Med-Staff Home Health, LLC

“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 the patients received the home health services that were written on their individualized plan of care when the patients did not receive visits according to the visit frequency as ordered on the plan of care in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to adversely affect the ordered care provided to all the provider’s patients. Findings included: Review of the provider’s policy, titled “PC – PLAN OF CARE/CARE PLAN,” revised March 2018 showed in part the following: - The agency provides care, treatment, and services for each patient according to the plan of care, treatment, and services; - All skilled services are furnished under the Plan of Care established by the physician. Qualified agency staff members administer drugs and treatments only as ordered by the physician; - The plan of care includes professional services, including the amount, frequency, and duration of service; - The homecare staff will implement the actions and interventions as identified in the Plan of Care; and - Patient care decisions and services to be provided are made based on the analysis of initial and ongoing assessments and physician orders. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the home health provider on 1/06/2024 after a skilled nursing facility stay for aftercare of a stage two pressure ulcer (skin injury caused by unrelieved pressure) of the right buttock and muscle weakness. The patient lived at home with his/her spouse/caregiver. The patient received skilled nursing services. Review of the Plan of Care (POC), dated 01/06/2024 to 03/05/2024, showed in part: - Skilled nurse (SN) one time a week for one week; and - Two times a week for eight weeks. Review of the clinical record showed: - The week of 01/07/2024 only one SN visit (order was for two) was completed. There failed to be any communication note or physician order for the missed visit; - The week of 01/14/2024 only one SN visit (order was for two) was completed. There failed to be any communication note or physician order for the missed visit; and - The week of 01/21/2024 only one SN visit (order was for two) was completed. There failed to be any communication notes or physician orders for the missed visits. During an interview on 01/30/2024 at 9:52 AM, the registered nurse/coder stated, he/she wrote an order at 6:33 AM today (01/30/2024) and dated it 01/09/2024 to change the order from one time a week times one week and two times a week times eight weeks to one time a week times nine weeks. During an interview on 01/31/2024 at 12:58 PM, the administrator stated clinical staff are to fill out a missed visit note and it is automatically sent to the primary care physician and they are to notify the supervisor verbally. During an interview on 01/31/2024 at 1:00 PM, the business office manager/assistant administrator stated every missed visit is faxed to the physician due to it goes to the fax que and the office staff fax it. The supervisor tries to make the visit up after being notified to move the visit accordingly.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on policy review, review of the provider’s quality assessment and performance improvement (QAPI) minutes and governing body meeting minutes and interview, the home health provider failed to provide documentation that showed the governing body provided oversight and approved of the provider’s QAPI program. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Quality Assessment and Performance Improvement (QAPI) Program,” dated 04/2018, showed in part: - The provider’s governing body ensures that the program accurately reflects the organization and the provision of services; - The provider maintains evidence of its QAPI program efforts as required by state and federal regulation; - The program utilizes quality data, including data measures from the OASIS (Outcome Assessment Information Set), EMR (electronic medical records), other third-party data providers and other relevant data, as identified by the governing body, in its program; - The frequency and detail of the data collection is approved by the governing body; - The governing body is responsible for ensuring the following: * That an ongoing program for quality improvement and patient safety is defined, implemented and maintained; * That the QAPI efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated for effectiveness; and * That clear expectations for patient safety are established, implemented, and maintained. Review of the provider’s policy titled, “Governing Body,” dated 04/2018, showed in part, the governing body: - Has ultimate responsibility and legal authority for the operations of the home health agency; - Meets as often as necessary, but at least annually, and written meeting minutes are maintained; and - Responsibilities include, but are not limited to, an annual evaluation of the home health provider’s performance in relation to the overall performance improvement plan and activities. Review of the provider’s QAPI binder and governing body minutes on 01/31/2024 showed the QAPI notes and the governing body minutes failed to contain evidence that the governing body was monitoring and approving any QAPI activities. During an interview on 01/31/2024, at 10:25 AM, the administrator stated that the governing body meetings are not a formal program, he/she knows that they need to be, but it had not been high on his/her priority list.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on policy review, review of provider’s governing body minutes and interview, the home health provider failed to provide documentation that showed the governing body assumed responsibility for the overall clinical and financial operations of the home health and it’s quality assessment performance improvement program (QAPI). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Governing Body,” dated 04/2018, showed in part, the governing body meets as often as necessary, but at least annually, and written meeting minutes are maintained. The governing body is responsible for, but not limited to, the following: - Ultimate responsibility and legal authority for the operations of the home health agency; - The adoption, approval and updating of policies and procedures for the operation and administration of the provider; - Oversight of fiscal management of the annual operating budget; - The annual evaluation of the home health provider’s performance in relation to the written mission, purpose and objectives; - The overall performance improvement plan and activities; - The effectiveness of the provider’s administrative practices, policies, procedures, and management of information; and - Ensuring that all services provided are consistent with accepted standards of practice and in compliance with applicable law and regulation. Review of the provider’s governing body meeting minutes, on 01/31/2024, showed in part the following: - The governing body failed to hold a meeting in 2023; - A meeting note, dated 11/11/2022, and the purpose was to appoint a back-up director of clinical services and back-up administrator. No other business was discussed; - A meeting note, dated 09/15/2021, and the purpose was to appoint a back-up director of clinical services and no other business was discussed; and - A meeting note, dated 04/14/2021, showed the governing body discussed the home health operations, budget, management and QAPI (this was the last time overall operations were discussed and was approximately 34 months ago). During an interview on 01/31/2024, at 10:25 AM, the administrator stated that the governing body meetings are not a formal program, he/she knows that they need to be, but it had not been high on his/her priority list. Findings were reviewed with the administrator on 01/31/2024, at 2:30 PM. The administrator stated that he/she had not really been involved in the governing body meetings but, he/she will be actively involved going forward.”

“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 a complete and accurate list of all the medications that the patient was currently using in, three of three home visit observations (Records/Patients #1, #2 and #3). This deficient practice has the potential to affect the home health provider’s ability to ensure safe and effective use of medications for all patients served by the provider. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 0/12/2024 with a primary diagnosis of acute and chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) and additional diagnoses of complications related to a bone marrow transplant, myeloblastic leukemia (a cancer of the blood cells) and idiopathic aseptic necrosis of the left femur (a bone condition that results from poor blood supply to an area of bone, causing localized bone death). The patient lived at home alone and had family who checked in on them throughout the week. Observation and interview on 01/30/2024 at 12:00 PM, during the patient’s home visit, showed the following discrepancies with the medication in the patient’s home and the provider’s medication profile: - The provider’s medication profile showed an order for calcium citrate (a mineral supplement) 250 milligrams (mg), take two tablets twice daily (BID). The patient was taking calcium carbonate 600 mg with vitamin D3 400 International Units (IU), one tablet daily; and - The patient stated that he/she was taking Senekot Laxative Gummies (senna leaf powder 34.8 mg) take four gummies up to twice daily as needed for constipation. The provider’s medication profile failed to contain this medication. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 01/06/2024 with a primary diagnosis of diabetes (a group of diseases that results in too much sugar in the blood) and additional diagnoses of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and end stage renal disease (a disease in which the kidneys no longer work as they should to meet the body’s needs). The patient goes to dialysis three times a week and recently moved back into his/her own home after an extended stay with one of his/her children. The patient has children and grandchildren who stay with the patient during the day. Observation and interview on 01/30/2024 at 10:10 AM, during the patient’s home visit, showed the following discrepancies with the medication in the patient’s home and the provider’s medication profile: - The patient had four docusate sodium (stool softener) capsules in an unlabeled medication bottle and stated that he/she took one capsule every day. The provider’s medication profile failed to contain this medication; and - The patient had a bottle of enteric coated aspirin 81 mg, take one tablet daily. The bottle showed a refill date of 01/23/2024 and the patient stated that he/she is taking this medication. The provider’s medication profile failed to contain this medication. During an interview on 01/31/2024, at 1:00 PM, the administrator stated that he/she expected the nurse to do medication reconciliation and look at the patient’s medications at every home visit and it is the registered nurse case manager’s responsibility to oversee medication reconciliation. Findings included: Review of the provider’s policy, titled “MM – MEDICATION MANAGEMENT,” revised August 2020 showed in part the following: - Upon admission, the Registered Nurse (RN), or Physical Therapist will complete an assessment of all medications the patient is taking, both prescription and over-the-counter (OTC) drugs and begin a medication profile; - All medications will be documented on the medication sheet as to the dose, frequency, route an indication. This includes prescription and non-prescription medication‘s, as well as home remedies as reported; - All medication in the home will be checked by the Agency nurse (RN) assigned to the respective patient’s care for proper drug, dosage, allergies, potential adverse reactions, or side effects, drug-drug or food-drug interactions, indications, and contraindications; - Ongoing medication monitoring is collaborative and essential to ensure appropriateness and continuity of care or services and to identify the potential complications from the therapy being provided; and - The ongoing medication monitoring process includes information necessary for maintaining an accurate medication history and a complete medication profile and for ensuring the safety of the medication and administration process. The medication profile will be used to evaluate the patient’s current medication regimen. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the home health provider on 1/06/2024 after a skilled nursing facility stay for aftercare of a stage two pressure ulcer (skin injury caused by unrelieved pressure) of the right buttock and muscle weakness. The patient was alert and orientated times three (person, place, time). The patient lived at home with his/her spouse. The patient received skilled nursing and physical therapy services. Observation on 1/31/2024 at 11:10 AM, during the patient’s home visit, showed the following: - The skilled nurse asked the patient if there had been any medication changes. The patient verbalized there had been no changes; - The state surveyor reviewed the provider’s Medication Profile form with the patient’s spouse/caregiver, along with the patient present, with the following discrepancies; * Spiriva Respimat (bronchodilator) inhalation 2.5 micrograms (mcg)/actuation (act) one puff daily. The patient and patient’s spouse stated he/she takes two puffs daily; * Omeprazole (acid reducer) 20 milligrams (mg) one capsule daily. The patient and patient’s daughter stated he/she takes it as needed about three to four times per a week; * Vitamin D3 2000 IU (international units) one daily. The medication failed to be on the provider’s list; and * Ketoconazole cream 2% as needed. The medication failed to be on the provider’s list.”

“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 review of the Nurse Practice Act, clinical record review, home visit observation, and interview, the home health provider failed to ensure the clinicians provided services as ordered by the physician or allowed practitioner in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect the provision of care for all the provider’s patients. Findings included: The Nursing Practice Act, Chapter 335, RSMo defined “Professional Nursing” at 335.016(15) as “the performance for compensation of any act which requires substantial specialized education, judgment and skill based on knowledge and application of principles derived from the biological, physical, social and nursing sciences, including, but not limited to: (a) Responsibility for the teaching of health care and the prevention of illness to the patient and his or her family; (b) Assessment, nursing diagnosis, nursing care, and counsel of persons who are ill, injured or experiencing alterations in normal health processes; (c) The administration of medications and treatments as prescribed by a person licensed by a state regulatory board to prescribe medication and treatments; (d) The coordination and assistance in the delivery of a plan of health care with all members of a health team; and (e) The teaching and supervision of other persons in the performance of any of the foregoing.” Review of the provider’s policy, titled “PC – PLAN OF CARE/CARE PLAN,” revised March 2018 showed in part the following: - The agency provides care, treatment, and services for each patient according to the plan of care, treatment, and services; - All skilled services are furnished under the Plan of Care established by the physician. Qualified agency staff members administer drugs and treatments only as ordered by the physician; - The plan of care includes treatments and specific types of services and equipment/supplies required to be provided for patient care; - The homecare staff will implement the actions and interventions as identified in the Plan of Care; and - Patient care decisions and services to be provided are made based on the analysis of initial and ongoing assessments and physician orders. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the home health provider on 1/06/2024 after a skilled nursing facility stay for aftercare of a stage two pressure ulcer (skin injury caused by unrelieved pressure) of the right buttock and muscle weakness. The patient lived at home with his/her spouse/caregiver. The patient received skilled nursing services. Review of the Plan of Care (POC), dated 01/06/2024 to 03/05/2024, showed in part: - The patient was admitted to home health services with a diagnosis of pressure ulcer of the right buttock, stage two and muscle weakness; - Frequency and duration of visits: * Skilled nurse (SN) 1wk1 (1 time weekly for 1 week), 2wk8 (2 times weekly for 8 weeks); and - Right buttocks pressure ulcer: cleanse with wound cleanser, cover with Aquacel (dressing for moderate to heavily exuding wounds) foam two times weekly and PRN (as needed) if soiled, CG (caregiver) to perform wound care in absence of SN. Observation on 1/31/2024 at 11:10 AM, during the patient’s home visit, showed the following: - The skilled nurse stated the spouse/caregiver would demonstrate the wound care; - Barrier placed on the table with dressing supplies including Xeroform (fine mesh gauze dressing for use on low exudating wounds); and - The spouse performed the dressing change to the right buttock applying the Xeroform provided by the provider. The skilled nurse failed to ensure services were provided as ordered. Both registered nurses (RNs) on the visit confirmed the dressing used was Xeroform, on 01/31/2024. During an interview on 01/31/2024 at 2:16 PM, the administrator stated that there is no reason to use Aquacel on the wound now. The wound is closed now and the nurse probably got a new order for Xeroform and didn’t write the order.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on record review and review of Chapter 26 Home Health Agencies, 19 CSR 30-26.010 (1)(B)(2)(A and B)(3) Home Health Licensure Rules, the agency failed to provide annual Alzheimer’s disease training, to one of six employee files reviewed (Employee/E3). This deficient practice has the potential to affect the safety of all patients served by the provider. Findings included: On 01/31/2024, at approximately 2:45 PM, the provider’s policy for employee Alzheimer’s training was requested. No policy was provided. Review of Chapter 26 Home Health Agencies, 19 CSR 30.26.010 (1) (B) (2) (A and B) (3) showed: (B) Licensed home health agencies shall provide dementia-specific training about Alzheimer’s disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients, or consumers with Alzheimer’s disease or related dementias; (2) Employees or independent contractors who do not provide direct care for, but may have daily contact with persons with Alzheimer’s disease or related dementias shall receive dementia-specific training that includes at a minimum: (A) An overview of Alzheimer’s disease and related dementias; and (B) Communicating with persons with dementia; and (3) Dementia-specific training about Alzheimer’s disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer’s disease and other related dementias. The training shall be provided annually and updated as needed. EMPLOYEE/E3: Review of the employee file on 01/30/2024 showed: - Hire date: 08/09/2022; and - Failed to show any yearly Alzheimer’s/dementia training since 08/09/2022. During an interview on 01/31/2024 at 1:20 PM, the business office manager (BOM) / assistant administrator stated, E3 should have had the annual Alzheimer’s training with all the other annual trainings, but somebody must have pulled it out of the packet she makes the copies from.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on clinical record review and interview, the home health provider failed to provide documentation that showed a complete discharge summary was sent to the patient’s primary physician in two of two discharge records reviewed (Records/Patients #5 and #6). This deficient practice has the potential to affect the continuity of care for all patients discharged by the provider. Findings included: On 01/31/2024, at approximately 2:45 PM, the provider’s policy for patient discharge summary was requested. No policy was provided. RECORD/PATIENT #5: Review of the clinical record showed, in part, the following: - A physician order, dated 12/12/2023, to discharge per patient request; - A discharge assessment, dated 12/13/2023, that showed “physician notified of discharge summary availability”; and - The record failed to show evidence that the complete discharge summary was sent to the patient’s primary physician within five business days of the patient’s discharge. During an interview on 01/31/2024, at 1:00 PM, the business office manager stated that they send every discharge summary over to the patient’s primary physician and he/she would find the fax verification to prove it was sent. At 3:00 PM the business office manager approached the surveyors and stated that he/she cannot prove the discharge summaries were faxed to the physician because someone deleted two year’s-worth of faxes and he/she does not have any way to get them back. Findings included: RECORD/PATIENT #6: Review of the clinical record showed, in part, the following: - A physician order, dated 12/27/2023, to discharge patient; - A discharge assessment, dated 12/27/2023, that showed “physician notified of discharge summary availability”; and - The record failed to show evidence that the complete discharge summary was sent to the patient’s primary physician within five business days of the patient’s discharge.”