Bethesda Home Health

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on policy review, record review, observation, and interview the home health provider failed to: - Ensure that each patient received an individualized plan of care that includes all elements (Refer to G574); - Ensure that all orders were transcribed and added to the patient’s medical record (Refer to G584); - Ensure that the physician was alerted to changes in the patient’s condition and/or that changes were communicated that might alter the plan of care (Refer to G590); and - Ensure that a visit schedule was available to the patient or caregiver (Refer to G614). The cumulative effect of these deficient practices have the potential to affect the care and services for all the provider’s patients.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on employee file review and interview the home health provider failed to ensure that one of four employee files reviewed contained emergency preparedness training on orientation (E-2). This deficient practice has the potential to affect all patients served by the provider. Findings included: E-2: Review of the employee file showed that E-2 was hired on 03/13/2023. Review of the employee’s training hours showed that the employee failed to complete any emergency preparedness training. The provider failed to ensure that any emergency preparedness education was completed during orientation. During an interview on 11/29/2023 at 4:25 PM, the human resources representative stated, “the employees have one year to complete all of the trainings except required courses like Dementia training.””

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on policy review, employee file review, and interview the home health provider failed to ensure that one of four employee files reviewed contained infection control training on orientation (E-2). This deficient practice has the potential to affect all patients served by the provider. Findings included: A policy was requested on 11/29/2023 regarding infection control education and a policy for “Hand Hygiene” was provided. Review of the policy, “Hand Hygiene,” dated 08/2023, showed in part, that “all agency employees, including contracted personnel, receive education regarding hand hygiene, including advantages and disadvantages of various hand cleaning methods, during orientation and at least annually thereafter.” E-2: Review of the employee file showed that E-2 was hired on 03/13/2023. Review of the employee’s training hours showed that the employee completed a training titled “Bag Technique in the Home,” on 04/30/2023. The provider failed to ensure that hand hygiene or any other infection control education was provided during orientation. During an interview on 11/29/2023 at 4:25 PM, the human resources representative stated, “the employees have one year to complete all of the trainings except required courses like Dementia training.””

“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 was held within 48 hours of the referral or within 48 hours of the patient’s return home in two of five records reviewed (Records/Patients #3 and #4) and failed to ensure a registered nurse (RN) conducted the initial assessment visit in one of five records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the home health provider’s policy titled, “Assessment,” revised 01/2023, showed in part: - Admission assessments should be performed by a RN within 48 hours of the time of the referral, the patient’s return home or the physician-ordered start of care date; and - If the physician orders only therapy services, the initial comprehensive assessment may be completed by an appropriate rehabilitation skilled professional (physical therapist (PT) or speech-language pathologist/speech therapist (SLP) within 48 hours of the time of referral, the patient’s return home or the physician-ordered start of care date. RECORD/PATIENT #3: Review of the clinical record showed a referral for home health services dated 11/09/2023. Review of the initial assessment showed, in part, the following: - Item M0102, on the Outcome and Assessment Information Set (OASIS; a standardized data collection tool), showed the physician ordered start of care date was answered as not applicable – no specific start of care date ordered by the physician; - OASIS item M1000 showed the patient was discharged from a skilled nursing facility; - OASIS item M1005 showed the inpatient discharge date was 11/10/2023; - OASIS item M0090 showed the assessment was completed on 11/14/2023 (96 hours after the patient’s return home); and - The provider failed to complete the initial visit assessment within 48 hours. RECORD/PATIENT #4: Review of the clinical record showed, in part: - The patient was discharged from a nursing and rehabilitation facility on 10/04/2023; - A referral to the home health provider was received by the provider on 10/13/2023; - The initial visit assessment was completed on 10/16/2023 (72 hours after the referral was received); and - The provider failed to complete the initial visit assessment within 48 hours. During an interview on 11/30/2023 beginning at 1:00 PM, the clinical manager stated that he/she would expect the nurse to call the physician and delay the admission if needed. RECORD/PATIENT #5: Review of the clinical record showed, in part: - A referral for home health services dated 08/24/2023; - The referral had orders for PT evaluation and treatment effective 08/24/2023, skilled nursing (SN) evaluation and treatment effective 08/24/2023 and occupational therapy (OT) evaluation and treatment effective 08/24/2023; - The initial assessment visit was completed by a PT; and - The provider failed to ensure the initial assessment visit was completed by a RN. During an interview on 11/28/2023 at 12:30 PM, the clinical manager stated that they try to get someone in there to admit the patient as quickly as possible when an evaluation order is received. He/she was not aware the RN must conduct the initial assessment unless it was a therapy only referral. He/she stated that they had always had therapy do the initial 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 conduct an accurate review of all medications taken by the patient in, but not limited to, three of five records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Management – Patient Information,” revised 01/2023, showed in part: - During the initial assessment visit, the registered nurse/therapist generates a list of the patient’s current medications, including prescription and over-the-counter (OTC) medications and herbal remedies. The information is documented in the provider’s medication profile; - The registered nurse performs a comprehensive drug regimen review of the patient’s current medications/herbal remedies during each comprehensive assessment. This information is documented in the comprehensive assessment or visit notes/memos; - Any questions or concerns about the patient’s current medications and herbal remedies are directed to the ordering physician; - The list of current medications is incorporated into the plan of care; - The patient’s medications are reviewed and assessed during each skilled visit; and - Any changes to the medications or changes in the patient’s response to the medications are conveyed to the ordering physician and documented in the medical record. RECORD/PATIENT #2: Review of the clinical record showed that the patient’s medication list dated 11/27/2023, included the medication Tylenol (a mild pain medication) 500 mg one tablet every six hours as needed. Observation on 11/28/2023 beginning at 9:25 AM, during the patient’s home visit, showed the patient reported taking the following medications that were not included on the medication list: - Tylenol 500 mg two tablets every six hours as needed for pain; - Senekot (a medication for constipation) 8.6 mg two tablets as needed- can take up to four tablets per day and used “a few days ago;” - Visine eye drops (used for red or itching eyes) one or two drops as needed four times per day and used “every now and then;” and - The nurse applied Vanicream (an over-the-counter lotion for dry skin) to his/her legs before re-applying tubigrips (a stocking that provides support and compression) to the legs and the patient stated “I use the lotion everyday.” RECORD/PATIENT #1: Observation and interview on 11/27/2023 beginning at 1:55 PM, during the patient’s home visit, showed the following medication discrepancies with the provider’s medication profile: - The medication profile showed an order for albuterol 2.5 milligrams (mg) / 3 milliliters (mL) 0.083% inhalation solution, inhale 3 mL by nebulizer two times a day PRN (Pro re nata – commonly used to mean as needed or as the situation arises) for wheezing. The patient stated that he/she did not have a nebulizer machine and was not taking this medication; - The medication profile showed an order for alprazolam 1 mg every eight hours. The medication was not in the home and the patient stated that he/she does not take this medication; - The medication profile showed an order for baclofen 5 mg, one tablet three times a day (TID). The medication in the patient’s home showed a bottle dated 11/14/2023 for baclofen 10 mg TID. The order date on the bottle was 08/30/2023; - The medication profile showed an order for MiraLax 17 grams (gm) daily PRN constipation. The medication was not in the home and the patient stated that he/she was not taking the medication; - The medication profile showed odansetron 4 mg every six hours PRN for nausea. The medication was not in the home and the patient stated that he/she was not taking the medication; - The medication profile showed oxycodone 5 mg, take one every six hours PRN pain. The medication was not in the home and the patient stated that he/she was not taking it; - Docusate sodium 50 mg / sennosides 8.6 mg was found with the patient’s medications and the patient stated he/she took it PRN. The medication was not listed on the patient’s profile; - Extra strength acetaminophen 500 mg was found with the patient’s medications and the patient stated that he/she took two every morning and evening. The medication was not listed on the patient’s profile; - Melatonin 5 mg was found with the patient’s medications and the patient stated that he/she took it daily at bedtime. The medication was not listed on the patient’s profile; and - Vitamin B12 2500 micrograms (mcg) was found with the patient’s medications and the patient stated that he/she took one every morning. The medication was not listed on the patient’s profile. During an interview immediately following the home visit, the quality assurance performance improvement (QAPI) nurse stated that there is usually a form in the admission packet that asks if there were any medication changes and there is a prompt on the tablet that encourages the clinician to ask the patient whether there were any medication changes. He/she would have to look at the policy to see how often the clinician was supposed to physically look at the patient’s medication bottles. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/14/2023 with a primary diagnosis of unspecified encephalopathy. The patient was discharged on from a skilled nursing facility (SNF) to the assisted-living facility (ALF) that serves as the patient’s permanent residence on 11/10/2023. Review of the initial assessment, dated 11/14/2023, showed in part, the following: - The patient was noted to have dementia; and - The patient had a memory deficit and impaired decision-making. Review of the provider’s medication profile showed the following discrepancies with the assisted living’s medication record: - The provider’s medication profile showed an order for estradiol 0.1 milligram/gram (mg/gm) vaginal cream, apply 1 gm intravaginally three times a week. The ALF medication record showed the dosage as 0.5 gm vaginally three times a week; - The provider’s medication profile showed an order for mirtazapine 7.5 mg, take two tablets one time a day at bedtime. The ALF medication record showed the dosage as 7.5 mg take one tablet one time a day; - The ALF medication record showed the patient uses Aspercreme with aloe 10% (trolamine salicylate), apply to affected areas topically PRN. The provider’s medication profile failed to include this medication. During the home visit, the certified occupational therapy assistant (COTA) asked the patient if there had been any medication changes. The patient stated that there had not been any changes. The COTA failed to confirm this statement with the ALF. During an interview on 11/30/2023 at 1:00 PM, the clinical manager stated that the clinicians do a full medication reconciliation with each comprehensive assessment and they ask the patient about medication changes at every visit. If medications are kept and passed by the ALF staff, he/she would expect the nurse to ask the ALF medication aide if there had been any changes.”

“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 provide an individualized plan of care that included, all pertinent diagnosis, all medications and treatments, and patient specific interventions and goals in three of five records reviewed (Records/Patients #2, #4 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the home health provider’s policy titled, “Care Planning and Coordination,” revised 11/2013, showed in part: - The purpose was to plan and provide individualized care and/or services appropriate to the goals and needs of patients serviced by the provider; - An individualized plan of care (POC) is developed by the provider’s registered nurse or licensed nurse for each patient based upon an assessment that reflects the patient’s identified problems and needs, consistent with physician or licensed independent practitioner’s orders or prescriptions in accordance with applicable laws and regulations; and - The plan of care includes dates of onset of problems/needs based upon assessment data and physician orders, measurable objective goal statements, interventions to address the identified patient needs, measurable patient outcomes. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/17/2023. Review of the plan of care (POC) dated 10/16/2023 to 12/14/2023 included the following interventions: - Agency VS (vital signs) parameters will be assessed each visit and reported to the MD (medical doctor): if diabetic glucose > (greater than) 250 or (Outcome and Assessment Information Set; a standardized data collection tool) showed the brief interview for mental status (BIMS – a tool to determine the individual’s attention, orientation and ability to register and recall new information) score was 15 (A BIMS score of 13 to 15 points indicates cognitive intactness); - OASIS item D0150, patient mood interview showed the clinician documented the patient denied that they had “little interest or pleasure in doing things” and denied “feeling down, depressed, or hopeless”; - The clinician documented the patient answered “never” to “how often do you feel lonely or isolated from those around you”; and - The clinician documented the patient had impaired decision making daily and their actions could have caused injury to self or others or could have jeopardized their personal safety. Review of the POC dated 08/26/2023, showed in part: - An intervention for “all patients with diagnosis of depression or hopelessness – assess mental status and medication compliance each visit. Instruct on signs and symptoms of any adverse reactions and assess efficacy of medications in controlling symptoms. Any verbalization of self-harm or suicidal ideation will be reported to MD (doctor of medicine) immediately and EMS (emergency medical services)/ 911”; - A goal that showed “patient demonstrated compliance with current antidepressant medication therapy and is able to verbalize s/s (signs/symptoms) to report to MD/home health clinician, target date 10/24/2023”; - The patient did not have a diagnosis of depression; and - The patient did not take antidepressants. The provider failed to provide an individualized POC with patient-specific interventions and goals. During an interview on 11/28/2023 at 12:30 PM, the clinical manager stated that the interventions for depression and the antidepressant medication compliance goals are editable and are only used for patients that have a diagnosis of depression. They have the ability to individualize each intervention and goal so the POC is specific to the patient. Findings were reviewed on 11/30/2023 at 1:00 PM with the clinical manager and the quality assurance/performance improvement nurse. Both stated that the physical therapist that performed the initial assessment is usually very thorough so the patient probably had something on his/her BIMS score or something in the assessment that triggered those POC interventions and goals. Both stated that, after reviewing the initial assessment, they could not find any documentation that would explain why the interventions and goals for depression were placed on the POC.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on policy review, record review and interview, the home health provider failed to ensure physician orders received verbally or by telephone were signed, dated, timed and documented in the clinical record and that verbal orders were authenticated and dated by the physician in two of five records reviewed (Records/Patients #3 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the home health provider’s policy titled, “Care Planning and Coordination,” revised 11/2013, showed in part: - An individualized plan of care (POC) is developed by the provider’s registered nurse (RN) for each patient based upon an assessment that reflects the patient’s identified problems and needs, consistent with physician or licensed independent practitioner’s orders or prescriptions in accordance with applicable laws and regulations; and - The POC includes the list of dates of onset of problems/needs based upon assessment data and physician orders and interventions to address the identified patient needs. Review of the home health provider’s policy titled, “Care Plan Implementation,” revised 11/2013, showed in part: - The home health provides care, treatment and/or services consistent with the type and frequency identified and documented in the POC; and - The home health provides care, treatment and/or services for each patient according to accepted professional standards and applicable laws and regulations. RECORD/PATIENT #3: Review of the clinical record showed, in part, the following: - A referral, dated 11/09/2023, that showed orders for skilled nursing (SN) to assess and evaluate; - The initial assessment performed by the RN, dated 11/14/2023, that showed the patient had a left forehead laceration that was scabbed over with bruising surrounding the wound and an intervention to leave open to air and monitor for signs and symptoms of infection. Skilled nurse was to perform the assessment one to two times weekly with skilled nurse visits; - The POC, dated 11/14/2023, that showed an order for Skilled nursing to assess and evaluate, with an effective date of 11/9/2023, and an intervention for SN to perform wound care one to two times weekly with skilled nurse visit (order does not specify the SN visit duration); - A communication note, dated 11/15/2023, showed the RN documented receipt of a telephone call from the primary physician’s office that “Dr. (doctor) ok with plan of care and frequency for nursing one to two times a week for a few weeks;” - A transcribed verbal order, dated 11/20/2023, that showed SN to visit one time a week for two weeks and the start date was 11/26/2023; and - The record failed to contain physician orders for the SN visits, with the visit frequency and duration, previously documented as received by the RN in the 11/15/2023 communication note. No further visits were made by the SN after the initial assessment visit on 11/14/2023. RECORD/PATIENT #5: Review of the POC, dated 08/26/2023, showed in part: - A primary diagnosis of hypertensive heart disease (changes in the heart and arteries as a result of chronic blood pressure elevation) with congestive heart failure (CHF- a decrease in the ability of the heart to pump blood) and chronic kidney disease (CKD – a chronic disease of the kidneys usually resulting in kidney failure); - An order that showed vital signs will be assessed each visit and reported to physician if temperature is greater than 100.4 degrees Fahrenheit, heart rate greater than 100 or less than 60, blood pressure (BP) greater than 180/100 or less than 100/60, respirations greater than 24 or less than 12, Oxygen saturations less than 90 percent, blood glucose greater than 250 or less than 80 and “weights – if 3-5 lbs (three to five pounds) weekly or greater than 2-3 lbs (two to three pounds) in 24 hrs (hours)”; and - The patient’s medications included furosemide (a diuretic used to remove excess fluid from the body) 40 milligrams (mg), potassium chloride (a mineral supplement used to treat or prevent low potassium in the blood) 20 milliequivalents (mEq) daily and metoprolol succinate ER (extended release) (used to treat high blood pressure, chest pain and CHF) 25 mg daily. Review of the physical therapy visit note, dated 09/06/2023, showed in part: - The patient had a resting blood pressure of 106/62; - The physical therapy assistant (PTA) documented the patient became dizzy with walking and needed to sit down; - The patient’s BP was 78/40 and re-assessed at 80/54 approximately 20 minutes later; and - The PTA documented that he/she made the family (spouse and daughter) aware of the low blood pressure and the daughter reported the patient had an appointment with the cardiologist later that day and she would inform the doctor of the BP readings. Review of the SN visit note, dated 09/07/2023, showed in part: - Medication interventions performed this visit: “Dc (discontinue])metoprolol and aspirin (named physician) on 09/96”; and - A narrative note that stated “medication profile updated and poc update, pt (patient) seen (named physician) cardiology dc aspirin and metoprolol, limit salt 1500 mg daily, limit fluid 2L (two liters) daily, pt verbal understanding”. Review of the physician orders showed the SN failed to document the orders, obtained during the 09/07/2023 visit, for physician authentication and signature. During an interview on 11/30/2023 at 1:00 PM, the clinical manager stated that the SN visits and the sodium and fluid restriction were on the care plan updates but were not generated as orders to be signed by the physician. He/she would expect the nurse to have transcribed the telephone orders or orders found during a home visit when they were received.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on policy review, record review and interview, the home health provider failed to notify the physician of a 21 pound weight loss from 08/26/2023 to 09/13/2023, on a patient with a diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and also was on a diuretic (used to remove excess fluid) and an antihypertensive (used to lower blood pressure) in one of five records reviewed (Record/Patient #5), the provider failed to alert the physician of weight changes in one record reviewed (Record/Patient #2), and the provider failed to notify the physician of missed scheduled visits in four of five records reviewed (Records/Patients #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the home health provider’s policy titled, “Care Planning and Coordination,” revised 11/2013, showed in part: - An individualized plan of care (POC) is developed by the provider’s registered nurse or licensed nurse for each patient based upon an assessment that reflects the patient’s identified problems and needs, consistent with physician or licensed independent practitioner’s orders or prescriptions in accordance with applicable laws and regulations; and - The physician is contacted as necessary and appropriate with reports of changes in the patient’s clinical status and/or needs, and for necessary orders and/or prescriptions. RECORD/PATIENT #3: Review of the clinical record showed a referral for home health services with orders for physical therapy (PT) to assess and evaluate. Review of the initial assessment, dated 11/14/2023, showed in part: - The patient required substantial/maximum assistance with transfers to and from bed to chair (item GG0170-E on the Outcome and Assessment Information Set, OASIS); - The patient required partial to moderate assistance with walking distances of 50 feet with two turns and 150 feet once standing (OASIS item GG0170-J,K); - The patient was dependent in his/her ability to go up and down a curb or up and one step (OASIS item GG0170-M); - The patient was dependent in his/her ability to bend/stoop from a standing position to pick up a small object from the floor (OASIS item GG0170-P); and - The patient had a history of falls within the last three months and had a fall risk assessment score of nine (a score of four or more is considered at risk for falling). Review of the PT evaluation, dated 11/16/2023, showed the PT recommended continued skilled PT services one time a week for eight weeks. Review of the physician orders show the home health provider failed to notify the physician of the patient’s assessed need for further PT services and failed to obtain orders for further treatment. During an interview on 11/30/2023, at 1:00 PM, the clinical manager stated that an order for further PT visits was not obtained because they did not want to overwhelm the patient by having too many people going into see the patient. They did not contact the physician and ask for an order to delay the PT visits because they discussed the patient and decided to not do additional PT visits. They did not think they needed to get an order to do that. RECORD/PATIENT #5: Review of the referral for home health services, dated 08/24/2023, showed an order for PT to assess and evaluate the patient. Review of the physician orders showed an order dated 09/05/2023 for PT two times a week for one week then one time a week for six weeks to start 9/5/2023. Review of the physical therapy assistant’s (PTA) visit note, dated 09/15/2023, showed the patient requested to hold PT services until after he/she was seen on 09/27/2023 by an orthopedic physician. The patient reported having too much knee pain to participate in therapy. The note failed to include documentation that the physician was notified of the missed visit or of the patient’s request to hold PT. During an interview on 11/30/2023 at 1:00 PM, the clinical manager stated that they generate a missed visit communication in their electronic medical record software and it automatically notifies the physician of the missed visit but he/she could not provide any evidence to show the physician was notified. He/she stated that once the missed visit note is generated, you cannot get back into it. Review of the initial assessment, dated 08/26/2023, showed in part: - The patient’s height was six feet tall and the patient’s weight was 200 pounds; - The patient had 1+ edema (swelling) to both feet; and - The patient was assessed to fatigue easily and had dyspnea (shortness of breath) on exertion. Review of the POC, dated 08/26/2023, showed, in part: - The patient was 96 years old and lived at home with the assistance of a caregiver; - A primary diagnosis of hypertensive heart disease (changes in the heart and arteries as a result of chronic blood pressure elevation) with congestive heart failure (CHF- a decrease in the ability of the heart to pump blood) and chronic kidney disease (CKD – a chronic disease of the kidneys usually resulting in kidney failure). The patient also had type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar); - An order that showed vital signs will be assessed each visit and reported to physician if temperature is greater than 100.4 degrees Fahrenheit, heart rate greater than 100 or less than 60, blood pressure (BP) greater than 180/100 or less than 100/60, respirations greater than 24 or less than 12, Oxygen saturations less than 90 percent, blood glucose greater than 250 or less than 80 and “weights – if 3-5 lbs (three to five pounds) weekly or greater than 2-3 lbs (two to three pounds) in 24 hrs (hours)”; and - The patient’s medications included furosemide (a diuretic used to remove excess fluid from the body) 40 milligrams (mg), potassium chloride (a mineral supplement used to treat or prevent low potassium in the blood) 20 milliequivalents (mEq) daily and metoprolol succinate ER (extended release) (used to treat high blood pressure, chest pain and CHF) 25 mg daily. Review of the skilled nursing (SN) visit note, dated 08/29/2023, showed, in part: - The patient’s weight was 195 pounds (a five pound weight loss in three days); - The patient had dyspnea on exertion, lungs were clear, no documentation of edema; - Under the heading of “Visit Plan- Contacts / Phone Calls” the SN documented “physician” and “supervisor” were contacted; and - The SN failed to document in the note what was discussed with the physician. Review of two communication notes, both dated 08/29/2023, showed: - At 2:38 PM, the SN spoke with someone at the primary care physician’s (PCP) office and documented that it was okay for the SN visits and the POC (the SN failed to document that the PCP was notified of the weight loss); and - At 2:46 PM the SN entered a narrative note regarding the patient’s wound and need for wound care. The note failed to contain any documentation that the physician was notified of the patient’s weight loss. Review of the SN visit note, dated 09/01/2023, showed in part: - The patient’s weight was 192 pounds (a three pound weight loss in three days and an eight pound loss in six days); - Lungs were clear, no cough noted; and - The SN failed to notify the physician of the weight loss. Review of the physical therapy visit note, dated 09/06/2023, showed in part: - The patient had a resting blood pressure of 106/62; - The patient became dizzy with walking and needed to sit down; - BP was 78/40 and reassessed at 80/54 approximately 20 minutes later; - The patient informed the PTA that he/she did not take his/her morning medications (which included the furosemide and the metoprolol succinate ER); - The PTA requested that the patient take his/her medications and the patient took them; - The family (spouse and daughter) were made aware of the low blood pressure and the daughter reported the patient had an appointment with the cardiologist later that day and she would inform the doctor of the BP readings; - The daughter was comfortable with monitoring the patient’s symptoms and did not feel the need to contact the patient’s PCP; - The PTA failed to notify the physician of the patient’s low BP; - The PTA failed to notify the supervising PT of the patient’s low BP. Review of the SN visit note, dated 09/07/2023, showed in part: - The patient’s weight was 188 pounds (down four pounds in 6 days); - Lungs were clear and dyspnea was noted on exertion; - Medication interventions performed this visit: “Dc (discontinue) metoprolol and aspirin (named doctor) on 09/96”; - A narrative note that stated “medication profile updated and poc update, pt (patient) seen (named doctor) cardiology dc aspirin and metoprolol, limit salt 1500 mg daily, limit fluid 2L (two liters) daily, pt verbal understanding”; and - The SN failed to notify the physician of the weight loss. Review of the SN visit note, dated 9/13/2023, showed in part: - The patient’s weight was 179 pounds (down 9 pounds in a week) - The SN summarized the weight loss as 21 pounds in three weeks; - Lungs were clear, no cough and dyspnea on exertion was noted; and - The SN failed to notify the physician of the weight loss. Review of the clinical record showed no laboratory orders or results. Review of the document titled “Agency Transfer Summary,” dated 09/18/2023, showed “per patient daughter reporting, patient was admitted to (named hospital) for kidney issues related to Lasix (furosemide) therapy.” During an interview on 11/28/2023 at 12:30 PM, the clinical manager stated that the parameters listed in the POC carry over onto each visit note and when the clinician marks the intervention completed, that means they notified the physician of any abnormalities. He/she was unable to provide any documentation that the physician was notified of the patient’s weight loss. During a telephone interview on 11/29/2023 at 10:28 AM, the patient’s PCP staff stated that they had no record of communication from the home health provider on 9/1/2023, 9/6/2023, 9/07/2023, or 9/13/2023 nor did they see any notes in their system close to those dates and they have nothing documented about the patient’s weight loss. There was a call from the provider’s nurse on 08/29/2023 but that was about a wound. The PCP staff was also able to view the cardiologist’s notes because they are in the same medical group and did not see any notes regarding communication from the provider about weight loss. The patient was admitted to the hospital from the emergency room on 09/17/2023 with acute kidney injury. During an interview on 11/29/2023 at 2:20 PM, the clinical manager stated the parameters listed in the patient’s POC regarding weight would refer to either a weight gain or a weight loss. During the interview, the surveyors requested to interview the PTA that provided the patient’s treatment on 09/06/2023 and the clinical manager informed the surveyors that the PTA was no longer employed with the provider. On 11/30/2023 at approximately 2:00 PM, findings were reviewed with the clinical manager, the quality assurance/performance improvement nurse and the administrator (the administrator joined via telephone) and no further documentation to show the physician was notified of the weight loss was provided. RECORD/PATIENT #2: Review of the clinical record showed that the patient was admitted to home health services on 08/17/2023 with a diagnosis of heart failure (a chronic disease in which the heart doesn’t pump blood as it should) and chronic kidney disease stage 3 (a chronic disease of the kidney that leads to renal failure). Review of the POC dated 10/16/2023 to 12/14/2023, showed the following: - Agency VS [vital signs] parameters will be assessed each visit and reported to the MD [medical doctor]: weights if 3-5 lbs [pounds] weekly or greater than 2-3 lbs [pounds] in 24 hours; and - Skilled nursing visits were ordered for two times per week for one week during the week of 10/16/2023 and ending on: 10/21/2023. Review of a skilled nurse (SN) visit dated 10/17/2023 showed a weight of “245 lbs [pounds] 0 oz [ounces] -3 lbs 0 oz (7 days)” and the record failed to show a notification to the physician of the weight loss; Review of a communication note dated 10/19/2023 showed that the sn called the patient for an update related to leg wounds and spoke to the patient’s caregiver. The caregiver stated that a second visit for 10/20/2023 was not needed and the record failed to show that the physician was notified of a missed visit; Review of a SN visit dated 10/31/2023 showed a weight of “250 lbs 0 oz +5 lbs 0 oz (8 days)” and the record failed to show a notification to the physician of the weight gain; Review of a SN visit dated 11/14/2023 showed a weight of “252 lbs 0 oz +2 lbs 0 oz (7days)” and the record failed to show a notification to the physician of the weight gain; and Review of a SN visit dated 11/21/2023 showed a weight of “240 lbs 0 oz -12 lbs 0 oz (7 days)” and the record failed to show a notification to the physician of the weight loss. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to home health services on 10/16/2023 with a diagnosis of type 2 diabetes with diabetic polyneuropathy (a group of diseases that results in too much sugar in the blood complicated by multiple peripheral nerves that malfunction) and a history of falls. Review of the POC dated 10/16/2023 to 12/14/2023 showed the following: - Skilled nursing visits were ordered for one time per week for one week during the week of 10/18/2023 and ending on: 10/21/2023; - Skilled nursing visits were ordered for one time per week for two weeks during the week of 10/20/23 and ending on: 10/28/2023; - Physical therapy (PT) visits were ordered for one time per week for two weeks during the week of 10/29/2023 and ending on: 11/11/2023; and - A physician’s order dated 11/08/2023 showed an order for PT visits one time a week for four weeks with a start date of 11/08/2023 and end date of 12/2/2023. Review of a SN visit note dated 10/20/2023 showed that the patient refused the visit due to having too many other appointments scheduled that day and the record failed to show that the physician was notified of the missed visit; and Review of the PT notes showed no visits were done the week of 11/05/2023 to 11/11/2023 and the week of 11/19/2023 and 11/25/2023 and the record failed to show that the physician was notified of the missed visits. During an interview on 11/30/2023 at approximately 11:00 AM the missed therapy visits were requested and the provider failed to provide any notes related to the missed visits. *****During an interview on 12/01/2023 beginning at 1:00 PM, the clinical manager and the QAPI nurse showed this surveyor in the compu”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on policy review, record review, observation, and interview the home health provider failed to ensure that a visit schedule was available to the patient and caregiver in one of three home visits conducted (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Plan Implementation,” revised 01/2023, showed that the “agency provides care, treatment and/or services consistent with the type and frequency identified and documented in the plan of care and on the days and at the times scheduled with the patient/family/caregiver.” RECORD/PATIENT #2: Review of the clinical record showed that the patient was admitted to home health services on 08/17/2023. Observation on 11/28/2023 beginning at 9:25 AM, during the patient’s home visit, showed that the patient’s home health folder contained visit schedules for August and September. The provider failed to provide visit schedules for October and November to the patient and/or caregiver. During an interview on 11/30/2023 beginning at 1:00 PM, the clinical manager stated that he/she would expect a visit schedule to be in the patient folder.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on policy review, record review, observation, and interview the home health provider failed to ensure that the plan of care (POC) was followed in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Plan Implementation,” reviewed 01/2023, showed in part, “agency provides care, treatment and/or services consistent with the type and frequency identified and documented in the plan of care and on the day and at the times scheduled with the patient/family/caregiver.” RECORD/PATIENT #2: Review of the clinical record showed: - A physician’s order was obtained on 10/31/2023 for the following: * “Perform wound care/dressing change: left frontal leg popped blister, clean with soap and water, pat dry, apply adhesive bordered foam dressing (an island type dressing that is highly absorbant) to wound, cover with tubigrip (a stocking used to provide firm support and compression to an affected area) size E toe top to knee bend, change tubigrip daily on am off pm, change dressing 2 (two) times weekly and as needed for soilage or dislodgement, SN (skilled nurse) to change 1 (one) time weekly with SNV (skilled nurse visit), pt/cg (patient/caregiver) to perform weekly and as needed in absence of SN (skilled nurse); and * “Perform wound care/dressing change: right frontal leg popped blister, clean with soap and water, pat dry, apply adhesive bordered foam dressing to wound, cover with tubigrip size E toe top to knee bend, change tubigrip daily on am off pm, change dressing 2 (two) times weekly and as needed for soilage or dislodgement, SN (skilled nurse) to change 1 (one) time weekly with SNV (skilled nurse visit), pt/cg (patient/caregiver) to perform weekly and as needed in absence of SN (skilled nurse).” - Review of a SN visit dated 11/14/2023, showed that the left leg shin/blister was healed and the treatment continued for the right leg/shin blister; - Review of a SN visit dated 11/21/2023, showed that the right anterior leg shin/blister was healed; and - The clinical record failed to contain orders to discontinue treatments to the right or left leg. Observation on 11/28/2023 beginning at 9:25 AM, during the patient’s home visit, showed that the registered nurse (RN) removed the patient’s tubigrip stockings from both legs, inspected both legs for open areas, applied moisturizing lotion to both legs, allowed the lotion to soak into the skin, and then reapplied the tubigrip stockings to both legs. The RN failed to clean the areas with soap and water, pat dry, and apply bordered foam dressings as ordered. During an interview on 11/30/2023 beginning at 1:00 PM, the clinical manager stated that he/she would expect the POC to be followed.”

“Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This Element is not met as evidenced by: Based on the results of this extended level survey, resulting in non-compliance with one Condition of Participation §484.60 Care Planning, Coordination of Services, and Quality Care, the provider may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends on 12/04/2025.”

“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 nationally-recognized standards, policy review, employee file review, and interview the home health provider failed to ensure that one out of four employee files contained the family care safety registry (FCSR) check as required and that one out of four employee files contained the employee disqualification list (EDL) check as required (E-1 and E-3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Safety Registry regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Safety Registry. Review of Section 192.2495.6, RSMo: “A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, 566 or 569, or any violation of subsection 3 of section 198.070 or section 568.020.” Review of Section 192.2495.7, RSMo (effective August 28, 2018): “Any in-home services provider agency or home health agency shall be guilty of a class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the family care safety registry or if such person: (1) Has any of the disqualifying factors listed in subsection 6 of this section; (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under chapter 195 or 579; (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under section 568.045, 568.050, 568.060, 568.175, 570.023, 570.025, 570.030, 570.040 as it existed prior to January 1, 2017, 570.090, 570.145, 570.223, 575.230, or 576.080; (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of section 577.010 or 577.012 and who is alleged and found by the court to be an aggravated or chronic offender under section 577.023; (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under section 589.400; (6) Is listed on the department of health and senior services employee disqualification list under section 192.2490; (7) Is listed on the department of mental health employee disqualification registry under section 630.170; or (8) Has a finding on the child abuse and neglect registry under sections 210.109 to 210.183.” Review of Section 192.2490.12 RSMo: “No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list.” Review of the provider’s undated policy titled, “Background Checks,” showed in part, that: - The FCSR should be checked before offer of employment, after offer of employment, and annually; and - The EDL should be checked before an offer of employment and quarterly. E-1: Review of the employee files showed that E-1 was hired on 02/25/2022 and the FCSR was checked on 01/12/2023. The provider failed to ensure that the FCSR was checked prior to the employee’s first contact with patients. During an interview on 11/29/2023 at 4:25 PM, with the human resources representative, further information for the employee’s FCSR prior to contact with patients was requested. During an interview on 11/30/2023 at 10:00 AM, the human resources representative stated that no other information was available for the employee’s FCSR check. E-3: Review of the employee files showed that E-3 was hired on 06/27/2023 and the EDL was checked on 07/17/2023. The provider failed to ensure that the EDL was checked prior to hire. During an interview on 11/30/2023 beginning at 1:00 PM, the clinical manager stated that he/she would expect the FCSR and the EDL to be checked correctly and according to the regulations.”