Harrison County Home Health & Hospice

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on clinical record review, and interview, the home health provider failed to ensure that a complete and accurate patient specific comprehensive assessment was completed for each patient. The provider failed to: - Ensure that the registered nurse conducted the initial assessment within 48 hours of the patient’s return home (G514); - Ensure that the comprehensive assessment was completed within 5 calendar days of the start of care (G520); and - Ensure that the comprehensive assessment adequately reflected the patient’s current health, psychosocial, functional, and cognitive status (G528). The cumulative effects of these deficient practices has the potential to effect all patients served by the home health provider.”

“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 record review, home visit observation, and interview, the provider failed to: - Ensure that each patient received services that were written in the plan of care (POC) and signed by the physician, when therapy treatment plans failed to be included on the POC, and were not signed by a physician or allowed practitioner (G572); -Ensure that each patient’s written individualized plan of care (POC) included safety measures to prevent against injury, functional limitations, patient-specific interventions, and all types of services required (G574); - Ensure drugs, services, and treatments were administered only as ordered by a physician (G580); - Promptly alert the relevant physician(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 (G590); - Ensure the integration of orders from all physicians or allowed practitioners involved in the plan of care (G604); - Ensure coordination of care to meet the patient’s needs (608); - Ensure that each patient and his or her caregiver received education regarding medication order changes, the reason for the order to discontinue the medication, and the risk for continuing the use of the medication against the physician’s order (G610); and - Ensure that the patient was provided a list with medication schedule/instructions, that included medications name, dose, and frequency in which medication were to be administered (616). The cumulative effect of these deficient practices has the potential to affect individualized and physician ordered care provided to all the provider’s patients.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on review of the provider’s rehabilitation services agreement, policy review, employee file review, and interview, the provider failed to ensure the contract PT (physical therapist) received the provider’s emergency management training in one of one contract employee file review (Contract PT). This deficient practice has the potential to adversely affect the care and services to all patients in the event of an emergency. Findings included: Review of the rehabilitation services agreement signed and dated by the provider’s administrator 07/27/2023 and signed by the contracting provider’s CEO (Chief Executive Officer) 08/11/2023 showed in part, “Orientation. Agency (provider) shall provide appropriate initial orientation to individuals supplying services under this Agreement. Thereafter, annual education will be provided.” Review of the provider’s undated policy, titled, “In Service Education”, showed in part certain in-service programs are determined by the Agency (provider) to be mandatory initially and annually for all staff. These include but are not limited to the Emergency Operations Plan. Contract PT Employee file review showed: - The contract PT had been hired in 2005 by the prior home health provider before the CHOW (change of ownership); and - There failed to be any evidence of emergency preparedness (EP) training since the CHOW of the home health provider. During an interview on 02/06/2024 at 11:30 AM, the clinical manager stated that: - He/she had all of the training from the “Named home health provider” (the prior provider before the CHOW); - The contract PT had worked for them (the provider) already; and - No EP training had been done with the contract PT since the CHOW.”

“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, and interview, the home health provider failed to ensure that each patient received services that were written in the plan of care (POC) and signed by the physician, when therapy treatment plans and orders/interventions, failed to be included on the POC, and were not signed by a physician or allowed practitioner in, three of five full records reviewed (Records/Patients #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted 11/21/2023 with a primary diagnosis of malignant neoplasm of the larynx (cancer of the voice box). Review of the POC dated 11/22/2023 to 01/20/2024 failed to show orders for physical therapy (PT) or Speech therapy (ST). Review the physical therapy evaluation dated 12/07/2023, showed in part: - Interventions, goals, rehab potential and discharge planning; - Care coordination marked with physician contacted with assessment findings and approved orders and, discipline and frequency; and - It failed to be signed by the PCP (primary care physician). Further review of the clinical record showed: - An ambulatory referral to speech therapy order dated 11/28/2023 signed by a referring PA-C (Certified physician assistant). - A Speech/Language Pathology evaluation dated 12/05/2023, showed in part: * Interventions, goals, rehab potential and discharge planning; * Care coordination with physician contacted with assessment findings and approved orders and, discipline and frequency failed to be marked; and - It failed to be signed by the PCP (primary care physician). Findings included: Review of the provider’s undated policy titled, “Care Planning Process,” showed, in part: - In order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems, the agency will utilize data/information gathered during patient assessments in the care planning process; and - The patient care plan for therapy services (PT- Physical Therapy, OT- Occupational Therapy, and SLP- Speech Language Pathology) will be developed and implemented with the physician. Review of the provider’s undated policy titled, “Physicians Verbal Orders,” showed, in part: - Drugs and treatments are administered by the agency staff only as ordered by the physician; - Orders are obtained prior to the provision of any care, including changes in the plan of care; - Orders for patient care are obtained from the physician, either verbally or in writing; - When a verbal order is received, the order must be written down, read back to verify order and receive confirmation from individual who gave order. A record of this order is documented on a physician’s supplemental order form. All orders include: * The patient’s name * Physicians name * Date and time the order is taken * The signature of the person taking the order * The specific order(s); and - All verbal orders must be subsequently signed by the physician. RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (left upper arm) and is temporally residing with his/her daughter; and - The SOC (start of care) assessment visit was on 01/08/2024. Review of the POC (plan of care), showed, in part: - Discipline showed SN (skilled nursing) with visit frequency of 2 (two) times a week for 2 weeks and 1 (one) time a week for 5 (five) weeks (No other disciplines were listed); - Intervention and goals for SN (No other interventions/goals for any other discipline); and - The POC failed to include PT and OT services. Review of the Occupational Therapy evaluation visit note dated 01/10/2024, showed, in part: - The plan of care section showed: * OT visit frequency of 1x/week (1 time for 1 week), 2x/week x3weeks (2 times a week for 3 weeks) * OT treatment plan showed, establish a home exercise program and ADL (activities of daily living) training - Care was coordinated with PT regarding the patient having difficulty using rolling walker due to LUE (left upper extremity) is NWB (non-weight-bearing); and - The clinical record failed to show a POC for OT that was signed by a physician. Review of the Physical Therapy evaluation visit note dated 01/11/2024, showed, in part: - The plan of care section showed: * PT visit frequency of 1x1 (1 time for 1 week), 2x3 (2 times a week for 3 weeks), and 1x1 * PT treatment plan showed, establish a home exercise program, therapeutic exercises, balance training, functional mobilities, and transfer training - Care was coordinated with nursing, PTA, and OT regarding the patient’s plan of care; and - The clinical record failed to show a POC for PT that was signed by a physician. RECORD/PATIENT #5: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/06/2024 with a primary diagnosis of a UTI (urinary tract infection- an illness in any part of the urinary tract, the system of organs that makes urine) and resided in the home when a spouse and adult daughter; - The patient’s daughter was listed as the primary caregiver; and - The SOC (start of care) assessment visit was on 01/06/2024. Review of the POC (plan of care), showed, in part: - Discipline showed SN (skilled nursing) with visit frequency of 2 times a week for 2 weeks and 1 time a week for 4 (four) weeks (No other disciplines were listed); - Intervention and goals for SN (No other interventions/goals for any other discipline); and - The POC failed to include PT and OT services. Review of the Physical Therapy evaluation visit note dated 01/11/2024, showed, in part: - The plan of care section showed: * PT visit frequency of 1x1 (1 time for 1 week), 2x3 (2 times a week for 3 weeks), and 1x1 * PT treatment plan showed, establish a home exercise program, therapeutic exercises, balance training, functional mobilities, and transfer training - Care was coordinated with nursing, PTA, and OT regarding the patient’s plan of care; and - The clinical record failed to show a POC for PT that was signed by a physician. Review of the Occupational Therapy evaluation visit note dated 01/18/2024, showed, in part: - The plan of care section showed: * OT visit frequency of 1x/week (1 time for 1 week), 2x/week x3weeks (2 times a week for 3 weeks) * OT treatment plan showed, establish a home exercise program and ADL (activities of daily living) training - Care was coordinated with PT regarding the patient having difficulty using rolling walker due to LUE (left upper extremity) is NWB (non-weight-bearing); and - The clinical record failed to show a POC for OT that was signed by a physician. During an interview on 02/06/2024 that at 3:00 PM, the Clinical Manager stated that: - Therapy should be on the POC; - He/she has to pull the information from the therapy evaluation visits and put it on the POC; - He/she didn’t realize that the POC for these patient’s did not include therapy; and - He/she is not sure why these patient’s were missed.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on policy review, clinical record review, and interview, the provider failed to ensure the initial assessment was completed within 48 (forty-eight) hours of the referral in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect the immediate needs of all the provider’s patients. Findings included: Review of the provider’s undated policy titled, “Initial/Comprehensive Assessment,” showed in part: - A RN (registered nurse), PT (physical therapist) or SLP (speech, language pathologist) must conduct the initial assessment visit within 48 hours of the referral, within 48 hours of the patient’s return home, or on the physician-ordered start of care (SOC) date; - The initial assessment visit is conducted to determine the immediate care needs of the patient; and - In the absence of a physician-specified start of care date, the initial assessment visit is conducted within 48 hours of the referral. RECORD/PATIENT #1: Review of a referral dated 01/16/2024 from an inpatient rehabilitation hospital showed HH/PT/OT/Skilled (home health/physical therapy/occupational therapy/skilled nurse). Review of the clinical record showed the patient was admitted to home health services on 01/22/2024 with a primary diagnosis of MS (multiple sclerosis- a disease in which the immune system eats away at the protective covering of nerves). Review of the SOC OASIS (Start of Care Outcome and Assessment Information Set; a standardized data collection tool) dated 01/22/2024 (six days following referral) showed: - Item M0090- Date assessment completed: 01/22/2024 - Item M1005, Inpatient discharge date 01/16/2024; and - Item M0102, Date of physician-ordered SOC marked N/A, no specific SOC date. Review of an inter-office communication note dated 01/18/2024 showed the RN called the patient and left a voicemail, the patient returned call and requested someone come on Monday (01/22/2024) so their spouse could be present. Further review of the clinical record failed to show a specific physician ordered start of care. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that he/she did not see a late SOC order and would have expected the initial assessment to have been completed within forty-eight hours of referral or discharge home since there was no late SOC order. RECORD/PATIENT #2: Review of the clinical record showed: - A referral dated 01/05/2024 from an acute care hospital; and - The patient was admitted to home health services on 01/16/2024 with a primary diagnosis of a fractured sacrum (a triangular shaped bone that lies at the bottom of the spine located just above the tailbone). Review of the SOC OASIS (Start of Care Outcome and Assessment Information Set; a standardized data collection tool) dated 01/16/2024 (11 days following referral) showed: - Item M0090- Date assessment completed: 01/16/2024; - Item M1005, Inpatient discharge date 01/11/2024; and - Item M0102, Date of physician-ordered SOC marked N/A, no specific SOC date. Review of an inter-office communication note dated 01/13/2024 showed the RN called the patient to set up admission time. Due to the weather, the patient requested to wait until the roads were better and it wasn’t quite as cold out. Patient request to be called tomorrow (01/14/2024) or Monday (01/15/2024) and stated they were doing okay at home. Further review of the clinical record showed: - A physician order dated 01/17/2024 (six days after discharge from the acute hospital) that showed patient to home health on 01/16/2024 per his/her request; and - It failed to contain an order within 48 hours of the patient’s return home. During an interview starting at 1:15 PM, the clinical manager stated that he/she would expect the PCP (primary care physician) to be contacted about the late SOC; and - The staff usually did call and they may have forgot to document with the weather.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on policy review, clinical record review, and interview, the provider failed to ensure the registered nurse (RN) completed the comprehensive assessment no later than five days after the start of care in one of five full records reviewed (Patient #3). This deficient practice has the potential to affect the needs of all the provider’s patients. Findings included: Review of the provider’s undated policy titled “Initial/Comprehensive Assessment,” showed in part: - A RN (registered nurse), PT (physical therapist), or SLP (speech language pathologist) must conduct the initial assessment within 48 hours of referral, within 48 hours of the patient’s return home or on the physician ordered start of care date; and - Completion of the comprehensive assessment must be completed in a timely manner consistent with the patient’s needs, but no later than five (5) calendar days after the start of care. Review of the provider’s policy titled, “Care Planning Process,” revised 02/08/2022, showed in part: - All disciplines involved in the patient’s care will contribute to the POC (plan of care); and - In order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems, the agency will utilize data/information gathered during patient assessments in the care planning process. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted with a primary diagnosis of malignant neoplasm of the larynx (cancer of the voice box). Review of the referral information, dated 11/20/2023 from an acute care hospital, showed in part, disposition: anticipate home with HH (home health) and PT (physical therapy) in AM if tolerating TF (tube feeding). Review of the updated referral information, dated 11/21/2023 from an acute care hospital, showed in part, a face to face completed and electronically signed by the patient’s inpatient physician, with disciplines requested: Skilled Nursing and physical therapy. Further review of the clinical record showed: - A SOC OASIS (Start of Care Outcome and Assessment Information Set; a standardized data collection tool) with Item M0090- Date assessment completed: 11/22/2023, and electronically signed by RN B; and - A PT evaluation completed 12/07/2023 (fifteen days after the initial assessment). During an interview on 02/07/2024, starting at 1:15 PM, the clinical manager stated that the disciplines on the referral are supposed to go within the first five days of SOC (start of care), that is the expectation.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s current health status including relevant past medical history in, three of five full records reviewed (Records/Patients #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Initial/Comprehensive Assessment,” showed, in part: -Each patient admitted by the agency will have appropriate initial/comprehensive assessments performed and documented; - The assessment will reflect the patient’s current health status and include information to demonstrate the patient’s progress toward achievement of desired outcomes; - A RN (registered nurse), PT (physical therapist), or SLP (speech language pathologist) must conduct the initial assessment within 48 hours of referral, within 48 hours of the patient’s return home or on the physician ordered start of care date; - Completion of the comprehensive assessment must be completed in a timely manner consistent with the patient’s needs, but no later than five (5) calendar days after the start of care; and - The initial comprehensive assessment also includes: * Relevant diagnosis and health status * Relevant medical history * Physical assessment/review of systems and pertinent physical findings * Strengths, goals and care preferences, including information that may be used to demonstrate the patient’s progress towards achievement of the goals identified by the patient and measurable outcomes identified by the agency * Drug allergies, sensitivities, past adverse drug reactions and past history of medication compliance * Laboratory results. Review of the provider’s undated policy titled, “Reassessments,” showed, in part: - The comprehensive assessment (including OASIS- Outcome and Assessment Information Set data elements) must be updated and revised as frequently as the patient’s condition warrants due to a major improvement or decline in health status; - staff will additionally reassess each patient with each home visit on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided; and - Staff will analyze the data from assessments and reassessments. Such analysis of data will assist staff in identifying and prioritizing patient needs and problems to direct care and services. RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (left upper arm) and is temporally residing with his/her daughter; and - The SOC (start of care) assessment visit was on 01/08/2024. Review of the SOC visit note dated 01/08/2024, showed, in part: - The pain section showed, “no pain,” marked (The skilled nurse failed to assess the patient’s history of pain); - The musculoskeletal section showed the patient had a fracture to left shoulder; - The functional status showed, “walker,” selected for device use prior to current illness, exacerbation, or injury (The skilled nurse failed to document functional limitations related to the patient’s recently fractured left arm); - The activities permitted section showed, no restrictions, up as tolerated, and walker listed (The skilled nurse failed to assess the patient’s ability to use a walker since recently fracturing the left arm requiring the left arm to be in a sling. During home visit observation the patient had to pull his/her arm through the sling to hold onto the walker with both hands); - The living arrangements section showed, the patient lives with other person(s) in the home, around the clock (The patient is currently staying with his/her daughter until the patient is able to return home and the daughter works); - The risk for rehospitalization section showed that the patient lives alone; and - The assessment summary section showed a comment that the patient was “alert and oriented elderly (male/female) with fractured humerus in a sling on left side” (The skilled nurse failed to document an assessment of any limitations/restrictions related to the patient’s use of a sling). Review of the Occupational Therapy evaluation visit note dated 01/10/2024, showed, in part: - The pain section had pain rated 6 out of 10 (0 being no pain and 10 being the worst pain), pain location of both knees and left shoulder, description was “shooting” pain, pain worse with movement, pain relieved with medications and rest, “impacts patient mobility and ability to perform ADL (activities of daily living) tasks” was noted in the impact on activities question, breakthrough medication needed for pain had “less than daily” selected, and the comment section had “Patient takes Tylenol 1xday (one time per day) with good pain relief” noted (The skilled nurse failed to assess the patient’s history of pain, what exacerbates pain, and interventions to relieve pain, including the use of Tylenol); - The musculoskeletal assessment section showed, “Patient is NWB (non-weightbearing) with LUE (left upper extremity) and has standard RW (rolling walker) so difficulty with balance during ambulation” (The skilled nurse failed to assess the patient’s non-weight bearing status with LUE, the use of rolling walker, and difficulty with balance during ambulation); and - The occupational therapist failed to document an assessment of the patient’s ability to use a walker while having the left upper extremity in a sling. Review of the Occupational Therapy visit note dated 01/16/2024, that began at 9:15 AM and ended at 10:30 AM, showed, in part: - The pain section had pain rated 6 out of 10, pain location of right bottom (buttocks), left shoulder and both knees listed, description was dull cramping pain, pain is worse with movement, sitting on sore (buttocks wound), and walking, pain relieved with medications and rest, frequency of pain and impact on activities had “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “majority of day, depending on activity” noted, and “Pt is using barrier cream on sore on bottom. Nurse states (he/she) will bring some cream and different dressing for it. Pt is taking 500mg Tylenol 2 tabs 2x/day for shoulder and knee pain” noted in the comments section; and - The care planning/coordination section had “spoke to SN (skilled nurse) regarding pts sore and HR” (The skilled nurse failed to assess the patient’s pain history and use of Tylenol to relieve pain. The Tylenol was discontinued by the physician on 01/10/2024 due to the risk of drug to drug interactions). Review of the SN (skilled nurse) visit note, dated 01/16/2024, that began at 10:15 AM and ended at 11:00 AM, showed, in part: - The patient had a heart rate of 100 beats/minute (beats per minute) with an irregular rhythm (The skilled nurse failed to assess for signs or symptoms related to new onset of irregular heart rhythm); - The pain assessment section showed, “no pain” (During the OT visit that began one hour prior to this visit, showed the patient’s pain was rated at a 6 out of 10. The skilled nurse failed to assess the patient’s history of pain); and - The musculoskeletal assessment section showed, “weakness” and required the use of an assistive device of a walker (The skilled nurse failed to assess the patient’s left upper extremity limitations/restrictions). Review of the Physical Therapy visit note dated 01/17/2024, showed, in part: - The visit was completed by a PTA (physical therapy assistant); - The vital signs section showed the patient’s blood pressure reading as 130/100; - The pain section showed, pain rated 3 out of 10 (0 being no pain and 10 being the worst pain), pain location of both knees and left shoulder, pain description was aching, pain relieved with medications and rest, and “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “Pt took Tylenol 500mg (milligrams), 2 tabs (tablets) at 1600 (4:00 PM)” noted; - The care planning/coordination section had the PT (physical therapist) was notified of the patient’s progress towards goals; and - The documentation failed to show if the patient’s blood pressure was reassessed by the PTA during the visit). Review of the SN visit note dated 01/19/2024, showed, in part: - The pain assessment section had “no pain” selected; - The musculoskeletal assessment section had “weakness” selected with an assistive device of a walker; and - The skilled nurse failed to assess the patient’s history of pain, left upper extremity limitations from fracture, left upper extremity sling and restrictions related to fracture. Review of the Physical Therapy visit note, dated 01/22/2024, that began at 9:00AM and ended at 9:40 AM, showed, in part: - The pain section was left blank (The PT failed to document a complete pain assessment); and - The patient’s response to skilled care provided this visit showed, “Pt participates well in therapy and is motivated to improve but continues to be limited by L (left) shoulder and B (bilateral) knee pain” noted (The PT failed to perform a complete pain assessment). Review of the SN visit note, dated 01/22/2024, that began at 9:45 AM and ended at 10:00 AM, showed, in part: - The pain assessment section showed “no pain” was selected (The skilled nurse failed to perform a complete pain assessment); and - The musculoskeletal assessment section showed “weakness” selected with an assistive device of a walker (The skilled nurse failed to assess the patient’s ability to use a walker with a fracture to the left arm requiring the use of a sling). Review of the Occupational Therapy visit note dated 01/23/2024, showed, in part: - The pain section showed pain rated 6 out of 10, pain location of bottom, both knees and left shoulder, description was dull, aching, throbbing pain, pain is worse with movement, pain relieved with medications and rest, frequency of pain and impact on activities had “daily” noted, how often breakthrough medication is needed for pain had 2-3 times/day selected, “Pt currently takes 500mg Tylenol 2 tabs 2x/day and it helps relieve pain,” noted in the comments section (The skilled nurse failed to assess the patient’s complete pain history, only documenting “no pain” during the SN visit the previous day); - The patient’s response to skilled care provided this visit showed, “pt tolerated well, although pt is not making progress towards ADL goals at this time d/t (due to) poor standing balance and limited motion to LUE” (The skilled nurse failed to document an assessment regarding the patient’s limited motion to LUE during the SN visits); and - The care planning/coordination section had care coordination with PT regarding pts progress/lack of progress towards goals. Review of the Physical Therapy visit note dated 01/30/2024, showed, in part: - The pain section showed pain rated 1 out of 10, pain location of left shoulder caused by fracture, pain description was left blank, pain relieved with repositioning, breakthrough medication “never” needed, frequency of pain and impact on activities had “daily but not constant and usually does not affect (his/her) activity which is limited for now per medical restrictions,” and “Pt does not take anything for pain and denied needing anything for pain management” was noted in the comments section (The PT failed to perform a complete pain history assessment. The OT visit notes showed that the patient had a history of pain that required the use of Tylenol); - The care planning/coordination section showed that care was coordinated with the PTA regarding the patient having an ortho (orthopedic) appointment for “shoulder” or “knee” on 02/09/2024 and discharge plan for next week (The PT failed to document the patient’s history with an orthopedic doctor and/or the patient being provided care from an orthopedic doctor). Review of the Occupational Therapy visit note dated 01/30/2024, showed, in part: - The visit was completed by the OTA (occupational therapy assistant); and - The pain section showed pain rated 5 out of 10, pain location of bottom, both knees and left shoulder, description was dull, aching, throbbing pain, pain is worse with movement, pain relieved with medications and rest, frequency of pain and impact on activities had “daily” noted, how often breakthrough medication is needed for pain had “daily” selected, “Pt has Tylenol 500mg (he/she) can take that relieves pain,” noted in the comments section (The OT assessments showed the patient’s history of pain requiring the use of Tylenol. The skilled nurse visit notes showed that the patient had “no pain” and the skilled nurse failed to perform a complete pain history assessment). Review of the SN visit note, dated 02/02/2024, showed, in part: - The pain assessment section showed “no pain” selected; - The musculoskeletal assessment section showed “weakness” selected with an assistive device of a walker; and - The skilled nurse failed to perform a complete assessment of the patient’s history of pain and left upper extremity limitations/restrictions related to fracture. RECORD/PATIENT #5: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/06/2024 with a primary diagnosis of a UTI (urinary tract infection- an illness in any part of the urinary tract, the system of organs that makes urine) and resided in the home when a spouse and adult daughter; - The patient’s daughter was listed as the primary caregiver; and - The SOC (start of care) assessment visit was on 01/06/2024. Review of the SOC visit note dated 01/06/2024, showed, in part: - The patient was discharged from an inpatient rehabilitation hospital or facility within the past 14 days; - The patients inpatient facility diagnosis was Takotsubo syndrome (a temporary heart condition that develops in response to an intense emotional or physical experience); - Additional hospital/facility stay diagnosis, surgeries, and treatments, showed, DM (diabetes mellitus-a disease that result in too much sugar in the blood), GERD (gastroesophageal reflux disease- a chronic disease in which stomach content persistently and regularly flows up into the esophagus), HTN (hypertension- high blood pressure, is when the pressure in the blood vessels is too high), hypothyroid (a condition in which the thyroid gland doesn’t produce enough thyroid hormone), rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), and total knee replacement (a surgical procedure to resurface a knee that is damaged); - Primary diagnosis and other diagnoses section showed the patient’s primary diagnosis listed as UTI with a symptom control rating of 3 (three- Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring). Other diagnoses included: Enterococcus as the cause of diseases classified elsewhere with a symptom control rating of 3, non-STEMI (Non-ST-Elevation Myocardial Infarction-a type of heart attack) with a symptom control rating of 2 (two- symptoms controlled with difficulty, affecting daily functioning, patient needs ongoing monitoring), atherosclerosis (build up a plaque inside the walls of the arteries) heart disease of coronary artery (a blockage in the arteries that supply blood and oxygen to the heart) with symptom control rating of 2, hypertensive heart and chronic kidney disease without heart failure symptom control rating of 2, type 2 diabetes mellitis with diabetic chronic kidney disease symptom control rating 1 (one- symptoms well controlled with current therapy), chronic kidney disease with symptom control rating one, metabolic encephalopathy with a symptom control rating of one, rheumatoid arthritis with a symptom control rating of one, dysphagia with a symptom control rating of one, hyperlipidemia with a symptom control rating of one, hypothyroidism with a symptom control rating of one, GERD with a symptom control rating of 0 (zero- asymptomatic, no treatment needed at this time), long term (current) use of antithrombolytics/antiplatelets (no symptom control rating), acquired absence of other organs (no symptom control rating); - Pertinent medical history and reason for home care/additional diagnosis information included: 12/20/2023 non-stemi, dx (diagnosis) of Takotsubo cardiomyopathy, metabolic encephalopathy (a problem in the brain that is caused by a chemical imbalance in the blood), chronic kidney disease (long standing disease of the kidneys leading to renal failure), uncontrolled hypothyroidism and noncompliance per H&P (history and physical); - The pain assessment section showed, pain rated 5 out of 10, location of mid back, pain caused by arthritis, description of pain was sharp, dull, and cramping, movement and the time of day made pain worse, medication and relaxation relieved pain, frequency of pain and impact on activities had “occasionally” and “infrequently” noted, how often breakthrough medication needed was left blank, and “current pain control medications adequate” was selected (The nurse failed to document what medication was used and/or when/how often) - Urinary assessment section showed “frequent UTI’s” and patient voids without problems; - Urinary history question (M1600), regarding if the patient had been treated for a urinary tract infection in the past 14 days, showed “no” selected (The skilled nurse failed to document why the primary diagnosis was a UTI and history of UTI treatments); - The cardiovascular/respiratory section failed to show documentation of a cardiac assessment related to the Takotsubo cardiomyopathy; - The cardiovascular/respiratory section showed, a cardiac history of heart failure, hypertension, non-STEMI, normal heart sounds, pitting edema to right and left ankle of 3+ (Grade 1+: up to 2mm (millimeter) of depression and rebounds (returns) immediately. Grade 2+: 3-4mm of depression and rebounds in 15 seconds or less. Grade 3+: 5-6mm of depression and rebounds in 60 seconds. Grade 4+: 8mm of depression and rebounds in 2-3 minutes), pitting edema to right and left calf of 2+, lung sounds are clear, and respirations are easy/non-labored; - The musculoskeletal assessment section showed “no deficits” selected (No further documentation of assessment findings to explain how the patient has ambulation limitations without musculoskeletal deficits); - The functional limitations section showed ambulation limitations and the patient required assistance when going up/down stairs or walking long distances (No further documentation to include what type of assistance needed); and - Interventions included daily weights and notify the physician of a weight gain of 5 (five) pound in 7 (seven) days. Review of the SN visit note, dated 01/08/2024, showed, in part: - The urinary assessment section showed, “voids without problems,” selected (The documentation failed to show a history of UTI’s and/or treatment); - The cardiovascular/respiratory section showed, normal heart sounds, dependent edema to right and left feet, pitting edema to right and left ankle of 1+, lung sounds are clear, and respirations are easy/non-labored (the documentation failed to include the patient’s weight); - The musculoskeletal section showed “weakness” selected (the assessment failed to include any further assessment details regarding weakness); and - Interventions/education provided this visit showed, medication, daily weights, elevation of lower extremities to prevent fluid retention (the skilled nurse failed to include an assessment of the patient’s weight and assessment of a daily weight log). Review of the SN visit note, dated 01/12/2024, showed, in part: - The cardiovascular/respiratory section showed dependent edema to right and left feet and respirations are easy/non-labored; - Interventions/education provided this visit showed, the importance of keeping feet elevated to help with dependent edema bilaterally in (his/her) feet and ankles; and - The skilled nurse failed to assess the patient’s weight and daily weight log. Review of the SN visit note, dated 01/16/2024, showed, in part: - The cardiovascular/respiratory section showed dependent edema to right and left feet, pitting edema to right and left ankle of 3+ (the documentation failed to show daily weights being assessed and patient was having increased edema); and - Interventions/education provided this visit showed, keep feet elevated to help with swelling (No documentation of assessment regarding the patient’s knowledge of the importance of daily weight compliance to monitor for the amount of fluid retention). Review of the PT visit note, dated 01/17/2024, showed, in part: - The pain assessment section showed, “no pain,” selected; - The “patient denies pain outside of normal aches and pains and has not taken medication for pain,” (the PT failed to document what the patient’s normal aches and pain were). Review of the PT visit note, dated 01/18/2024, showed, in part: - The pain assessment section showed, “no pain,” selected; - The “Pt has occasional arthritis pain but has not taken medication for it,” was noted in the comments section (No further pain assessment details were documented); - The patients response to skilled care provided, showed, “Pt tolerated treatment fairly well but does seem to be somewhat more SOA (short of air) with activities this date. SpO2 (oxygen saturation) monitored and remained WNL” (within normal limits); and - No further documentation and/or follow up assessment for the shortness of air. Review of the SN visit note, dated 01/19/2024, showed, in part: - The cardiovascular/respiratory section showed, pitting edema to right and left ankle of 1+; - The integumentary section showed, “Pt has a bruise on top of right foot but denies any pain with palpitation” in the comment section, normal skin color, warm and dry, and wounds identified was left blank (No further assessment documentation regarding the bruise and the history of how/when the bruise developed); - Interventions/education provided this visit showed, teaching related to edema of lower extremities bilaterally (the skilled nurse failed to perform an assessment of the patient’s weight during the visit and the daily weight log). Review of the SN visit note, dated 01/22/2024, showed, in part: - The cardiovascular/respiratory section showed, pitting edema to right and left ankle of 2+, respirations are easy/non-labored; - The integumentary section showed, “Recheck of bruise on right ankle area above foot shows improvement in coloration. Pt continues to deny any pain at the site,” normal skin color, warm and dry, and “no” wounds identified (the skilled nurse failed to assess the patient’s history of the bruise); and - Interventions/education provided this visit showed, the importance of keeping legs elevated to promote drainage of edema in bilateral lower extremities (the skilled nurse failed to assess the patient’s weight and daily weight log). Review of the PT visit note, dated 01/22/2024, showed, in part: - The vital signs section showed, “vitals obtained from nursing documentation, as patient was seen by HH (home health) nurse prior to this visit,” noted (The physical therapist failed to assess the patient’s vital signs and documented vital signs that were obtained by another clinician (SN) during a previous visit); - The pain assessment section showed, “no pain,” and “pt denies pain and has not required medication for pain” (the PT failed to perform a complete pain history assessment); and - The documentation failed to show the patient’s history of SOA experienced during the previous therapy visit (on 01/18/2024) and/or if the SOA had resolved. Review of the ST (speech therapy) evaluation visit note, dated 01/22/2024, showed, in part: - The vital signs section was left blank and “vitals taken by SN shortly before ST visit. See SN note,” was noted in the comments (The ST failed to assess the patient’s vital signs); - The assessment section related to the prior level and current functional status was left blank. The comment section for attention span and memory, had “roughly within functional limits. Patient oriented x4 (times), mild memory impairment, patient able to recall 2/3 unrelated words with delay intact.” The comment section of problem solving had “mild deficit” noted (Other areas/systems to assess were left blank); - The pain assessment section showed, “patient denies pain” and pain location had “n/a (not applicable)” (The ST failed to perform a complete assessment of the patient’s pain history); - Treatment/education initiated this visit showed, “clinician educated on memory strategies including writing things down, use of alarms/reminders, rehearsal, self talk. Patient and daughter verbalized understanding,” noted; - The coordination details section showed, informed care team of ST eval only; and - The ST failed to document a complete comprehensive assessment and/or findings during the evaluation visit (The referral records showed, speech therapy treatments included, cognitive training, dysphasia therapy, speech language communication therapy. Goals for speech therapy to address cognition, expression of language, comprehensive, safety awareness and safe swallowing). Review of the SN visit note, dated 01/29/2024, showed, in part: - The cardiovascular/respiratory section showed, pitting edema to right ankle of 2+ and left ankle of 1+ (The skilled nurse failed to assess the patient’s weight and daily weight log); and - The integumentary section showed, the patient had normal skin color, skin was warm and dry, and no wounds were identified (The skilled nurse failed to document a follow-up assessment of the bruise to the top of the patient’s right foot). Review of the SN visit note, dated 02/02/2024, showed, in part: - A PRN (as needed) visit was made due to patient having a fall; - The pain assessment section showed, pain rated a 2 out of 10, location was the left flank, cause of the pain was a fall, description of pain was dull and aching, pain was worse with movement, pain relieved by ice and rest, current pain control medications adequate, and “Pt has fist sized bruising to left flank area from fall earlier in the day, denied increased pain with palpitation. Pt encouraged to place ice on site to help minimize bruising,” was noted in the comment section (The skilled nurse failed to include documentation of the pain control medications and/or history of pain medication use); - The cardiovascular/respiratory section showed, pitting edema to right ankle and left ankle of 3+ selected, “Pt has 2+ edema bilaterally to lower ext (extremities),” dyspnea with moderate exertion and cough (The skilled nurse failed to include further documentation related to the patient having dyspnea with moderate exertion and cough. These are new/not previously documented symptoms); - The integumentary section showed, the patient had normal skin color, the skin was warm and dry, and wounds identified question was left blank; - The wound documentation flowsheet chart showed, wound #1 documented, location of the wound was the left flank, the type of wound was listed as a trauma wound, the wound status showed the wound was closed, and “fist size bruise from fall earlier in the daytime” was noted (No further assessment details were documented); and - The skilled nurse failed to assess the patient’s weight, daily weight log, a follow-up assessment of the bruise to the top of the right foot (identified on 01/19/2024), and measurements of the trauma wound to the left flank. Review of the SN visit note, dated 02/03/2024, showed, in part: - A PRN visit was made due to the patient having a large blister on the right foot; - The pain assessment section showed, “no pain” selected (The skilled nurse failed to perform a complete pain history assessment. The patient had pain to the left flank the previous day due to a fall); - The cardiovascular/respiratory section showed, edema to right ankle and left ankle of 4+, lung sounds are clear, and respirations are easy/non-labored (The skilled nurse failed to assess the patient’s weight, daily weight log, and perform a follow-up assessment and/or documentation of the patient’s history of dyspnea with moderate exertion and cough that was noted during the SN visit the previous day); - The integumentary section showed, the patient had normal skin color, skin was warm and dry, and the wounds identified section was left blank; - The wound documentation flowsheet chart showed, wound #1 documented, location of left flank, the type of wound was listed as a trauma wound, the wound status showed the wound was closed, and “Pt bruising has darkened to a deep purple” (The skilled nurse failed to document the measurement of the bruise); - The wound documentation flowsheet chart showed, wound #2 documented, location of right ankle, the type of wound was listed as a venous ulcer, wound status showed closed, the length was 5 cm (centimeters) and the width was 4 cm, surrounding tissue was shiny with edema, the wound was covered with 4x4’s (gauze) and secured with coban (a cohesive elastic wrap), and “patient has a small egg sized blister on right ankle that is intact and fluid filled at this time. Applied dressing and will recheck on next visit” (The skilled nurse failed to assess the patient’s weight and daily weight log to monitor the amount of fluid retention. The patient’s edema progressed, a fluid filled blister developed, and the patient’s weight was not assessed during the skilled nurse visit); - The interventions/education provided this visit showed, “dressed right ankle/foot explaining to daughter and patient that popping the blister would just open up the wound and make it a higher risk for infection. Explained to let the blister pop on its own and keep it covered. Reminded patient/cg (patient and caregiver) to apply ice to bruising, and to keep feet elevated to decrease swelling of feet and ankles,” (The skilled nurse failed to assess the amount of fluid retention by weighing the patient); and - Plan for next visit showed, assessment for general wellness, vitals, pain, recheck bruising and blister, teaching on wound care, and treatments/procedures of lab draw (The skilled nurse failed to assess and/or document what the lab draw was for and/or related to. The clinical record failed to show orders for lab draws). During an interview on 02/07/2024 that began at 1:15 PM, the Clinical Manager stated that: - Staff should be completing full assessments of the patient’s including the patient’s compliance with physician orders and documenting any noncompliance; - The nurse should be following up with patients regarding pain and vital sign; and - The nurse does a great job but does not always document the best. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted 11/22/2023 with a primary diagnosis of malignant neoplasm of the larynx (cancer of the voice box). Review of the POC dated 11/22/2023 to 01/20/2024, showed in part, under SN endocrine (system that consists of mainly glands that create and release hormones that assist in blood sugar regulation) interventions: Assess/perform/instruct Pt/Pcg (patient/Pt’s care giver): blood glucose testing daily and importance of recording and compliance. Review of the SOC (start of care) OASIS (Outcome and Assessment Information Set; a standardized data collection tool) dated 11/22/2023, SN visit notes dated 11/23/2023, 11/27/2023, 11/30/2023, 12/04/2023, 12/07/2023, 12/11/2023, 12/14/2023, 12/19/2023, 12/21/2023, 01/03/2024, and 01/08/2024 all failed to contain any documentation of any blood sugar results. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that he/she would expect blood glucose results to be documented.”

“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 that each patient’s written individualized plan of care (POC) included safety measures to prevent against injury, functional limitations, patient-specific interventions, and all types of services required, in three of five full records reviewed (Records/Patients #1, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 01/22/2024 with a primary diagnosis of MS (multiple sclerosis- a disease in which the immune system eats away at the protective covering of nerves). Review of the POC dated 01/22/2024 to 03/21/2024 showed, in part: - It failed to contain documentation of the patient having an implanted baclofen pump (a permanently implanted pump that delivers baclofen (medication given to treat muscle spasticity) to the spinal fluid; and - The safety measures portion failed to have anything documented. Observation on 02/02/2024 at 1:30 PM, during the patient’s home visit showed the patient complain of slight discomfort with palpation to abdomen. Per interview conducted during observation, the patient stated that it was just because of the implanted baclofen pump. During an interview on 02/07/2024, starting at 1:15 PM, the clinical manager stated that: - The baclofen pump and dosage should be included on the POC; and - The safety measures on the POC should not be left blank. Findings included: Review of the provider’s undated policy titled, “Care Planning Process,” showed, in part: - In order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems, the agency will utilize data/information gathered during patient assessments in the care planning process; - The patient care plan for therapy services (PT- Physical Therapy, OT- Occupational Therapy, and SLP- Speech Language Pathology) will be: * The Plan of Care CMS #485 (certification/recertification orders): developed and implemented with physician. Demonstrates problems in interventions through physician orders and long range goals identified * Initial Assessment: description of problems and changes. Demonstrates identified problems, interventions, and goals at time of admission * Visit Notes: documents modifications to care/service, current problems, interventions, and short term goals; individualized. Will be revised as problems are identified. Review and revision will be ongoing with each home visit and will be based on patient’s health status, environment and relevant baseline data from assessments to determine current needs, problems, interventions and goals. Will reflect goal evaluation/goal resolution * All initial and ongoing assessments will utilize relevant baseline data to determine patient problems, needs, interventions and goals - The Plan of Care for Skilled Nursing will be: * Initial care plan will be CMS #485 Plan of Care, which is developed and implemented with physician. Demonstrates problems (diagnoses), interventions (physician orders) and long range goals identified * Initial Assessment: description of problems and changes. Demonstrates identified problems, interventions, and goals at time of admission * Visit Notes: documents modifications to care/service, current problems, interventions, and short term goals; individualized. Will be revised as problems are identified. Review and revision will be ongoing with each home visit and will be based on patient’s health status, environment and relevant baseline data from assessments to determine current needs, problems, interventions and goals. Will reflect goal evaluation/goal resolution * All initial and ongoing assessments will utilize relevant baseline data to determine patient problems, needs, interventions and goals; and - Care will be coordinated initially and ongoing among staff providing care. Care planning for each patient will be individualized to include: * Problems and needs * Goals based on problems, needs, conditions, wishes and ability to respond to care or services * Specific care or services to be provided including frequency, type and duration * Implementation of actions and interventions * Review and revision as indicated. Review of the provider’s undated policy titled, “Physicians Verbal Orders,” showed, in part: - Purpose: To document verbal orders received from the patient’s physician; - Drugs and treatments are administered by the agency staff only as ordered by the physician. Only authorized staff receives and record verbal orders. Verbal orders are put in writing and signed and dated by the RN (registered nurse) or qualified therapist responsible for furnishing or supervising the care. Orders are obtained prior to the provision of any care, including changes in the plan of care; - Orders for patient care are obtained from the physician, either verbally or in writing; - Verbal orders may be taken by licensed staff according to agency policy; - All verbal orders must be subsequently signed by the physician; and - When a verbal order is received, the order must be written down, read back to verify order and receive confirmation from individual who gave order. A record of this order is documented on a physician’s supplemental order form. All orders include: * The patient’s name * Physicians name * Date and time the order is taken * The signature of the person taking the order * The specific order(s). RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (left upper arm) and is temporally residing with his/her daughter; and - The SOC (start of care) assessment visit was on 01/08/2024. Review of the POC (plan of care), showed, in part: - The patient has a fractured humerus and wears a sling; - The patient requires a walker to ambulate; - Functional limitations showed endurance listed; - The POC failed to show interventions and/or orders for the sling to the LUE (left upper extremity) and/or mobility restrictions for the LUE; and - Cardiovascular intervention showed, “check PT/INR (PT- Prothrombin time, measures how long it takes for a clot to form in the blood sample. INR- international normalized ratio, is a type of calculation based on PT test results) weekly” and PRN (as needed) starting 01/10/2024 (The POC intervention failed to show who was to check the PT/INR, how the PT/INR was to be checked, and who to report the PT/INR results to). Review of the SOC visit note dated 01/08/2024, showed, in part: - The musculoskeletal section showed the patient had a fracture to left shoulder; - The functional status showed, “walker,” selected for device use prior to current illness, exacerbation, or injury; - The assessment summary section showed a comment that the patient was “alert and oriented elderly (male/female) with fractured humerus in a sling on left side;” and - The activities permitted section showed, no restrictions, up as tolerated, and walker listed. During home visit observation, on 02/05/2024, beginning at 1:30 PM, showed, in part: - The patient’s left arm was in a sling; - The patient reported that he/she was ordered by the doctor to limit the use of his/her left arm and he/she is not to put any weight on the left arm; - The patient reported that he/she received OT services but they (OT) discharged him/her last week because they have done all they can do until the restrictions are discontinued by the doctor; - The PT confirmed that OT discharged the patient until after the patient follows up with the physician and the plan is to begin outpatient therapy after being cleared by the doctor; - The PT confirmed that the patient has restrictions to LUE until his/her follow-up appointment with the doctor; and - The PT was unsure why the POC failed to show the restrictions to the LUE and interventions for the sling. During an interview on 02/06/2024 that at 2:45 PM, the Clinical Manager stated that: - There were no orders received for LUE restrictions and the use of a sling; - If the physician was contacted for orders or clarification, it did not get documented; and - The POC should have included the sling and any restrictions to the patient’s left arm. RECORD/PATIENT #5: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/06/2024 and resided in the home when a spouse and adult daughter; - The patient’s primary diagnosis on the POC showed, UTI (urinary tract infection); - The POC failed to show interventions and/or orders for a UTI; - The referral record showed the patient had a PMH (past medical history) of a UTI in December that he/she was treated for (The referral failed to show the patient had a UTI at the time of the patient’s discharge home); - The patient’s daughter was listed as the primary caregiver; and - The SOC (start of care) assessment visit was on 01/06/2024. During an interview on 02/07/2024, beginning at 1:15 PM, the Clinical Manager stated that: - He/she did not know why the patient’s primary diagnosis was listed as a UTI; - Coding is done by someone else; and - He/she has no clue how the primary diagnosis coding is determined.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure treatments were provided as ordered by the physician, when the staff provided treatments without physician orders in, two of five full records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning Process,” revised 02/08/2022, showed in part: - All disciplines involved in the patient’s care will contribute to the POC (plan of care); - The following factors should be considered during the care planning process: * Individualized patient needs. * Monitoring effectiveness of medications, as appropriate. * Pain and symptom management, as appropriate. - The POC may include, but will not be limited to: * Individualized goals and interventions. * Specific services to be provided. * Medications and treatments. - During each home visit, the clinician will monitor the patient’s response to care against the established POC; and - In the event that the patient is not achieving goals and the POC needs to be altered, the physician will be notified. Review of the provider’s undated policy titled, “Physicians Verbal Orders,” showed, in part: - Purpose: To document verbal orders received from the patient’s physician; - Drugs and treatments are administered by the agency staff only as ordered by the physician. Only authorized staff receives and record verbal orders. Verbal orders are put in writing and signed and dated by the RN (registered nurse) or qualified therapist responsible for furnishing or supervising the care. Orders are obtained prior to the provision of any care, including changes in the plan of care; - Orders for patient care are obtained from the physician, either verbally or in writing; - Verbal orders may be taken by licensed staff according to agency policy; - All verbal orders must be subsequently signed by the physician; and - When a verbal order is received, the order must be written down, read back to verify order and receive confirmation from individual who gave order. A record of this order is documented on a physician’s supplemental order form. All orders include: * The patient’s name. * Physicians name. * Date and time the order is taken. * The signature of the person taking the order. * The specific order(s). RECORD/PATIENT #4: Review of the clinical record, showed in part: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (bone in upper arm) left side and was temporarily residing with his/her daughter; - The referral record showed: * The patient’s history during his/her inpatient admission and the care that was provided. * An inpatient admitting diagnosis of Gastroenteritis (an intestinal infection that causes diarrhea, cramps, nausea, vomiting, and fever). * A discharge summary with discharge to home with self care. * A discharge medication list. * The discharge summary showed, in part, “will order home health and plan for close follow-up next week in clinic we will discuss (his/her) future goals of care,” noted in the hospital course section. * A Home Health Face-To-Face Encounter that showed in part: physical therapy (PT) and occupational therapy (OT) were the home health services needed for weakness, humerus fracture, and gait training. * The referral record failed to include orders for home health services. - The SOC (start of care) assessment visit was completed by a RN (registered nurse) on 01/08/2024; - The clinical record failed to include any orders, including verbal orders, received from the physician to start home health services; - The POC (plan of care) was signed by the physician on 01/16/2024 and failed to include PT and OT services; and - The clinical record failed to include any orders for PT and/or OT. Review of the OT evaluation visit note dated 01/10/2024, showed in part: - The plan of care summary section, showed in part: * Occupational therapy visit frequency of 1x/week x1 week (1 time for 1 week) and 2x/week x3 weeks (two times a week for three weeks). * OT treatment plan showed ADL (activities of daily living) training and home program established. * Care Planning/Coordination showed, care was coordinated with PT. * Coordination details showed, the patient was having difficulty using RW (rolling walker) at home due to LUE (left upper extremity) being NWB (non-weight bearing); * Plan for next visit showed, teach HEP (home exercise program); - The occupational therapist failed to notify the physician and obtain orders for OT services; and - OT did not have plan of care orders that were signed by a physician. Review of the Physical Therapy (PT) evaluation visit note dated 01/10/2024, showed, in part: - The plan of care summary section showed: * Physical therapy visit frequency of 1x1 (1 time for 1 week), 2x3 (two times a week for three weeks), and 1x1; * PT treatment plan showed establish home exercise program, therapeutic exercises, balance training, functional mobilities, and transfer training; * Care Planning/Coordination showed, care was coordinated with the nurse, the PTA (physical therapy assistant), and OT; * Coordination details showed that care was coordinated regarding the patient’s POC; - The physical therapist failed to notify the physician and obtain orders for PT services; and - PT did not have plan of care orders that were signed by a physician. RECORD/PATIENT #5: Review of the clinical record, showed in part: - The patient was admitted to home health services on 01/06/2024 with a primary diagnosis of a UTI (urinary tract infection- an illness in any part of the urinary tract, the system of organs that makes urine) and resided in the home with a spouse and adult daughter; - The referral record showed: * The referral was faxed to the provider on 01/04/2024 with a fax cover sheet that showed the patient had a targeted discharge date of 01/05/2024 and would need physical therapy (PT), occupational therapy (OT), and speech therapy (ST); * The patient’s history during his/her inpatient admission and the care that was provided; * Additional diagnoses included: Metabolic encephalopathy (a problem in the brain that is caused by a chemical imbalance in the blood), Takotsubo cardiomyopathy (a temporary heart condition that develops in response to an intense emotional or physical experience), hypothyroidism (a condition in which the thyroid gland doesn’t produce enough thyroid hormone), recent non-STEMI (Non-ST-Elevation Myocardial Infarction-a type of heart attack), dysphagia, and hypertension (high blood pressure, is when the pressure in the blood vessels is too high); * An inpatient primary diagnosis of nontraumatic brain dysfunction; * A discharge order for patient to discharge to home with home health for PT, OT, and ST services to evaluate and develop a plan of care; * An inpatient progress note with active medications the patient was taking while inpatient; * The referral record failed to include any other orders, including, orders for discharge medications; and * A progress note showed active problems of coronary artery disease, recent NSTEMI, presumed Takotsubo cardiomyopathy and continue medical management with Aspirin, Plavix, Atorvastatin, and metoprolol. - The patient’s daughter was listed as the primary caregiver for the patient; - The SOC (start of care) assessment visit was completed on 01/06/2024; and - The POC (plan of care) was signed by the physician on 01/10/2024. Review of the POC showed, in part: - Skilled nursing services was the only discipline listed; and - The physician signed the POC on 01/10/2024. Review of the Physical Therapy evaluation visit note dated 01/11/2024, showed, in part: - The plan of care section showed: * PT visit frequency of 1x1 (1 time for 1 week), 2x3 (2 times a week for 3 weeks), and 1x1; * PT treatment plan showed, establish a home exercise program, therapeutic exercises, balance training, functional mobilities, and transfer training; - Care was coordinated with nursing, PTA, and OT regarding the patient’s plan of care; and - The clinical record failed to show PT treatment orders and/or a POC signed by a physician. Review of the Occupational Therapy evaluation visit note dated 01/18/2024, showed, in part: - The plan of care section showed: * OT visit frequency of 1x/week (1 time for 1 week), 2x/week x3weeks (2 times a week for 3 weeks) * OT treatment plan showed, establish a home exercise program and ADL (activities of daily living) training - Care was coordinated with PT; and - The clinical record failed to show OT treatment orders and/or a POC signed by a physician. Review of the SN visit note, dated 02/03/2024, showed, in part: - A PRN visit was made due to the patient having a large blister on the right foot; - The wound documentation flowsheet chart showed, wound #1 documented, location of left flank, the type of wound was listed as a trauma wound, the wound status showed the wound was closed, and “Pt bruising has darkened to a deep purple” (The skilled nurse failed to document the measurement of the bruise); - The wound documentation flowsheet chart showed, wound #2 documented, location of right ankle, the type of wound was listed as a venous ulcer, wound status showed closed, the length was 5 cm (centimeters) and the width was 4 cm, surrounding tissue was shiny with edema, the wound was covered with 4x4’s (gauze) and secured with coban (a cohesive elastic wrap), and “patient has a small egg sized blister on right ankle that is intact and fluid filled at this time. Applied dressing and will recheck on next visit” (The skilled nurse failed to assess the patient’s weight and daily weight log to monitor the amount of fluid retention. The patient’s edema progressed, a fluid filled blister developed, and the patient’s weight was not assessed during the skilled nurse visit); - The interventions/education provided this visit showed, “dressed right ankle/foot explaining to daughter and patient that popping the blister would just open up the wound and make it a higher risk for infection. Explained to let the blister pop on its own and keep it covered. Reminded patient/cg (patient and caregiver) to apply ice to bruising, and to keep feet elevated to decrease swelling of feet and ankles”; and - The skilled nurse provided wound care treatment and educated the patient and caregiver to apply ice without obtaining orders from the physician. During an interview on 02/06/2024 that began at 2:45 PM, RN A stated that: - He/she did not obtain orders from the physician prior to providing treatment; - He/she just puts the orders in and faxes them to the physician for signature; and - No orders were received for the patient to apply ice. During an interview on 02/07/2024 that began at 10:20 AM, the Clinical Manager stated that: - There were no orders received with the referral; - Staff look at the patients discharge papers that the patient was sent home with to see what the discharge orders are; - Staff are supposed to call the PCP (primary care provider) and get verbal orders but staff forget to do that; - An RN always completes the SOC visits and if the patient has a nursing need the SN obtains verbal orders for nursing; - No verbal orders were received for the RN to do the SOC visits; - The SN is the only discipline on the POC and signed by the physician; and - PT and OT should be on there with the SN and they are not; - PT and OT do not have a POC signed by a physician; and - No PT or OT verbal orders for treatment have been received and entered into the patients records.”

“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 to changes in the patient’s condition or needs, to clarify orders and/or receive orders, in four of five full records reviewed (Records/Patients #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 01/16/2024 with a primary diagnosis of a fractured sacrum (a triangular shaped bone that lies at the bottom of the spine located just above the tailbone). Review of the POC dated 01/16/2024 to 03/15/2024 failed to include Tylenol documented as a medication the patient was to be taking. Review of the PT (physical therapy) evaluation, dated 01/18/2024, showed under the care coordination section, in part: - Conferenced with SN (skilled nursing); and - Regarding PT POC, SN: Patient states he/she takes Tylenol. This needs reconciled on med sheet. Review of an Inter-Office Communication Note, dated 01/18/2024, documented by the PT, showed: - The patient takes Tylenol; and - This (patient taking Tylenol) needs reconciled in medication sheet. Further review of the clinical record failed to show any communication with the physician documented regarding the patient taking Tylenol which failed to be included in the POC. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that the process generally was: - PT generally would put a note in the Inter-Office Communication, and called or texted and the nurse followed up; and - The nurse should have taken care of this. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted with a primary diagnosis of malignant neoplasm of the larynx (cancer of the voice box). Review of the POC dated 11/22/2023 to 01/20/2024 showed in part, under the nutritional requirements: Diet NPO (nothing by mouth). Review of a ST evaluation dated 12/05/2023, showed in part, the following documentation: - Patient noncompliant with prescribed diet of NPO; - Patient admitted to eating soft/pureed foods; - Patient educated on risks of aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed) and importance of compliance with prescribed diet; and - It failed to show any communication with the physician documented regarding the patient’s noncompliance with their prescribed NPO diet. Review of a ST visit note dated 12/22/2023, showed in part, the following documentation under the subjective portion of the visit note: - Upon arrival to the patient’s home, the patient was at the kitchen sink rinsing their mouth after they had finished a piece of toast for breakfast; - Patient reports he/she took quarter sized bites; - Patient reported he/she had been eating hotdogs, chips, and sausage- Patient assured the ST that they were small bites that were adequately masticated (chewed) prior to swallowing; - While eating chips he/she admitted occasionally finding food particles around tracheostomy (a surgical opening in the airway in the windpipe to facilitate breathing) dressing; and - Patient stated he/she “feels stuff build up in his/her lungs” but speculated this had to do with their COPD (Chronic Obstructive Pulmonary Disease- a group of lung diseases that block airflow and make it difficult to breathe) and patient has a follow up visit with their doctor this afternoon; and - It failed to show any communication with the physician documented regarding the patient’s noncompliance with their prescribed NPO diet. Review of a ST visit note dated 01/04/2024, showed in part, the following documentation under the subjective portion of the visit note: - Patient reported he/she was eating solid foods one to two times a day; - This includes cereal, sausage, hotdogs, brats, mashed potatoes, et cetera; - He/she stated that they avoided stringy foods, specifically green beans, due to a previous experience with the bean of a green bean getting stuck in their tracheostomy; - The ST asked the patient who cleared them for food PO (by mouth) the patient stated that they believed they were able to tolerate solid foods, but admitted they were not cleared by a physician; - The patient reported that they were finding food particles in their tracheostomy dressing less frequently than reported at the last visit; and - It failed to show any communication with the physician documented regarding the patient’s noncompliance with their prescribed NPO diet. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that: - He/she would expect the diet noncompliance to be communicated to the PCP; and - He/she was sure the PCP was notified. Findings included: Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed, in part: - Agency staff members regularly communicate and document to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care; - The Agency must: * Assure communication with all physicians involved in the plan of care * Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient * 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 - Staff provides the physician with patient information on an ongoing basis; and - The clinical manager provides oversight of all patient care services, including coordinating patient care. RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (left upper arm) and is temporally residing with his/her daughter; - The referral record showed: * The patient’s history during his/her inpatient admission and the care that was provided * An inpatient admitting diagnosis of Gastroenteritis (an intestinal infection that causes diarrhea, cramps, nausea, vomiting, and fever) * A discharge summary with discharge to home with self care * A discharge medication list * The discharge summary showed, in part, “will order home health and plan for close follow-up next week in clinic we will discuss (his/her) future goals of care,” noted in the hospital course section * A Home Health Face-To-Face Encounter that showed, in part, physical therapy and occupational therapy were the home health services needed for weakness, humerus fracture, and gait training * The referral record failed to include orders for home health services - The SOC (start of care) assessment visit was completed by a RN (registered nurse) on 01/08/2024; - The clinical record failed to include any orders, including verbal orders, received by the physician to start home health services; and - The POC (plan of care) was signed by the physician on 01/16/2024. Review of the SOC visit note dated 01/08/2024, showed, in part: - The drug regimen review showed issues were identified and the physician was notified of the medication issues (The skilled nurse failed to include documentation of what the issues identified were and the Prescribed/recommended actions included); - The musculoskeletal section showed the patient had a fracture to left shoulder; - The activities permitted section showed, no restrictions, up as tolerated, and walker listed (The skilled nurse failed to notify the physician to confirm/clarify if the patient had any activity restrictions related to the left arm fracture); and - The assessment summary section showed a comment that the patient was “alert and oriented elderly (male/female) with fractured humerus in a sling on left side” noted (The skilled nurse failed to notify the physician to receive orders for the sling to the left arm). Review of a Medication Issue Communication/Order document, dated 01/10/2024, showed, in part: - A drug interactions report showing the patient’s drug to drug interactions; - Stop medication(s) showed, acetaminophen was written (Also known as Tylenol, which is an analgesic medication that is used to treat minor aches and pains, and reduce fever); - The physician signed and dated it on 01/10/2024; and - It was faxed to the home health agency on 01/10/2024 at 2:41 PM. Review of the Occupational Therapy (OT) evaluation visit note dated 01/10/2024, showed, in part: - The musculoskeletal assessment section showed, “Patient is NWB (non-weightbearing) with LUE (left upper extremity) and has standard RW (rolling walker) so difficulty with balance during ambulation,” noted; - The patient’s LUE was in a sling due to a fractured humerus; - Activities permitted showed NWB LUE; - The assessment summary section showed, “patient with significant decline in ADL (activities of daily living) status due to multiple hospitalizations and patient is NWB on LUE and wearing a sling. Patient had appointment with orthopedic doctor for L (left) shoulder on 1/12/24 but this has been cancelled due to the weather;” - The plan of care summary section showed: * Occupational therapy visit frequency of 1x/week x1 week (1 time for 1 week) and 2x/week x3 weeks (two times a week for three weeks) * OT treatment plan showed ADL training and home program established * Care Planning/Coordination showed, care was coordinated with PT (physical therapy) * Coordination details showed, the patient is having difficulty using RW at home due to LUE is NWB * Plan for next visit showed, teach HEP (home exercise program); and - The occupational therapist failed to notify the physician and receive orders for the plan of care. Review of the Physical Therapy (PT) evaluation visit note dated 01/10/2024, showed, in part: - The patient had difficulty walking related to LUE fracture; - The patient had 2+ edema to BLE (bilateral lower extremities); - Activities permitted showed NWB LUE; - The plan of care summary section showed: * Physical therapy visit frequency of 1x1 (1 time for 1 week), 2x3 (two times a week for three weeks), and 1x1; * PT treatment plan showed establish home exercise program, therapeutic exercises, balance training, functional mobilities, and transfer training * Care Planning/Coordination showed, care was coordinated with the nurse, the PTA (physical therapy assistant), and OT * Coordination details showed that care was coordinated regarding the patient’s POC; and - The physical therapist failed to notify the physician regarding the evaluation, the patient’s edema, and receive orders for the plan of care. Review of the Occupational Therapy visit note dated 01/16/2024, that began at 9:15 AM and ended at 10:30 AM, showed, in part: - The pain section had pain rated 6 out of 10, pain location of right bottom (buttocks), left shoulder and both knees listed, description was dull cramping pain, pain is worse with movement, sitting on sore (buttocks wound), and walking, pain relieved with medications and rest, frequency of pain and impact on activities had “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “majority of day, depending on activity” noted, and “Pt is using barrier cream on sore on bottom. Nurse states (he/she) will bring some cream and different dressing for it. Pt is taking 500mg Tylenol 2 tabs 2x/day for shoulder and knee pain” noted in the comments section; and - The OT failed to notify the physician regarding the patient’s pain, the patient’s continued use of Tylenol for pain, and the need for OT POC orders. Review of the SN (skilled nurse) visit note, dated 01/16/2024, that began at 10:15 AM and ended at 11:00 AM, showed, in part: - The patient had a heart rate of 100 beats/minute (beats per minute) with an irregular rhythm; and - The skilled nurse failed to notify the physician regarding the new onset of an irregular heart rhythm. Review of the Physical Therapy visit note dated 01/17/2024, showed, in part: - The visit was completed by a PTA (physical therapy assistant); - The vital signs section showed the patient’s blood pressure reading as 130/100; - The pain section showed, pain rated 3 out of 10 (0 being no pain and 10 being the worst pain), pain location of both knees and left shoulder, pain description was aching, pain relieved with medications and rest, and “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “Pt took Tylenol 500mg (milligrams), 2 tabs (tablets) at 1600 (4:00 PM)” noted; - The care planning/coordination section showed, care was coordinated with the PT (physical therapist) regarding the patient’s progress towards goals (The documentation failed to show that care was coordinated with the physician); and - The PTA failed to notify the physician of the patient’s abnormal blood pressure reading and the patient’s continued use of Tylenol. Review of the Occupational Therapy visit note dated 01/23/2024, showed, in part: - The pain section showed pain rated 6 out of 10, pain location of bottom, both knees and left shoulder, description was dull, aching, throbbing pain, pain is worse with movement, pain relieved with medications and rest, frequency of pain and impact on activities had “daily” noted, how often breakthrough medication is needed for pain had 2-3 times/day selected, “Pt currently takes 500mg Tylenol 2 tabs 2x/day and it helps relieve pain,” noted in the comments section (The skilled nurse failed to assess the patient’s complete pain history, only documenting “no pain” during the SN visit the previous day); - The patient’s response to skilled care provided this visit showed, “pt tolerated well, although pt is not making progress towards ADL goals at this time d/t (due to) poor standing balance and limited motion to LUE;” and - The OT failed to notify the physician regarding the patient’s pain, the continued use of Tylenol, the need for OT POC orders, and the patient’s lack of progress towards goals. Review of the Occupational Therapy visit note dated 01/30/2024, showed, in part: - The visit was completed by the OTA (occupational therapy assistant); - The pain section showed pain rated 5 out of 10, pain location of bottom, both knees and left shoulder, description was dull, aching, throbbing pain, pain is worse with movement, pain relieved with medications and rest, frequency of pain and impact on activities had “daily” noted, how often breakthrough medication is needed for pain had “daily” selected, “Pt has Tylenol 500mg (he/she) can take that relieves pain,” noted in the comments section; and - The OTA failed to notify the physician regarding the continued use of Tylenol. During an interview on 02/07/2024 that began at 10:20 AM, the Clinical Manager stated that: - There were no orders received with the referral; - Staff look at the patients discharge papers that the patient was sent home with to see what the discharge orders are; - Staff are supposed to call the PCP (primary care provider) and get verbal orders but staff forget to do that; - An RN always completes the SOC visits and if the patient has a nursing need the SN obtains verbal orders for nursing; - No verbal orders were received for the RN to do the SOC visit; - The staff should document any non-compliance and report it to the physician; and - The physician should have been notified of the patient’s continued use of Tylenol. RECORD/PATIENT #5: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/06/2024 with a primary diagnosis of a UTI (urinary tract infection- an illness in any part of the urinary tract, the system of organs that makes urine) and resided in the home when a spouse and adult daughter; - The referral record showed: * The referral was faxed to the provider on 01/04/2024 with a fax cover sheet that showed the patient had a targeted discharge dare of 01/05/2024 and would need PT, OT, and ST * The patient’s history during his/her inpatient admission and the care that was provided * Additional diagnoses included: Metabolic encephalopathy (a problem in the brain that is caused by a chemical imbalance in the blood), Takotsubo cardiomyopathy (a temporary heart condition that develops in response to an intense emotional or physical experience), hypothyroidism (a condition in which the thyroid gland doesn’t produce enough thyroid hormone), recent non-STEMI (Non-ST-Elevation Myocardial Infarction-a type of heart attack), dysphagia, and hypertension (high blood pressure, is when the pressure in the blood vessels is too high) * An inpatient primary diagnosis of nontraumatic brain dysfunction * A discharge order for patient to discharge to home with home health for PT, OT, and ST services to evaluate and develop a plan of care * An inpatient progress note with active medications the patient was taking while inpatient * The referral record failed to include any other orders, including, orders for discharge medications * A progress note showed active problems of coronary artery disease, recent NSTEMI, presumed Takotsubo cardiomyopathy and continue medical management with Aspirin, Plavix, Atorvastatin, and metoprolol - The patient’s daughter was listed as the primary caregiver for the patient; - The SOC (start of care) assessment visit was completed on 01/06/2024; and - The POC (plan of care) was signed by the physician on 01/10/2024. Review of the SOC visit note dated 01/06/2024, showed, in part: - The SOC visit was conducted by a RN (The clinical record failed to show an order for a skilled nurse to evaluate and develop a plan of care); - The drug regimen review showed issues were identified and the physician was notified of the medication issues (The skilled nurse failed to include documentation of what the issues identified were and the Prescribed/recommended actions included); and - The cardiovascular/respiratory section showed, a cardiac history of heart failure, hypertension, non-STEMI, normal heart sounds, pitting edema to right and left ankle of 3+ (Grade 1+: up to 2mm (millimeter) of depression and rebounds (returns) immediately. Grade 2+: 3-4mm of depression and rebounds in 15 seconds or less. Grade 3+: 5-6mm of depression and rebounds in 60 seconds. Grade 4+: 8mm of depression and rebounds in 2-3 minutes), pitting edema to right and left calf of 2+ (The SN failed to notify the physician regarding the edema). Review of the medication profile, showed, in part: - Aspirin (used to reduce the risk of heart attack) and Atorvastatin (treats high cholesterol and triglyceride levels which may reduce the risk of stroke, heart attack, and heart and blood vessel problems) was not listed on the medication profile (The were in the referral record for medications the patient was taking); and - The skilled nurse failed to document the physician was notified to clarify the medication discrepancies and obtain medication orders. Review of the SN visit note, dated 01/08/2024, showed, in part: - The cardiovascular/respiratory section showed, dependent edema to right and left feet, pitting edema to right and left ankle of 1+ (The SN failed to notify the physician regarding the patient’s edema); and - The skilled nurse failed to notify the physician regarding the edema. Review of the Physical Therapy evaluation visit note dated 01/11/2024, showed, in part: - The plan of care summary section showed: * Physical therapy visit frequency of 1x1, 2x3, and 1x1; * PT treatment plan showed, establish home exercise program, therapeutic exercises, balance training, functional mobilities, and transfer training * Care Planning/Coordination showed, care was coordinated with the nurse and the PTA regarding the patient’s POC; and - The physical therapist failed to notify the physician regarding the evaluation and receive orders for the plan of care. Review of the SN visit note, dated 01/12/2024, showed, in part: - The cardiovascular/respiratory section showed dependent edema to right and left feet; and - The skilled nurse failed to notify the physician regarding the edema. Review of the SN visit note, dated 01/16/2024, showed, in part: - The cardiovascular/respiratory section showed dependent edema to right and left feet, pitting edema to right and left ankle of 3+; and - The SN failed to notify the physician of the edema. Review of the PT visit note, dated 01/18/2024, showed, in part: - The visit was completed by a PTA; - The patient’s response to skilled care provided this visit, showed, “Pt tolerated treatment fairly well but does seem to be somewhat more SOA (short of air) with activities this date. SpO2 (oxygen saturation) monitored and remained WNL” (within normal limits); and - The PTA failed to notify the physician of the increased SOA. Review of the Occupational Therapy evaluation visit note dated 01/18/2024, showed, in part: - The patient would benefit from UB (upper body) general strengthening/endurance on an outpatient basis - OT provided UE (upper extremity) general strengthening exercises; - the patient was able to complete all exercises with verbal cueing and verbalized understanding of HEP (home exercise program) at this time; - The care planning/coordination of care section showed that physical therapy was informed of this was an evaluation only (no further OT needed) and UE HEP program was established; and - The occupational therapist failed to notify the physician regarding the evaluation visit and the recommendations of the patient benefitting from OT on an outpatient basis. Review of the SN visit note, dated 01/19/2024, showed, in part: - The cardiovascular/respiratory section showed, pitting edema to right and left ankle of 1+; - The integumentary section showed, “Pt has a bruise on top of right foot but denies any pain with palpitation” in the comment section, normal skin color, warm and dry, and wounds identified was left blank; and - The SN failed no notify the physician of the edema and bruise to the patient’s right foot. Review of the SN visit note, dated 01/22/2024, showed, in part: - The cardiovascular/respiratory section showed, pitting edema to right and left ankle of 2+; - The integumentary section showed, “Recheck of bruise on right ankle area above foot shows improvement in coloration. Pt continues to deny any pain at the site” was noted; - The SN failed to notify the physician regarding the edema and right ankle bruise. Review of the SN visit note, dated 01/29/2024, showed, in part: - The cardiovascular/respiratory section showed, pitting edema to right ankle of 2+ and left ankle of 1+; and - The SN failed to notify the physician of the edema. Review of the SN visit note, dated 02/02/2024, showed, in part: - A PRN (as needed) visit was made due to patient having a fall; - The pain assessment section showed, pain rated a 2 out of 10, location was the left flank, cause of the pain was a fall, description of pain was dull and aching, pain was worse with movement, pain relieved by ice and rest, current pain control medications adequate, and “Pt has fist sized bruising to left flank area from fall earlier in the day, denied increased pain with palpitation. Pt encouraged to place ice on site to help minimize bruising,” was noted in the comment section; - The cardiovascular/respiratory section showed, pitting edema to right ankle and left ankle of 3+ selected, “Pt has 2+ edema bilaterally to lower ext (extremities),” dyspnea with moderate exertion and cough; - The wound documentation flowsheet chart showed, wound #1 documented, location of the wound was the left flank, the type of wound was listed as a trauma wound, the wound status showed the wound was closed, and “fist size bruise from fall earlier in the daytime” was noted; - The primary care provider was notified of the fall; and - The skilled nurse failed to notify the physician of the patient’s edema, dyspnea with moderate exertion, cough, and pain from the fall. Review of a communication note, received from the primary providers office, dated 02/02/2024, showed, in part: - The home health nurse contacted the provider to report the patient had a fall and bumped his/her left flank; - There was a softball size lump on his/her left flank that was non-tender; - The patient does not have any pain in the area and vitals are normal (The patient did have pain in the area); - If additional tenderness develops in the area, an ultrasound will be done; and - The SN failed to inform the physician that the patient had edema to bilateral lower extremities, dyspnea with moderate exertion, cough, and pain to left flank. Review of the SN visit note, dated 02/03/2024, showed, in part: - A PRN visit was made due to the patient having a large blister on the right foot; - The cardiovascular/respiratory section showed, edema to right ankle and left ankle of 4+; - The wound documentation flowsheet chart showed, wound #1 documented, location of left flank, the type of wound was listed as a trauma wound, the wound status showed the wound was closed, and “Pt bruising has darkened to a deep purple” (The skilled nurse failed to document the measurement of the bruise); - The wound documentation flowsheet chart showed, wound #2 documented, location of right ankle, the type of wound was listed as a venous ulcer, wound status showed closed, the length was 5 cm (centimeters) and the width was 4 cm, surrounding tissue was shiny with edema, the wound was covered with 4x4’s (gauze) and secured with coban (a cohesive elastic wrap), and “patient has a small egg sized blister on right ankle that is intact and fluid filled at this time. Applied dressing and will recheck on next visit” (The skilled nurse failed to assess the patient’s weight and daily weight log to monitor the amount of fluid retention. The patient’s edema progressed, a fluid filled blister developed, and the patient’s weight was not assessed during the skilled nurse visit); - The interventions/education provided this visit showed, “dressed right ankle/foot explaining to daughter and patient that popping the blister would just open up the wound and make it a higher risk for infection. Explained to let the blister pop on its own and keep it covered. Reminded patient/cg (patient and caregiver) to apply ice to bruising, and to keep feet elevated to decrease swelling of feet and ankles;” and - The skilled nurse failed to notify the physician to report the edema and fluid filled blister. The SN failed to receives physician orders to cover the blister with 4x4 gauze and coban and orders for the patient to apply ice to bruising. Review of a communication note, received from the primary providers office, dated 02/06/2024, showed, in part: - The home health nurse contacted the provider to report the patient’s critical AST (Aspartate Aminotransferase Test- is a blood test that looks for liver damage) lab value of 144 (The lab results showed the normal range was 15-46 units per liter); - The physician ordered the patient to stop taking his/her Atorvastatin; and - The SN failed to inform the physician that the medication was not on the medication profile (The referral showed the patient was taking Atorvastatin but the medication profile failed to include it at the SOC. The SN failed to clarify medication discrepancies with the provider on admission). During an interview on 02/06/2024 that began at 3:10 PM, RN A stated that: - He/she did not notify the physician of the patient’s edema; - Only the fall was reported to the physician; - The pain was not reported to the physician because the patient has chronic pain and uses a heating pad (his/her) back when sitting down; and - No orders were received for the patient to apply ice or heat. During an interview on 02/07/2024 that began at 1:15 PM, the Clinical Manager stated that: - The PCP should be called after the initial evaluation visits to confirm the plan of care and to clarify and discrepancies; - The medications are reviewed on the SOC and discrepancies should be clarified with the physician and documented; and - The physician should always be notified when a patient has a change in condition or an abnormal assessment finding.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on policy review, record review, and interview, the provider failed to integrate orders from all physicians involved in the plan of care (POC), to assure that coordination of all services and interventions were provided to the patient in, one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed, in part: - Agency staff members regularly communicate and document to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care; - The Agency (provider) must: * Assure communication with all physicians involved in the plan of care * Integrate orders from all physicians involved in the POC to assure the coordination of all services and interventions provided to the patient * 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 - Staff provides the physician with patient information on an ongoing basis; and - The clinical manager provides oversight of all patient care services. Oversight includes: * Coordinating patient care; * Coordinating referrals; * Ensuring that patient needs are continually assessed; and * Ensuring the development, implementation and updates of the individualized plan of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted 11/21/2023 with a primary diagnosis of malignant neoplasm of the larynx (cancer of the voice box). Review of the referral information, dated 11/20/2023 from an acute care hospital, showed in part, disposition: anticipate home with HH (home health) and PT (physical therapy) in AM if tolerating TF (tube feeding). Review of the updated referral information, dated 11/21/2023 from an acute care hospital, showed in part, a face to face completed and electronically signed by the patient’s inpatient physician, with disciplines requested: Skilled Nursing (SN) and physical therapy. Review of the POC dated 11/22/2023 to 01/20/2024 showed: - SN two times a week for four weeks; and - The POC failed to include orders for physical therapy. Review of the physical therapy evaluation dated 12/07/2023, showed in part: - Interventions, goals, rehab potential and discharge planning; - The CARE COORDINATION section of the visit was marked with: physician contacted with assessment findings and approved orders, discipline and frequency; and - The evaluation failed to be signed by the PCP (primary care physician). Further review of the clinical record showed: - An ambulatory referral/order for speech therapy, dated 11/28/2023, signed by a referring PA-C (Certified physician assistant). - A Speech/Language Pathology evaluation dated 12/05/2023, showed in part: * Interventions, goals, rehab potential and discharge planning; * The CARE COORDINATION section of the visit note failed to include coordination with the physician for assessment findings, approval of orders, discipline and frequency of orders; and - The evaluation visit failed to be signed by the PCP. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that: - There was an ambulatory referral order for ST, and provided a copy of the order; - He/She did not see where the ambulatory referral order for ST was communicated with the PCP and approval obtained; and - He/she would expect the PCP to be notified of the order received for ST.”

“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, and interview, the home health provider failed to coordinate care delivery to meet the patient’s needs, between all individuals involved in the patient’s care, as well as the patient and/or caregiver(s) in, three of five full records reviewed (Records/Patients #2, #4, and #5). This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 01/16/2024 with a primary diagnosis of a fractured sacrum (a triangular shaped bone that lies at the bottom of the spine located just above the tailbone). Review of the POC dated 01/16/2024 to 03/15/2024 failed to include Tylenol documented as a medication the patient was to be taking. Review of the PT (physical therapy) evaluation, dated 01/18/2024, showed under the care coordination section, in part: - Conferenced with SN (skilled nursing); and - Regarding PT POC, SN: Patient states he/she takes Tylenol, this needs reconciled on med sheet. Review of an Inter-Office Communication Note, dated 01/18/2024, documented by the PT, showed: - The patient takes Tylenol; and - This (patient taking Tylenol) needs reconciled in medication sheet. Further review of the clinical record failed to show any follow up documentation with the PCP regarding the patient taking Tylenol which failed to be included in the POC. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that the process generally was: - PT generally would put a note in the Inter-Office Communication, and called or texted and the nurse followed up; and - The nurse should have taken care of this. Findings included: Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed, in part: - Agency staff members regularly communicate and document to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care; - The Agency must: * Assure communication with all physicians involved in the plan of care * Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient * 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 - Staff provides the physician with patient information on an ongoing basis; and - The clinical manager provides oversight of all patient care services, including coordinating patient care. Review of the provider’s undated policy titled, “Care Planning Process,” showed, in part: - In order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems, the agency will utilize data/information gathered during patient assessments in the care planning process; - All initial and ongoing assessments will utilize relevant baseline data to determine patient problems, needs, interventions and goals; - Care will be coordinated initially and ongoing among staff providing care; and - Care planning for each patient will be individualized to include: * Problems and needs * Goals based on problems, needs, conditions, wishes and ability to respond to care or services * Specific care or services to be provided including frequency, type and duration * Implementation of actions and interventions * Review and revision as indicated. RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (left upper arm) and is temporally residing with his/her daughter; and - The SOC (start of care) assessment visit was on 01/08/2024. Review of the SOC visit note dated 01/08/2024, showed, in part: - The drug regimen review showed issues were identified and the physician was notified of the medication issues; - The skilled nurse failed to include documentation of what the issues identified were and the prescribed/recommended actions included; and - The SN failed to document coordination of care with the physician, PT, and/or OT, regarding the SOC assessment findings. Review of a Medication Issue Communication/Order document, dated 01/10/2024, showed, in part: - A drug interactions report showing the patient’s drug to drug interactions; - Stop medication(s) showed, acetaminophen was written (Also known as Tylenol, which is an analgesic medication that is used to treat minor aches and pains, and reduce fever); - The physician signed and dated it on 01/10/2024; and - It was faxed to the home health agency on 01/10/2024 at 2:41 PM. Review of the medication profile showed, Acetaminophen listed, with a discontinued date of 01/10/2024. Review of the Occupational Therapy evaluation visit note dated 01/10/2024, showed, in part: - The pain section had pain rated 6 out of 10 (0 being no pain and 10 being the worst pain), pain location of both knees and left shoulder, description was “shooting” pain, pain worse with movement, pain relieved with medications and rest, “impacts patient mobility and ability to perform ADL (activities of daily living) tasks” was noted in the impact on activities question, breakthrough medication needed for pain had “less than daily” selected, and the comment section had “Patient takes Tylenol 1xday (one time per day) with good pain relief” noted (The skilled nurse failed to assess the patient’s history of pain, what exacerbates pain, and interventions to relieve pain, including the use of Tylenol); - The musculoskeletal assessment section showed, “Patient is NWB (non-weightbearing) with LUE (left upper extremity) and has standard RW (rolling walker) so difficulty with balance during ambulation” (The clinical record failed to show coordination of care with the skilled nurse and/or PT regarding the patient being NWB to the LUE and/or where the OT obtained the information from); and - The occupational therapist failed to inform the SN of the patient’s pain and continued use of Tylenol. Review of the Occupational Therapy visit note dated 01/16/2024, that began at 9:15 AM and ended at 10:30 AM, showed, in part: - The pain section had pain rated 6 out of 10, pain location of right bottom (buttocks), left shoulder and both knees listed, description was dull cramping pain, pain is worse with movement, sitting on sore (buttocks wound), and walking, pain relieved with medications and rest, frequency of pain and impact on activities had “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “majority of day, depending on activity” noted, and “Pt is using barrier cream on sore on bottom. Nurse states (he/she) will bring some cream and different dressing for it. Pt is taking 500mg Tylenol 2 tabs 2x/day for shoulder and knee pain” noted in the comments section; and - The care planning/coordination section had “spoke to SN (skilled nurse) regarding pts sore and HR;” and - The OT failed to inform the SN that the patient had pain and the continued use ofTylenol. Review of the Physical Therapy visit note dated 01/17/2024, showed, in part: - The visit was completed by a PTA (physical therapy assistant); - The vital signs section showed the patient’s blood pressure reading as 130/100; - The pain section showed, pain rated 3 out of 10 (0 being no pain and 10 being the worst pain), pain location of both knees and left shoulder, pain description was aching, pain relieved with medications and rest, and “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “Pt took Tylenol 500mg (milligrams), 2 tabs (tablets) at 1600 (4:00 PM)” noted; - The care planning/coordination section had the PT (physical therapist) was notified of the patient’s progress towards goals; and - The PTA failed to coordinate care with the patient’s SN regarding the high blood pressure, pain, and continued use of Tylenol. Review of the Occupational Therapy visit note dated 01/23/2024, showed, in part: - The pain section showed pain rated 6 out of 10, pain location of bottom, both knees and left shoulder, description was dull, aching, throbbing pain, pain is worse with movement, pain relieved with medications and rest, frequency of pain and impact on activities had “daily” noted, how often breakthrough medication is needed for pain had 2-3 times/day selected, “Pt currently takes 500mg Tylenol 2 tabs 2x/day and it helps relieve pain,” noted in the comments section; - The patient’s response to skilled care provided this visit showed, “pt tolerated well, although pt is not making progress towards ADL goals at this time d/t (due to) poor standing balance and limited motion to LUE;” - The care planning/coordination section had care coordination with PT regarding pts progress/lack of progress towards goals; and - The OT failed to coordinate care with the SN regarding the patient’s continued pain, Tylenol use, and lack of progress towards goals. Review of the Physical Therapy visit note dated 01/30/2024, showed, in part: - The care planning/coordination section showed that care was coordinated with the PTA regarding the patient having an ortho (orthopedic) appointment for “shoulder” or “knee” on 02/09/2024 and discharge plan for next week; and - The PT failed to coordinate care with the SN regarding the patient’s doctors appointment and the plan to discharge the patient from PT services. Review of the Occupational Therapy visit note dated 01/30/2024, showed, in part: - The visit was completed by the OTA (occupational therapy assistant); - The pain section showed pain rated 5 out of 10, pain location of bottom, both knees and left shoulder, description was dull, aching, throbbing pain, pain is worse with movement, pain relieved with medications and rest, frequency of pain and impact on activities had “daily” noted, how often breakthrough medication is needed for pain had “daily” selected, “Pt has Tylenol 500mg (he/she) can take that relieves pain,” noted in the comments section; - The discharge planning section showed, OT to d/c or place pt (patient) on hold next visit; and - The OTA failed to inform the SN of the patient’s pain, Tylenol use, and plan to discharge the patient from OT services. During home visit observation on 02/05/2024, beginning at 1:30 PM, showed, in part: - The patient reported that he/she received OT services but they (OT) discharged him/her last week because they have done all they can do until the restrictions are discontinued by the doctor; - The PT confirmed that the patient has restrictions to LUE until his/her follow-up appointment with the doctor; and - The PT confirmed that OT discharged the patient until after the patient follows up with the physician and the plan is to begin outpatient therapy after being cleared by the doctor. During an interview on 02/06/2024 that at 2:15 PM, RN A stated that: - PT and OT never contacted him/her regarding the patients continued use of Tylenol; - He/she was unaware that the patient had been discharged from OT services; and - He/she was never notified by PT or OT regarding the patient having pain. During an interview on 02/06/2024 that at 2:45 PM, the Clinical Manager stated that: - He/she was unaware that OT discharged the patient; - He/she was unable to find any record of OT coordinating care regarding discharge plans to anyone; and - Sometimes coordination is done by secured text messaging and staff do not always document it in the patient’s chart. RECORD/PATIENT #5: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/06/2024 with a primary diagnosis of a UTI (urinary tract infection- an illness in any part of the urinary tract, the system of organs that makes urine) and resided in the home when a spouse and adult daughter; - The patient’s daughter was listed as the primary caregiver; and - The SOC (start of care) assessment visit was completed by a RN on 01/06/2024. Review of the PT visit note, dated 01/18/2024, showed, in part: - The patients response to skilled care provided, showed, “Pt tolerated treatment fairly well but does seem to be somewhat more SOA (short of air) with activities this date. SpO2 (oxygen saturation) monitored and remained WNL” (within normal limits); and - The PT failed to inform the SN regarding the patient having SOA. During an interview on 02/07/2024 that began at 1:15 PM, the Clinical Manager stated that: - Therapy should be coordinating any change in condition to the SN; and - The SN will make a visit to assess the patient’s status and report changes in condition to the physician.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that each patient and his or her caregiver(s), received education regarding the physician order to discontinue the use of Tylenol due to drug to drug medication interaction, and the risks for continued use, in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed, in part: - The agency must 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; and - Ensure that each patient, and his or her caregiver(s), where applicable, receives ongoing education and training provided by the agency, as appropriate, regarding the care and services identified in the plan of care. Review of the provider’s undated policy titled, “Nursing Services,” showed, in part: - Professional nursing services will be provided by a registered nurse and include: * Counseling and educating the patient and family regarding the disease process, self-care techniques and prevention strategies * Coordination of services * Informing the physician and other staff of changes in the patient’s needs; and - Nursing care will be provided in accordance with the patient’s plan of care, under the supervision of a registered nurse. RECORD/PATIENT #4: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (left upper arm) and is temporarily residing with his/her daughter; and - The SOC (start of care) assessment visit was on 01/08/2024. Review of the SOC visit note dated 01/08/2024, showed, in part: - The drug regimen review showed issues were identified and the physician was notified of the medication issues (The skilled nurse failed to include documentation of what the issues identified were and the prescribed/recommended actions included); and - The patient was education on medication side effects and information. Review of a Medication Issue Communication/Order document, dated 01/10/2024, showed, in part: - A drug interactions report showing the patient’s drug to drug interactions; - Stop medication(s) showed, acetaminophen was written (Also known as Tylenol, which is an analgesic medication that is used to treat minor aches and pains, and reduce fever); - The physician signed and dated it on 01/10/2024; and - It was faxed to the home health agency on 01/10/2024 at 2:41 PM. Review of the Occupational Therapy visit note dated 01/16/2024, that began at 9:15 AM and ended at 10:30 AM, showed, in part: - The pain section showed pain rated 6 out of 10, pain location of right bottom (buttocks), left shoulder and both knees listed, description was dull cramping pain, pain is worse with movement, sitting on sore (buttocks wound), and walking, pain relieved with medications and rest, frequency of pain and impact on activities had “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “majority of day, depending on activity” noted, and “Pt is using barrier cream on sore on bottom. Nurse states (he/she) will bring some cream and different dressing for it. Pt is taking 500mg Tylenol (analgesic medication to treat pain) 2 tabs 2x/day for shoulder and knee pain” noted in the comments section; and - The care planning/coordination section had “spoke to SN (skilled nurse) regarding pts sore and HR.” The clinical record failed to show education provided to the patient regarding the physician’s order to stop taking Tylenol due to the risk of drug-to-drug interaction with Coumadin (blood thinner). - A drug interactions report showing the patient’s drug to drug interactions; - Stop medication(s) showed, acetaminophen was written (Also known as Tylenol, which is an analgesic medication that is used to treat minor aches and pains, and reduce fever); - The physician signed and dated it on 01/10/2024; and - It was faxed to the home health agency on 01/10/2024 at 2:41 PM. During an interview on 02/07/2024 that began at 1:15 PM, the Clinical Manager stated that: - The medications are reviewed on the SOC and discrepancies should be clarified with the physician and documented; and - The patient should have been informed that the physician ordered him/her to stop taking Tylenol.”

“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, home visit observation, and interview, the provider failed to provide the patient/caregiver with a copy of written instructions outlining the patient’s medication schedule/instructions in, but not limited to, one of three home visit observations, (Record/Patient #1). This deficient practice has the potential to adversely affect the medication administration of all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed, in part, the agency (provider) will coordinate care with the patient by providing a copy of written instructions outlining patient medication schedule/instructions, including: medication name, dosage, route and frequency and which medications will be administered by agency personnel acting on behalf of the agency. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 01/22/2024 with a primary diagnosis of MS (multiple sclerosis- a disease in which the immune system attacks the protective covering of nerves). Observation on 02/02/2024 at 1:30 PM, during the patient’s home visit, the admission folder was reviewed and failed to contain a copy of the written POC or a current written medication list. Per interview conducted during observation, RN B stated that he/she: - Did not leave a written medication list; and - Probably should. During an interview on 02/07/2024, starting at 1:15 PM, the clinical manager stated that: - The medication list is on the POC; and - The POC should have been in the home with the written medication list on it; and - This was the first skilled nurse visit since the patient was admitted.”

“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 policy review, clinical record review, and interview, the provider failed to provide SN (skilled nursing) and PT (physical therapy) services at the frequency ordered in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to adversely affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Care Planning Process,” showed, in part: - In order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems, the agency will utilize data/information gathered during patient assessments in the care planning process; - The patient care plan for skilled nursing will be: * Initial care plan will be CMS #485 Plan of Care, which is developed and implemented with the physician; and * Demonstrates problems (diagnoses), interventions (physician orders) and long-range goals. Review of the provider’s undated policy titled, “Physicians Verbal Orders,” showed, in part: - Drugs and treatments are administered by the agency staff only as ordered by the physician; - Orders are obtained prior to the provision of any care, including changes in the plan of care; - Orders for patient care are obtained from the physician, either verbally or in writing; - When a verbal order is received, the order must be written down, read back to verify order and receive confirmation from individual who gave order. A record of this order is documented on a physician’s supplemental order form. Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed, in part: - Agency staff members regularly communicate and document to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care; - The Agency must: * Assure communication with all physicians involved in the plan of care * Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient; and * 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. - Staff provides the physician with patient information on an ongoing basis; and - The clinical manager provides oversight of all patient care services, including coordinating patient care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted with a primary diagnosis of malignant neoplasm of the larynx (cancer of the voice box). Review of a physician order dated 12/22/2023, showed: - Date order received: 12/21/2023; - Effective date: 12/21/2023; and - Visit Frequency: RN/LVN (registered nurse/licensed vocational nurse- (SN)) one time a week for three weeks starting 12/21/2023. Further review of the clinical record showed: - There failed to be a SN visit the following week (12/24/2023 to 12/30/2023; and - There failed to be any communication by the SN with the physician regarding the failure to follow the visit frequency the week of 12/24/2023 to 12/30/2023). Review of the PT evaluation visit dated 12/07/2023 showed: Frequency/Duration of physical therapy visits 1x1, 2x3, 1x1 (one time a week for one week, two times a week for three weeks and one time a week for one week. Further review of the clinical record showed: - PT visits at a frequency of 1x1, 2x2 and failed to show any visits the following week (12/24/2023 to 12/30/2023); and - There failed to be any communication by the PT with the physician regarding the failure to follow the visit frequency the week of 12/24/2023 to 12/30/2023. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that: - He/she would expect the POC to be followed; and - The PCP should have been notified of the missed visits.”

“Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This Element is not met as evidenced by: Based on review of the rehabilitation services agreement, employee file review, and interview, the provider failed to ensure contract staff were provided annual agency In-service training in one of one contract employee file reviewed (Contract Physical Therapist-PT). This deficient practice has the potential to affect all patients of the provider served by contract employees. Findings included: Review of the rehabilitation services agreement signed and dated by the provider’s administrator on 07/27/2023 and signed by the contracting provider’s CEO (Chief Executive Officer) 08/11/2023, showed, in part, “Orientation. Agency shall provide appropriate initial orientation to individuals supplying services under this Agreement. Thereafter, annual education will be provided.” Contract PT Employee file review showed: - The contract PT had been hired in 2005 by the prior home health agency before the CHOW (change of ownership); and - The file failed to contain evidence of agency in-service from 06/2022 through the date of the survey exit, 02/07/2024. During an interview on 02/06/2024 at 11:30 AM with the clinical manager, he/she stated that: - I have all of the training from “Named home health provider” (the prior provider before the CHOW); - This contract PT worked for them already; - No training has been done with this contract PT since the CHOW; - I only did home health agency In-service training with our staff here; and - We were approved to start taking home health patients in June of 2022, but we were not made aware and did not start taking patients until January of 2023.”

“Org. had partial/extended survey CFR(s): 484.80(f)(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 This Element is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with two Conditions of Participation: 484.55 Comprehensive assessment of patients, and 484.60 Care planning, Coordination of Services and Quality of Care, the provider may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 02/07/2026.”