Cooperative Home Care, Inc.

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure that wounds were measured 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. Findings included: A policy for wound measurements was requested but not provided by survey exit. RECORD/PATIENT #1: Review of the clinical record showed that the patient was re-admitted to home health services on 12/13/2024, with a diagnosis of an unstageable pressure area (tissue damage to the skin that is caused by unrelieved pressure and cannot be accurately evaluated because it is covered by a layer of dead tissue) to the sacral region and a diagnosis of an unstageable pressure ulcer of the right heel. Review of the resumption of care assessment, dated 12/13/2024, showed: - A wound assessment that noted wound number one on the posterior right heel of the wound location sheet that was described as: “unstageable, observable, no drainage, no odor, peri wound skin (the skin surrounding the wound) intact, N/A (not applicable) edema, thickened wound edges, located on the bottom, wound care completed;” - A wound assessment that noted wound number two on the sacral area of the wound location sheet that was described as: “stage II, observable, small amount of drainage, serosanguinous in color (drainage of a wound that is usually light pink to red in color), thin consistency, no odor, peri wound skin intact, N/A edema, appearance of the wound bed red, wound edges intact, wound care completed;” and - The provider failed to ensure that measurements were completed of both wounds. Review of the recertification assessment, dated 12/17/2024, showed: - A wound assessment that noted wound number one on the posterior right heel of the wound location sheet that was described as: “unstageable, observable, no drainage, no odor, peri wound skin intact, N/A edema, appearance of wound bed brown, wound edges intact, located on the bottom, wound care completed;” - A wound assessment that noted wound number two on the sacral area to the wound location sheet that was described as: “stage II, observable, small amount of drainage, serosanguinous in color, thin consistency, no odor, peri wound intact, appearance of wound bed red, wound care completed;” and - The provider failed to ensure that measurements were completed of both wounds. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to home health services on 11/06/2024, with a diagnosis of Type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood) with a foot ulcer (an open sore on the foot). Review of the plan of care dated, 11/06/2024, showed in part that, the wound to the left fifth toe was to be assessed, measured, and described on visits. Review of a skilled nursing visit note, dated 11/11/2024, showed: - A wound assessment that noted a wound on the anterior left fifth toe of the wound location sheet that was described as: “arterial, observable, N/A drainage, N/A odor, N/A peri wound skin, N/A edema, N/A wound edges, wound care done;” and - The provider failed to ensure that wound measurements were completed. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted to home health services on 09/03/2024, with a diagnosis of nondisplaced fracture of the medial condyle of the right tibia (a fracture of the tibia bone in the right leg) and secondary diagnoses of acute osteomyelitis (an infection in the bone) of the right tibia and fibula, and encounter for change and removal of surgical wound dressing. Review of the plan of care dated, 09/03/2024, showed in part that, wound number two to the left lower medial leg was to be assessed, measured, and described on visits. Review of the initial assessment, dated 09/03/2024, showed: - The skin assessment area showed two wounds to the left lower extremity; - A wound assessment that noted wound number one on the anterior outside of the upper part of the left leg of the wound location sheet that was described as: “surgical wound, observable, small amount of drainage, serosanguinous in color, thin consistency, tunneling (a channel or tract that extends from the surface of a wound deeper into the underlying tissue)/undermining (the edges of the wound have separated from the surrounding healthy tissue creating a dead space beneath the skin) ½ centimeter (cm), no odor, peri wound skin intact, N/A edema, N/A wound edges, wound care completed;” - A wound assessment that noted wound number two on the anterior inside of the lower part of the left leg of the wound location sheet that was described as: “surgical wound, observable, large amount of drainage, serosanguinous in color, thin consistency, no odor, N/A peri wound skin, N/A edema, wound edges intact, wound care done;” and - The provider failed to ensure that measurements were completed of both wounds. Review of a skilled nursing visit, dated 09/09/2024, showed: - A wound assessment that noted wound number one on the anterior outside of the upper part of the left leg of the wound location sheet that was described as: “surgical wound, not healing, observable, large amount of drainage, clear color, thin consistency, tunneling/undermining 5 cm at 11 o’clock, no odor, peri wound intact, N/A edema, wound edges intact, wound care completed;” - A wound assessment that noted wound number two on the anterior inside of the lower part of the left leg of the wound location sheet that was described as: “surgical wound, early/partial granulation (soft, pink, new healthy tissue in a healing wound), observable, large amount of drainage, serosanguinous in color, thin consistency, no odor, peri wound erythematous (reddened or showing redness), N/A edema, red wound bed, wound edges intact, wound care completed;” and - The provider failed to ensure that measurements were completed of both wounds. Review of a skilled nursing visit, dated 09/16/2024, showed no assessment of the patient’s wounds. Review of a skilled nursing visit, dated 09/18/2024, showed no assessment of the patient’s wounds. During an interview on 12/18/2024 at 12:30 PM, the director of quality assurance nurse stated that staff have been instructed to measure wounds weekly, with a start of care (initial assessment), and with any signs of deterioration and notify the physician if there are changes. He/she further stated the provider did not currently have a written policy for this and that measurements should be obtained for all kinds of wounds. During an interview on 12/18/2024 at 1:40 PM, the director of clinical services stated that he/she would expect wounds to be measured weekly, with a start of care, and when there was a change in the wound.”

“Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This Element is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure that criteria were met to facilitate a transfer or discharge from care in one of two discharge records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Discharge Criteria and Planning,” revised February 2024, showed in part, that: The patient will be discharged from services as follows: - Discharge is necessary for the patient’s welfare because the agency (provider) and the physician/practitioner who is responsible for the home health plan of care agree that the agency can no longer meet the patient’s needs, based on the patient’s acuity; - The patient or payor will no longer pay for the services provided by the agency; - The discharge is appropriate because the physician/practitioner who is responsible for the home health plan of care and the agency agree that measurable outcomes and goals set forth in the plan of care have been achieved and the agency and physician/practitioner responsible for the home health plan of care agree that the patient no longer needs the agency’s services; - The patient refuses services or elects discharge; - The patient/family requests discharge; - The patient’s (or other persons in the patient’s home) behavior is disruptive, abusive or uncooperative to the extent that delivery of care to the patient or the ability of the agency to operate effectively is seriously impaired. The agency will do the following before it discharges a patient for cause: * Advise the patient, representative (if any), the physician(s)/practitioner(s) issuing orders for the home health plan of care and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services of the patient after discharge from the agency (if any) that a discharge for cause is being considered; * Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home or situation; * Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; * Document the problem(s), behaviors and circumstances that warranted discharge for cause and efforts made to resolve the problem(s) and enter documentation into its clinical record; * The medical record will reflect: * Identification of the problems encountered; * Assessment of the situation; * Communication among the agency management, caregiver, legal representative and the physician/practitioner responsible for the plan of care; * A plan to resolve the issue; and * Results of the plan implementation. * Only in extreme situations when there is a serious imminent threat of physical harm to agency staff, the agency may take immediate action to discharge or transfer the patient without first making efforts to resolve the underlying issue; * Evidence in the record will be documented that the agency provided the patient and his or her representative (if any) with information including contact numbers for other community resources and names of other agencies or providers that may be able to provide services to the patient; and - The patient refuses to follow physician’s/practitioner’s prescribed plan of care/treatment (physician/practitioner will be notified). RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted to home health services on 09/03/2024, with a diagnosis of nondisplaced fracture of the medial condyle of the right tibia (a fracture of the tibia bone in the right leg) and secondary diagnoses of acute osteomyelitis (an infection in the bone) of the right tibia and fibula, and encounter for change and removal of surgical wound dressing. Review of the initial assessment, dated 09/03/2024, showed: - The patient was alert and oriented to person, place, time, date, and situation; - The patient showed no cognitive, behavioral, or psychiatric symptoms (reported or observed); - The patient showed no disruptive behavior symptoms such as physical, verbal, or other disruptive/dangerous symptoms that were injurious to self or others or jeopardized personal safety (observed or reported); - The patient’s environment was documented as safe for the patient and safe for the employee; and - The patient/caregiver had the desire and ability to participate in care and work towards mutually agreed upon goals. Review of the plan of care, dated 09/03/2024, showed the patient was alert and cooperative and discharge plans were “when wound heals.” Review of a skilled nurse (SN) note, dated 09/09/2024, showed: - The patient had a physician visit at the wound care clinic on “Friday” (09/06/2024) with no changes to the plan of care; - The patient was alert and oriented to person, place, date/time, and situation; - Treatments were completed to wound number one and wound number two as ordered by the physician; and - No behaviors or refusals of care were documented. Review of a SN note, dated 09/16/2024, showed: - The patient had a physician visit prior to the visit; - The patient was alert and oriented to person, place, date/time, and situation, and agitated; - Treatments were completed to wound number one and wound number two as ordered by the physician; and - The nurse note stated that patient appeared “flustered and uninterested in SN visit.” Review of a SN note, dated 09/18/2024, showed: - The patient was alert and oriented to person, place, date/time, and situation; - Treatments were completed to wound number one and wound number two as ordered by the physician; and - The nurse note stated that the patient “answered the door and immediately began to light his/her cigarette. I asked him/her if he/she could please wait to smoke after the visit which would take about 30 minutes. He/She immediately became upset and stated, “What?! No! You’re not gonna come here and tell me I can’t smoke in my own house?! I can’t even smoke in my own house?!” I explained to him I had visits with other patients who have respiratory issues, and the smoke from the cigarettes would linger on my clothing and that would present other issues for those patients. He/She scoffed and put the cigarette out. And kept mumbling curse words under his/her breath;” and - The incident was reported to the director of clinical services for “patient belligerence towards this SN.” Review of a discharge from the home health provider assessment, dated 09/19/2024, showed: - The patient showed no cognitive, behavioral, or psychiatric symptoms (reported or observed); - The patient showed no disruptive behavior symptoms such as physical, verbal, or other disruptive/dangerous symptoms that were injurious to self or others or jeopardized personal safety (observed or reported); - The treatments were completed to wound number one and wound number two as ordered by the physician, however, the patient refused to have wound number one covered; - The patient was to follow-up with the wound care clinic at discharge; and - The primary reason for discharge was listed as “no longer meets admission criteria-environment unsafe for employees.” Review of a client logging report, dated 09/19/2024, showed that the director of clinical services documented that the patient was notified via phone that he/she was being discharged from the home health provider due to inappropriate behavior with staff and that the payor source had been notified and was in agreement. The provider failed to make efforts to resolve any problems with the patient’s behavior, failed to document the efforts made to resolve the problems, and failed to show that the patient’s behavior was disruptive, abusive, and uncooperative to the extent that delivery of care to the patient or the ability of the provider to operate effectively was seriously impaired. During an interview on 12/18/2024 beginning at 1:40 PM, the administrator stated that patient #5 was a worker’s compensation patient and that the representative from worker’s compensation had been notified of the patient’s behavior and had decided to stop his/her care with the home health provider. He/She further stated that he/she would expect the documentation to reflect the patient and their behavior.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on policy review, clinical record review, home visit observation, and interview, the home health provider failed to ensure a complete and accurate medication list was maintained in, but not limited to, two of three home visit observations (Record/Patient #2, and #3). This deficient practice has the potential to affect the provider’s ability to ensure safe and effective use of medications for all patient’s served by the provider. Findings included: Review of the provider’s policy titled, 8.15.1 “Medication Reconciliation,” revised February 2024, showed in part: - The provider will reconcile patient’s medications at time of admission and on an ongoing basis in order to identify any potential adverse effects and drug reactions; - At time of admission, the admitting registered nurse (RN) will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency; * Any concerns or discrepancies will be reconciled by a RN with the patient’s physician/practitioner; * Discrepancies include duplications, omissions, changes, contraindications and/or unclear information; and - Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/02/2024 with a primary diagnosis of aftercare following surgery for neoplasm (abnormal mass of tissue that forms when cells grow and divide more than they should or do not die when they should) and malignant (cancer) neoplasm of ascending colon (first part of the large intestine). The patient resided in his/her home with an adult child as the caregiver. Observation and interview on 12/17/2024 at 11:33 AM, showed the following discrepancies: - The medication profile showed the patient used Bacitracin external ointment (antibiotic to treat external skin infections) 500 unit/gram (GM) small dose applied three times a day to incision on left lower quadrant surgical wound. The patient and caregiver stated he/she had not used since 12/05/2024; - The medication profile showed the patient took Farxiga (oral medication to improve blood sugar control) 10 milligrams (mg) once a day. The patient and caregiver stated he/she had not used since 12/04/2024; - The medication profile showed the patient took Lipitor (oral medication to control cholesterol) 20 mg at bedtime. The medication bottle showed the patient took 40 mg one by mouth daily. The patient and caregiver stated he/she took 40 mg at bedtime and had been since 12/04/2024; - The medication profile showed the patient took oxycodone (narcotic analgesic for moderate to severe pain) oral capsule 5 mg as needed (PRN) every four hours for pain. The patient and caregiver stated he/she had not used since 12/04/2024; - The medication bottle showed the patient took Lasix (diuretic) 20 mg one by mouth daily. The patient and caregiver stated he/she had been taking since 12/04/2024. The medication failed to be on the provider’s list; - The medication bottle showed the patient took Jardiance (used to treat type 2 diabetes)10 mg one by mouth daily. The patient and caregiver stated he/she had been taking since 12/04/2024. The medication failed to be on the provider’s list; - The medication bottle showed the patient took Senna S (stool softener) 50 mg/8.6 mg one by mouth daily. The patient and caregiver stated he/she had been taking since 12/04/2024. The medication failed to be on the provider’s list; - The medication bottle showed the patient took oxycodone/acetaminophen (narcotic analgesic) 10/325 mg one by mouth PRN/pain. The patient and caregiver stated he/she took one at bedtime and three PRN and had been taking since 12/04/2024. The medication failed to be on the provider’s list; and - The medication bottle showed the patient took Eliquis (blood thinner) 2.5 mg one by mouth twice a day. The patient and caregiver stated he/she had been taking since 12/04/2024. The medication failed to be on the provider’s list. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/21/2024 with a primary diagnosis of aftercare following joint replacement surgery, presence of left artificial hip joint and hypertension (elevated blood pressure). The patient resided in his/her own apartment. Observation and interview on 12/17/2024 at 9:25 AM, showed the following discrepancies: - The medication profile showed the patient took acetaminophen (mild analgesic) eight-hour tablet extended release 650 mg twice a day for arthritic pain. The patient stated he/she had been taking one at bedtime; - The medication profile showed the patient took aspirin 81 mg chewable tablet once a day for blood clot prevention. The patient stated he/she had not been taking for a couple of years; - The medication profile showed the patient took Celebrex (nonsteroidal anti-inflammatory) 200 mg two times a day for arthritis. The patient stated he/she had been taking100 mg twice a day; - The medication profile showed the patient took Vitamin D3 (supplement) oral tablet chewable 25 micrograms (1000 UT) once a day. The patient stated he/she had been taking 50 mcg three times daily; - The medication profile showed the patient took levothyroxine sodium (thyroid medication) capsule 112 mcg once a day. The patient stated he/she had been taking 88 mcg daily; - The medication profile showed the patient took Vitamin B complex (supplement) capsule one a day. The patient stated he/she did not take anymore, and it had been a while since he/she took it; - The medication profile showed the patient took ibuprofen (mild to moderate pain) tablet 200 mg PRN every six hours as needed for pain. The patient stated he/she was told not to take since returning home; - The medication profile showed the patient took Percocet (narcotic analgesic) tablet 5-325 mg PRN every four hours for post-op pain. The patient stated he/she was not taking and never took after returning home; - The medication profile showed the patient took tramadol (narcotic analgesic) tablet 50 mg PRN every six hours as needed for post-op pain. The patient stated he/she did not take tramadol; - The medication bottle showed the patient took glucosamine chondroitin (supplement) triple strength 1500 mg/120 mg one tablet twice a day. The patient stated he/she had been taking one twice a day and had been taking since 12/04/2024. The medication failed to be on the provider’s list; and - The medication bottle showed the patient took ropinirole (dopamine to treat restless leg syndrome) 1 mg one by mouth at bedtime. The patient stated he/she had been taking since 12/09/2024. The medication failed to be on the provider’s list. During an interview on 12/18/2024 starting at 1:44 PM, the director of clinical services stated that he/she expects medications to be reviewed every visit and reconciled with start of care, resumption of care and with new medications and discontinued medications.”