Phoenix Home Care and Hospice

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to ensure the provider’s patient rights information contained the following: -Provide written notice of rights and responsibilities and the provider’s transfer and discharge policies to a patient-selected representative within four business days of the initial evaluation visit (G0422); -Right to receive all services outlined in the plan of care (G0436); -Right to be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and its purpose (G0444); -The home health may only transfer or discharge the patient from the home health if the transfer or discharge is necessary for the patient’s welfare because the home health provider and the physician or allowed practitioner who is responsible for the home health plan of care agree that the home health provider can no longer meet the patient’s needs, based on the patient’s acuity (G0454); -The home health may only transfer or discharge the patient from the home health if the home health advises the patient, the representative, the physician or allowed practitioner issuing orders for the home health plan of care, and the patient’s primary care practitioner that a discharge for cause is being considered (G0464); -The home health may only transfer or discharge the patient from the home health if the home health makes efforts to resolve the problems presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation (G0466); -The home health may only transfer or discharge the patient from the home health if the home health provides the patient and representative with contact information for other agencies or providers who may be able to provide care (G0468); -The home health may only transfer or discharge the patient from the home health if the home health documents the problem(s) and efforts made to resolve the problem(s), and enter the documentation into the clinical record (G0470); and -Information must be provided to patients in plain language and in a manner that is accessible and timely to persons with disabilities and persons with limited English proficiency through the provision of language services at no cost to the individual (G0490). The cumulative effect of these deficient practices has the potential to affect all patients served by the provider.”

“Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to— (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations. This Standard is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to ensure patients were informed of the right to have access to patient rights information that was provided in a language and manner that is accessible and timely to persons with disabilities and persons with limited English proficiency. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient/Client Rights and Responsibilities,” dated 05/01/2024, showed the home health will inform the patient of the right to access auxiliary aids and language services, and how to access these services (for persons with disabilities and for persons with limited English proficiency). Review of the admission folder, provided to the team coordinator on 09/30/2024, showed the notice of patient rights and other information given to a patient during the initial visit, failed to contain information regarding this patient right. On 10/01/2024 at approximately 2:00 PM, the administrator provided an admission packet that included an inserted loose sheet document. The document included bullet points with the missing patient rights information added. The separate loose document was not found in the admission packet provided on 09/30/2024. During an interview on 10/02/2024 at 11:00 AM, the administrator stated that they did not add the missing information to the additional document. They called the corporate office regarding the missing patient rights information and their office told them they were aware that some of the patient rights were missing. The separate document was sent to them by their corporate office, and they were told there were new admission booklets that included the missing information. The corporate office told them they had not yet mailed the booklets to the individual providers.”

“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; Patient Rights, the provider may not train or competency evaluate their home health aides for a period of two years following the date of this survey. The restriction ends 10/02/2026.”

“Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This Element is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to provide written information that included the patient’s rights and responsibilities and the provider’s transfer and discharge policies that could be given to a patient-selected representative within four business days of the initial evaluation visit. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient/Client Rights and Responsibilities,” dated 05/01/2024, showed the home health will provide written notice of the patient’s/client’s rights and responsibilities and the provider’s transfer and discharge policies to a patient/client selected representative within four business days of the initial evaluation visit. Review of the admission folder, provided by the team coordinator on 09/30/2024, showed the notice of patient rights, and other information given to a patient during the initial visit, failed to contain information regarding this patient right. On 10/01/2024 at approximately 2:00 PM, the administrator provided an admission packet that included an inserted loose sheet document. The document included bullet points with the missing patient rights information added. The separate loose document was not found in the admission packet provided on 09/30/2024. During an interview on 10/02/2024 at 11:00 AM, the administrator stated that they did not add the missing information to the additional document. They called the corporate office regarding the missing patient rights information and their office told them they were aware that some of the patient rights were missing. The separate document was sent to them by their corporate office, and they were told there were new admission booklets that included the missing information. The corporate office told them they had not yet mailed the booklets to the individual providers.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to include the right of the patient to receive all services outlined in the plan of care (POC). This deficient practice has the potential to affect all patient’s served by the provider. Findings included: Review of the provider’s policy titled, “Patient/Client Rights and Responsibilities,” dated 05/01/2024, showed the patient has the right to receive all services outlined in the POC. Review of the admission folder, provided by the team coordinator on 09/30/2024, showed the notice of patient rights, and other information given to a patient during the initial visit, failed to contain the right to receive all services outlined in the POC. On 10/01/2024 at approximately 2:00 PM, the administrator provided an admission packet that included an inserted loose sheet document. The document included bullet points with the missing patient rights information added. The separate loose document was not found in the admission packet provided on 09/30/2024. During an interview on 10/02/2024 at 11:00 AM, the administrator stated that they did not add the missing information to the additional document. They called the corporate office regarding the missing patient rights information and their office told them they were aware that some of the patient rights were missing. The separate document was sent to them by their corporate office, and they were told there were new admission booklets that included the missing information. The corporate office told them they had not yet mailed the booklets to the individual providers.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to ensure the patient was informed of the correct state home health hotline hours. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient/Client Rights and Responsibilities,” dated 05/01/2024, showed the patient has the right to be advised of the state toll free home health telephone hotline, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local agencies. Review of the admission packet supplied on entrance showed hotline hours of 7 AM-8 PM Monday - Friday. The admission packet failed to show the correct state hotline hours (7 AM-8 PM, seven days a week). During an interview 10/02/2024 at 10:30 AM, the administrator stated that he/she agreed that the hours were wrong in the admission packet, and he/she has contacted the corporate office regarding updating the incorrect hotline hours.”

“Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This Element is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to ensure the patient right information given to the patient included the right to access auxiliary aids and language services and how to access such services. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of provider’s policy titled, “Patient/Client Rights and Responsibilities,” dated 05/01/2024, showed the home health provider will inform the patient of the right to access auxiliary aids and language services, and how to access these services (for persons with disabilities and for persons with limited English proficiency). Review of the admission folder, provided to the team coordinator on 09/30/2024, showed the notice of patient rights and other information given to a patient during the initial visit, failed to contain information regarding this patient right. On 10/01/2024 at approximately 2:00 PM, the administrator provided an admission packet that included an inserted loose sheet document. The document included bullet points with the missing patient rights information added. The separate loose document was not found in the admission packet provided on 09/30/2024. During an interview on 10/02/2024 at 11:00 AM, the administrator stated that they did not add the missing information to the additional document. They called the corporate office regarding the missing patient rights information and their office told them they were aware that some of the patient rights were missing. The separate document was sent to them by their corporate office, and they were told there were new admission booklets that included the missing information. The corporate office told them they had not yet mailed the booklets to the individual providers.”

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to inform the patient that a transfer may only occur if the transfer or discharge is necessary for the patient’s welfare because the provider and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the provider can no longer meet the patient’s needs, based on the patient’s acuity and that the provider must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the provider’s capabilities. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient/Client Rights and Responsibilities,” dated 05/01/2024, showed the patient/client and representative (if any), have a right to be informed of the provider’s policies for transfer and discharge. Review of the admission folder, provided to the team coordinator on 09/30/2024, showed the notice of patient rights and other information given to a patient during the initial visit, failed to contain information regarding this patient right. On 10/01/2024 at approximately 2:00 PM, the administrator provided an admission packet that included an inserted loose sheet document. The document included bullet points with the missing patient rights information added. The separate loose document was not found in the admission packet provided on 09/30/2024. During an interview on 10/02/2024 at 11:00 AM, the administrator stated that they did not add the missing information to the additional document. They called the corporate office regarding the missing patient rights information and their office told them they were aware that some of the patient rights were missing. The separate document was sent to them by their corporate office, and they were told there were new admission booklets that included the missing information. The corporate office told them they had not yet mailed the booklets to the individual providers.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to include the patient’s right to be informed that the home health provider may only transfer or discharge the patient if they have advised the patient, the patient’s representative, the physician issuing orders for the plan of care and the primary practitioner who will be providing services to the patient after discharge from the home health that a discharge for cause is being considered. 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, “Patient/Client Transfer, Discharge, and Agency Dissolution,” dated 05/02/24 showed, before it discharges a patient/client for cause, the provider must advise the patient/client, representative (if any), physician(s)/non-physician practitioner(s) issuing orders for the home health plan of care, and patient’s/client’s primary care practitioner or other healthcare professional who will be responsible for providing care and services to the patient/client after discharge from the provider (if any) that a discharge for cause is being considered. Review of the admission folder, provided by the team coordinator on 09/30/2024, showed the notice of patient rights, and other information given to a patient during the initial visit failed to contain the information regarding the patient’s rights related to the home health discharge of a patient for cause. On 10/01/2024 at approximately 2:00 PM, the administrator provided an admission packet that included an inserted loose sheet document. The document included bullet points with the missing patient rights information added. The separate loose document was not found in the admission packet provided on 09/30/2024. During an interview on 10/02/2024 at 11:00 AM, the administrator stated that they did not add the missing information to the additional document. He/she stated that they called the corporate office regarding the missing patient rights information and their office told them they were aware that some of the patient rights were missing. The separate document was sent to them by their corporate office, and they were told there were new admission booklets that included the missing information. The corporate office told them they had not yet mailed the booklets to the individual providers.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to include the patient’s right to be informed that, before the provider can discharge a patient for cause, they must first make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation. This deficient practice has the potential to affect all patient’s served by the provider. Findings included: Review of the home health provider’s policy titled, “Patient/Client Transfer, Discharge, and Agency Dissolution,” dated 05/02/24 showed, before it discharges a patient/client for cause, the provider must make efforts to resolve the problem(s) presented by the patient’s/client’s behavior, the behavior of other persons in the patient’s/client’s home, or the situation. Review of the admission folder, provided by the team coordinator on 09/30/2024, showed the notice of patient rights, and other information given to a patient during the initial visit failed to include this patient right. On 10/01/2024 at approximately 2:00 PM, the administrator provided an admission packet that included an inserted loose sheet document. The document included bullet points with the missing patient rights information added. The separate loose document was not found in the admission packet provided on 09/30/2024. During an interview on 10/02/2024 at 11:00 AM, the administrator stated that they did not add the missing information to the additional document. He/she stated that they called the corporate office regarding the missing patient rights information and their office told them they were aware that some of the patient rights were missing. The separate document was sent to them by their corporate office, and they were told there were new admission booklets that included the missing information. The corporate office told them they had not yet mailed the booklets to the individual providers.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to include the patient’s right to be informed that, before the provider can discharge a patient for cause, they must first provide the patient and representative with contact information for other providers who may be able to provide care. This deficient practice has the potential to affect all patient’s served by the provider. Findings included: Review of the home health provider’s policy titled, “Patient/Client Transfer, Discharge, and Agency Dissolution,” dated 05/02/24 showed, before it discharges a patient/client for cause, the provider must provide the patient/client and representative (if any), with contact information including contact numbers for other community resources and/or names for other agencies or providers who may be able to provide care and enter this documentation into its clinical records. Review of the admission folder, provided by the team coordinator on 09/30/2024, showed the notice of patient rights, and other information given to a patient during the initial visit failed to include this patient right. On 10/01/2024 at approximately 2:00 PM, the administrator provided an admission packet that included an inserted loose sheet document. The document included bullet points with the missing patient rights information added. The separate loose document was not found in the admission packet provided on 09/30/2024. During an interview on 10/02/2024 at 11:00 AM, the administrator stated that they did not add the missing information to the additional document. He/she stated that they called the corporate office regarding the missing patient rights information and their office told them they were aware that some of the patient rights were missing. The separate document was sent to them by their corporate office, and they were told there were new admission booklets that included the missing information. The corporate office told them they had not yet mailed the booklets to the individual providers.”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to include the patient’s right to be informed that, before the provider can discharge a patient for cause, they must first document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical records. 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, “Patient/Client Transfer, Discharge, and Agency Dissolution,” dated 05/02/24 showed, before it discharges a patient/client for cause, the provider must document the problem(s}, behaviors and circumstances of the problems, and the provider’s attempted interventions and efforts made to resolve the problem(s) and enter this documentation into its clinical records. Review of the admission folder, provided by the team coordinator on 09/30/2024, showed the notice of patient rights, and other information given to a patient during the initial visit failed to include this patient right. On 10/01/2024 at approximately 2:00 PM, the administrator provided an admission packet that included an inserted loose sheet document. The document included bullet points with the missing patient rights information added. The separate loose document was not found in the admission packet provided on 09/30/2024. During an interview on 10/02/2024 at 11:00 AM, the administrator stated that they did not add the missing information to the additional document. He/she stated that they called the corporate office regarding the missing patient rights information and their office told them they were aware that some of the patient rights were missing. The separate document was sent to them by their corporate office, and they were told there were new admission booklets that included the missing information. The corporate office told them they had not yet mailed the booklets to the individual providers.”

“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 an initial assessment was performed within 48 hours of the referral in, but not limited to, one of five full 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, “Timelines,” dated 05/02/2024, showed the evaluation visit for admission to home health is conducted within 48 hours of referral, or within 48 hours of the patient’s/client’s return home, or on the physician and/or non-physician practitioner start of care date. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health on 07/08/2024 with a primary diagnosis of osteomyelitis (a bone infection). The patient had additional diagnoses of diabetes mellitus (a group of diseases that results in too much sugar in the blood), lung cancer, and methicillin-resistant staphylococcus aureus (MRSA – a bacteria resistant to certain antibiotics) in the lungs. He/she lived in his/her own home with his/her spouse. Review of the referral documents showed, in part: - Skilled nursing facility (SNF) discharge orders, dated 07/03/2024, for home health physical therapy, occupational therapy, and nursing; and - The provider’s referral document dated 07/05/2024. Review of the initial assessment, dated 07/08/2024, showed the registered nurse (RN) documented a physician ordered start of care date of 07/08/2024 (item M0102 on the Outcome and Assessment Information Set – OASIS). Review of the physician orders dated 07/08/2024, showed: - “Admit to home health services on 07/08/2024 due to osteomyelitis of L (left) foot and ankle” (three days after referral obtained); - The order was signed by the physician on 09/10/2024. During an interview on 10/02/2024 at 10:30 AM, the executive director stated that the physician’s order for a start of care date should have been obtained within the 48-hour window and agreed the provider was not in compliance.”

“Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This Element is not met as evidenced by: Based on job description review, record review, and interview, the home health provider failed to ensure a registered nurse (RN) performed the initial assessment in one of five full records reviewed (Record/Patient #1) and failed to ensure the RN did the recertification comprehensive assessment 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 job description titled, “Job Description, Home Health Registered Nurse,” dated/reviewed 12/2017 showed, the duties of the RN included completing comprehensive and OASIS (Outcome and Assessment Information Set) assessments and providing ongoing interdisciplinary assessment of the patient. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services with a primary diagnosis of aftercare for cervical spine discectomy and fusion. He/she lived in his/her home with his/her spouse. Review of the provider’s referral document, dated 08/09/2024, showed the skilled nursing facility (SNF) referral included orders for skilled nursing (SN), physical therapy (PT), and occupational therapy (OT). Review of the initial assessment, dated 08/12/2024, showed the assessment was completed by the physical therapist. During an interview on 10/02/2024 at 10:06 AM, the administrator stated that the process for referrals was as follows: Orders are received via the electronic fax system then the quality assurance team checked for a face-to-face visit, medication list, and history of illness. Then it is dated with the verified date. He/she was aware that a RN was required to complete the comprehensive assessment unless it was a therapy only admission. He/she could not find a documented reason why the PT did the admission. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 06/06/2024 with a primary diagnosis of urinary tract infection. Additional diagnoses included a stage three pressure injury (skin injury caused by unrelieved pressure), paraplegia (paralysis in the lower limbs and trunk), and diabetes mellitus (a group of diseases that results in too much sugar in the blood). Review of the plan of care (POC) dated 06/06/2024, showed SN visits were ordered after the initial assessment due to discovery of the patient’s pressure injury. Review of the SN evaluation showed nursing visits began on 06/10/2024 and the visit schedule was one time a week for eight weeks. Review of the recertification assessment dated 08/01/2024, showed the recertification comprehensive assessment was completed by the PT. Review of the recertification POC dated 08/05/2024, showed orders for SN (effective 07/31/2024) one time a week for eight weeks. During an interview on 10/02/2024 at 12:37 PM, the administrator stated that the PT did the recertification assessment because there was a scheduling mistake. It was their error.”

“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 that an accurate and updated medication profile was kept for each patient in two of five full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 06/06/2024 with a primary diagnosis of urinary tract infection. Additional diagnoses included a stage three pressure injury (skin injury caused by unrelieved pressure), paraplegia (paralysis in the lower limbs and trunk), and diabetes mellitus (a group of diseases that results in too much sugar in the blood). Observation and interview on 10/01/2024 at 3:45 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 tadalafil (used to treat erectile dysfunction) 5 milligram (mg) daily. The patient stated that he/she no longer took this medication; - The provider’s medication profile showed an order for nystatin swish and swallow (used to treat yeast infection in the mouth) 100000 units/milliliter (mL) give 5 mL four times daily. The patient stated that he/she no longer took this medication; - The provider’s medication profile showed an order for hydroxyzine 25 mg take one tablet three times daily as needed (pro re nata - PRN) for itching. The patient stated that he/she no longer took this medication; - The provider’s medication profile showed an order for phospha (a nutritional supplement) 155-852-130 mg take one tablet twice a day. The patient stated that he/she no longer took this medication; - The provider’s medication profile showed an order for Alphagan ophthalmic 0.1% in 1 mL solution give I drop in each eye. The patient stated that he/she no longer took this medication; - The provider’s medication profile showed an order for Alka-Seltzer Heartburn + Gas 750-80 mg give one tablet daily. The patient stated that he/she no longer took this medication; - The provider’s medication profile showed an order for melatonin (a sleep hormone) 3 mg take two tablets at bedtime. The patient stated that he/she no longer took this medication; - The provider’s medication profile showed an order for gabapentin (used to treat nerve pain) 300 mg take one capsule three times a day. The patient stated that he/she no longer took this medication; - The provider’s medication profile showed an order for loperamide (used to treat diarrhea) 2 mg take one by mouth every six hours PRN. The patient stated that he/she no longer took this medication; - The provider’s medication profile showed an order for Dulcolax 10 mg suppository, insert one per rectum every other day for constipation. The patient stated that he/she no longer took this medication; - The provider’s medication profile showed acetaminophen 325 mg take two tablets every six hours PRN for pain. The patient stated that he/she no longer took this medication; and - The provider’s medication profile showed tacrolimus (an anti-rejection drug for transplant patients) 1 mg take three capsules twice per day. The patient’s medication bottle (dated 08/28/2024) showed the patient was taking 3 capsules in the morning and 4 capsules in the evening. During an interview on 10/02/2024 at 10:06 AM, the executive director stated that the nurse should do a medication reconciliation at every visit. Findings included: Review of the provider’s policy titled, “Orders for Care,” dated 11/01/2020, showed all orders are kept current and renewed or updated as appropriate. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/14/2024 with a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure. The patient lived at home with a family caregiver. Review of the document titled, “Medication Profile,” dated 08/14/2024-10/12/2024 showed the patient was taking Metolazone (a diuretic) 2.5 milligram (mg) tablet. Take one tablet every Monday, Wednesday, and Friday. This medication was not in the patient’s home. Review of the patient’s medications on 10/01/2024, beginning at 9:30 AM, showed the patient had a prescription for Clindamycin (an antibiotic) 300 mg capsules. Take two capsules prior to dental work. This medication as not on the provider’s medication profile. During an interview on 10/02/2024 at 11:00 AM, the home health administrator stated that he/she would expect the medication list to match what the patient was taking and the medications that were in the patient’s home.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure a resumption of care assessment was performed within 48 hours of the patient’s return home in one of one resumption of care record reviewed (Record/Patient #1). This deficient practice has the potential to affect any patient on service that has resumption of care. Findings included: Review of the home health provider’s policy titled, “Timelines,” dated 05/02/2024, showed the evaluation visit for admission to home health is conducted within 48 hours of referral, or within 48 hours of the patient’s/client’s return home, or on the physician and/or non-physician practitioner start of care date. RECORD/PATIENT #1: Review of the clinical record showed the patient: - Was admitted to home health services on 08/12/2024 from a skilled nursing facility (SNF) with a primary diagnosis of aftercare for cervical spine discectomy and fusion; - Lived in his/her home with his/her spouse; - Was re-admitted to the hospital on 08/13/2024 with shortness of breath on exertion and peripheral edema (swelling in legs); - Was discharged from the hospital on 08/15/2024; - Was readmitted to the home health provider on 08/20/2024 (five days after discharge); and - The provider failed to complete the reassessment within 48 hours of readmission. During an interview on 10/02/2024 at 12:37 PM, the administrator stated that the readmission assessment was delayed due to a communication error on their part. It was not documented in the medical record and was their mistake.”

“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 individualized plan of care (POC) included orders for oxygen with flow rate and a cervical spine collar in, but not limited to, one of five full records reviewed (Record/Patient #1). 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, “Plan of Care,” dated 05/02/2024, showed in part each patient/client must receive an individualized written plan of care, including any revisions or additions. The individualized POC must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the provider anticipates will occur as a result of implementing and coordinating the plan of care. The individualized POC must include the following: - The types of services, supplies, and equipment required; - The POC should list required, non-routine supplies and equipment that are medically necessary for the patient’s/client’s care; and - All medications and treatments. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 08/12/2024 from a skilled nursing facility (SNF) with a primary diagnosis of aftercare for cervical spine discectomy and fusion. The patient was re-admitted to the hospital for dyspnea (shortness of breath) and peripheral edema (swelling of the legs). The patient was re-admitted to home health on 08/20/2024. He/she lived in his/her own home with his/her spouse. Review of the SNF referral records showed orders for a soft cervical collar for watching television and eating and a hard cervical collar for ambulating and sleeping. Review of the skilled nurse (SN) notes showed, in part: - On 08/23/2024, the patient had dyspnea when walking more than 20 feet and coordination with the primary care physician showed oxygen was being ordered; - On 08/28/2024, the patient was not wearing oxygen upon the nurse’s arrival and the oxygen saturation was 88%. The patient was placed back on oxygen and saturations increased to 96%; and - The SN notes failed to mention the cervical collar. Review of the physical therapy (PT) notes showed, in part: - On 08/23/2024, the patient reported he/she went to the emergency room and was sent home with a borrowed oxygen tank. The patient stated that he/she had an oxygen concentrator on order from a (named medical equipment provider) and it was supposed to have a flow rate of two liters per minute (L/min) via nasal cannula; - On 08/27/2024, the patient voiced concern because the oxygen was delivered and he/she was having difficulty navigating through the home with the long tubing. The patient was wearing the hard cervical neck collar; - On 09/03/2024, the patient had his/her oxygen turned up to four L/min. and the PT turned it down to two and a half L/min. The patient continued to struggle with the tubing during ambulation; and - On 09/24/2024, the patient reported he/she no longer needed to wear the cervical neck collar when up moving around. Review of the POC, dated 08/12/2024 and the resumption of care POC, dated 08/20/2024 showed the provider failed to include the order for oxygen and the order for wearing the cervical collars. During an interview on 10/02/2024 at 12:37, the administrator stated that the orders for the oxygen and the cervical collars should have been included in the POC.”

“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 changes to the patient’s condition 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, “ Monitoring Patient Care/Coordination of Care,” dated 08/01/2020, showed the provider will assure effective communication with all physicians and/or non-physician practitioners involved in the plan of care. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/14/2024 with a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure. The patient lived at home with a family caregiver. Review of the skilled nurse (SN) wound documentation showed the following: -On 08/14/2024, the patient had three wounds: *wound #1 to the left lower calf; *wound #2 to the left lower calf; and *wound to the right anterior calf. -On 08/26/2024, wound #2 to the left lower calf was documented as healed. The SN failed to report this change to the physician; -On 09/05/2024, the wound to the right anterior calf was documented as healed. The SN failed to report this change to the physician; and -On 09/16/2024, there was a new wound to the left medial shin. The SN failed to report this change to the physician. During an interview on 10/02/2024 at 11:00 AM, the home health administrator stated that he/she would expect the SN to report any changes in the patient’s condition to the physician.”

“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 wound documentation was completed 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, “Instructions for Wound Care Addendum,” dated 09/01/2015, showed any discipline providing wound care should complete the assessment of the type of wound including stage if it is a pressure ulcer, measurement of length, width, and depth in centimeters, undermining, tunneling, and appearance of wound bed, peri-wound tissue, odor and drainage. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/14/2024 with a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure and multiple wounds. The patient lived at home with a family caregiver. Review of the document titled, “Registered Nurse (RN) - Skilled Nursing Visit,” dated 08/29/2024, failed to show wound documentation during wound care. During an interview on 10/02/2024 at 11:00 AM, the administrator stated that he/she would expect wound assessment documentation to be completed on every visit.”

“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 policy review, Alzheimer’s training review, and interview, the home health provider failed to ensure that the Alzheimer’s/Dementia training included information regarding understanding and dealing with family issues. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Employee Orientation - Addendum,” dated 10/20/2023, showed at a minimum, the training required for persons providing direct care will address understanding and dealing with family issues. Review of the home health provider’s Alzheimer’s/Dementia training failed to show information regarding understanding and dealing with family issues. During an interview on 10/01/2024 at 2:35 PM, the administrator stated that the content was missing from the Alzheimer’s/Dementia training.”