Integrity Home Care + Hospice

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to: -Ensure nursing staff followed the provider’s policy and procedures regarding communication with patients and document a complete occurrence (incident) report (G702); and -Ensure nursing staff provided timely follow-up, assessment, instructions for notifying the on-call service and/or notify the on-call service to contact the patient, and instruct the patient to seek medical attention when the patient reported abnormal symptoms, provided complete wound assessments; documented a complete assessment of a patient’s report of fainting/dizziness and document what specific abnormal findings were reported to the physician. This was identified at an immediate jeopardy level (G706). The cumulative effect of these deficient practices has the potential to affect all patients served by the provider.”

“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 staff followed their policies and procedures regarding communication with patients in one of five records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Confidentiality of Protected Health Information (PHI),” revised 10/23/2023, showed in part that PHI includes all medical and care-related information, specific to an individual, that can be identified by use of name, address, telephone, and mobile numbers. Cell phones, cordless phones, texting, and other electronic communications will be used only when standard telephones are not available. Any unsecured communication (texts, instant messaging, or other electronic communication) must be completely de-identified prior to transmission. Review of an undated form titled, “Technology Usage and Protected Health Information Agreement,” showed in part that each person with access to protected health information must: - Not exhibit or divulge the contents of any record/report except to fulfill a work assignment and in accordance with policy; and - Not divulge any information that identifies PHI. RECORD/PATIENT #1: Review of text messages printed by the provider from RN A’s phone showed on 05/16/2024, the patient texted RN A regarding abnormal symptoms he/she had, and the patient and RN A texted back and forth on 05/18/2024 and 05/19/2024. During an interview on 06/03/2024, at 12:35 PM, the administrator stated that patients are supposed to call the office. Sometimes the staff do not give patients their phone number, but the patients had it from their caller ID (identification). Texting is not the preferred mode of communication, but with some clients it is their preferred mode. The clinicians can answer the patient’s texts. During an interview on 06/10/2024, at 3:10 PM, the administrator stated that for texting to be secure it needed to be inside a secured program like a patient portal within a medical system. The texting from the patient to the nurse was not a secure mode.”

“Eligible training/competency evaluation orgs. CFR(s): 484.80(f) A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years: (1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; or (2) Permitted an individual who does not meet the definition of a “qualified home health aide” as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or (3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or (4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or (5) Was found to have compliance deficiencies that endangered the health and safety of the HHA’s patients, and had temporary management appointed to oversee the management of the HHA; or (6) Had all or part of its Medicare payments suspended; or (7) Was found under any federal or state law to have: (i) Had its participation in the Medicare program terminated; or (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA’s patients; or (v) Been closed, or had its patients transferred by the state; or (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program. This Standard is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with one Condition of Participation: §484.75 Skilled professional services, the home health provider may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 06/13/2026.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the registered nurse (RN) provided timely follow up, assessment, instruction, and coordination for three of five patients sampled. The home health nurse failed to notify on-call staff and/or arrange an on-call visit for the patient, provide instruction for the patient to seek medical attention, or notify the physician when a patient who reported to the nurse that he/she had a fall, fever, displayed non-sensical speech throughout texts, and a big infected very painful bump that took up the whole right side of the genitalia (the external sexual organs) The patient was subsequently admitted to the hospital for severe sepsis, septic shock (these are life threatening conditions that occur when the body has an extreme response to an infection, causing organ dysfunction), and necrotizing fasciitis (a flesh-eating disease that spreads quickly and destroys tissue under the skin) and required emergency surgery. This example was identified as an immediate jeopardy (Record/Patient #1). The home health failed to ensure nursing staff documented complete wound assessments for a patient (Record/Patient #2). The home health provider failed to document assessment and reporting of fainting/dizziness for a patient (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Client Care Coordination,” reviewed 03/24/2023, showed in part that care coordination will include assuring coordination of care delivery to meet the client’s needs and involves the client, client’s representative, if any, and caregiver as appropriate, and integrating services to assure the identification of client needs and factors that could affect safety and treatment effectiveness and the coordination of care provided by all disciplines. Review of the provider’s policy titled, “Communication with Physicians,” reviewed 03/24/2023, showed in part that throughout the duration of service, whenever a change in client status occurs that requires the physician to be notified, the communication will be documented. This communication can be documented on the clinical notes, nurses’ notes or on a coordination of service form. The SBAR (situation, background, assessment, and recommendation) method of communication with physicians is encouraged due to its effectiveness. Review of the provider’s policy titled, “On Call Availability and Access to Services,” revised 05/03/2021, showed home health care services can be accessed 24 hours a day, 7 days per week through an on-call system. An on-call manager with access to an RN for clinical consultation is available after business hours. Clients and employees are instructed on procedures for contacting the providers after hours at admission and orientation. The client, caregivers, and facility staff receive written information at the time of admission regarding how and when to access care after business hours. Review of the provider’s policy titled, “Wound Care – Assessment and Treatment,” revised 09/09/2021, showed in part that staff should verify physician’s orders, which should include frequency of dressing change, location of wound, solution and procedure for cleansing, as applicable, specific treatment to be applied, type of dressing, and who should perform the wound care. Documentation should include wound location, drainage, communication with physician regarding client progress, response, or recommended need for a change in treatment. The RN or PT (physical therapist) will complete an assessment of the wound by measuring, assessing, and documenting effective wound treatment per physician orders. The ICC (integumentary (pertaining to the skin) command center (a wound assessment tool) will be completed at every visit and measurements completed and documented weekly. RECORD/PATIENT #1: Review of the record showed the patient was admitted to service on 04/02/2024. Diagnoses included acute pancreatitis (an inflammation of the organ (pancreas), type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood), and non-pressure chronic ulcer of the left lower leg (a skin ulceration due to poor circulation). Review of text messages from the patient to registered nurse (RN)-A showed: On 05/16/2024 (Thursday), at 7:43 PM, the patient wanted to update the home health nurse that he/she had a fall yesterday and thought he/she was running a fever, “everything is intact except my butt and elbow”; On 05/16/2024 and 05/17/2024 (Friday), the nurse failed to respond to the patient’s text; On 05/18/2024 (Saturday), at 9:32 AM, the patient texted “I hate to bother you on your day off, but my blood sugar is 180. Is there anything I can do for that? I haven’t been eating regularly the last few days”; At 4:48 PM, I feel a little bit better. Monday would be good (unclear what this referred to); At 6:04 PM, (two days after the patient’s first text) the nurse texted the patient and asked if the patient felt like he/she had an infection. “How is your appetite now? Getting enough hydration?”; At 6:04 PM, the patient responded that he/she had a big, infected bump on the “hoo ha”. It took up the whole right side. At 6:08 PM, “I’m drinking water the best I can”; At 6:08 PM, the nurse texted “Yowsa”! Is it painful to? Do you think you need to get it looked at? Not sure if you’ve had one before; At 6:11 PM, the patient responded no, but, at the moment I don’t have a doctor until June 5. The patient stated that he/she wanted to scream every time he/she sat down and he/she had never had one this size; At 6:12 PM, the nurse asked if he/she had a way to do a sits (sitz bath, a warm water bath you sit in to relieve discomfort in the perineal (genitalia) region) or an Epsom salt soak? I bet you have a Bartholin glad (gland) cyst (a fluid filled lump inside the vaginal opening) or infected follicle (inflammation of a hair follicle). Very painful; At 6:18 PM, the patient responded that he/she could not really tell. I’m dying long ass lips. Nothing. (non-sensical, unsure what this meant, could be indicative of something abnormal with the patient); At 6:19 PM, the nurse responded, “I’m so sorry! Maybe we can make some calls Monday; At 6:23 PM, the patient responded, “Once they dropped her off, he watched the parking lot she got (non-sensical, unsure what this meant); At 6:23 PM, the nurse responded, “??”; At 6:24 PM, the patient responded that we can get ahold of somebody in the morning that would be awesome; At 6:25 PM, the nurse responded, “I’ll see what I can do; At 6:25 PM, the patient responded Ty (thank you); The nurse failed to document he/she provided instruction on how to contact the on-call staff, make arrangement for the patient to be seen by on-call staff, or advise to go to the emergency room to seek medical attention; On 05/19/2024 (Sunday) at 11:09 AM, the patient texted, “Did I miss you? I’m sorry somebody just informed me at Sunday; At 12:09 PM, the nurse responded, “It’s OK. I’ll be there around 9:00 tomorrow morning (the nurse failed to inquire how the patient was doing at this time); and At 12:10 PM, the patient responded “KK”. Review of the medical record beginning on 06/03/2024, showed no nursing notes and/or coordination note entries between 05/16/2024 and 05/20/2024 regarding the patient’s report of abnormal symptoms via texting to RN-A until 05/20/2024, when the nurse made a visit to the patient. During an interview on 06/03/2024, at 12:35 PM, the administrator stated that patients are supposed to call the office. Sometimes the staff do not give patients their phone number, but the patients had it from caller ID (identification). Texting is not the preferred mode of communication, but with some clients it is their preferred mode. The clinicians can answer the patient’s texts. The clinicians should document the texted information in a coordination note. (it should be noted that in the text exchange between the patient and the home health nurse, RN-A failed to inform the patient to call the office) Review of RN-A’s visit note dated 05/20/2024, the patient reported a non-injury fall over the weekend and felt feverish two nights ago. The patient had a knot the size of baseball to the vaginal area that broke open over the weekend with foul odor and drainage. RN-A spoke with the NP’s medical assistant and reported abnormal findings and scheduled an appointment at 2:00 PM tomorrow (05/21/2024). RN-A discussed with patient the dangers of infection that may not be treated right away. The patient discussed with the patient’s caregiver and decided to go to the emergency room on 05/20/2024 for evaluation. Review of the hospital record dated 05/20/2024, showed in part that the patient presented to the emergency department (ED) at 11:08 AM, for a wound check with concerns for a necrotic (dead tissue) in the vulva (genitalia). The patient had a vaginal cyst that erupted over the weekend. The patient had a large necrotic area, approximately 4 x 6 centimeters (cm) of necrosis on the vulva with pus drainage. The patient was alert to person, place, and time. The radiology report showed the right side of the mons pubis (an area of fatty tissue that covers the pubic bone) concerning for necrotizing fasciitis. Urgent surgical consultation is recommended. The critical care notes showed critical care was necessary to treat or prevent imminent (immediate) or life-threatening deterioration of the following conditions: sepsis. The primary diagnosis was necrotizing fasciitis. General surgery was emergently consulted in the ED. The patient was emergently taken to the operating room for debridement (removal of dead tissue) and will be taken back tomorrow for further debridement. Other diagnoses included severe sepsis with septic shock. During an interview on 06/05/2024, beginning at 12:27 PM, RN-A stated that: He/she typically communicated with patients through phone calls. They also have the on-call number in their folders; He/she used a google phone app tied to his/her personal phone number; Patients do text me. I don’t tell them to text me. If they text, I will call and talk to them and have them call the on-call number. If there’s an issue, I usually tell them to call the on-call number. I also tell them if they can’t get me try the on-call number. If I’m not on call, I usually don’t have my phone on me.; He/she worked on 05/16/2024 and 05/17/2024. The patient texted him/her on 05/16/2024 at 7:43 PM that he/she fell, nothing hurt, but elbow and butt sore. I responded on 05/18/2024, at 6:04 PM; When asked why he/she had not responded before, he/she stated that he/she may have tried to call. The nurse looked at his/her call log and said he/she did not call. It was unusual for him/her not to respond. It was over a weekend. The calls go over an app on his/her phone. He/she did not have an answer for that; He/she usually documented texted concerns from patients in a narrative or at the next visit usually at the time it occurred, but he/she did not this time; He/she didn’t see her or call on-call because the patient told him/her that he/she wanted to wait until Monday. I should have told her to go to the hospital right away; When asked if he/she asked the patient how he/she was doing on Sunday (05/19/2024), the nurse responded “No”; On 05/20/2024 he/she was going to assess the area, but when the patient stood up, the patient needed to go to the bathroom. While the patient was in the bathroom, the in-home caregiver came in and stated that the patient needed to go to the hospital. RN-A said I know, but he/she does not want to go. The patient liked things his/her way; and He/she called the NP’s medical assistant while the patient was in the bathroom. The patient came out and sat in a chair. I told him/her what an infection could lead to. I told the patient he/she needed to go to the hospital, and the caregiver encouraged that he/she needed to go. The appointment was made with the NP in case he/she didn’t go the hospital. The caregiver called the ambulance. He/she did not wait for the ambulance to arrive. During an interview on 06/06/2024, beginning at 9:20 AM, Patient #1 stated that: The nurse would text to let me know when he/she was coming for visits; The nurse did not tell him/her to call the on-call number after hours or to call the office if he/she needed something on the days the nurse was not there; He/she thought the first text was on Thursday (05/18/2024), and thought it was about having a fever but wasn’t sure; Regarding the text that he/she did not have a doctor until June 5, the patient stated that he/she saw the NP, but thought he/she needed an MD (medical doctor) due to his/her history of back surgery. He/she did not remember the fall; In reference to the text on 05/18/2024, at 4:48 PM, Monday was the time the nurse wanted to do my leg wraps; He/she did not remember Saturday. He/she did not think the nurse told him/her to call the on-call number or offer to call on-call or come out. When asked if he/she would have accepted a nurse visit before 05/20/2024, the patient stated, “Oh hell yeah”; When asked about the non-sensical texts, the patient stated that with the state my head was in, he/she did not know what they were about. He/she did not remember what getting ahold of somebody in the morning was in reference to; and When asked if the nurse told him/her to seek medical attention or go to the emergency room (ER), the patient stated that he/she thought the nurse just recommended to schedule a doctor’s appointment. He/she did not remember the nurse talking to him/her about going to the ER before his/her caregiver got there. During an interview with the NP’s medical assistant (MA) on 06/06/2024, beginning at 1:15 PM, the MA stated that: If the patient reported a fall and fever they would expect the home health nurse to make note of it and call to let them know. If needed, they would call and speak to the patient; When asked about the non-sensical texts, the MA stated that they may have thought the patient had a urinary tract infection; They were not informed of any issues by the nurse until 5/20/2024; If the patient reported a large, infected area, that took up the whole right side of the genitalia and made them want to scream every time they sat down, they would expect the nurse to visualize the area and call them; They had 24/7 availability and depending on what was reported, they would instruct the nurse or the patient on what to do; On 5/20/2024, the nurse reported the patient had an open wound with foul odor. The nurse did not report a size. When the NP saw the picture of the area, he/she stated that if he/she had known the area was that bad, he/she would have immediately sent the patient to the ER;; and The patient was good to message them, but there were no previous notes. They did not know about area until 5/20/2024. During an interview on 06/06/2024, beginning at 4:25 PM, RN-A stated that: Regarding the text on 05/18/2024, at 4:48 PM, he/she did not know, but assumed the statement about Monday would be good, was about the regular visit on Monday; He/she did not know what the text regarding not having a doctor referred to; The patient saw an NP, and they have an after-hours number; When asked whether the non-sensical texts on 05/18/2024, at 6:18 PM and 6:22 PM, made him/her think something was going on with the patient, RN-A stated that he/she did not necessarily think something was seriously wrong at the time; Regarding the text on 05/18/2024, at 6:24 PM and 6:25 PM, about getting ahold of someone in the morning, the nurse stated that he/she was clearly confused on the day and thinking the next day was Monday. The patient referenced it would be okay on Monday (05/20/2024); and Regarding his/her text on 05/18/2024, at 6:04 PM, when he/she questioned if the patient had an infection, and the patient reported a large, infected area that was very painful should have prompted an immediate evaluation, a visit by a nurse, or to be advised to go to the ER, RN A stated “Yes, I see that now looking back”. During an interview on 06/10/2024, beginning at 3:10 PM, the administrator stated that when the patient first texted, RN-A should have called the patient, reached out to on-call staff, or told the patient if they were not working, that he/she needed to call the on-call number. It was not appropriate to respond via texting. The nurse should have made a visit or arranged a visit. Either way, the patient needed to be seen by a nurse. RECORD/PATIENT#2: Review of the record showed the patient was admitted to service on 03/12/2024. Diagnoses included hypertensive heart disease (heart problems caused by long term high blood pressure), heart failure (a condition where the heart does not pump blood as well as it should), and diabetes mellitus. Review of the hospital discharge dated 04/02/2024, included wound care, if applicable, keep wound clean and dry. The instructions did not specify what procedure (s) the patient underwent. Review of the resumption of care (ROC, after hospitalization) orders dated 04/04/2024, included that the skilled nurse (SN) would assess and monitor the right incision (did not include location other than right) each visit. The orders included that the SN would instruct on incision care (failed to specify what incision care). Review of the nursing ROC assessment dated 04/04/2024, showed the patient had at least one (observable) surgical wound. The patient had an active wound that was newly epithelialized (healing). The assessment failed to include what the incision was from, location, measurements, whether incision care was provided or needed, or clarification with the physician regarding incision care of the wound. Review of a nursing visit note report dated 04/11/2024, the nurse documented he/she provided education including skin integrity/prevention of pressure ulcers, rotate position every two hours, turn in bed at night, keep area clean and dry (failed to document what area), and be mindful of any soreness and report for an assessment. He/she assessed the surgical incision (failed to indicate where the incision was) which was fully epithelialized (healed). During an interview on 06/04/2024, beginning at 12:00 (noon) with the administrator and clinical manager (CM)-B, CM-B stated that the nurses usually documented wound assessments and measurements in the wound care section. He/she would look for more information regarding the incision and incision care. During an interview on 06/05/2024, at 4:20 PM, the associate director stated that the hospital referral for the 04/04/2024, ROC showed the patient had a heart catheterization (a tube is inserted into a blood vessel in your groin or arm to the arteries of your heart) on 03/28/2024. The assessment of the surgical incision should have been much clearer. He/she did not see where the nurse clarified with the physician the order for incision care on the plan of care (POC). He/she did not see the heart catheterization procedure on the POC. The only diagnosis he/she saw that would go with the heart catheterization was atherosclerosis (a build-up of plaque on the artery walls). RECORD/PATIENT #3: Review of the record showed the patient was admitted to service on 05/01/2024. The primary diagnosis was atrial fibrillation (an irregular heartbeat). Review of the nursing start of care assessment dated 05/01/2024, showed under the section for cardiovascular (pertaining to the heart) assessment, the nurse documented fainting/dizziness. The narrative section included that the patient complained of dizziness. The assessment failed to include whether this was a new symptom, how often it occurred, and/or when it occurred, extent, duration, etc. The nurse documented he/she contacted the physician for clarification of medication discrepancies/abnormal assessment findings/approval of the plan of care (POC). The physician’s office verified medications, gave verbal approval for a physical therapy evaluation, and blood glucose parameters. The nurse failed to specifically document whether the patient’s dizziness was discussed. During an interview on 06/04/2024, beginning at 12:00 (noon), with the administrator and CM-B, CM-B stated that the patient was hospitalized with pneumonia on 05/07/2024. CM-B stated that the nurse probably should have documented more about the dizziness, and that the abnormal assessment findings probably needed to be a little more specific. He/she would expect the nurse to report the dizziness to the physician. The nurse documented noteworthy findings in the narrative then contacted the physician. He/she did not see specifically where the dizziness was reported. He/she would it assume the abnormal findings included all the above narrative.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure staff documented all communication with the patient and failed to complete a comprehensive occurrence report in one of five records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the provider’s policy titled, “Chart Data Requirements,” revised 10/23/2023, showed in part that follow-up assessments are completed in the electronic medical record (EMR) and these include any change in the client condition reflected on nurse’s notes/clinical notes, and the fall investigation form. Clinical documentation is completed in the EMR and should include ongoing documentation of identified problems, any changes in client status, and documentation of client and caregiver education. Review of the provider’s policy titled, “Incident Reporting and Documentation,” revised 08/31/2021, showed in part that employees are instructed during the orientation process that it is mandatory to report all incidents, including adverse events or serious events, to their supervisors immediately. An incident is defined as any occurrence that is not consistent with the routine delivery of care. Clients are told at the time of admission what procedure to follow should they need to report any problems they are having. Reportable incidents include a change in client condition. All incidents must be reported as soon as possible, but not more than 24 hours after learning of a potential incident. All client related incidents will be documented the applicable electronic documentation system and centralized reporting system. Review of a form titled “Code of Ethical Behavior,” and signed by RN A on 09/20/2024, included in part that the employee will: - Not fail to report an incident or injury occurring to the client while on duty and whether medical attention was or was not needed; - Report accidents or injuries occurring in the absence of staff and reported by the client or client’s family. This should be reported to your supervisor as soon as possible; and - Obey established policies, guidelines, and other written policies. RECORD/PATIENT #1: Review of the record showed the patient was admitted to service on 04/02/2024. Diagnoses included acute pancreatitis (an inflammation of the organ (pancreas), type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood), and non-pressure chronic ulcer of the left lower leg (a skin ulceration due to poor circulation). Review of text messages printed by the provider from RN-A’s phone showed on 05/16/2024, the patient texted RN-A regarding abnormal symptoms he/she was had, and the patient and RN-A texted back and forth on 05/18/2024 and 05/19/2024. Review of the medical record beginning on 06/03/2024, showed no nursing notes and/or coordination note entries between 05/16/2024 and 05/20/2024 regarding the patient’s report via texting of abnormal symptoms to RN-A until 05/20/2024, when the nurse made a visit to the patient. Review of RN-A’s visit note dated 5/20/2024, the patient reported a non-injury fall over the weekend and felt feverish two nights ago. The patient had a knot the size of baseball to the vaginal area that broke open over the weekend with foul odor and drainage. RN-A spoke with the NP’s (nurse practitioner) medical assistant and reported abnormal findings and scheduled an appointment at 2:00 PM tomorrow (05/21/2024). RN-A discussed with patient the dangers of infection that may not be treated right away. The patient discussed with the caregiver and decided to go to the emergency room today for evaluation. Review of a client occurrence reports dated 05/20/2024, showed the nature of the occurrence was a fall. The description of the occurrence showed on 05/202024, at 9:47 AM, reported to the NP’s office. The report failed to include any other information related to RN-A’s nursing visit on 05/20/2024, or that the patient had went to the hospital emergency department regarding his/her symptoms. During an interview on 06/03/2024, at 12:35 PM, the administrator stated that patients are supposed to call the office. Sometimes the staff do not give patients their phone number, but the patients obtain the number from caller ID (identification). Texting is not the preferred mode of communication, but with some clients it is their preferred mode. The clinicians can answer the patient’s texts. The clinicians should document the texted information in a coordination note. During an interview on 06/05/2024, beginning at 12:27 PM, with RN-A and the administrator, RN A stated that he/she usually documented texted concerns from patients in a narrative, coordination note, or at the next visit. He/she usually documented the notes at the time it occurred, but he/she did not this time. The administrator stated that the occurrence report should have been documented by RN-A in a comprehensive report.”

“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 policy review, employee file review, and interview the home health provider failed to ensure one employee received emergency preparedness training during orientation in one of six employee files reviewed (Employee #6). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Emergency Management Program and Plan-Home Health, Medicare Certified Home Care and Hospice Offices,” revised 03/16/2020, showed in part, that all field employees and contractors must complete emergency training upon hire and every two years. Training and demonstration must be documented. EMPLOYEE #6: Review of the employee file showed: - Date of hire: 04/24/2023; and - No record of emergency preparedness training at orientation. During an interview on 11/15/2023, at 9:04 AM, the director of clinical operations stated that employees should have emergency preparedness training within their first 90 days during orientation. During an interview on 11/15/2023, at 10:22 AM, the director of clinical operations stated that he/she could not find proof the employee had emergency preparedness training during orientation.”

“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 the patient received nursing services as ordered on the plan of care and the physician was notified of the missed visit in one of seven records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Missed Visits/Hours,” last reviewed 03/24/2023, showed that the physician must be notified when the plan of care is altered due to few visits or hours of service being provided as ordered. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/20/2022. The primary diagnosis for the current certification period of 10/16/2023 to 12/14/2023 was chronic ulcers of the right lower leg. The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “Home Health Certification and Plan of Care,” with certification dates of 10/16/2023 to 12/14/2023 showed that the patient was to receive nursing visits for wound care three times per week on Monday, Wednesday, and Friday. Review of the nursing visit documentation showed the nurse failed to visit the patient on Wednesday, 10/18/2023, and visited the patient on Thursday, 10/19/2023. The clinical record failed to contain documentation the physician was notified regarding the missed nursing visit (10/18/2023). During an interview on 11/15/2023 at 10:53 AM, the director of clinical operations stated that they would have expected the physician to be notified of the missed visit.”

“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, record review, and interview, the home health provider failed to ensure the initial assessment visit occurred within 48 hours of referral 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 policy titled, “Admission Criteria and Procedure - Medicare Certified Offices,” dated 08/14/2023 showed the initial assessment must be completed within 48 hours of referral. RECORD/PATIENT #3: Review of the clinical showed: -An order dated 09/22/2023 to admit the patient to home health services with a primary diagnosis of Alzheimer’s disease; and -The initial assessment was completed on 09/25/2023, 3 days after the start of care order. During an interview on 11/15/2023 at 2:10 PM, the home health director of clinical operations stated that he/she had nothing to provide regarding the late start of care assessment.”

“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 status in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Client Assessment and Reassessment,” revised 07/05/2021, showed in part: - A comprehensive assessment gives registered nurses (RN) and therapists insight into a client’s status through observation, measurement of vital signs, and the client’s self- reported symptoms; - It includes the client’s medical history and diagnoses and a complete physical assessment; - The data collected is used to determine the client’s need for care and services to be provided, the need for further assessments, and the creation of the plan of care; and - Review of all medical equipment, resources and supplies in the home relevant to services provided. Review of the provider’s policy titled, “Chart Data Requirements and Format – Home Health Practice,” revised 10/23/2023, showed in part that the OASIS (Outcome Assessment and Information Set)-Comprehensive Adult Nursing Assessment included physical assessment, pain effects on sleep, therapy and/or activities of daily living. Review of the provider’s policy titled, “Pain Assessment and Management,” revised 07/05/2023, showed in part: - Pain is assessed for all clients at admission by a registered nurse (RN) or therapist; - In general, a client’s pain level is assessed using a 0 to 10 scale (with 0 equivalent to no pain and 10 representing the worst pain ever experienced); - When a client reports the presence of pain (1 – 10) or a recent history of pain, the nurse or therapist will assess and document other factors as appropriate to determine if pain is a problem or requires intervention. The areas to be assessed may include any or all of the following: *Origin (what is the source of the pain); *Location; *Severity (Is it continuous or intermittent); *Are there any associated symptoms; *Any factors that make the pain worse; *What helps to relieve the pain; and *What are the current pain relief methods used and are they effective. RECORD/PATIENT #4: Review of the referral information dated 10/19/2023, showed: - The patient was hospitalized from 10/14/2023 to 10/19/2023 for bacteremia (bacteria in the bloodstream) due to klebsiella pneumonia (a bacteria found in the gut) due to pneumonia (lung infection) and a UTI (urinary tract infection). The primary reason for home health care included in part, sacroiliac (low back and buttocks) pain, obstructive sleep apnea on CPAP (continuous positive airway pressure, a machine that uses mild air pressure to keep the airways open while sleeping), and type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood); - Use blood glucose meter to check blood sugars up to three times a day; and - Insulin (injectable medication used to lower blood sugar) lispro (fast acting insulin) per sliding scale (the amount of insulin administered is dependent on the blood sugar reading) three times daily. Review of the initial comprehensive assessment dated 10/20/2023, showed: - The patient had pain rated at a level of four that interfered with activity, occasionally interfered with sleep, therapy activities, and day to day activities; and - Blood sugars were checked daily and ranged from 100 to 200. Review of the initial comprehensive assessment, dated 10/20/2023, failed to: - Include the location of the pain, the description of the pain, what made the pain worse, and what interventions the patient used for the pain relief and the effectiveness of those interventions; - Include an assessment related to the use of the CPAP machine; - Include an assessment of lung sounds; - Include an assessment of how often the patient was checking his/her blood sugars and if he/she was taking the sliding scale insulin as ordered; and - Include if the patient had a history of issues with hypoglycemia (low blood sugar) or hyperglycemia (high blood sugars). During an interview on 11/15/2023, beginning at 9:10 AM, the director of clinical operations stated that he/she would expect the CPAP to be addressed. The pain assessment should include the location, what the patient was taking for pain, its effectiveness, and a description of the pain. Lung sounds should be included in the assessment. The assessment should include the patient’s history of low or high blood sugars and education of signs and symptoms to watch for. During an interview on 11/15/2023, beginning at 1:30 PM, the director of clinical operations stated that he/she did not find information regarding the patient’s CPAP in the comprehensive assessment. Their computer system was not set up to include all the components of the pain assessment but would expect staff to document all the components of the pain assessment. Their computer system did not have an assessment for lung sounds in the comprehensive assessment but would expect staff to have added lung sounds to their assessment.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on policy review, record review, home visit observation, and interview the home health provider failed to ensure staff performed a complete/accurate medication reconciliation and maintained an accurate/updated medication profile in four of five full records reviewed (Records/Patients #1, #2, #4, and #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Chart Data Requirements and Format – Home Health Practice,” revised 10/23/2023, showed in part: - All home health clients will have a medication list in the home; and - The medication profile is updated as changes occur. Review of the provider’s policy titled, “Client Assessment and Reassessment,” revised 07/05/2021, showed in part that client assessments and reassessments included current and past medication use and history, including allergies, potential adverse effects, drug reactions/interactions, significant side effects and duplicate drug therapy. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/20/2022, with a primary diagnosis of chronic ulcers of the right lower leg. The patient resided in his/her own home with the assistance of their spouse. During a home visit observation on 11/13/2023 at 1:00 PM, a review of the patient’s medications showed the provider’s medication profile failed to contain orders for nystatin cream ordered on 09/15/2023. The patient reported that he/she used the cream for excoriated areas. During an interview on 11/15/2023 at 10:53 AM, the director of clinical operations stated that the medications on the provider’s medication profile should contain the correct medications and they had already notified the physician of the updated medications. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 10/19/2023, with a primary diagnosis of fracture (break) of the left ulna (arm) and a laceration of the left lower leg secondary to a motor vehicle accident. The patient resided alone in a private residence. During a home visit observation on 11/15/2023 at 12:00 PM, a review of the patient’s medications showed: - The provider’s medication profile failed to contain the following medications found in the patient’s home: * Docusate sodium (a stool softener); * Tums (a medication used to treat heart burn); * Tylenol (a medication used to treat pain; * Vitamin D3 (a vitamin supplement); and - The provider’s medication profile contained an order for a Lidocaine 5% patch. The patient stated that he/she had never filled the prescription for the patch. During an interview on 11/15/2023 at 1:39 PM, the director of clinical operations stated that the medications on the provider’s medication profile should contain the correct medications and they had already notified the physician of the updated medications. RECORD/PATIENT #4: Review of the referral information dated 10/19/2023, showed in part, the patient was hospitalized from 10/14/2023 to 10/19/2023 for bacteremia (bacteria in the bloodstream) due to klebsiella pneumonia (a bacteria found in the gut) due to pneumonia (lung infection) and a UTI (urinary tract infection). The primary reason for home health care included in part, sacroiliac (low back and buttocks) pain, obstructive sleep apnea on CPAP (continuous positive airway pressure, a machine that uses mild air pressure to keep the airways open while sleeping), and type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). Review of the hospital discharge medication list dated 10/19/2023, showed the following discrepancies with the home health provider’s medication profile: - The discharge medication list showed an order for acidophilus (lactobacillus, a probiotic to promote gut health), 25 million cell/100 milligrams (mg), take two tablets by mouth three times a day with meals. The provider’s medication profile failed to include this medication; - The discharge medication list showed an order for lactobacillus 10 billion cell, one capsule two times a day for seven days. The provider’s medication profile showed an order for lactobacillus 100 million cell granules packet three times a day with meals; - The discharge medication list showed an order for budesonide (a steroid medication to decrease inflammation) 0.5 mg/2 milliliters (ml) one vial per nebulizer (turns medication into a mist for inhalation) two times a day. The provider’s medication profile showed an order for budesonide 0.25 mg/2 ml two times a day; - The discharge medication list showed an order for health eyes oral (vision supplement) daily. The provider’s medication profile failed to include this medication; - The discharge medication list showed an order for atorvastin (Lipitor, reduces cholesterol) 40 mg (frequency not included). The provider’s medication profile showed an order dated 10/20/2023, for atorvastin 40 mg every night and an order dated 10/26/2023, for Lipitor 40 mg daily (this showed a duplicate medication); and - The discharge medication list showed an order for oxybutynin (used to treat overactive bladder) 5 mg every 8 hours as needed. The provider’s medication profile showed an order for oxybutynin 5 mg every eight hours. Review of the initial comprehensive assessment dated 10/20/2023, showed: - The nurse used the referral information and medications found in the home for the medication reconciliation; - The medications on the medication list matched those ordered; - No issues were found during the drug regimen review; - No discrepancies were noted; and - The physician was contacted for medication discrepancies (above showed no discrepancies) but failed to document what the medication discrepancies were. During an interview on 11/15/2023, beginning at 9:10 AM, the director of clinical operations stated that staff reconcile medications with the most recent medication list from the referral. In the home, they ask the patient to provide all medications and compare the home medications with the medication list. They would note any discrepancies and contact the physician for clarification. If discrepancies are found, staff should document the specific discrepancies. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 07/18/2023, with a primary diagnosis of non-pressure ulcer of the left heel and mid-foot with fat layer exposure and a secondary diagnosis of type 2 diabetes mellitus. Review of the client medication report, dated 11/13/2023, showed an order for 5 ml of Medihoney (an antibacterial wound treatment that contains honey) topical paste to be used daily. Review of the plan of care, dated 09/16/2023 - 11/14/2023, failed to show an order for Medihoney. During an interview on 11/15/2023 at 2:10 PM, the home health director of clinical operations stated that the Medihoney was a part of the previous wound care order, and he/she would have expected the order to be discontinued when the wound order changed.”

“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, and interview, the home health provider failed to ensure the plan of care (POC), included all equipment required, patient-specific interventions, and goals for all pertinent diagnoses 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, “Client Plan of Care (POC),” dated 07/05/2021, showed in part, the following: - The POC would include statements of individualized client needs and problems, and -The individualized POC is based on the client’s medical diagnosis, physician’s order, comprehensive assessment, and client input. RECORD/PATIENT #4: Review of the referral information dated 10/19/2023, showed in part: - The patient was hospitalized from 10/14/2023 to 10/19/2023 for bacteremia (bacteria in the bloodstream) due to klebsiella pneumonia (a bacteria found in the gut) due to pneumonia (lung infection) and a UTI (urinary tract infection). The primary reason for home health care included in part, sacroiliac (low back and buttocks) pain, obstructive sleep apnea on CPAP (continuous positive airway pressure, a machine that uses mild air pressure to keep the airways open while sleeping), and type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood); - Use blood glucose meter to check blood sugars up to three times a day; and - Insulin (injectable medication used to lower blood sugar) lispro (fast acting insulin) per sliding scale (the amount of insulin administered is dependent on the blood sugar reading) three times daily. Contact the physician’s office of blood sugar readings greater than 250 or greater than 180 for two consecutive readings. Review of the initial comprehensive assessment dated 10/20/2023, failed to show: - An assessment related to the use of the CPAP machine; - An assessment of how often the patient was checking his/her blood sugars and if the patient was taking the sliding scale insulin as ordered; and - If the patient had history of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugars). Review of the POC dated 10/20/2023, failed to show: - All equipment (CPAP machine); - Patient-specific interventions and goals regarding the CPAP machine; and - The correct intervention (patient-specific) for when to notify the physician regarding the patient’s blood sugars, in all sections of the POC (was documented in one section of the POC to notify the physician of blood glucose readings greater than 70 (should have said less than) or greater than 300 (order showed above 250 or above 180 for two consecutive readings). During an interview on 11/15/2023, beginning at 9:10 AM, the director of clinical operations stated that he/she would expect the CPAP to at least be included with the DME (durable medical equipment) information on the POC. Sometimes in their computer system if they chose CPAP, it showed oxygen supplies. He/she stated that the parameter to report blood sugars above 300 was not their policy. He/she would have expected the nurse to clarify the parameters with the physician and include those parameters on the POC. RECORD/PATIENT #5: Review of the clinical record showed the provider admitted the patient to service on 07/18/2023, with a primary diagnosis of a non-pressure ulcer of the left heel and mid-foot with fat layer exposure and a secondary diagnosis of type 2 diabetes mellitus. Review of the document titled, “Home Health Certification and Plan of Care,” dated 09/16/2023 - 11/14/2023, showed the following: - Skilled nurse to perform wound care to the left heel; - Patient had glucometer listed in durable medical equipment (DME) list; and -The POC failed to include patient-specific interventions regarding diabetes and the use of the glucometer. During an interview on 11/15/2023 at 2:10 PM, the home health director of clinical operations stated that he/she would expect there to have been sugar monitoring in relation to wound healing.”