Visiting Nurse Association

“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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure that the patients received the home health services that were written on their individualized plan of care (POC) when the patients did not receive specific detailed pain assessment as ordered on the plan of care in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to adversely affect the ordered care provided to all the provider’s patients. Findings included: Review of the provider’s policy titled, “Plan of Care/Physician Orders Policy,” dated reviewed/revised “2/2019”, showed in part, the direct service providers conform to the doctor’s orders as noted on the POC. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to home health services on 05/22/2025 with a primary diagnosis of encounter for change or removal of drains; - The patient had a PleurX (brand) drainage catheter (a thin, flexible tube placed in the chest to drain fluid from the pleural space (fluid filled space that surrounds the lungs) to make it easier to breathe). In a healthy human, the pleural space contains a small amount of fluid (about 10 to 20 milliliters); - The patient also had diagnoses of malignant neoplasm of right choroid (a cancer that develops in the choroid, the vascular layer beneath the retina. It is the most common primary malignancy of the posterior segment of the eye in adults.) and secondary malignant neoplasm of the liver and intrahepatic bile duct (cancer that has spread from another part of the body to the liver and the bile ducts within the liver); and - The patient lived at home with an adult child. Review of the POC dated 05/22/2025 to 07/20/2025 showed skilled nurse (SN) to assess pain including: pain level, frequency, location, quality, precipitating factors, and side effects. Review of the SN visit note dated 05/28/2025 showed: - “Patient seen for PleurX drain procedure. Patient tolerated without complaints”; and - The SN failed to document a pain assessment as ordered in the POC. Review of the SN visit note dated 05/30/2025 showed: - “Patient seen for PleurX draining. Drained today without complaints”; and - The SN failed to document a pain assessment as ordered in the POC. Review of the SN visit note dated 06/03/2025 showed: - “Patient seen for PleurX drain procedure. Patient denies any pain with draining”; and - The SN failed to document a pain assessment as ordered in the POC. Review of the SN visit note dated 06/06/2025 showed: - “Patient seen for PleurX draining. Patient tolerated draining without complaints”; and - The SN failed to document a pain assessment as ordered in the POC. Review of the SN visit note dated 06/10/2025 showed: - “Patient seen for PleurX drain procedure. Patient tolerated without complaints”; and - The SN failed to document a pain assessment as ordered in the POC. Observation on 06/10/2025 at 9:00 AM, showed registered nurse (RN)-A failed to complete a pain assessment that included pain level, frequency, location, quality, precipitating factors, and side effects as ordered on the POC. During an interview on 06/11/2025 at 10:30 AM, the alternate administrator stated that the POC should be followed.”

“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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure an accurate medication review and/or update of the patient medications was completed, in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Reconciliation,” dated reviewed/revised “01/2018,” showed in part: - The case manager is responsible for accurate medication reconciliation. The case manager or designee (physical therapy assistant (PTA), licensed practical nurse (LPN), certified occupational therapy assistant (COTA) will perform medication reconciliation every visit; - All other disciplines will assess for changes on their visit and ensure the electronic medical record (EMR) is updated when the discrepancy is identified; - The EMR will consist of medications actually in the home and what the patient says he/she is taking (discrepancies from the written discharge instructions will be noted in a clinical note and called to the doctor); and - All other disciplines other than the case manager and/or nursing will observe and interview the patient for changes. If discrepancies are noted a medication reconciliation will be completed and the EMR is updated at the visit the discrepancy was identified. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to home health services on 05/22/2025 with a primary diagnosis of encounter for change or removal of drains; and - The patient had a PleurX (brand) drainage catheter (a thin, flexible tube placed in the chest to drain fluid from the pleural space (fluid filled space that surrounds the lungs) to make it easier to breathe). In a healthy human, the pleural space contains a small amount of fluid (about 10 to 20 milliliters). Review of the provider’s current medication profile, showed in part: - Fluoxetine (a medication given to treat depression) 20 mg (milligrams). Take one capsule two times a day; and - Potassium Chloride 20 milliequivalent extended release. Take one tablet two times daily. Observation on 06/10/2025 at 9:00 AM, with registered nurse (RN)-A, the following medication discrepancies were noted when a medication reconciliation was performed with the patient: - The patient was taking the fluoxetine once daily (it was ordered twice daily); and - The patient was taking the potassium chloride every other day (it was ordered two times daily). Per interview conducted with the patient during observation the patient stated that: - He/she had never taken the fluoxetine twice a day; - He/she had taken the potassium every other day “for a long time”; and - The first person that had come must have gotten that wrong. He/she was the one that had taken/written the medication list down. During an interview on 06/11/2025 at 10:30 AM the alternate administrator stated that the provider’s policy was to have a correct medication list.”

“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 policy review, record review, home visit observation, and interview, the home health provider failed to develop a complete/individualized plan of care (POC), in two of five full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect the care for all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care/Physicians Orders,” revised on 09/2019, showed in part: - A physician’s written plan of care is required for each patient receiving home health services; - The plan of care is developed by the patient’s physician in consultation with agency home health care service providers, and the patient/caregiver, and includes the following in part: * Medications, allergies, and treatments * Any safety measures to protect against injury * Any other appropriate item. (Example: laboratory procedures and any contraindications or precautions to be observed) - Within 24 (twenty-four) hours of the initial assessment visit by the care provider, the physician must be consulted to confirm the appropriateness of the initial plan of care or to approve additions or modifications to the original plan; - Agency (home health provider) professional staff promptly alerts the physician to any change that suggests a need to alter the plan of care; - The direct service providers conform to the doctor’s orders as noted on the plan of care; and - Agency (home health provider) staff administers drugs and treatments only as ordered by the physician. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to home health services on 05/06/2025 with the primary diagnosis of interstitial cystitis (a chronic, painful bladder condition) without hematuria (blood in the urine); and - The patient resided at home alone. Review of the POC dated 05/06/2025 to 07/04/2025 showed: - An additional diagnosis of type 2 (two) diabetes mellitus with hyperglycemia (a group of diseases that results in too much sugar in the blood); - Skilled nurse (SN) to assess blood sugar monitoring and results and notify the medical doctor (MD) as indicated; - SN to perform skin care; and - The POC failed to include the frequency for how often the patient was to check blood sugar levels, blood sugar results that needed to be reported to the MD, and what specific skin care the SN was to provide. Observation on 06/10/2025, beginning at 3:40 PM showed, in part: - The patient reported that he/she did not check his/her blood sugar levels; - The physician did not require the patient to check blood sugars; and - The patient did not have any open wounds that required the SN to perform wound care on. During an interview on 06/11/2025 that began at 10:50 AM, the predesignated administrator stated that: - The patient’s physician was contacted for clarification of blood sugar monitoring and verification was received that the patient did not have to check blood sugar levels; - Blood sugars were monitored by the physician twice a year by obtaining labs; - The patient did not have any open wounds but was using barrier cream to his/her coccyx to prevent skin breakdown; and - Orders were received and the POC was updated to include the use of barrier cream for prevention of skin breakdown and blood sugar monitoring by the physician twice a year via Hgb A1C lab draws. RECORD/PATIENT#3: Review of the clinical record showed: - The patient was admitted to home health services on 05/22/2025 with a primary diagnosis of encounter for change or removal of drains; - The patient had A PleurX drainage catheter (a thin, flexible tube that’s placed in your chest to drain fluid from your pleural space (fluid filled space that surrounds the lungs. This can make it easier for you to breathe.) In a healthy human, the pleural space contains a small amount of fluid (about 10 to 20 ml (milliliters)); - The patient also had diagnoses of malignant neoplasm of right choroid (a cancer that develops in the choroid, the vascular layer beneath the retina. It is the most common primary malignancy of the posterior segment of the eye in adults.) The patient also had a secondary malignant neoplasm of the liver and intrahepatic bile duct (cancer that has spread from another part of the body to the liver and the bile ducts within the liver) and long-term current use of anticoagulants (blood thinning medication); and - The patient lived at home with an adult child. Review of the start of care assessment dated 05/22/2025 showed: - The patient had a pleurx drain; and - The patient was taking an anticoagulant medication. Review of the POC dated 05/22/2025 to 07/20/2025 showed: - A primary diagnosis of encounter for change or removal of drains (the patient had a pleurx drain); - An other pertinent diagnosis of long term current use of anticoagulants; and - The POC failed to be individualized with the management of/education for care of the pleurx drain or interventions to monitor for signs or symptoms of bleeding (such as excessive or abnormal bruising) or active bleeding due to the administration of anticoagulant therapy. Observation on 06/10/2025 at 9:00 AM, showed: - The patient had a pleurx drain; and - The patient was on an anticoagulant medication (apixaban). During an interview on 06/11/2025 at 10:30 AM the alternate administrator stated that: - Pleurx drain management, and education should have been on the POC; and - Education regarding the high-risk medication (apixaban) should have been on the POC.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to ensure each patient received complete/accurate written instructions related to their medication schedule/instruction in, but not limited to, one of three home visit observations (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the home health provider’s policy titled, “Medication Reconciliation” dated reviewed/revised “01/2018”, showed in part, “Reconciliation: The visiting staff observes meds in the home, written med list in the home and EMR (electronic medical record); all should match prior to leaving home.” RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to home health services on 05/22/2025 with a primary diagnosis of encounter for change or removal of drains; - The patient had a PleurX (brand) drainage catheter (a thin, flexible tube placed in the chest to drain fluid from the pleural space (fluid filled space that surrounds the lungs) to make it easier to breathe). In a healthy human, the pleural space contains a small amount of fluid (about 10 to 20 milliliters); - The patient also had diagnoses of malignant neoplasm of right choroid (a cancer that develops in the choroid, the vascular layer beneath the retina. It is the most common primary malignancy of the posterior segment of the eye in adults.) and secondary malignant neoplasm of the liver and intrahepatic bile duct (cancer that has spread from another part of the body to the liver and the bile ducts within the liver); and - The patient lived at home with an adult child. Observation on 06/10/2025 at 9:00 AM, showed the home health provider failed to ensure a written medication schedule was placed in the patient’s home. Per interview conducted during observation, the patient stated that: - He/she did not have a written med list in their home; - He/she had some of their meds on their phone; and - The home health provider never left a list. During an interview on 06/11/2025 at 10:30 AM, the alternate administrator stated that the expectation was to leave a medication list in the home.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on review Missouri regulations, policy review, employee file review, and interview, the home health provider failed to ensure all staff had the Employee Disqualification List (EDL) checked prior to hire and failed to ensure all persons offered employment, registered with the Family Care Safety Registry (FCSR) prior to patient contact in one of four employee files reviewed (Employee #3). This deficient practice had the potential to affect all the patients served by the provider. Findings included: Review of Section 192.2490.12 RSMo: “No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) and (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list.” Review of Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Registry, regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Registry. Review of Section 192.2495.6, RSMo: “A provider is guilty of a Class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other states or has been found guilty of a crime, which if committed in Missouri would be a Class A or B felony violation of Chapter 565,566, or 569, or any violation of Subsection 3 of section 198.070 or section 568.020.” Review of Section 192.2495.7, RSMo (effective August 28, 2018): “Any in-home services provider agency or home health agency shall be guilty of a Class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the Family Care Safety Registry or if such person: - (1) Has nay disqualifying factors listed in Subsection 6 of this section; - (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony under Chapter 195 or 579; - (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under Section 568.045, 568.050, 568.175, 570.023, 570.025, 570.030, 570.040, as it existed prior to January 1,2017, 570.090, 570.145,570.223, 575.230, or 576.080; - (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of Section 577.010 or 577.012 and who is alleged and found by the court to be and aggravated or chronic offender under Section 577.023; - (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under Section 589.400; - (6) Is listed on the Department of Health and Senior Services Employee Disqualification List under Section 192.2490; - (7) Is listed on the Department of Mental Health Employee Disqualification Registry under Section 192.2490; and - (8) Has a finding on the Child Abuse and Neglect Registry under Sections 210.109 to 210.183.” Review of the provider’s policy titled, “HR Onboarding Process,” dated reviewed/revised “7/15/20”, showed in part, the following pre-employment requirements must be met prior to beginning employment: - Missouri Family Care Safety Registry; and - EDL check. Employee #3: Review of the employee file showed: - Contract Speech Therapist (ST); - Date of hire: 03/02/2025; - Date of first patient contact: 03/02/2025; and - The file failed to contain an EDL check or evidence the employee was registered with the FCSR at the time of survey 06/11/2025. During an interview on 06/11/2025 at 9:10 AM, the alternate administrator stated that they (the provider) did not have an FCSR but they were submitting it. (The state agent (SA) was given a copy of the FCSR transaction 06/11/2025 at 9:27 AM). During an interview on 06/11/2025 at 9:18 AM the alternate administrator stated that this was all they sent him/her for an EDL and the SA was given a copy of a Confidential Background Screening Report, order #1859591122, which failed to contain evidence the employee was not on the Missouri EDL.”