Cameron Regional Medical Center Home Health Agency

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition 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 individualized plan of care (POC) that included all pertinent diagnoses and treatments (G574); -Promptly alert the physician when the patient had a change in condition (G590); and -Ensure the coordination of care to meet the patient’s needs (G608). The outcome of care on Record/Patient #2 and the cumulative effect of these deficient practices has the potential to affect all patients on service.”

“Eligible training/competency evaluation orgs. CFR(s): 484.80(f) A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years: (1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; or (2) Permitted an individual who does not meet the definition of a “qualified home health aide” as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or (3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or (4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or (5) Was found to have compliance deficiencies that endangered the health and safety of the HHA’s patients, and had temporary management appointed to oversee the management of the HHA; or (6) Had all or part of its Medicare payments suspended; or (7) Was found under any federal or state law to have: (i) Had its participation in the Medicare program terminated; or (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA’s patients; or (v) Been closed, or had its patients transferred by the state; or (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program. This Standard is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with two Conditions of Participation: Care planning, coordination of services, and quality of care, the home health provider may not train, or competency evaluate their home health aides for a period of two (2) years following the date of this survey. This restriction ends 12/04/2026.”

“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 three home visit observations (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Care,” last reviewed 09/19/2019, showed in part: - Upon start of care, review patient medications in the home; - Contact physician with any found discrepancies; and - Clinicians should conduct another medication reconciliation for any new medications added, or at least with 60-day span for recertification. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/04/2024 with primary diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe); and - The patient resided at home alone. Observation and interview on 12/03/2024 at 9:30 AM, with Registered Nurse (RN) A, showed the following medication discrepancies: - Gabapentin (an anticonvulsant used to treat seizures and is commonly used to treat nerve pain) 100 MG (milligrams) 1 (one) capsule BID (twice daily) listed on the medication profile. The patient reported no longer taking this medication; - Metamucil (a fiber supplement that aides in digestive health) 3 (three) capsules daily. This failed to be on the medication profile and the patient reported taking; - Prednisone (a steroid medication used to reduce inflammation)10 mg daily. This failed to be on the medication profile and the patient reported that he/she had been on this medication since June; - The Lidocaine (a local anesthetic used to treat pain) 5 (five) % patch. This failed to be on the medication profile, but the patient had one applied under his/her right breast; - Supplemental oxygen was not listed on the medication profile and the patient required 3 (three) l/min (liters per minute); - Hydrocodone-Acetaminophen (a combination pain medication that includes Hydrocodone and Acetaminophen) 5 mg-325 mg take 2 (two) tablets every 6 (six) hours as needed for moderate pain, was listed on the medication profile. The bottle showed every 4 (four) hours as needed for pain; and - The Tramadol-Acetaminophen 37.5 mg-325 mg (a combination pain medication that includes both Tramadol and Acetaminophen) take 2 tablets every 6 hours as needed for pain, was listed on the medication profile. The bottle was for tramadol 50 mg take 1-2 tablets every 6 hours for pain. During an interview on 12/04/2024 at 2:40 PM, the Administrator stated that: - He/she had seen all of the medication discrepancies; and - The nurse (RN A) contacted the physician and updated the medication profile after the home visit.”

“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 ensure an individualized plan of care (POC) that included all pertinent diagnoses and treatments, in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect the coordination of care and services for all patients on service with the provider. Findings included: Review of the provider’s policy titled, “Administrative/Patient Care,” last revised 03/30/2020, showed in part: - The plan of treatment provides the signed Physician consent for implementation of focus of care and treatment; - Interventions and goals should address the reason for treatment and home health focus of care; and - The plan of treatment should paint the picture of the patient’s condition including co-morbidities. Review of the provider’s policy titled, “Patient Care,” last reviewed 03/27/2003, showed in part: - The plan of treatment will include: * Diagnosis * Medications with dosage, administration, and frequency * Treatments and their frequency; and - Drugs and treatments are administered by agency (provider) only as ordered by the physician. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/04/2024 with primary diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe); and - The patient resided at home alone. Observation and interview on 12/03/2024 at 9:30 AM, with Registered Nurse (RN) A, showed: - The patient had a large lump in the middle of his/her back; - The patient reported the lump had been there for years and was being monitored by his/her physician. The clinical record failed to show documentation and/or a history of the lump on the patient’s back; - The patient had shingles under his/her right breast; - The patient reported having shingles four times in the past year. The plan of care failed to show a diagnosis and/or past medical history of shingles; - A lidocaine (local anesthetic pain blocker) patch was present under his/her right breast; - The patient reported the lidocaine patch was previously prescribed for relief of pain caused by the shingles. The plan of care failed to show documentation and/or orders/interventions for the lidocaine patch; and - The patient was on supplemental oxygen per nasal cannula at 3 (three) liters per minute. The plan of care failed to include orders/interventions for oxygen. During an interview on 12/04/2024 at 2:40 PM, the Administrator stated that: - The plan of care usually contained all pertinent diagnoses and interventions for oxygen use; and - It was the nurse (RN C)’s first time completing a start of care and plan of care.”

“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 policy review, record review, and interview, the home health provider failed to promptly alert the physician when the patient had a change in condition, in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Care,” last reviewed 03/27/2003, showed in part, that the Registered Nurse (RN) will promptly alert the physician of any changes in the patient’s condition suggesting a need to alter the plan of treatment. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/04/2024 with primary diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe); and - The patient resided at home alone. Review of the discharge instructions, dated 11/01/2024, showed in part, that the patient was to receive supplement oxygen per nasal cannula at 2 (two) L/min (liters per minute). Review of the start of care visit on 11/04/2024, showed in part, the patient was receiving supplement oxygen per nasal cannula at 3 (three)L/min. The clinical record failed to show documentation that the physician was notified of the increase in oxygen since being discharged from the hospital on 11/01/2024. During an interview on 12/04/2024 at 2:40 PM, the Administrator stated that he/she would expect the physician to be notified of a change in the patient’s condition.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. 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 the coordination of care met the patient’s pain needs in one of three home observations (Record/Patient #2). This deficient practice has the potential to affect the coordination of care and services for all patients on service with the provider. Findings included: Review of the provider’s policy titled, “Administrative/Patient Care,” revised March 30, 2020, showed in part: - A 485/Plan of Treatment will be completed on all patients when admitted to home care; - The 485 provides the outline of the patient status in all areas, to include prescribed medications, and treatments to be carried out by the registered nurse (RN); - Interventions and goals should address the reason for treatment and home health focus of care; and - The plan of treatment should paint the picture of the patient’s condition. Review of the provider’s policy titled, “Administrative,” revised June 5, 2023, showed in part: - Subject: RN; - Provide professional nursing care for an assigned patient according to establish standards and practices; - The position requires a nurse who is well trained in all aspects of patient care and has the ability to make sound professional judgments and good clinical assessments, and therapeutic treatment of patients. Responsibilities include direct patient care; - Establish and initiates patient clinical record, plan of care with interventions and patient centered goals; - Regularly evaluate the patient needs; - Regularly evaluate the patient needs and progress toward goals; - Comply with established nursing standards; and - Report any unusual symptoms or problems to the administrator of home health. Review of the provider’s policy titled, “Wound Care,” revised May 9, 2022, showed in part, to document frequency of wound care in each order, and whom would be providing (example: patient or caregiver three times weekly and nurse two times weekly). RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 11/15/2024 with a primary diagnosis of Type II diabetes mellitus (a group of diseases that results in too much sugar in the blood) with foot ulcer and a non-pressure chronic ulcer of other part of left foot with other specified severity (a persistent open sore or wound that develops on a specific area of the foot, often caused by various underlying conditions. This condition can be extremely debilitating, as it can lead to pain, discomfort, and difficulty in walking or performing daily activities). The patient resided in an assisted living facility (ALF) with paid caregivers. Review of the OASIS (Outcome and Assessment Information Set; collection of standard data elements used to assess and improve home health care)-E start of care, dated 11/15/2024, showed in part: - The patient was orientated to person, place, and time; - The patient lived in an ALF; - The assisted living provided support with meals, assistance with activities of daily living (ADLs), medication administration, and etc.; - Location of pain: left toe; - Intensity of pain: 6 (six) on a scale of 0 (zero; no pain) to 10 (worst pain); - Quality of pain: sore, aching pain; - What made pain worse: touching it, putting on shoes; - What made pain better: rest, being barefoot or in loose house shoes; - Relief rating of pain, i.e. (that is), pain level after medications: 2 (two); - Medications patient took for pain: Tylenol (analgesic) 325 milligrams (mg) one to two tabs every four to six hours. Patient and caregivers encouraged to use pain medication if patient was hurting, both verbalized understanding. Patient also had Voltaren (nonsteroidal anti-inflammatory) cream available once daily as needed; - Patient’s pain goal: no pain; - Integumentary Status: patient has a diabetic ulceration to the top of his/her second left toe and left great toe; - Wound care worksheet: wound one - left great toe, 1 (one) centimeter (cm) L (length) x 0.3 (three) cm W (width); - Treatment: scabbing to top of great left toe, no drainage present, washed and left open to air; - Patient response to treatment: patient reported having pain in his/her left toes, tolerated well; - Wound pain: 3; - Wound care worksheet: wound two – second toe left foot, 5 (five) cm (L) x 3 cm (W) x 0.1 cm D (depth); - Treatment: maceration to top of second toe on left foot. Covers the majority of the top layer of second toe. Cleaned and dry dressing applied. Patient has appointment with podiatry and nurse practitioner that day; - Patient response to treatment: patient had pain associated with dressing change. Was able to tolerate; - Wound pain: 6; - Interventions performed: Patient had pain to his/her second toe on left foot related to macerated skin, caregivers educated to administer Tylenol for pain; and - Wound care to second toe on left foot – wash wound with soap and water, normal saline (NS) or wound wash, pat dry. Cover with dry dressing or gauze and tape. To be performed daily by paid caregivers when skilled nurse (SN) was not in the home. SN to assess wound with each visit and report any complications to primary care provider (PCP). Review of the plan of care (POC), dated 11/15/2024 through 01/13/2025, showed in part: - The patient was admitted to home health services on 11/15/2024; - Diagnoses included of Type II diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of left foot with other specified severity, non-pressure chronic ulcer of other part of right foot with fat layer exposed and cellulitis (common, potentially serious bacterial skin infection) of left toe; - Cephalexin (antibiotic) 500 mg one tablet three times daily for cellulitis of second toe on left foot; - Voltaren (nonsteroidal anti-inflammatory drug used to treat pain) External 1% 2-4 grams (gm) to apply topically to painful joints, 4 gms to lower joints and 2 gms to upper joints daily as needed for pain; - Acetaminophen (mild to moderate pain) Oral 325 mg two tablets by mouth every six hours as needed for pain; and - Wound care to second toe on left foot – wash wound with soap and water, NS or wound wash, pat dry. Cover with dry dressing or gauze and tape. To be performed daily by paid caregivers when SN was not in the home. SN to assess wound with each visit and report any complications to PCP. Observation and interview on 12/03/2024 at 8:39 AM, during the patient’s home visit, showed the following: - The patient was sitting in his/her recliner with feet elevated; - RN B asked the patient how he/she was feeling; - The patient stated “this toe is hurting”; - RN B started removing the dressing off the toe and patient stated “ooh” (used to express emotions including pain) “ooh” “ooh” as the nurse continued to remove the dressing the patient again stated “ooh” “ooh”; - RN B stated “it looks better and unsure why it hurts so bad”; - RN B washed the patient’s toe with soap and water and the patient scrunched up in the chair (as if pulling back) and stated “ooh” “ooh” as he/she grimaced (ugly, twisted expression on a person’s face, typically expressing disgust or pain) and tilted head back into the chair (bent neck back)’ - RN B asked the patient to rate his/her pain and patient stated a “9” (nine) on a scale 0-10 when being touched and a “5” when not being touched; - RN B asked the patient if he/she wanted pain medications and the patient stated “yes”; - RN B stated “all you have is Tylenol, let me dress this and we will see about getting Tylenol”; - RN B placed the dry dressing on the foot and then the patient’s socks; - RN B stated, “I forgot to take a picture”, he/she removed the sock and pulled the gauze dressing back to get a picture and the patient stated “ooh”; - Patient stated “you know I’m 103”; - RN B asked about the pain and patient stated “it hurts”, RN B asked if it hurt all the time and the patient nodded his/her head in a “yes” gesture; - Patient stated “did you say you were going to give me some pills to stop this” as he/she held up his/her left foot; - Patient stated, “but this really hurts” (holding up left foot); - RN B stated “I’m going to find someone to give you some meds to help with that”; - RN B left the patient’s room to find a staff member (paid caregiver) to administer the patient some pain medication. There was no nurse at the nurse’s station and the director of nursing (DON) was in the hallway, so RN B asked the DON to tell someone the patient needed pain meds; - RN B returned to the patient’s room and verbalized he/she had told someone about the pain medication; and - A paid caregiver from the facility entered the room at 9:10 AM (31 minutes after the visit started) bringing in two Tylenol for the patient. Surveyor asked if the patient took the Tylenol often and the paid caregiver verbalized, it was the first time he/she had given the patient any, but the records showed the patient hadn’t taken any since the 23rd of November (10 days prior). RN B failed to stop the wound care dressing, when the patient was complaining of pain and administer Tylenol and wait for it to take affect before proceeding with the dressing change. The nurse failed to coordinate with the ALF staff to have them administer the Tylenol prior to his/her arrival to do the dressing change. During an interview on 12/04/2024 at 3:10 PM, the Administrator stated the following: - He/she would expect pain medication to be administered prior to dressing changes if the patient complained of pain with touching; - He/she would expect the staff to stop the dressing change and offer pain medications if the patient rated his/her pain a “9” during the dressing change; - He/she would expect the patient to be pre-medicated prior to dressing changes; and - Staff should coordinate care and call the facility and tell the paid caregivers to medicate the patient with pain meds 30-40 minutes prior to the dressing change.”