Santa Fe Home Care of New Mexico

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on observation, record review, interview, and policy review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Skilled Professional Services and an investigation of Immediate Jeopardy (IJ) began on 07/10/24 at 10:24 AM when the HHA did not: 1) Coordinate services with members of the Interdisciplinary Team. 2) Provide teaching to caregivers. 3) Inform the physician of changes in patient condition. 4) Obtain physician orders for wound care. 5) Conduct assessments of wounds. These deficient practices have the potential to affect all 44 patients receiving services from the HHA. The cumulative effects of multiple and pervasive deficient practices in Skilled Professional Services had the potential to jeopardize the health and safety of all 44 patients who receive services from the HHA. Findings include: 1. The HHA failed to discuss and coordinate services for one of five sampled patients Patient (P) 7 with the Interdisciplinary Team that included the Registered Nurse (RN) 1, Licensed Practical Nurse (LPN) 1, Occupational Therapist (OT) 1, Physical Therapist (PT) 1, and the patient’s attending physician. Refer to G706. 2. The HHA failed to ensure for one of five sampled patients P7, provide colostomy care teaching to the patient’s caregiver. Refer to G714. 3. The HHA failed to ensure for one of five sampled patients P7, to communicate a change in condition to the attending physician, obtain physician orders for wound treatment, and conduct wound assessments. Refer to G718. Following confirmation of the IJ with the State Survey Agency, the HHA Administrator and Director of Nursing (DON) were informed on 07/10/24 at 10:24 AM that Immediate Jeopardy existed at G700 related to the failure to obtain physician orders for wound care treatments, provide teaching to caregivers, inform the physician of changes in patient condition, and appropriately assess wounds. A copy of the IJ template was provided via email at that time. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 07/10/24 at 6:30 PM. The Administrator was notified that the interventions identified in the removal plan were reviewed and verified as implemented, and the IJ was removed on 07/10/24 at 7:00 PM.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on Emergency Preparedness (EP) Plan review, policy review, and interview, the Home Health Agency (HHA) failed to review and update the EP plan every two years. This deficient practice had the potential to affect all 44 patients receiving services from the HHA. Findings include: Review of the agency’s undated “Emergency Preparedness Disaster Plan,” located in the “Administrative Policy Manual” under the “Emergency Preparedness” tab, revealed a hand-written note on the cover sheet stating, “Updated 03/20/20” signed by the Administrator. Review of the agency’s undated policy titled, “Emergency Preparedness and Response Plan” located on page five of 26 in the “Administrative Policy Manual” under the “Emergency Preparedness” tab revealed, “…The Agency will develop and maintain an emergency preparedness training and testing program for staff, volunteers and contracted staff, that is based on the emergency plan, risk assessment, policies and procedures, and the communication plan. The training and testing program will be reviewed and updated at least annually.” During an interview on 07/09/24 at 9:30 AM, the Administrator confirmed that the EP Plan was not reviewed since 03/20/20.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on Emergency Preparedness (EP) Plan review, policy review, and interview, the Home Health Agency (HHA) failed to ensure that eight of eight agency staff reviewed received EP Plan training every two years. This deficient practice had the potential to affect all 44 patients receiving services from the agency. Findings include: Review of the agency’s undated “Emergency Preparedness Disaster Plan,” located in the “Administrative Policy Manual” under the “Emergency Preparedness” tab, failed to reveal documentation that eight agency staff received training on the agency’s EP Plan. Review of the agency’s undated policy titled, “Emergency Preparedness and Response Plan” located on page five of 26 in the “Administrative Policy Manual” revealed, “…The Agency will provide initial and annual training in emergency preparedness policies and procedures to all new and existing staff, contract staff, and volunteers. The Agency will also provide training to all staff when new or updated policies and/or procedures are issued. The Agency will maintain documentation of the training. …” During an interview on 07/09/24 at 9:30 AM, the Administrator confirmed that agency staff had not received training on the EP Plan since 2021.The Administrator was unable to provide documentation that any staff training was performed.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on Emergency Preparedness (EP) Plan review, policy review, and interview, the Home Health Agency (HHA) failed to conduct an exercise to test the EP Plan annually and failed to conduct a facility-based functional exercise every two years. This deficient practice had the potential to affect all 44 patients receiving services from the HHA. Findings include: Review of the agency’s undated “Emergency Preparedness Disaster Plan” located in the “Administrative Policy Manual” under the “Emergency Preparedness” tab, failed to reveal documentation that an annual exercise or a facility-based functional exercise was performed every two years. Review of the agency’s undated policy titled, “Emergency Preparedness and Response Plan” located on page five of 26 in the “Administrative Policy Manual” under the “Emergency Preparedness” tab revealed, “…The Agency will conduct two (2) exercises to test the emergency plan at least annually. The Agency will do the following: (1) Participate in a full-scale exercise that is community based. lf a community-based exercise is not accessible, an individual, facility-based exercise will be conducted. …” During an interview on 07/09/24 at 9:30 AM, the Administrator confirmed that an annual test and a facility-based functional exercise was not performed every two years. The Administrator was unsure as to when the last test was performed and was unable to provide documentation that an exercise was ever performed.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on documentation review, policy review, and interview, the Home Health Agency (HHA) failed to develop a Performance Improvement Project based on an analysis of Quality Assurance Policy Improvement (QAPI) data for 2023 and failed to start a Performance Improvement Project for 2024. This deficient practice had the potential to affect all 44 patients receiving services from the HHA. Findings include: Review of the agency’s binder titled, “Quality Assurance” failed to reveal documentation that a Performance Improvement Project was completed for 2023 and that a Performance Improvement Project for 2024 was started. Review of the agency’s undated policy titled, “Quality Assurance” revealed, “The focus of quality improvement activities is to identify opportunities for improved performance by the Agency. The improvement of performance can be accomplished by: 1. Redesigning a process which will lead to improved processes and performance by the Agency 2. Designing a new process leading to innovation 3. Improvement strategy may be implemented system wide or may encompass only a limited area of concern or staff performance. The Professional Advisory Committee, management, and others involved with clients including physicians and staff participate in evaluating the information collected and improving the process and performance of the Agency. The design is reviewed and reevaluated based upon the Agency mission, goals and visions. The information is presented quarterly at the OBQI meetings. At this time, identified problems are analyzed. …” During an interview on 07/09/24 at 10:00 AM, the Administrator confirmed that Performance Improvement Projects were not completed for 2023 and were not started for 2024.”

“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 record review, policy review, observation, and interviews, the Home Health Agency (HHA) failed to ensure the patient’s medication lists matched the patients’ medications in the home for two of three sampled patients (Patient (P) 6 and P7) and for P6 the HHA failed to ensure that a Registered Nurse (RN) reviewed the medication list after the patient was admitted by a Physical Therapist (PT). This deficient practice had the potential to affect all 44 patients receiving services from the HHA. Findings include: 1. Review of the agency’s undated policy titled, “Medication Profile” revealed,”…The nurse performs ongoing medication monitoring to determine their action, indications, special precautions, patient’s/ client’s response to therapy, side effects, allergies and contraindications, and to ensure appropriateness and continuity of care and includes the information necessary for creating an accurate medication history and a complete medication profile and to identify the potential complications from the therapy being provided and to help ensure the safety of the medication use process …” Review of P6’s “Medication List” dated 06/26/24, found in P6’s Electronic Medical Record (EMR) under the medication tab, indicated that P6’s medications were reconciled by a PT ( Physical Therapy) during admission to the HHA on 06/26/24. There was no documentation found that an HHA RN reviewed P6’s medications for accuracy, possible medication side-effects and drug interactions. During an interview on 07/08/24 at 4:00 PM, the Director of Nursing (DON) confirmed there was no documentation indicating that an RN reviewed P6’s medication list. Observation on 07/09/24 at 1:30 PM in P6’s home, and review of P6’s “Medication List” dated 06/26/24 revealed the following: a. Ferrous Sulfate (iron) and Cyanocobalamin (forms blood cells) were listed on P6’s medication list; however, were not found in P6’s home. b. Advil (for pain), vitamin D and Memantine (for memory) were not listed on P6’s medication list; however, were found in P6’s home. During an interview on 07/09/24 at 12:50 PM, Family Member (F) 1 stated P6 was, “no longer taking Ferrous Sulfate or Cyanocobalamin” and confirmed that P6 was taking Advil as needed (prn) for pain, vitamin D and Memantine. During an interview on 07/09/24 at 12:50 PM, PT1 confirmed that the patient was taking Advil as needed for pain and confirmed that the medications on the medication list were different from what was in the patient’s home. 2. Review of P7’s “Medication List” dated 06/03/24, found in P7’s EMR under the medication tab, indicated that P7’s medications were reconciled by an RN during admission to the HHA on 06/03/24. Observation on 07/09/24 at 1:30 PM in P7’s home and review of P7’s “Medication List” dated 06/03/24, revealed the following: a. An empty bottle of furosemide (diuretic), filled on 06/27/24, was found in P7’s home; however, was not listed on P7’s medication list. b. Sertraline HCl (antidepressant) was on P7’s medication list; however, Sertraline was not found in P7’s home. During an interview on 07/09/24 at 1:40 PM, (Family Member (F) 2 stated that P7 was “out of Sertraline for two weeks” and was out of furosemide for one week.” F2 also advised that the furosemide was prescribed for a short trial and was unsure if P7 was to continue this medication. During an interview on 07/09/24 at 3:10 PM, the DON stated that P7’s “furosemide must have just been ordered” and stated that he/she was “unaware that the patient did not have any Sertraline left.””

“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 record review, policy review, and interview, the Home Health Agency (HHA) failed to coordinate services with the Interdisciplinary Team including Registered Nurse (RN) 1, Licensed Practical Nurse (LPN) 1, Occupational Therapist (OT) 1, Physical Therapist (PT) 1, and the patient’s attending physician for one of five active sampled patients (Patient (P) 7) . This deficient practice had the potential to affect 44 patients receiving services from the HHA. Findings include: Review of the agency’s undated policy titled, “Initial Comprehensive Assessment” revealed, “… 4. Pertinent information acquired during the initial nursing assessment will be shared with other team staff members to ensure continuity of care. …” Review of P7’s “Home Health Certification and Plan of Care” dated 06/03/24, found in P7’s Electronic Medical Record (EMR) under the “Admission” tab, indicated that P7 was admitted to the HHA on 06/03/24 by RN1 with a primary diagnosis of cerebral infarction (ischemic stroke) and secondary diagnoses of urinary tract infection, pressure ulcer of right heel, pressure ulcer of left heel, muscle weakness, encounter for attention to colostomy, essential hypertension, hypothyroidism, and depression. There was no documentation found that P7’s Interdisciplinary Team, RN1, LPN1, OT1, PT1, and the attending physician collaborated about P7’s care. During an interview on 07/09/24 at 2:15 PM, OT1 stated, “I’ve been trying to get someone to do something about [his/her] wound – I even sent pictures from my phone of the uncovered wound to the nurse on 07/02/24 and nobody has addressed it.” During an interview on 07/09/24 at 3:10 PM, RN1 confirmed receipt of a picture of P7’s wound sent by OT1 and confirmed that there was no collaboration among P7’s Interdisciplinary Team members (OT1, PT1, RN1, LPN1, and the attending physician) regarding P7’s care plan including wound care orders. During an interview on 07/09/24 at 4:00 PM, the Administrator stated, “we don’t have any type of formal Interdisciplinary Team Meetings, we just talk to each other when we need to.” The Administrator confirmed that members of the Interdisciplinary Team (OT1, PT1, RN1, LPN1, and the patient’s physician) should have collaborated to discuss the best course of treatment for P7.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on record review, policy review, and interview, the Home Health Agency (HHA) failed to provide colostomy care teaching to the patient’s caregiver for one of five sampled patients (Patient (P) 7). This deficient practice had the potential to affect 44 patients receiving services from the HHA. Findings include: Review of the agency’s undated policy titled, “Service Policy Nursing Services,” revealed, “a. Nursing Services shall mean the services provided by nurses within the practice of the profession of nursing. The practice of the professional nurse is defined as diagnosing and treating human responses to actual or potential health problems through such services as directing the plan of care, case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens prescribed by a licensed or otherwise legally authorized physician or dentist. A nursing regimen shall be consistent with and shall not vary any existing medical regimen.” Review of P7’s “Home Health Certification and Plan of Care,” dated 06/03/24, found in P7’s Electronic Medical Record (EMR) under the “Admission” tab, indicated that P7 was admitted to the HHA on 06/03/24 by Registered Nurse (RN)1 with a primary diagnosis of “cerebral infarction” (ischemic stroke) and a secondary diagnosis including “encounter for attention to colostomy.” On 06/03/24, in the “Mental Status” section of the “Home Health Certification and Plan of Care,” RN1 documented P7’s mental status was not oriented to time, forgetful, and impaired judgement with poor decision making. The plan of care developed by RN1 did not include interventions for teaching P7’s caregivers about colostomy care. Review of P7’s “Skilled Nursing Visit” notes found in P7’s EMR under the “Skilled Nursing Visits” tab revealed the following: 1. On 06/05/24, RN1 documented, “… Patient presents with a new colostomy located to [his/her] left lower abdominal area, the stoma is bright red in color, and on changing the colostomy bag today there was semi-soft stool brown in color. Patient was instructed on the importance of cutting the wafer to the exact size of the template in the box in order to make sure the opening is not too large or too small for the size of the stoma and patient verbalized understanding.” RN1 provided teaching to P7, not to P7’s caregiver, after assessing on 06/03/24 that the patient was not oriented to time, was forgetful, had impaired judgement with poor decision making. 2. On 06/13/24, Licensed Practical Nurse (LPN)1 documented, “… Pt’s (patient) caregiver in room during visit. Pt. has assistance from a neighbor as well. … Left heel has black escar [sic] but is closed. Pt. states [he/she] has someone maintain preventive care … to colostomy.” LPN1 did not document the individual responsible for performing the colostomy care and did not document that he/she provided or offered teaching on colostomy care to P7’s caregiver, who was present during the visit. 3. On 06/14/24, LPN1 documented, “… Pt. alone as caregiver has gone home. SN [Skilled Nursing] delivered supplies for ostomy care. Pt. refused care as [his]/her neighbor is maintaining ostomy care. SN educated pt. on the importance of maintaining colostomy care.” LPN1 did not document any attempt to contact the neighbor to provide colostomy care teaching. 4. On 06/18/24, RN1 documented, “… Patient presents with a new colostomy located to [his/her] left lower abdominal area, the stoma is bright red in color, and on changing the colostomy bag today there was semi-soft stool brown in color. Patient was instructed on the importance of cutting the wafer to the exact size of the template in the box in order to make sure the opening is not too large or too small for the size of the stoma and patient verbalized understanding.” RN1 provided teaching to P7, not to P7’s caregiver, after assessing on 06/03/24 that the patient was not oriented to time, was forgetful, had impaired judgement with poor decision making. 5. On 06/27/24, RN1 documented, “… Upon arrival to patients home today, [P7] is sitting on bed and is alone …The colostomy is in place with some semi-soft brown stool present. [P7] stated his willing and able Cg (neighbor) continues to assist him with his needs to include changing his colostomy bag …[neighbor] not present today on this snv[skilled nursing visits] …” RN1 did not document any attempt to contact the neighbor to provide colostomy care teaching. 6. On 07/05/24, LPN1 documented, “… Patient presents with a new colostomy located to his left lower abdominal area, the stoma is bright red in color, and on changing the colostomy bag today there was semi-soft stool brown in color. …” RN1 did not document that colostomy care teaching was provided to P7’s caregiver. During an interview on 07/09/24 at 1:40 PM, (Family Member (F) 2) stated “I take care of [P7’s] colostomy and I made multiple phone calls during the past two weeks to the agency to report that the colostomy bag keeps falling off. [P7] was crying and was so embarrassed because [he/she] felt as though [he/she] was a burden to me. A nurse came out on 06/20/24 and just put a piece of white tape around the bag and left. I finally figured out what I was doing wrong.” During an interview on 07/09/24 at 3:10 PM, the Director of Nursing (DON) confirmed there was no documentation that colostomy care teaching was provided to P7’s caregiver.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review, observation, interview, and policy review, the Home Health Agency (HHA) failed to ensure communication was provided to the attending physician for one of five sampled patients (Patient (P) 7) to obtain wound treatment orders and to notify of a change in patient condition. This deficient practice had the potential to affect all 44 patients receiving care from the HHA. Findings include: Review of the HHA undated policy titled, “Physician’s Plan of Treatment” revealed, “Physician’s orders are established and documented for the health care services the Agency provides to those patients/clients who: a. Are being actively treated by a physician for a diagnosed health care problem b. Have a health care need or change in physical status requiring medical intervention. …” The HHA was unable to provide a wound care policy when requested. Review of P7’s “Home Health Certification and Plan of Care” dated 06/03/24, found in P7’s Electronic Medical Record (EMR) under the admission tab, indicated that P7 was admitted to the HHA on 06/03/24 by an agency Registered Nurse (RN) with a primary diagnosis of cerebral infarction (ischemic stroke) and secondary diagnoses including pressure ulcer of right heel, pressure ulcer of left heel, and encounter for attention to colostomy. Review of P7’s “Comprehensive Assessment” dated 06/03/24, found in P7’s EMR under “Start of Care Visits” tab, revealed RN 1 documented, “positive bilateral pedal pulses, left heel wound bed – black, eschar [tissue death] 80%; surrounding tissue – fragile. …Wound measurement was documented zero. …Cleansed wound with normal saline solution (NSS), covered with wet to dry dressing and secure with heel sock.” RN1 documented, “[P7’s] reported heel pain as a 4 out of 10 and constant.” There was no documentation the physician was contacted to obtain wound care orders and to report P7’s constant heel pain. Review of P7’s “Skilled Nursing Visit” notes found in P7’s EMR under the “Skilled Nursing Visits” tab, revealed the following: 1. On 06/05/24, RN1 documented, “positive bilateral pedal pulses” and “heel areas were cleansed with st. ns [sterile normal saline]/4x4’s, patted dry, and cover with wet to dry dressing and secured with a heel sock.” There was no documentation that a wound assessment including wound measurements was conducted and the physician was contacted to obtain wound care orders. 2. On 06/13/24, License Practical Nurse (LPN) 1 documented, “positive bilateral pedal pulses “ … pt’s. (patient) rt. (right) heel is closed without wound; lt. heel has black escar [sic] [tissue death] but is closed. Pt. states [he/she] has someone maintain preventive care to heel …” There was no documentation that a wound assessment including wound measurements was conducted and the physician was contacted to obtain wound care orders. 3. On 06/18/24, RN1 documented, “…positive bilateral pedal pulses … “heel areas were cleansed with st. ns /4x4’s, patted dry, and cover with a wet to dry dressing and secured with a heel sock.” There was no documentation that a wound assessment including wound measurements was conducted, and t the physician was contacted to obtain wound care orders. There was no documentation that RN1 conducted a pain assessment. 4. On 06/27/24, RN1 documented, “positive bilateral pedal pulses …The nurse using an aseptic technique performed wound care as ordered: cleansed with st. ns (normal saline solution) 4x4’s, patted dry, covered bilat [bilateral] heels with a wet to dry dressing and secured with a clean sock for both feet. The patient exhibits a smaller ulcerated area to rt. Lower heel it presents as black eschar but is not open or draining. The left heel also presents with eschar black in color, slightly boggy to the feel but not open. Patient does verbalize discomfort when he walks.” There was no documentation that a wound assessment including measurements was conducted, the physician was contacted to obtain wound care orders, and the physician was notified of the P7’s report of pain when ambulating. 5. On 07/05/24, LPN1 documented, “positive bilateral pedal pulses …SN [skilled nurse] educated pt. on the importance of floating heels is a pressure injury (bed sore) measure to implement to prevent heel wound if someone is bound to their bed for long periods of time.” There was no documentation that a wound assessment including wound measurements was conducted and the physician was contacted to obtain wound care orders. LPN1 did not perform a pain assessment. Observation on 07/05/24 at 5:00 PM in P7’s home revealed, RN1 removed P7’s left heel dressing and checked pedal pulses. RN1 performed wound care that included cleaning the wound with normal saline solution, wiping over the wound with skin prep (forms a protective barrier between the skin and adhesives) and covered the dressing with a bordered gauze and wrapped in Kerlix dressing. P7 did not have a pedal pulse on the left foot and the left foot appeared pale and was cool to touch [per RN1]. P7 grimaced and reported a severe burning pain when RN1 placed the skin prep on the patient’s wound. The patient also reported numbness to the left foot and had to walk on his toes. RN1 did not measure the wound because she/he did not have a measuring tape. RN1 did not contact P7’s attending physician to obtain wound care orders, report the absence of pedal pulses, and that the left foot was numb, had pallor, and was cool to touch. During an interview on 07/09/24 at 3:30 PM, RN1 stated, “the doctor is impossible to get in touch with.” RN1 confirmed that he/she had been performing wound care without a physician’s order that included a wet-to-dry dressing on the left heel since the patient was admitted on 06/03/24. During an interview on 07/09/24 at 4:00 PM, the Administrator stated the agency did not have a policy or protocol for wound care and how to properly document assessments of wounds. During an interview on 07/10/24 at 8:30 AM, the Administrator confirmed that wound care was provided to P7 without a physician’s order since the patient was admitted on 06/03/24 and agreed that the patient’s physician should have been contacted on 07/09/24 after the 5:00 PM visit to report the new findings of absence of pedal pulse, the color and temperature of the P7’s left foot, and the patients report of pain.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review, policy review, and interview, the Home Health Agency (HHA) failed to ensure a discharge summary was provided to the attending physician for two of two sampled patients (Patient (P) 3 and P4) reviewed for discharge. This deficient practice had the potential to affect all 44 patients receiving care from the HHA. Findings include: Review of the agency’s undated policy titled, “Discharge/Transfer Policy” revealed, “… 5. Prior to discharging the patient/client, the attending physician shall be notified. A written discharge summary, which shall be prepared within 30 days of discharge, will be sent to the physician with a copy maintained in the clinical record. The discharge summary will include: a. The reason for discharge b. The patient/client’s physical and psychosocial status at the time of discharge c. A summary of the care and services provided d. Patient/client progress toward desired goals e. Instructions and referrals provided to the patient/client. …” 1.Review of “Comprehensive Assessment,” dated 07/02/24 found in P3’s Electronic Medical Record (EMR) under the assessments tab, indicated that P3 was discharged from the HHA on 07/02/24. There was no documented evidence that a discharge summary was sent to P3’s attending physician. 2.Review of “Comprehensive Assessment,” dated 06/07/24 found in P4’s EMR under the assessments tab, indicated that P4 was discharged from the HHA on 06/07/24. There was no documented evidence that a discharge summary was sent to P4’s attending physician. During an interview on 07/08/24 at 3:30 PM, the Director of Nursing confirmed that discharge summaries were not provided to P3’s and P4’s attending physicians.”