 9/11/24 at 12:14 p.m. P2’s independent living skills (ILS) worker stated FM-A called her on 9/2/24 and reported that she had $8,000.00 taken from a small safe in the home. FM-A stated P2, P2’s PCA, and herself were the only three people who knew about the safe. FM-A stated she called the PCA and confronted her about the missing money on 9/1/24. On 9/2/24 the PCA and her mother, the agency’s scheduler went to P2’s home and told P2 and FM-A that they were messing with the wrong people and used “vulgar language.” In addition, they allegedly told P2 and FM-A they would lose all of their medical home care services if anyone knew they stored money in their home. The ILS worker stated P2, and his wife were scared following the visit with PCA-A and the agency scheduler. Upon interview on 9/12/24 at 1:38 p.m. P2’s family member (FM)-A stated she noticed $8000.00 missing from a safe in the home. She stated it appeared someone had broken into it with a fork. The only person who knew about the safe were P2, FM-A, and PCA-A. She stated she called PCA’s mother on 9/1/24 and told her the family would not report the incident to the police if PCA-A returned the money. PCA-A called FM-A and stated she did not take the money. On 9/2/24 PCA-A and her mother went to P2’s home and were shouting at P2 and FM-A “swearing and threatening” them that they would lose all of their medical services if anyone knew they had “a lot” of money stored in the home. FM-A stated she fired PCA-A during the conversation. FM-A stated a couple of days later a staff member from the agency called her and told her if she felt money was missing, she should call the police. She could not recall who reached out to her from the agency. She stated she found PCA for P2 from another agency but kept this agency for skilled nursing. Upon interview on 9/12/24 at 2:54 p.m. the agency scheduler stated FM-A was her mom’s cousin. She stated FM-A called her on 9/1/24 and stated PCA-A had stolen $8,000 from her safe. The scheduler stated she and her daughter, PCA-A went to P2’s home on 9/2/24 and had a conversation with P2 and FM-A. She stated P2 and FM-A were accusatory toward PCA-A and her. PCA-A gave P2 back the keys to his home and stated she would not be back. The scheduler stated she was uncertain what the agency did to investigate the allegations. Upon interview on 9/12/24 at 4:17 p.m. the director of nursing (DON) stated for the investigation of the missing money she called and spoke with the wife and advised her to call the police. She stated P2 was PCA-A’s only client and she did not pull her off the schedule as she was aware she was refusing to see P2. The DON did not provide a home visit to P2 during the investigation. No other staff were interviewed. She stated she did not have any documentation of an investigation other than the Minnesota Adult Abuse Protection Report (MAARC) regarding the theft allegations which the DON reported to the state agency. The DON was unaware that documentation was needed in an investigation. An agency policy titled Identifying and Reporting Abuse/Neglect or Exploitation of patients indicated to maintain patient confidentiality and rights during the reporting and the investigation process, as appropriate.”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on interview and record review the agency failed to report allegations of verbal abuse to the state agency for 1 of 1 patients (P2). During a complaint investigation the state surveyor (writer) was notified of new verbal abuse allegations and reported it to the agency. The agency failed to then report the new allegations to the appropriate entities. P2’s POC dated 9/9/24 – 11/7/24 indicated P2’s pertinent diagnoses included legal blindness, type 2 diabetes, and Meniere’s disease bilaterally (inner ear disease which causes dizziness). P2’s orders for discipline were skilled nursing weekly for medication management and compliance monitoring. Patient care assistant (PCA) -A up to 43.75 hours a week to assist with grooming, bathing, dressing, meal preparation, mobility, run errands and homemaking. Upon interview on 9/11/24 at 12:14 p.m. P2’s independent living skills (ILS) worker stated P2’s family member (FM)-A called her on 9/2/24 and reported that she had $8,000.00 taken from a small safe in her home. She stated P2, P2’s PCA-A, and FM-A were the only three people who knew about the safe. FM-A stated she called PCA-A and confronted her about the missing money on 9/1/24. On 9/2/24 the PCA-A and her mother, the agency’s scheduler went to P2’s home and told P2 and FM-A that they were messing with the wrong people and used “vulgar language.” In addition, they allegedly told P2 and FM-A they would lose all of their medical home care services if anyone knew they stored money in their home. The ILS worker stated P2, and FM-A were scared following the visit with the PCA and the agency scheduler. Upon telephone conversation on 9/12/24 at 12:56 p.m. writer reported the allegations of verbal abuse to the agency’s director of nursing (DON). Writer stated there were new allegations of verbal abuse when the PCA-A and the scheduler, went to P2’s home and had a confrontational conversation using vulgar language and threats with P2 and FM-A leaving them fearful. Email correspondence on 9/12/24 at 1:37 p.m. DON indicated she did not file a Minnesota Adult Abuse Reporting Center (MAARC) report following the new allegations of verbal abuse because the staff member is no longer working with P2. In addition, the note indicated the agency had already filled out a report on P2 regarding the theft allegations. Upon interview on 9/17/24 at 9:47 a.m. DON stated she didn’t think she needed to add another MAARC report since the surveyor was already investigating the theft allegations and because the PCA was no longer working with P2. An agency policy titled Identifying and Reporting Abuse/Neglect or Exploitation of Patients undated indicated when abuse or neglect is suspected or identified, the employee is to report the observations or findings.”

“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 observation, interview, and record review the facility failed to ensure medication reconciliation was completed to ensure medication changes were updated for 1 of 1 patient (P3) observed during medication set-up. Findings include: P3’s physician signed plan of care (POC) for certification period 6/11/24 – 8/9/24, indicated P3 had diagnoses of major depression disorder, spinal stenosis of the lumbar region (pressure on the spinal cord and nerves of the lower back), borderline personally, and chronic pain syndrome. P3 required skilled nurse visits weekly for general health assessment and medication management. P3’ s POC dated 8/10/24 – 10/9/24 was completed without any medication changes, however faxed to the physician on 8/13/24, but not signed and returned to the agency. P3’s medication POC medication list, indicated the following medication orders: Bupropion 75 milligrams (gm) 1 tablet daily by mouth. Upon observation and interview on 9/12/24 at 10:30 a.m., licensed practical nurse (LPN)-A started medication set up. P3’s bottle of Bupropion was for 100 mg 1 tablet daily. LPN-A placed the 100 mg tablet in the med-setup. LPN-A also placed atorvastatin 20 mg 1 tablet, Vibegron 75 mg 1 tablet and Aricept 5 mg 1 tablet into the med set box. The atorvastatin, Vibegron and the Aricept were not listed on the POC. LPN-A stated all of those medications were on her list and P3 had a list on her laptop of all her medications which included the Atorvastatin, Vibegron, Aricept, and the Bupropion with a dose of 100 mg 1 tablet daily. LPN-A stated the case manager takes care of the POC; therefore, she did was not aware that the identified medications were not on the POC. She stated she had her own list that she follows when setting up and assists P3 to keep an up-to-date list on her laptop. P3 provides the surveyor with her personal medication list. Upon observation and interview on 9/12/24 at 11:00 a.m. P3 had peppermint oil, Vicks vapor rub, CBD oil, Asper-cream, and Ibuprofen 200 mg tablets on her end tab. LPN-A asked P3 if she was mixing the Vicks and the peppermint for better pain control, if she had enough Ibuprofen in her bottle until her next visit and if she was using the Asper-cream and CBD oil. LPN-A stated she was unaware that over-the-counter medications needed to be on the POC. She stated the case manager handles the POC. The POC did not indicate use of the Vicks, peppermint, Ibuprofen, CBD oil or Asper-cream. Upon interview on 9/17/24 at 9:47 a.m., the director of nursing (DON) expected lpn staff to notify the case manager or any medications changes and she expected the case managers to add any over-the-counter medications to the POC at the recertification visit. An agency policy titled Medication Prescriptions and Refills no date, directed nurses to ensure a current written prescriber’s prescription must be obtained for any medication, including an over-the-counter medication whenever staff were responsible for medication set up or medication management.”

“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 interview and record review the agency failed ensure patient’s plan of care (POC) included safety measures to protect against injury for 6 of 6 patient’s reviewed (P1, P2, P3, P4, P5, and P6). Findings include: P1’s POC dated 8/22/24 – 10/20/24 indicated P1’s pertinent diagnoses were hidradenitis suppurativa (a chronic skin condition featuring lumps in the groin and armpits.), cellulitis, non-pressure chronic ulcer of the skin, bipolar disorder, schizophreniform disorder, and type 2 diabetes. P1’s safety measure included, falls, infection, noncompliance, hypo/hyperglycemia (high or and low blood sugar readings). The POC did not include any interventions for the safety measures identified. P2’s POC dated 9/9/24 – 11/7/24 indicated P2’s pertinent diagnoses were legal blindness, type 2 diabetes, and Meniere’s disease bilaterally (inner ear disease which causes dizziness). P2’s safety measures included only falls. The POC did not provide any specific safety measures for P2’s blindness or diabetes. In addition, the POC did not include any interventions for the safety of the falls. P3’s POC dated 6/11/24 – 8/9/24, indicated P3’s pertinent diagnoses were major depression disorder, spinal stenosis of the lumbar region (pressure on the spinal cord and nerves of the lower back), borderline personally, and chronic pain syndrome. P3’s safety measures included fall precautions, history of cutting behaviors, signs and symptoms of infection, and universal compliance. The POC did not indicate any interventions for the safety measures identified. P4’s POC dated 8/10/24 – 10/8/24, indicated P4’s pertinent diagnoses were pressure ulcer of the sacral region, stage 4 (full thickness of the skin lost, maybe to the bone, tendons, or muscles), Parkinson’s disease and repeated falls. P4’s safety measures were full code; stand by assist from group home staff for activities of daily living (ADL’s) as needed. The POC does not identify any interventions for P4’s pressure ulcer. P5’s POC dated 8/24/24 – 10/22/24 indicated P5’s pertinent diagnoses were quadriplegia (paralysis from the neck of the body to the feet), neurogenic bowel (nervous system condition in which causes uncontrollable bowels), neuromuscular bladder (a nervous system condition which causes uncontrolled bladder) and major depression disorder. P5’s safety measures included skin breakdown, infection, and falls. The POC did not identify any interventions for the safety measures identified. P6’s POC dated 7/4/24 – 9/1/24 indicated P6’s pertinent diagnoses were pressure ulcer of the sacral region, stage 4, Parkinson’s disease and reported falls. P6’s POC did not include any safety measures. Upon interview on 9/17/24 at 9:47 a.m. the director of nursing (DON) stated the safety measures on the POC should contain interventions along with the identified measures. An agency policy titled Plan of Care undated indicated the plan of care shall be completed in full to include any safety measures to protect against injury.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on observation, interview, and record review the facility failed to notify the patients of all planned services for 2 of 3 patients reviewed (P1 and P2). P1 was not informed of changes to her services on two separate occasions when she required wound care. P2 was not notified of the frequency of visits initiated on his start of care. In addition, there were no visit schedules in the patient’s homes. Findings include: P1’s service plan addendum, dated 7/15/21 indicated P1 received patient care assistant (PCA) services for dressing, grooming, bathing, and toileting up to 70 hours a week. Registered nursing (RN) or licensed practical nurse (LPN) visits for medication management and compliance, skin assessments and lab draws every other week. Independent home support for advocating for patient during physician visits up to 10 hours a week and supervisory visits every other week. There were no new service plan addendum documents from 7/16/21 – 4/26/24. P1’s home health certification and plan of care dated 2/25/24 - 4/24/24 indicated P1 received skilled nursing visits every other week and two as needed visits. PCA visits up to 70 hours per week, homemaking (HMK) visits up to 5 hours per week, personal support up to 10 hours per week and RN supervisory visits every other week. P1’s hospital visit note dated 3/22/24 indicated P1 had skill nursing home care orders for daily dressing changes. P1’s wound clinic note dated 3/28/24 indicated P1 had skilled nursing home care orders for every 2-3 days dressing changes. Upon interview on 4/24/24 at 2:28 p.m. P1 stated she was uncertain of the frequency of visits she was supposed to have received when the skilled nursing visits changed when her services were increased for wound cares. Upon interview on 4/26/24 at 2:56 p.m. the Clinical Nurse Manager stated it was the patients right to be informed of any changes in the plan of care during their services. P2’s home health certification and plan of care dated 1/13/24 -3/12/24 indicated P1 had RN/LPN visits up to daily and two as needed visits. P2’s home health change of care notice (HHCCN) undated by the agency indicated under items and services indicated “homecare.” Under the title reason for care indicated “nursing services for wound care.” The form did not indicate the disciple of the provider or the frequency of the service. The form was signed by P2 1/14/24. There were no additional service notification forms in P2’s chart from his start of care date of 1/13/24 – 4/26/24. Upon interview on 4/25/24 at 11:10 a.m. P2 along with family member (FM)-A stated P2 receives dressing changes 3-4 times a week whenever the agency “has time.” P2 and FM-A were not certain what the frequency the physician had ordered for the cares. Upon observation on 4/25/24 at 12:09 p.m. LPN-A completed her visit with P2 and stated, “I am not certain when your next visit will be, but I will see you next week, probably Tuesday.” Upon interview on 4/26/24 at 2:56 p.m. the Clinical Nursing Manager stated the plan of care should state the exact frequency the agency is providing care for the patient.”

“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 observation, interview, and record review the facility failed to provide a detailed plan of care for 3 of 3 patients reviewed (P1, P2 & P3). P1’s care plan lacked pertinent diagnoses, frequency of visits and wound care orders. P2’s care plan lacked proper frequency of visits, supplies observed in the home and specific orders for negative pressure wound therapy (wound vac). P3’s care plan lacked multiple assessment areas. Findings include: P1’s home health certification and plan of care dated 2/25/24 - 4/24/24 indicated P1 received skilled nursing visits every other week and 2 as needed visits. Personal care assistant (PCA) visits up to 70 hours per week, homemaking (HMK) visits up to 5 hours per week, personal support up to 10 hours per week and RN supervisory visits every other week. P1’s diagnoses were diabetes mellitus, autoimmune disorder, anxiety, and depression. P1’s hospital visit note dated 3/22/24 indicated P1 had skill nursing home care orders for daily dressing changes for a wet to dry dressing change. These orders were not added to the care plan. P1’s wound clinic note dated 3/28/24 indicated P1 had skilled nursing home care orders for every 2-3 days dressing changes. P1’s leg wound recommendations: Wash wounds with wound cleanser or mild soap and water. Apply ½ non adhesive foam to each open/draining wound on the leg. Wrap leg with ace from toes to below the knee. Wrap ace as need. Hold in place with paper tape and wrap with roll gauze. Watch for signs of infection. Make sure there was a doctor follow the open hand wound as it had an exposed tendon. Recommendation for the index finger wound: Apply Medi-honey gel to the finger wound, cover with non-adhesive dressing. These orders were not on the care plan. In addition, the visit note included pertinent diagnoses which were not on the home care agencies plan of care of below the knee amputation, asthma, compression fracture of T1 vertebra (neck), compression fracture of T3 vertebra (neck) and wounds. Upon interview on 4/24/24 at 2:28 p.m. P1 stated she was a below the knee amputee and in 3/2024 fell from a van and required the agency to provide wound care for her and during the fall she neck. Upon interview on 4/25/24 at RN-A stated she was completing the wound care as ordered. She left the orders from the wound clinic at P1’s home. She stated she called the licensed practical nurse and educated her on the orders. She denied adding the new treatment plan to P1’s care plan. P2’s home health certification and plan of care dated 1/13/24 -3/12/24 indicated P1 had RN/LPN visits up to daily and 2 as needed visits. P2 was a quadriplegic with pressure ulcers and diagnosed with chronic pain. DME and supplies were identified only as wound care supplies and w/c [sic]. Upon observation and interview on 4/25/24 at 11:10 a.m. P2’s family member (FM)-A stated he provided paid PCA services for P2. FM-A had just completed a shower for P2. In the bathroom P2 had grab bars in the shower. P2 was wheeled out of the bathroom on a mobile shower chair into his bedroom to be transferred to his bed for his wound care. The wound care completed by the agency was the use of a wound vac. P2 had an indwelling Foley catheter. After the wound vac treatment P2 was transferred into an electric wheelchair. None of the observed supplies were documented on the care plan. In addition, the wound vac instructions were not documented on the care plan. P3’s home health certification and plan of care dated 3/15/24 -5/12/24 indicated P3’s pertinent diagnoses were pressure ulcer of the sacral region, Parkinson’s disease, weakness, falls, and fusion of the spine. P3 was to receive wound cares twice daily, education on wound healing, wound cares, vital sign checks, medication reconciliation, health assessment and health management. The orders did not identify which discipline would be providing the cares. In addition, the following assessment areas on the care plan lacked any documentation: DME and supplies Safety Measures Nutritional requirements Allergies Functional Limitations Activities Permitted Prognosis Upon interview on 4/26/24 at 2:56 p.m. the Clinical Nurse Manager stated all diagnoses, specific wound care instructions and all the assessment areas should be completed on the care plan. An agency policy titled Medical Supervision dated 12/07 indicated the care plan will include: Description of patient needs, patient goals, description of specific services to be provided, a list of actions to be taken for delivery of care which includes the duration of actions.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to promptly alert the primary care physician (PCP) for 1 of 3 patients reviewed (P1). P1 was admitted to the hospital following a fall she sustained where she fractured her neck and developed wounds to her hand and legs. P1 was followed by a wound clinic who provided orders to the HHA. P1 developed an infection in her finger, was readmitted to the hospital with the finger amputated. Following P1’s first hospital discharge and changes to the HHA services the PCP was not notified of what cares were being provided or the change in status prior to the second hospitalization. Findings include: P1’s home health certification and plan of care dated 2/25/24 - 4/24/24 indicated P1 received skilled nursing visits every other week and 2 as needed visits. PCA visits up to 70 hours per week, homemaking (HMK) visits up to 5 hours per week, personal support up to 10 hours per week and RN supervisory visits every other week. P1’s hospital visit note dated 3/22/24 indicated P1 had skilled nursing home care orders for daily dressing changes. Additional orders were for Physical and Occupational therapy to evaluate and treat. P1’s wound clinic note dated 3/28/24 indicated P1 had skilled nursing home care orders for every 2-3 days dressing changes. P1’s leg wound recommendations: Wash wounds with wound cleanser or mild soap and water. Apply ½ non adhesive foam to each open/draining wound on the leg. Wrap leg with ace from toes to below the knee. Wrap ace as need. Hold in place with paper tape and wrap with roll gauze. Watch for signs of infection. Make sure there was a doctor follow the open hand wound as it had an exposed tendon. Recommendation for the index finger wound: Apply Medi-honey gel to the finger wound, cover with non-adhesive dressing. P1 was to follow-up with primary M.D. make sure there is a doctor that is following the open hand wound as it has exposed tendon. Be aware of any signs of infection with this wound. See same day clinic or ER if infection is suspected. P1’s HHA skilled care note dated 4/8/24 at 2:00 p.m. lacked documentation under measurements for wound location, size, and drainage. A narrative note indicated the skilled service provided was wound care to the left index finger and P1 tolerated well. No signs of infection. P1’s wound clinic note dated 4/10/24 indicated P1 was very worried about the left 2nd finger wound and was tearful. She was concerned that the wound was too moist and concerned about infection. She stated it was painful. The wound had drained a moderate to large amount and was leaking around the dressing a small amount. The drainage was pale green and odorless. Peri wound (around the wound) the skin was macerated (softening and breaking down of the skin from prolonged exposure to moisture.) The tendon was visible in the wound base with a small amount of slough (yellowish material in the wound bed). The left hand, thumb, and 1st an 2nd fingers were swollen, slightly red and warm. Undermining (erosion underneath the wound margins) were noted from 7 o’clock to 12 o’clock. The wound edges were open. The homecare recommendations were to have P1 seen in a same day clinic (SDC) for left hand infection. P1 declined but agreed to seek medical attention the next day. P1 was to follow-up with PCP the following day regarding possible infection of the left hand. Wash wounds with wound cleanser or mild soap and water. Do not soak the hand. Pat dry and apply marble size amount of Iodosorb daily or every other day. Secure with paper tape and ace wrap with gentle pressure. Try to elevate hand above the heart level at all times. P1 was to be seen back in the wound clinic in 1 week. P1’s HHA skilled care note dated 4/12/24 at 2:00 p.m. lacked documentation under wound location, wound size, and wound drainage. A narrative note indicated the skilled services provided were completed wound care to left index finger and client tolerated well. No signs of infection noted at that time. P1’s HHA skilled care note dated 4/14/24 at 1:00 p.m. lacked documentation under wound location, wound size, and wound drainage. A narrative note indicated P1 was provided skilled nursing services for wound care to her index finger and tolerated well. The peri-wound area was red, and a pulse was noted in the wound. P1 had a PCP appointment the following day and will discuss chances of an infection. Assessment of pain was 6/10. P1’s hospital discharge summary dated indicated P1 was admitted with left hand ulceration with cellulitis requiring a status post Ray amputation (a surgical procedure to remove the finger) of the left index finger, performed on 4/17/24. On 4/19/24 P1 was discharged home with cares provided by a different HHA. Upon interview on 4/25/24 at 8:38 a.m. registered nurse (RN)-B the PCP’s clinical nurse stated P1 was seen on 4/15/24 for an infection in her left index finger. P1 presented with a low-grade fever of 99 degrees Fahrenheit and complained of chills. P1’s left had had a quarter sized ulcer with an exposed tendon with surrounding tissue showing redness and drainage. The PCP was worried about a “staph” infection and sent P1 to the hospital for intravenous antibiotics. RN-B stated she did not receive any updates from the HHA regarding P1’s care. She stated the only forms she received from the HHA was “every 60-day order sheet that he signs.” The last notification from the HHA was on 02/25/24. Upon interview on 4/24/249 at 11:00 a.m. Licensed practical nurse (LPN)-A stated she was the nurse who mostly provided wound cares for P1. She stated she provided cares from the orders provided by the wound care clinic left at P1’s house. LPN-A stated on 4/14/24 she “thought” P1 had an infection and did not report her findings to any RN at the HHA because she was aware that P1 had an appointment with her PCP the following day. Upon interview on 4/25/24 at 2:56 p.m. RN-A, P1’s case manager stated she went to visit P1 and P1 had new orders from the wound clinic on 3/38/24. She stated P1 would not allow RN-A to take the order sheet, so she left it in the home. She stated P1’s skilled nurse frequency was decreased to every other day. RN-A stated she did call the wound clinic to have them fax a copy to the agency. RN-A was uncertain if the agency ever received the fax. She stated the wound was starting to heal she thought until 4/14/24 when LPN-A called RN-A during the nursing visit. RN-A recommended P1 be seen the emergency room immediately. RN-A stated she thought P1 did go to the emergency room that day. She denied documenting in P1’s chart about the recommendations she had given to P1, and LPN-A and she denied notifying the PCP of the change in P1’s status. RN-A stated she was unaware to reach out to the PCP for orders and updates and she was taking orders from the Clinical Wound Specialist at the wound clinic. Upon interview on 4/26/24 at 2:20 p.m. the clinical nurse manager stated when a change happens the LPN needs to inform and RN or the case manager so they can notify the provider. An agency policy titled Medical Supervision dated 04/07 indicated the agency has a responsibility to report a change of condition to the provider promptly.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview, and record review the facility failed to assure communication with all physicians involved for 2 of 3 patients reviewed (P1 and P2). Both P1 and P2 had providers outside of their primary care physicians (PCP) involved in their care. This deficient practice led to the facilities inability to integrate all services and orders. Findings include: P1’s home health certification and plan of care dated 2/25/24 - 4/24/24 indicated P1 received skilled nursing visits every other week and two as needed visits. Personal care assistant (PCA) visits up to 70 hours per week, homemaking (HMK) visits up to 5 hours per week, personal support up to 10 hours per week and RN supervisory visits every other week. P1 had diabetes mellitus, autoimmune disorder, anxiety, and depression. P1’s face sheet undated only identified a primary care physician. Upon interview on 4/24/24 at 2:28 p.m. P1 stated her other providers consisted of a psychologist, psychiatrist, rheumatologist, gastroenterologist, independent living skills worker (ILS), and wound care specialist. In addition, P1 stated she was a below the knee amputee and in 3/2024 fell from a van and required the agency to provide wound care for her. Upon interview on 4/25/24 at RN-A stated she was aware P1 had other providers and stated she had taken orders from other providers as they can write orders, not just her PCP, but denied having them in P1’s record and updating the PCP when new came from other providers. P2’s home health certification and plan of care dated 1/13/24 -3/12/24 indicated P1 had RN/LPN visits up to daily and two as needed visits. P2 was a quadriplegic with pressure ulcers and diagnosed with chronic pain. P2’s face sheet only identified a primary care physician. Upon interview on 4/25/24 at 11:10 a.m. P2 along with family member (FM)-A stated P2 had a wound care specialist and a PCA not through the home health agency providing services. Upon interview on 4/26/24 at 2:56 p.m. the Clinical Nurse Manager stated all providers should be listed on the medical record for continuity of care. An agency policy titled Medical Supervision dated 12/07 indicated If the patient is under the care of more than one physician the patient the agency is responsible to the referring physician until such time a change in care is agreed by the patient/family and physician. The referring physician will be informed of involvement of other medical providers. Copies of the plan of care will be sent to other physicians with primary physician and patient consent.”

“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 interview and record review, the agency failed to conduct an exercise to test the emergency plan at least annually. This had the potential to impact all patients who received care from the agency. The agency’s most recent full scale, community-based emergency preparedness exercise and facility-based functional exercises with after action reports were requested however was not received. An agency email communication dated 4/16/24, indicated there had been some leadership changes over the past year and the testing information and after-action reports had not been located. When interviewed on 4/11/24 at 4:15 p.m., the administrator acknowledged a full-scale and facility emergency preparedness exercise was required every other year as part of their emergency plan. The administrator was not able to find the completed exercises and after-action plans and would continue to look for them. An agency policy for emergency preparedness testing was requested however was not received.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review the agency failed to ensure patients’ plan of care (POC) was individualized and identified patient specific and measurable outcomes and goals for 2 of 3 patients (P5, P3) whose care plans were reviewed for content and accuracy. Furthermore, the agency failed to ensure current and relevant measurable goals and outcomes were listed for 1 of 3 patients (P4) whose care plans were reviewed for content and accuracy. Centers for Medicare and Medicaid Services (CMS) dated 3/15/24, identified patient specific and measurable outcomes and goals as: a change in health status, functional status, or knowledge, which occurs over time in response to a health care intervention that provides end-result functional and physical health improvement/stabilization. Patient-specific goals must be individualized to the patient based on the patient’s medical diagnosis, physician comprehensive assessment and patient input. Progress/non-progress toward achieving the goals is evaluated through measurable outcomes. P5’s plan of care (POC) for certification period 3/8/24-5/6/24, indicated P5 had diagnoses of traumatic brain injury and bipolar disorder. P5required skilled nurse visits weekly for general health assessment and medication management. P5’s goal was to remain safe in home with home care services. P5’s POC lacked individualized and measurable outcomes in response to interventions provided. P3’s POC for certification period 3/1/24-5/25/24, indicated P3 had diagnoses of prostate cancer and glaucoma. P3 required weekly skilled nurse services for general health assessment, medication management, and safety concerns. P3’s goals were to remain in home, be safe and have medication compliance. P3’s POC lacked individualized and measurable outcomes in response to interventions provided. P4’s POC for certification period 2/7/24-4/6/24, indicated P4 had diagnoses of atrial fibrillation (rapid heartbeat) and obesity, and weakness. P4 required physical therapy up to three times a week for strength, ambulation, use of exercise bike, and instruct how to get off the floor if fallen. P4’s POC lacked current individualized and measurable outcomes in response to interventions provided. When interviewed on 4/10/24 at 9:00 a.m., physical therapist (PT)-A stated they were not involved in the development P4’s POC. PT-A stated an assessment is updated every 30 days and when visit orders were changed, a verbal order was placed to the provider. PT-A verified P4’s POC did not contain the correct goals P4 was currently focused on. PT-A further stated P4 was focused on walking down the hall independently, gaining strength for an upcoming wedding. The bike and learning how to get off the floor from a fall were initial goals at the start of therapy services last year, however, are very long term and was not safe to assist with exercise bike or have P4 attempt to get up from the floor. Furthermore, PT-A did not have any specific discharge goals for P4 and stated if the patient was working and making progress, would continue to see them. When interviewed on 4/10/24, at 11:30 a.m., registered nurse (RN)-A verified P5 and P4’s POC did include general goals however the goals were not patient specific. RN-A stated there was not a specific way communication between disciplines took place and felt communication was normally pretty good. RN-A further stated PT goals had not been included in P4’s POC and RN-A needed to ensure there was better communication. When interviewed on 4/11/24 at 8:47 a.m., the acting director of nursing (DON) expected patients POC’s to include goals that are individualized to the patient. Furthermore, DON stated the POC should contain goals from all disciplines providing care. An agency policy titled Plan of Care no date, directed staff to ensure an individualized POC was developed to meet specific identified needs and to support patients to attain personal health goals.”

“Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This Element is not met as evidenced by: Based on interview and record review the agency failed to ensure provider notification of refusal of home care services was completed and documented before discharging 1 of 1 patient (P7) reviewed for refusal of services. P7’s plan of care (POC) for certification period 1/24/23-3/23/24, indicated P7 had diagnoses of post-traumatic stress disorder and major depressive disorder. P7’s POC indicated P5 required weekly skilled services for general health assessment and medication management and set up. P7’s recertification nursing note dated 1/25/24, indicated P7 was non-compliant with taking medications and frequently did not answer door or inform nurse she wouldn’t be home when visit scheduled. Discussion was had with P7 about importance of compliance with nurse visits. P7’s last skilled nursing visit note on 3/9/24, indicated P7 was non-compliant with medications and stated she forgets. P7 often did not answer door or inform nurse when no longer available for appointment. P7 was very anxious. P7 was reminded about the importance of taking medications as ordered. P7 had no discharge plans due to ongoing medical needs. P7’s medical record lacked indication P7 had a nurse visit for the weeks of 3/10/24, 3/17/24, and 3/24/24. P7’s missed visit documentation was requested however was not received. P7’s medical record lacked indication P7’s provider was notified of continued non-compliance of medications and nurse visits. P7’s medical recorded lacked evidence P7 had been educated on risks/benefits of refusal of cares prior to discharge from the facility. P7’s discharge summary dated 3/25/24, indicated P7 required support with medications. P7 discharged on 3/22/24 due to client’s busy schedule with appointments and client was “not really available” for nurse visits. P7 was discharged from agency and voice message left for P7 to return call. When interviewed on 4/11/24 at 8:47 a.m., the acting director of nursing (DON) stated P7 was discharged due to non-compliance with nurse visits. DON stated they couldn’t get ahold of P7 for several visits and patient was discharged. DON was not sure if P7’s provider was aware of the refusals but expected staff to communicate missed visits and refusals to providers.”

“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 observation, interview, and record review the facility failed to ensure medication reconciliation was completed to ensure medication changes were updated for 1 of 1 patients (P5) observed during medication set up. P5’s plan of care (POC) for certification period 3/8/24-5/6/24, indicated P5 had diagnoses of traumatic brain injury and bipolar disorder. P5’s required skilled nurse visits weekly for general health assessment and medication management. P5’s medication profile dated 4/9/24, indicated the following medication orders: -Vitamin D3 1000unit tablet once daily -magnesium oxide 400 milligrams (mg) once daily An observation on 4/9/24 at 11:53 a.m., registered nurse (RN)-A started medication set up. RN-A pulled out R5’s medication list from R5’s box of medications. During medication set up, RN-A placed one tablet of magnesium into P5’s medication cassette. Review of the P5’s magnesium bottle showed the dose was 250mg and was not the 400mg that was on P5’s medication profile. RN-A then placed one tablet of the vitamin D3 into R5’s medication cassette. Review of P5’s vitamin D3 showed the dose was 125 mcg (5000units) and was not the 1000unit dose that was on P5’s medication profile. When interviewed on 4/10/24 at 11:30 a.m., RN-A verified P5’s vitamin D3 and magnesium medications did not match what was on P5’s medication orders. RN-A stated the providers did not really mind differences in supplement medication as family picked them up at the store. How does RN-A know this? Is it documented somewhere? RN-A verified there had not been a verbal order for the dose change and stated there should be a new order obtained if the dosing of the medications did not match up. When interviewed on 4/11/24 at 8:47 a.m., the acting director of nursing (DON) expected staff to notify providers of any medication changes or when doses of medications did not match on the patient’s medication list. DON further stated this was important to ensure the correct doses for the patient was given. An agency policy titled Medication Prescriptions and Refills no date, directed nurses to ensure a current written prescriber’s prescription must be obtained for any medication, including an over-the-counter medication whenever staff were responsible for medication set up or medication management.”

“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 interview and record review the agency failed to ensure patients’ plan of care (POC) included individualized and patient specific interventions for 2 of 5 patients (P5, P3) a failed to ensure a patient’s diagnoses and current medications were included for 1 of 5 patients (P1) currently receiving home care services. Furthermore, the agency failed to ensure the patients’ risk for rehospitalization was included for 5 of 5 patients (P1, P2, P3, P4, P5,) and durable medical equipment (DME), for 1 of 5 patients (P4) currently receiving home cares services. P5’s plan of care (POC) for certification period 3/8/24-5/6/24, indicated P5 had diagnoses of traumatic brain injury and bipolar disorder. P5’s required skilled nurse visits weekly for general health assessment and medication management. P5’s goal was to remain safe in home with home care services. P5’s POC lacked patient specific interventions and education needed for P5 to maintain or improve health status. P5’s POC lacked patient specific interventions and education interventions needed for P5 to maintain or improve health status. Furthermore, P5’s POC did not include a rehospitalization risk. P3’s POC for certification period 3/1/24-5/25/24, indicated P3 had diagnoses of prostrate cancer and glaucoma. P3 required weekly skilled nurse services for general health assessment, medication management, and safety concerns. P3’s goals were to remain in home, be safe and have medication compliance. P3’s POC lacked patient specific interventions and education needed for P3 to maintain or improve health status. Furthermore, P5’sP3’s POC did not include a rehospitalization risk. P1’s POC for certification period 2/25/24-4/27/24, indicated P1 required skilled nursing services for health management. P1’s POC lacked P1’s diagnoses, current medications, and rehospitalization risk. P4’s POC for certification period 2/7/24-4/6/24, indicated P4 had diagnoses of atrial fibrillation (rapid heartbeat) and obesity, and weakness. P4 required physical therapy up to three times a week for strength, ambulation, use of exercise bike, and instruct how to get off the floor if fallen. P4’s POC lacked patient specific interventions and education needed for P4 to maintain or improve health status. P4’s POC lacked indication a manual wheelchair and bedrails were needed to assist P4 in mobility. Furthermore, P4’s POC did not include a rehospitalization risk. P2’s POC for certification period 2/25/24-4/24/24, indicated P2 had diagnoses of hidradenitis suppurativa (a chronic skin condition involving bumps under the skin that can open to wounds) and pain. P2 required skilled nursing services three times a week for wound care. P2’s POC did not include a rehospitalization risk. When interviewed on 4/10/24, at 11:30 a.m., registered nurse (RN)-A verified no hospitalization risks had been included in the POC and verified P4’s POC had not included P4’s manual wheelchair and bedrails. RN-A acknowledged POCs were lacking patient specific interventions and education and needed to be better when looking at it. RN-A stated when documentation was not being completed at the time of the visits, things may be missed when entering the information later. When interviewed on 4/11/24 at 8:47 a.m., the acting director of nursing (DON) expected patients POC’s to include patient specific interventions and education that was needed to support the patient. This was important to ensure it was clear what cares and teaching was being provided, as the POC was the communication between the provider and other services provided. DON acknowledged risk for rehospitalization was not included in POC’s and wasn’t sure how to pull information into the care plan from the documentation system. An agency policy titled Plan of Care no date, directed staff to ensure an individualized POC was developed to meet specific identified needs and to support patients to attain personal health goal. Staff were directed to include diagnoses, mediation lists, and all supplies and equipment needed for care; however, the policy did not instruct staff to ensure rehospitalization risk was included.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review the agency failed to ensure the plan of care (POC) was reviewed and signed by the attending provider at least every 60 days. for 2 of 7 patients (P5, P7) who received home care services. P5’s plan of care (POC) for certification period 3/8/24-5/6/24, indicated P5 had diagnoses of traumatic brain injury and bipolar disorder. P5 required skilled nurse visits weekly for general health assessment and medication management. P5’s POC had not been signed by a nurse, faxed, or signed by P5’s attending provider when provided to the surveyor on 4/9/24. P7’s POC for certification period 1/24/24-3/23/24, indicated P7 had diagnoses of post-traumatic stress disorder and major depressive disorder. P7’s required skilled nursing weekly for general health assessment and medication management/set up. P7’s POC was signed by P7’s provider on 4/1/24. When interviewed on 4/11/24 at 8:47 a.m., the acting director of nursing (DON) expected nursing to sign off when patients POC was completed. The POC was then faxed to the provider for signature. DON stated sometimes POCs were faxed several times before obtaining a signature, but acknowledged obtaining the signature was important. DON stated the POCs were the patients’ orders and having the review and signature was important to ensure orders were appropriate for care. An agency policy titled Plan of Care no date, directed staff to develop the POC within 5 working days after the assessment. The POC then must be sent to the provider to review and sign. The POC must be reviewed and signed by the provider at least every 60 days.”

“Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner’s issuing orders for the HHA plan of care. This Element is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure provider notification of a revised care plan for 1 of 3 patients (P4) whose charts were reviewed for provider notification. P4’s plan of care for recertification period 12/14/23-2/6/24, indicated P4 had diagnoses of heart failure, weakness, and obesity. P4’s POC indicated physical therapy evaluate and treat up to three times weekly for ambulation, use of exercise bike and teaching how to get up from floor if fallen. P4’s 30-day physical therapy certification dated 1/29/24, indicated P4 had some progress and would continue to be seen one-two times a week for strengthening, balance and ambulation. P4’s physical therapy certification lacked indication it had been sent for provider signature. P4’s plan of care for recertification period 2/7/24-4/6/24, indicated P4 had diagnoses of heart failure, weakness, and obesity. P4’s POC indicated physical therapy evaluate and treat up to three times weekly for ambulation, use of exercise bike and teaching how to get up from floor if fallen. An observation on 4/10/24 at 8:20 a.m., physical therapist (PT)-A started P4’s home visit. PT-A worked with P4 on lower body and core strengthening, balance, and ambulation with a four wheeled walker in the hallway outside of the apartment. PT-A stated P4 had been gaining strength and had been able to walk farther since the start of treatment last fall. When interviewed on 4/10/24 at 9:05 a.m., PT-A stated currently, P4 required therapy to increase strength and ambulation. PT-A stated a therapy assessment was completed every 30 days to assess P4’s progress. PT-A verified P4’s POC indicated visits up to three times a week for ambulation, use of bike and teaching about getting up from floor. PT-A stated those goals could be good in the future but was not the current goals for P4. P4 was not in a place to get themselves off the floor after a fall or use the exercise bike. Currently P4 had been working on strengthening and ambulation. PT-A was not sure how their 30-day assessment was incorporated into P4’s POC. PT-A stated they were not involved in the POC development. When interviewed on 4/10/24, at 11:30 a.m. registered nurse (RN)-A verified P4’s therapy orders were not included in the POC. RN-stated during the recertification time, she should have reviewed P4’s therapy plan and discussed with PT-A. RN-A stated any order changes related to therapy during a certification period was sent to the provider by the therapist. When interviewed on 4/11/24 at 8:47 a.m., the acting director of nursing (DON) stated there needed to be better communication between PT-A and RN-A when developing plan of care development. Therapy completed care plans every 30 days and those should be faxed to the provider at that time. Furthermore, DON stated during the recertification process, nurses and therapist were expected to communicate to ensure the patient’s POC was accurate to the cares being provided. A facility policy titled Skilled Professional Services no date, directed all skilled staff to participate in collaboration of care and to provide services ordered in the POC, and communicate with providers to communicate changes in the POC.”

“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 interview and record review, the agency failed to ensure skilled services were provided as ordered by the provider for 1 of 5 patients (P3) reviewed who were currently receiving skilled services from the agency. P3’s plan of care (POC) for certification period 3/1/24-5/25/24, indicated P3 had diagnoses of prostate cancer and glaucoma. P3 required weekly skilled nurse services for general health assessment, medication management, and safety concerns. P3’s medical record lacked indication P3 had received skilled nursing services for the weeks of 3/24/24 and 3/31/24. P3’s medical record lacked missed visit notes or provider notification of missed visits for the weeks of 3/24/24 and 3/31/24. P3’s skilled nurse notes and missed visit notes for the weeks of 3/24/24 and 3/31/24 were requested however were not received. When interviewed on 4/10/24 at 11:30 p.m., registered nurse (RN)-A stated staff try to reschedule during the same week if an appointment time had to be cancelled. If the patient was not seen at all, a missed visit note should be placed. RN-A further stated the missed visit was documented by the service that was missed and then sent electronically to the provider. When interviewed on 4/11/24 at 8:47 a.m., the acting director of nursing (DON) stated there were two different medical records to document in currently as the agency was in the process of changing over. DON reviewed skilled nurse visit notes for P3 during the week of 3/24/24 and 3/31/24 and verified no visit notes or missed visit notes. DON expected staff to have notes completed and any missed visits to be communicated to the provider. A facility policy titled Clinical Documentation no date, directed staff to ensure an accurate record of services provided. This included to ensure missed visits were documented and report to the provider. The policy further directed documentation of communication with patients and providers will be documented in the medical record.”

“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 interview and document review the agency failed to ensure home health aide (HHA) services were ordered by the provider and included in the plan of care (POC) for 1 of 1 patients (P3) reviewed for HHA services. P3’s POC for certification period 1/30/24-3/30/24, indicated P3 had diagnoses of prostate cancer and glaucoma. P3 required weekly skilled nursing visits for general health assessment, medication management and safety concerns. Furthermore, P3 required HHA services twice weekly for bathing, grooming, and dressing. P3’s POC for certification period 3/31/24-5/25/24, indicated P3 had diagnoses of prostate cancer and glaucoma. P3 required weekly skilled nurse services for general health assessment, medication management, and safety concerns. P3’s POC lacked indication P3 received HHA services or what treatments or interventions were needed. When interviewed on 4/10/24 at 11:05 a.m., home health aide (HHA)-A stated they had been working with P3 for several months. HHA stated once a week, P3 was assisted with showering, shaving, and dressing. P3 further stated cares provided hadn’t changed since they started working with him. When interviewed on 4/10/24, at 11:30 a.m., registered nurse (RN)-A verified P3’s HHA services had not been included in the POC. RN-A further stated this information was just missed for the current certification period. When interviewed on 4/11/24 at 8:47 a.m., the acting director of nursing (DON) expected HHA services to be included in the patient’s POC. An accurate POC was important to ensure patients received the appropriate services. The POC was also the official orders from the provider and directed how and when to provide services. An agency policy titled Plan of Care no date, directed staff to ensure the POC included the type, frequency and duration of all visits and services provided.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure home health aide (HHA) visits were supervised every 14 days for 1 of 1 patient reviewed (P3) for HHA services. P3’s POC for certification period 3/1/24-5/25/24, indicated P3 had diagnoses of prostate cancer and glaucoma. P3 required weekly skilled nurse services for general health assessment, medication management, and safety concerns. P3’s POC lacked indication P3 received HHA services or what treatments or interventions were needed. P3’s POC for certification period 1/30/24-3/30/24, indicated P3 had diagnoses of prostate cancer and glaucoma. P3 required weekly skilled nurse services for general health assessment, medication management, and safety concerns. P3’s received HHA services two times a week for bathing, grooming, and dressing. P3’s nursing visit notes from dates 1/31/24- 4/7/24, indicated P3 had supervisory visits for HHA services on 2/7/24, 2/28/24, 3/13/24, and 4/10/24. This indicated the time between supervisory visits was over 14 days. When interviewed on 4/10/24 at 11:05 a.m., home health aide (HHA)-A stated had been working with P3 for several months. HHA stated once a week, P3 was assisted with showering, shaving, and dressing. P3 further stated cares provided hadn’t changed since they started working with him. When interviewed on 4/10/24, at 11:30 a.m., registered nurse (RN)-A verified supervisory visits occurred every 14 days and would be a separate note placed when completing the visit note for that day. RN-A wasn’t sure if there were any missed notes and didn’t have a computer onsite to review. RN-A took notes about the visits and documented at a later time. There was not anything that prompted her to complete the supervisory note and may have missed a few. RN-A further stated supervisory notes were needed to ensure the patients were getting support they needed, and things were going well. When interviewed on 4/11/24 at 8:47 a.m., the acting director of nursing (DON) expected staff were expected to complete supervisory visits and document them. This was to ensure HHA cares were going well and there were no concerns. An agency policy titled Home Health Aide Supervision no date, directed when skilled services were provided, skilled staff must make as supervisory visit at least every 2 weeks to assess relationships and determine whether goals were being met.”

“Goals in the patient’s plans of care CFR(s): 484.110(a)(3) Goals in the patient’s plans of care and the patient’s progress toward achieving them; This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure medical records reflected the patient’s progress towards identified goals of care for 2 of 5 patients (P1, P5) currently receiving skilled services from the agency. P1’s POC for certification period 2/25/24-4/27/24, indicated P1 required weekly skilled nurse services for edema care and wraps, vital signs, and general health education. P1’s start of care (SOC) visit note dated 2/25/24, indicated P1 required skilled services for edema management, education on wraps, vistal sign checks, and compliance with medications. P1’s goals were to be compliant with elevation of legs, edema wraps and nurse visits and to be free of edema. A review of P1’s skilled nurse visit notes from 2/25/24- 4/6/24, all lacked documentation of P1’s progress towards identified goals. P5’s plan of care (POC) for certification period 3/8/24-5/6/24, indicated P5 had diagnoses of traumatic brain injury and bipolar disorder. P5’s required skilled nurse visits weekly for general health assessment and medication management. P5’s goal was to remain safe in home with home care services. A review of P5’s skilled nurse visit notes from 3/8/24- 4/6/24, all lacked documentation of P5’s progress towards identified goals. When interviewed on 4/10/24 at 11:30 a.m., registered nurse (RN)-A verified P5’s progress notes did not have documentation of progress towards P5’s goals. RN-A further stated documentation was completed after the visits and things get missed. When interviewed on 4/11/24 at 8:47 a.m., the acting director of nursing (DON) verified P1’s and P5’s nursing notes did not include documentation of P1’s progress towards their goals. DON further indicated the notes designed to ensure that was documented, however that section was left blank. DON stated this was important to understand progress towards goals to help in care plan revision or additional support needed. A facility policy titled Clinical Documentation no date, directed staff to ensure accurate record of services provided, response and ongoing need of care.”