Palmeira Home Healthcare

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure a physician order was clear, complete and appropriately authenticated and dated for 1 of 18 patients (Patient #14) and failed to ensure a home health aide documented vital signs for 1 of 18 patients (Patient #15). Findings include: Patient #14 On 9/28/2024, the agency admitted Patient #14 with secondary malignant neoplasm of bone. The agency certified the patient from 9/28/2024 through 11/26/2024. On 9/30/2024 at 1:19 PM, a physician ordered skilled visit frequency weekly for four weeks every other week until discharge. The nurse signed the order 11/30/2024, which had not occurred yet in the timing of the survey 11/19/2024 through 11/27/2024. Aside from the above anachronism, the order was invalid due to failing to indicate a skilled discipline in the order. None of the disciplines with documented skilled visits even remotely resembled the ordered frequency. On 11/26/2024 in the afternoon, the Clinical Manager and Administrator confirmed the finding. Patient #15 On 8/20/2022, the agency admitted Patient #15 with diabetes mellitus II with foot ulcer and history of infectious diseases. The agency recertified the patient continuously with the current focus episode of 10/14/2023 through 12/12/2023. On 10/14/2023, the plan of care revealed a physician ordered home health aide visits twice weekly throughout the care episode. The latest home health aide plan of care revealed the home health aide was to take and document vital signs each visit. On 10/20/2023, a home health aide conducted and documented a home health aide visit, indicating a complete set of vital signs were taken, but the home health aide failed to document the vital signs. For every documented home health aide visit of the above care episode, the home health aide visits lacked documented evidence of temperatures taken for each visit, despite the home health aide noting a complete set of vital signs were taken on each visit. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the findings.”

“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 observation, record review and interview, the agency failed to ensure its admission booklet contained the correct home health hotline phone number for all patients. Findings include: On 11/19/2024 in the afternoon, a home visit was conducted. On 11/20/2024, five home visits were conducted throughout the day. On 11/21/2024 in the morning, a home visit was conducted. On 11/19-20/2024 during the home visits conducted, the surveyor contacted the home hotline phone number provided in the agency’s booklet. Instead of the complaint line, the surveyor was solicited with an elder alert system. On 11/26/2024 in the agency’s office, the surveyor contacted the home health hotline number in front of the Clinical Manager and Administrator, using the number provided in an admission booklet from the office and the same solicitation was received. The finding was confirmed.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure it documented the existence and resolution of complaints for 1 of 18 patients (Patient #15). Findings include: Patient #15 On 8/20/2022, the agency admitted Patient #15 with diabetes mellitus II with foot ulcer and history of infectious diseases. The agency recertified the patient continuously with a focus episode of 10/14/2023 through 12/12/2023. On 11/17/2023, a physician ordered a resumption of care with skilled nursing visits three times weekly. On 11/28/2023, a licensed practical nurse (LPN) conducted and documented a skilled nursing visit, revealing the Clinical Manager accompanied the LPN on the visit. The LPN documented the patient conveyed numerous grievances to the Clinical Manager. The agency’s grievance log lacked documented evidence correlating with any complaints conveyed at or in near proximity to 11/28/2023. On 11/27/2024 in the afternoon, the Clinical Manager indicated the complaints were addressed as routine issues.”

“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 record review and interview, the agency failed to ensure a start of care was conducted within 48 hours of discharge for 1 of 18 patients (Patient #1). Findings include: Patient #1 On 3/19/2023, the agency admitted Patient #1 with hypertensive encephalopathy and pneumonia due to methicillin resistant Staphylococcus aureus. On 3/13/2023, the hospital referred the patient for home health services. On 3/14/2023, an unsigned phone message revealed the spouse agreed to the start of care on 3/18/2023. This was contradicted by a complaint the bureau received in real time regarding the availability of a nurse on 3/16-17/2023. Someone at the agency documented a later referral date on the patient’s face sheet as 3/17/2023. On 3/18/2023, the nurse was a no call/no show at the patient’s house, none of which was documented at the agency. The patient was unable to get through to the agency until 3/19/2024. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator were unable to provide documented evidence of any other information addressing the late start of care. Procedure #4 of the Care Planning Process policy (4-001) provided revealed the registered nurse informed the patient’s physician of any changes that suggested a need to change the plan of care. Changes must be written, dated and signed by the professional making the changes and forwarded to the physician for approval and signature. The patient/family was informed of changes in the plan of care and the registered nurse documented in the chart if the patient understood and was agreeable to the revised plan of care. Complaint #96875”

“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, observation and interview, the agency failed to ensure a patient’s allergies were addressed for 2 of 18 patients (Patient #5 and #9) and failed to ensure an accurate medication profile for 2 of 18 patients (Patient #13 and #14). Findings include: Patient #5 On 11/8/2023, the agency admitted Patient #5 with failure to thrive and altered mental status. On 11/8/2023, the plan of care and medication profile both lacked documented evidence the patient’s allergies were listed or whether the patient did not have allergies. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the finding. Patient #9 On 11/25/2023, the agency admitted Patient #9 with atherosclerotic heart disease of the coronary artery. On 11/25/2023, the plan of care and medication profile both lacked documented evidence the patient’s allergies were listed or whether the patient did not have allergies. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the finding. Patient #13 On 11/14/2024, the agency admitted Patient #13 with hemiplegia. On 11/14/2024, the agency certified the patient from 11/14/2024 through 1/12/2025. On 11/14/2024, the plan of care revealed a physician ordered a home health aide once the week of 11/17/2024 through 11/23/2024. On 11/21/2024, a home visit was conducted with a home health aide. During the visit, a medication reconciliation was conducted. Of note were two medications, one of which was neither on the plan of care nor the medication profile provided. The other was listed at a different dose. The plan of care and medication profile lacked documented evidence of Hydralazine. A container was identified in the home, filled on 11/12/2024, with Hydralazine 25 milligrams three times daily. The plan of care and medication profile both listed Amlodipine at 10 milligrams daily. A container was identified in the home, filled on 11/12/2024, with Amlodipine 2.5 milligrams nightly at 9:00 PM. On 11/21/2024, a skilled nursing visit was conducted and documented after the visit with the home health aide. The medication profile was updated to include Hydralazine 25 milligrams three times daily, but the Amlodipine 10 milligrams daily was still listed. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the finding. Patient #14 On 11/6/2014, the agency admitted Patient #14 with encounter for surgical wound dressing. On 11/6/2024, both the plan of care and medication profile listed Citalopram 10 milligrams daily. On 11/20/2024, a home visit was conducted with a physical therapist for a discharge. A medication reconciliation revealed the medication Citalopram (Celexa) was actually Escitalopram (Lexapro) according to the container’s label. After the visit, the difference between the two medications was mentioned to the therapist. The medication profile was not corrected.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure it conducted and documented skilled visits as ordered for 8 of 18 patients (Patient #1, #3, #4, #5, #7, #14, #15 and #16). Findings include: Procedure #4 of the Care Planning Process policy (4-001) provided revealed the registered nurse informed the patient’s physician of any changes that suggested a need to change the plan of care. Changes must be written, dated and signed by the professional making the changes and forwarded to the physician for approval and signature. The patient/family was informed of changes in the plan of care and the registered nurse documented in the chart if the patient understood and was agreeable to the revised plan of care: Patient #1 On 3/19/2023, the agency admitted Patient #1 with hypertensive encephalopathy and pneumonia due to methicillin resistant Staphylococcus aureus. On 3/19/2023, the plan of care revealed a physician ordered skilled nursing visits four times for the first week of the episode. The clinical record lacked documented evidence the agency conducted and documented skilled nursing visits aside from the start of care visit on 3/19/2023. The clinical record lacked documented evidence a physician changed, discontinued or reduced the frequency. On 11/27/2024 in the afternoon, the Clinical manager confirmed the finding. Patient #3 1) On 10/13/2024, the agency admitted Patient #3 with open wound of the left wrist. On 10/13/2024, the plan of care revealed a physician ordered an occupational therapy evaluation. On 10/17/2024, a physician ordered late occupational therapy evaluation. The clinical record lacked documented evidence an occupational therapy evaluation was conducted and documented or that the order was changed or discontinued. 2) On 11/3/2024, a physician ordered every other week skilled nursing visits due to patient request. The clinical record contained documented evidence of weekly skilled nursing visits dated 11/7/2024, 11/14/2024 and 11/19/2024. On 11/26/2024 in the afternoon, the Clinical Manager and Administrator confirmed the above findings. 3) On 10/13/2024, the plan of care revealed a physician ordered twice weekly skilled nursing visits and to cleanse left wrist area with wound cleanser, apply dry gauze to wound and secure in place daily. On 10/16/2024, a registered nurse conducted and documented a skilled nursing visit with wound care as cleansed with betadine, applied xeroform and dressed with adhesive foam. The nursing goals included the original plan of care order as current on the obverse side of the skilled nursing visit form. On 11/26/2024 in the afternoon, the Clinical Manager and Administrator confirmed the finding the order was not followed. Patient #4 On 10/3/2024, the agency admitted Patient #4 with stage 2 pressure ulcer of left heel. On 10/3/2024, the plan of care revealed a physician ordered an occupational therapy evaluation and a social services evaluation. The clinical record revealed an occupational therapy evaluation was conducted and documented on 10/15/2024, and a social services evaluation was conducted and documented on 10/16/2024. The clinical record lacked documented evidence why the evaluations were so delayed. The orders were not changed or discontinued. On 11/26/2024 at 12:55 PM, the Administrator indicated secondary discipline evaluations ordered were expected to be conducted within five days and confirmed the findings. Patient #5 On 11/8/2023, the agency admitted Patient #5 with failure to thrive and altered mental status. On 11/10/2023, an occupational therapy evaluation was conducted and documented. On 11/8/2023, the plan of care lacked documented evidence a physician ordered an occupational therapy evaluation. On 11/10/2023 the patient was transferred to acute care for altered mental status. On 11/22/2023, the agency resumed home health care for the patient. A physician ordered twice weekly skilled nursing visits to begin the following week. For the week of 11/26/2023 through 12/2/2023, the clinical record contained documented evidence only one skilled nursing visit was conducted and documented on 11/29/2023. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the findings. Patient #7 On 8/5/2024, the agency admitted Patient #7 with stage 3 pressure ulcer of the sacral region, complicated urinary tract infection and fitting and adjustment of urinary device. The agency certified the patient from 8/5/2024 through 10/3/2024. On 8/5/2024, a physician wrote an order for monthly Foley catheter change as needed for leakage/dislodgement. On 9/30/2024, the agency recertified the patient from 10/4/2024 through 12/2/2024. On 8/5/2024 and 10/4/2024, the plans of care lacked documented evidence a physician ordered a monthly Foley catheter change or sized the Foley catheter in place. On 10/4/2024, the plan of care revealed a physician ordered twice weekly weekly skilled nursing visits. On 10/11/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/14/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/16/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/20/2024, an “as needed” skilled nursing visit revealed a nurse changed the Foley catheter due to nonfunction. The Foley size was 24 french and 30 milliliter balloon. On 10/21/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/25/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/28/2024, a skilled nursing visit revealed urinary tract infection symptoms were present and a urine specimen was collected. On 10/29/2024, the lab result revealed the patient was positive for urinary tract infection. On 10/30/2024, a physician ordered 24 french and 30 milliliter balloon for the monthly changes. On 10/30/2024, an “as needed” skilled nursing note revealed a nurse documented the new Foley as 24 french and 15 milliliter balloon. On 11/1/2024, a skilled nursing visit revealed the visit nurse obtained the lab result confirming the infection and antibiotic ordered at pharmacy for pick-up. On 11/13/2024, a skilled nursing note revealed a nurse documented a new Foley catheter change as 22 french and 30 milliliter balloon. The monthly Foley catheter change order (8/5/2024) was not transferred to the plans of care. The size of the Foley catheter was not identified per order change until 10/30/2024. The Foley catheter changes performed and documented on 10/30/2024 and 11/13/2024 were the wrong size. The plan of care lacked documented evidence for the extra “as needed” skilled nursing visits conducted and documented on 10/20/2024 and 10/30/2024. On 11/27/2024 in the afternoon, the Clinical Manager and the Administrator confirmed the findings, indicating the agency was reliant upon using specific requisition forms for labs which had to be physician signed prior to establishing an order for the lab, despite appearing on the plan of care. The catheter size should be physician-ordered. Procedure #1 of the Foley Catheter Care and Management policy (4-007) provided revealed for nurses to verify the doctor’s order. Patient #14 On 9/28/2024, the agency admitted Patient #14 with secondary malignant neoplasm of bone. On 9/28/2024, the plan of care revealed a physician ordered an occupational therapy evaluation and a social services evaluation. The clinical record revealed an occupational therapy evaluation was conducted and documented on 10/2/2024. On 10/2/2024, the occupational therapy evaluation revealed a physician ordered occupational therapy weekly for six weeks. The clinical record revealed occupational therapy visits were conducted and documented weekly until the week of 11/3/2024 through 11/9/2024. On 11/10/2024, a physician order was obtained to discharge the patient during the coming week, which was conducted and documented on 11/13/2024. The clinical record lacked documented evidence why the occupational therapy discharge visit was not conducted between 11/3/2024 and 11/9/2024. The clinical record lacked documented evidence of a missed visit, communication note, change or discontinuation order between 11/3/2024 and 11/9/2024. The order to discharge the following week was written after the fact. The social services evaluation, ordered 10/2/2024, was conducted and documented on 10/15/2024. The clinical record lacked documented evidence why the evaluation was so delayed. The order was not changed or discontinued. On 11/26/2024 at 12:55 PM, the Administrator indicated secondary discipline evaluations ordered were expected to be conducted within five days and confirmed the above findings. Patient #15 On 8/20/2022, the agency admitted Patient #15 with diabetes mellitus II with foot ulcer and history of infectious diseases. The agency recertified the patient continuously with a focus episode of 2/16/2023 through 4/16/2023. On 2/16/2023, the plan of care revealed a physician ordered three times weekly (Tuesday, Thursday and Saturday) throughout the care episode for a chronic diabetic foot ulcer. The clinical record revealed skilled nursing visits were conducted on those mornings without fail the first half of March with the exception of 3/9/2023. The clinical record lacked documented evidence of a missed visit. On 3/9/2023 at 6:24 PM, a registered nurse obtained a physician order to reduce the skilled nursing visits to two times for that week with no reason specified, but the agency cannot reduce visit frequency as a means to cover a missed visit after an undocumented missed, scheduled skilled nursing visit. The agency recertified the patient continuously with a focus episode of 10/14/2023 through 12/12/2023. On 10/14/2023, the plan of care revealed a physician ordered skilled nursing visits daily for wound care. The clinical record lacked documented evidence of a skilled nursing visit conducted and documented on 10/16/2023. The clinical record lacked documented evidence of a physician order that changed, modified or discontinued the skilled nursing visit. The clinical record lacked documented evidence of a missed visit for 10/16/2023. On 10/14/2023, the plan of care revealed a physician ordered home health aide visits twice weekly throughout the care episode. On 10/25/2023, a physician ordered twice weekly home health aide visits to continue. The clinical record revealed the last home health aide visit conducted and documented dated 10/30/2023. The clinical record lacked documented evidence of a physician order that changed, modified or discontinued the home health aide visits. The clinical record lacked documented evidence of any missed home health aide visits after 10/30/2023. On 11/17/2023, the agency resumed patient care after an acute care stay. The comprehensive assessment revealed an intent to order an occupational therapy evaluation. On 11/28/2023, a physician ordered an occupational therapy evaluation. The clinical record lacked documented evidence an occupational therapy evaluation was conducted and documented, addressed with a missed visit or that the order was changed or discontinued. On 11/26/2024 at 12:55 PM, the Administrator indicated secondary discipline evaluations ordered were expected to be conducted within five days and confirmed the findings. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed all the above findings. Patient #16 On 8/6/2024, the agency admitted Patient #16 with encounter for non-surgical wound dressing. On 8/6/2024, the clinical record lacked documented evidence a physician ordered home health aide visits. On 8/6/2024, a home health aide plan of care revealed twice weekly home health aide visits. The clinical record contained documented evidence of unordered home health aide visits conducted on 8/12/2024 and 8/23/2024, which constituted weekly visits. On 11/26/2024 in the afternoon, the Clinical Manager and Administrator confirmed the findings.”

“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 record review, interview and agency practice guidelines, the agency failed to ensure it notified a physician or the discharging hospital regarding the need for orders to address the presence of an intravenous line for three days after the start of care for 1 of 18 patients (Patient #1). Findings include: Patient #1 On 3/19/2023, the agency admitted Patient #1 with hypertensive encephalopathy and pneumonia due to methicillin resistant Staphylococcus aureus. The start of care OASIS assessment revealed the Registered Nurse documented and was aware the physician ordered intravenous antibiotic management without any orders to maintain the intravenous line or any antibiotics. The intravenous line dressing was clean, dry and intact. On 3/19/2023, the plan of care revealed a physician ordered intravenous antibiotic management and was aware the patient had an intravenous line in the left arm. The intravenous line dressing was clean, dry and intact. On 3/19-21/2023, the clinical record lacked documented evidence anyone contacted a physician or the hospital to obtain orders to change the dressing, maintain the intravenous line or have it discontinued. The clinical record lacked documented evidence of orders for intravenous medication. On 3/21/2023, a physical therapist documented a communication note from an evaluation conducted, revealing the patient was wondering about the intravenous line and if it could be removed. On 3/22/2023, the Case Manager at the hospital was contacted regarding the intravenous line and what to do. On 3/24/2023, the Clinical Manager contacted the patient/spouse regarding awaiting an answer from the case manager at the hospital. On 3/24/2023, the agency finally received a faxed reply from the hospital case manager to remove the intravenous line at the next skilled nursing visit. On 3/26/2023, a skilled nursing visit documented removal of the intravenous line. On 11/27/2024 in the afternoon, the Clinical Manager indicated there was a wait to hear about what to do with the intravenous line. There was no documented evidence anyone contacted the case manager at the hospital for three days. The agency’s Guide To Line Care provided revealed for the patient’s intravenous line: transparent dressing change was required weekly and as needed. Flushing agents included Heparin 3 milliliters of 100 units/milliliter Heparin daily and 3 milliliters of Normal Saline daily when the intravenous line was not in use. The clinical record lacked documented evidence any of the Guide To Line Care items were ordered or administered between 3/19-26/2023. Complaint #96875”

“Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner’s issuing orders for the HHA plan of care. This Element is not met as evidenced by: Based on record review, interview, policy review and contract review, the agency failed to ensure a missed visit was documented clearly as to why the visit was missed and notify the physician accordingly for 1 of 18 patients (Patient #2) and failed to document a missed visit and notification of a change to the plan of care for 1 of 18 patients (Patient #15). Findings include: Patient #2 On 10/31/2024, the agency admitted Patient #2 with right-sided hemiplegia. On 10/31/2024, the plan of care revealed a physician ordered a physical therapy evaluation. On 11/5/2024, a physical therapy evaluation revealed a physician ordered twice weekly physical therapy visits starting the following week. On 11/13/2024, a physical therapy assistant (PTA) documented a missed visit because of a scheduling conflict. The supervisor was notified by fax. The scheduling conflict failed to distinguish whether or not the patient had the conflict or the PTA. The visit was not made up, nor was the physician notified. The physical therapy assistant was contracted and followed the contracted language of notifying the agency. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the finding. The agency’s Missed Visit policy provided revealed physician notification was required with a missed visit. The intake team would provide another visit if another visit was available. [The agency’s policy was out of sync with what contracted personnel were required to do for missed visits]. Patient #15 On 8/20/2022, the agency admitted Patient #15 with diabetes mellitus II with foot ulcer and history of infectious diseases. The agency recertified the patient continuously with a focus episode of 2/16/2023 through 4/16/2023. On 2/16/2023, the plan of care revealed a physician ordered skilled nursing visits for wound care three times weekly (Tuesday, Thursday and Saturday) throughout the care episode for a chronic diabetic foot ulcer. On 3/7/2023, a skilled nursing visit revealed the patient complained about the third party wound care provider not calling or showing up to provide wound care on 3/6/2023. The clinical record revealed skilled nursing visits were conducted on March mornings before noon without fail the first half of March with the exception of 3/9/2023. The clinical record lacked documented evidence of a missed visit. On 3/9/2023 at 6:24 PM, a registered nurse obtained a physician order to reduce the skilled nursing visits to two times for that week with no reason specified, but the agency cannot reduce visit frequency as a means to cover a missed visit after an undocumented missed, scheduled skilled nursing visit. The clinical record lacked documented evidence the agency contacted the patient regarding 3/9/2023. The clinical record lacked documented evidence of an attempt to conduct a make-up visit on 3/10/2023. On 3/11/2023, a skilled nursing visit revealed the patient had respirations of 22 and temperature of 101.5 Fahrenheit. The patient stated being upset about no nursing visit on 3/9/2023. The licensed practical nurse documented the patient had a raised abscess in the diabetic ulcer. The patient also had a thick layer of purulent drainage on the left shin wound. The physician was contacted and immediately ordered Augmentin and Doxycycline twice daily for a week and for the patient to come for an office visit on 3/13/2023, as the patient refused the recommended emergency department visit. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the findings but thought they were covered with a physician order, but it was explained the agency changed the plan of care, failed to document a missed visit in real time and the reason for the missed visit and failed to document patient notification. Complaint #102707”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure it arranged for a mobile physician in a timely manner for 1 of 18 patients (Patient #18). Findings include: Patient #18 On 10/14/2024, the agency admitted Patient #18 with hypertension, anxiety disorder and long term opiate analgesic use. On 10/14/2024, the clinical record revealed a request for a mobile primary care physician. The clinical record lacked documented evidence the above request was ever addressed. On 11/20/2024, a skilled nursing home visit was conducted with a registered nurse. During the visit, it was identified the patient did not take the ordered blood pressure medication Lisinopril 20 milligrams daily. The patient was completely out of ordered Alprazolam 0.5 milligrams and Hydrocodone/Acetaminophen 5/325 milligrams as needed. The patient had a blood pressure of 164/94 with a radial pulse of 110 and demonstrated anxiety and depressed mood during the visit. Although the registered nurse was able to obtain a visit with a physician appointment for the following day for high blood pressure and medication refills, the patient did not have transportation and/or was unable to drive, as expressed during the visit, and was forced to contact someone immediately to secure transportation to the appointment the next day. The plan documented for the next skilled nursing visit was still (after five weeks) to arrange for a mobile physician for continuity of care. On 11/26/2024 in the afternoon, the Clinical Manager and Administrator indicated a mobile physician could usually be obtained within a few days, but there was no documented evidence in five weeks why a mobile physician could not be obtained for the patient prior to the home visit conducted on 11/20/2024.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation and interview, the agency failed to ensure it notified a patient of a missed visit in a timely manner for 1 of 18 patients (Patient #3). Findings include: On 10/13/2024, the agency admitted Patient #3 with open wound of the left wrist. On 10/13/2024, the plan of care revealed a physician ordered twice weekly skilled nursing visits. On 11/3/2024, the physician ordered a reduction in skilled nursing visits to one every other week. On 11/19/2024 in the afternoon, a skilled nursing home visit was conducted with a registered nurse. During the visit, the spouse and patient indicated they had been waiting most of the day for the visit. They were told 10:00 AM to Noon for the visit, but the home visit with the surveyor commenced at 3:00 PM. The agency did not inform them of the missed visit until setting up the surveyor’s home visit after the 2-hour window of time lapsed. On 11/21/2024 in the afternoon, the Clinical Manager and Administrator indicated a licensed practical nurse called off for a family emergency after 11:00 AM on 11/19/2024. The process was someone from the agency was supposed to contact the patient to cancel.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure it delivered services specified in the plan of care for 1 of 18 patients (patient #7). Findings include: Patient #7 On 8/5/2024, the agency admitted Patient #7 with stage 3 pressure ulcer of the sacral region, complicated urinary tract infection and fitting and adjustment of urinary device. The agency certified the patient from 8/5/2024 through 10/3/2024. On 8/5/2024, a physician wrote an order for monthly Foley catheter change as needed for leakage/dislodgement. On 9/30/2024, the agency recertified the patient from 10/4/2024 through 12/2/2024. On 8/5/2024 and 10/4/2024, the plans of care lacked documented evidence a physician ordered a monthly Foley catheter change or sized the Foley catheter in place. On 10/4/2024, the plan of care revealed a physician ordered twice weekly skilled nursing visits. On 10/11/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/14/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/16/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/20/2024, an “as needed” skilled nursing visit revealed a nurse changed the Foley catheter due to nonfunction. The Foley size was 24 french and 30 milliliter balloon. On 10/21/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/25/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/28/2024, a skilled nursing visit revealed urinary tract infection symptoms were present and a urine specimen was collected. The clinical record lacked documented evidence why it took 17 days to collect a urine specimen. The plan of care at recertification revealed a nurse could go ahead and collect a urine specimen if urinary tract infection symptoms were present. The clinical record lacked documented evidence why the nurse did not collect a urine specimen. On 10/29/2024, the lab result revealed the patient was positive for urinary tract infection. On 10/30/2024, a physician ordered 24 french and 30 milliliter balloon for the monthly changes. On 10/30/2024, an “as needed” skilled nursing note revealed a nurse documented the new Foley as 24 french and 15 milliliter balloon. On 11/1/2024, a skilled nursing visit revealed the visit nurse obtained the lab result confirming the infection and antibiotic ordered at pharmacy for pick-up. On 11/13/2024, a skilled nursing note revealed a nurse documented a new Foley catheter change as 22 french and 30 milliliter balloon. The monthly Foley catheter change order (8/5/2024) was not transferred to the plans of care. The size of the Foley catheter was not identified per order change until 10/30/2024. The Foley catheter changes performed and documented on 10/30/2024 and 11/13/2024 were the wrong size. On 11/27/2024 in the afternoon, the Clinical Manager and the Administrator confirmed the findings, indicating the agency was reliant upon using specific requisition forms for labs which had to be physician signed prior to establishing an order for the lab, despite appearing on the plan of care. The catheter size should be physician-ordered. Procedure #1 of the Foley Catheter Care and Management policy (4-007) provided revealed for nurses to verify the doctor’s order.”