Las Vegas Home Health Care, Inc.

“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 observation, interview, record review and document review, the agency failed to maintain condition level compliance with the following Condition of Participation: 42 CFR §484.50 Patient rights Findings include: The cumulative effect of the following systematic practices resulted in the failure of the agency to protect and promote patient rights in the delivery of care to patients: 1) Ensure patient confidentiality/privacy with the clinical record (See Tag G0438). 2) Ensure patients were provided the correct home health hotline phone number in a conspicuous manner (See Tag G0444). 3) Ensure patients were not neglected and/or that neglect was reported (See Tag G0488).”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review, interview and document review, the agency failed to ensure an effective Governing Body was legally responsible for the conduct of the agency and failed to maintain condition level compliance with the following Condition of Participation: 42 CFR §484.105 Organization and administration of services Findings include: The cumulative effect of the following systematic practices resulted in the failure of the agency to deliver statutory-mandated care to patients. 1) Ensure the skilled visiting staff was accountable to the Governing Body for the quality of care provided to patients (See Tag G0942). 2) Ensure its Clinical Manager implemented established policies in the operation of the agency (See Tag G0958).”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on interview, personnel record review and document review, the agency failed to provide documented evidence the direct care staff members had signed and completed the training on the agency’s emergency preparedness (EP) plan for 10 of 10 employee files reviewed (Employee 1 to 10). The deficient practice had the potential to affect the direct care staff members’ ability to assist the agency in continuing to provide patient care and address safety needs of the patients, and staff members in protecting themselves in the event of an emergency. Findings include: A review of ten employee files and the agency’s EP binder revealed there was no documented evidence an EP training was provided to the ten employees. On 05/02/2024 at 3:22 PM, the Human Resources (HR) Manager confirmed the findings and explained EP training was provided to the office-based personnel but not to the direct care staff members. Upon reading the agency’s EP policy, the HR Manager acknowledged an initial EP training, and at least every two years thereafter, should have been provided to all staff members. The agency’s policy titled Emergency Operations Plan (EOP) Training Program dated February 2024, documented the agency would provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement and volunteers (if applicable) consistent with their expected roles. The agency would provide emergency preparedness training at least every two years. Training should be modified, incorporating any lessons learned from the most recent exercises, real-life emergencies which occurred in the last two years and during review of the emergency operations plan every two years. The agency would maintain documentation of the training.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview, record review and document review, the agency failed to electronically transmit each completed OASIS assessment within 30 days of completing the assessment of the beneficiary for 9 of 13 quarters since the last recertification survey in April 2021, and for 2 of 7 sampled patients (Patient 5 and 7). Patient 5 (P5) P5’s start of care was 12/18/2023 and was recertified for the period 02/16/2024 to 04/15/2024. The Outcome and Assessment Information Set (OASIS) assessment for the recertification period was completed on 02/12/2024. The OASIS Agency Final Validation report from the Centers for Medicare and Medicaid Services (CMS) documented the said OASIS assessment was electronically transmitted on 04/03/2024 and the submission date was more than 30 days. On 05/02/2024 at 9:45 AM, the Director of Nursing (DON) confirmed the findings and acknowledged the OASIS assessment should have been electronically transmitted to the CMS system within 30 days of completing the assessment. Patient 7 (P7) P7’s start of care was 01/07/2024 and the certification period was from 01/07/2024 to 03/06/2024. The OASIS Agency Final Validation report from CMS documented P7’s OASIS assessment was electronically transmitted on 03/20/2024 and the submission date was more than 30 days. On 05/02/2024 at 2:43 PM, the DON confirmed the findings and acknowledged P7’s OASIS assessment was transmitted late. The agency’s policy titled Reporting of OASIS Information dated February 2024, documented the agency would electronically transmit completed, encoded and locked OASIS data for each completed OASIS assessment at least monthly to the System (CMS System). According to the state’s OASIS Education Coordinator in the pre-survey report, the agency was out of compliance due to late transmission of OASIS for 9 of 13 quarters since the last recertification survey in April 2021. The assessments submitted late for the nine quarters varied from a low of 11.2% to a high of 40.5% of all quarterly submissions. On 05/03/2024 at 9:05 AM, the Administrator confirmed the findings and indicated a need to tighten the window for clinicians to submit their assessments, so they could be reviewed sooner for final submission.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review, interview and policy review, the Governing Body failed to demonstrate responsibility for effective operation and management of the home health agency. Findings include: The agency failed to ensure an effective Governing Body demonstrated responsibility for effective operation and management of the home health agency. Specifically, the Governing Body failed to: 1) Ensure the agency’s OASIS submissions were uploaded in a timely manner for 9 of the last 13 quarters (See Tag G0372). On 05/03/2024 at 9:05 AM, the Administrator confirmed the finding and was directly responsible for timely uploading, and the problem continued up to the present. 2) Ensure the ability of patients to exercise patient rights (See Tags G0438, G0444 and G0488). On 05/03/2024 at 2:50 PM, the Director of Nursing confirmed the findings. 3) Ensure the skilled visiting staff was accountable to the Governing Body for the quality of care provided to patients due to a Clinical Manager’s lack of oversight (See Tag G0958). On 05/03/2024 at 2:50 PM, the Director of Nursing confirmed the findings. 4) Ensure there was an administrative policy protecting patient confidentiality/privacy regarding using an agency endorsed device and method of obtaining wound photos and not using personal devices to obtain the same (See Tag G1028). On 05/03/2024 a 9:05 AM, the Administrator confirmed the finding. On 05/03/2024 at 2:50 PM, the Director of Nursing confirmed the finding. 5) Ensure the agency hired a qualified social worker (See Tag G1076).”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on signed job description, record review and interview, the Clinical Manager failed to provide oversight of patient care services and personnel, failing to enforce agency policies entwined with job responsibilities as outlined below. Findings include: According to the agency’s signed job description for Clinical Manager, the agency’s Clinical Manager failed to provide oversight of patient care services and personnel as follows: 1) Responsibility #15: Failing to ensure confidentiality/privacy of patient clinical information (See Tag G0438). 2) Responsibility #19: Failing to ensure conspicuous dissemination of the correct home health hotline phone number to patients (See Tag 0444). 3) Responsibility #17-20: Failing to follow-up with a referral of potential neglect to elder protective services (See Tag 0488). 4) Responsibility #24: Failing to ensure nurses reconciled medications included with patients’ medication profiles (See Tag 0536). 5) Responsibility #24: Failing to ensure nurses administered services and treatments as ordered by physicians (See Tag 0580). 6) Responsibility #30: Failing to ensure accurate clinical documentation (See Tag G0716). 7) Responsibility #10: Failing to ensure coordination of patient care regarding a wound care referral and subsequent services and treatment (See Tag G0962). 8) Responsibility #30: Failing to ensure nurses authenticated clinical documentation (See Tag G1024). The Director of Nursing provided policies for the above identified deficiencies. On 05/03/2024 at 2:50 PM, the Director of Nursing confirmed the above findings, verbalizing the Clinical Manager reported to the Director of Nursing.”

“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 interview, record review and document review, the agency failed to ensure skilled visit notes were authenticated for 1 of 7 sampled patients (Patient 4). The deficient practice had the potential for failing to ensure the care and services were provided to the patients in a timely manner and documented accurately. Findings include: Patient 4 (P4) P4 was admitted on 03/03/2024, with diagnoses including chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity and chronic kidney disease. Review of P4’s medical record revealed the following skilled nursing (SN) and therapy visit notes had no signature and title of the staff who completed the form: - SN Visit Note on 03/14/2024: Signature/Date section of the electronic form was left blank. - SN Visit Note on 03/23/2024: Signature/Date section of the electronic form was left blank. - Physical Therapy Functional Reassessment dated 04/05/2024 On 05/01/2024 at 1:31 PM, the Director of Nursing (DON) confirmed the findings and explained the clinical staff members such as the nurses and therapists were expected to enter their electronic signature and title (occupation) once the visit notes were completed. The DON indicated the date when the staff members electronically signed the document should have been entered in the visit notes. The agency’s policy titled Medical Record Entries and Authentication dated February 2024, documented all medical entries would be dated and authenticated. All entries in the medical record would be authenticated by staff signature and title. By authenticating entries in the patient’s record, staff was validating the correctness of the information. If automated clinical record system was used, authentication would include a signature and title.”

“Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This Standard is not met as evidenced by: Based on record review, interview and policy review, the agency failed to establish policies and procedures to ensure the security of clinical records and the privacy of information contained within such records to prevent loss or unauthorized use in the patient’s home, in transit, and in the office setting for 1 of 7 patients (Patient #6). The deficient practice placed patients at risk for private information to be accessed. Findings include: Patient 6 (P6) On 08/01/2023, the agency admitted Patient 6 with pressure ulcer of the right buttocks. The agency continuously recertified P6 through 05/26/2024. On 03/06/2024, the Clinical Manager documented a communication note revealing the following: The Home Health Aide (HHA) contacted the agency’s office to report P6 had multiple pressure ulcers on the sacrum, buttocks, heel and mid-back. The HHA had sent pictures via e-mail. On 05/03/2024 at 10:15 AM, the HHA indicated the wound pictures were sent to the Clinical Manager with a personal phone. After the phone call, the Clinical Manager verbalized the HHA texted the wound pictures from a personal phone to a receiving personal phone. The Clinical Manager then e-mailed them to the agency’s e-mail account where they were printed out and placed into P6’s clinical record. The Clinical Manager showed the Inspector the wound pictures, which were still currently on the Clinical Manager’s phone and not deleted. On 05/03/2024 at 2:45 PM, the Director of Nursing indicated the agency handed out I-pads to all clinicians after the previous recertification survey in April 2021. The I-pad could have been used to take the pictures and then brought to the office to download and print the pictures and or upload them into the electronic clinical record. Clinicians should not use personal electronic devices to photograph patients’ wounds. The Administrator verbalized the agency did not have any policy more specific to photographing patients’ wounds and placing them in the clinical record. Responsibility #15 of the Clinical Manager’s signed job description, dated 3/11/2015, revealed the Clinical Manager observed confidentiality and safeguarded all patient related information. Procedure #7 of the Information Confidentiality, Security and Data Integrity policy revealed the agency would monitor staff compliance with confidentiality, privacy and security. Information from monitoring activities and new advancements in technology would be used by leaders to improve confidentiality, privacy and security. On 05/03/2024 at 9:05 AM, the Administrator verbalized the agency lacked documented evidence of a policy or procedure describing using an agency endorsed device and method of obtaining wound photos and not using personal devices to obtain the same.”

“Social Worker CFR(s): 484.115(m) Standard: Social worker. A person who has a master’s or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has 1 year of social work experience in a health care setting. This Standard is not met as evidenced by: Based on interview, record review and document review, the agency failed to ensure the social worker (Employee 4) hired to provide the medical social services, obtained a master’s or doctoral degree in social work. The deficient practice had the potential for the patients not receiving the required social services per the physician’s orders from a qualified staff. Findings include: Employee 4 was hired on 08/23/2023 as a Medical Social Worker. Employee 4’s Job Description documented the following: - Subject: Medical Social Worker (MSW) - Qualifications included, 1) A person who had a master’s or doctoral degree from a school of social work accredited by the Council on Social Work Education, and had one year of social work experience in a health care setting, or; 2) Had a baccalaureate degree in social work, psychology, sociology or other field related to social work, and had at least one year of social work experience in a health care setting (functions as an assistant); 3) Two years of appropriate experience (for assistant). - Supervised by Director of Clinical Services/Clinical Manager. If Social Work Assistant, supervised by the Social Worker. - Employee 4 signed the Job Description on 08/23/2023. Employee 4’s personnel record lacked documented evidence of a master’s degree or doctoral degree in social work. The agency’s list of active employees did not include any other Social Worker aside from Employee 4. On 05/02/2024 at 2:31 PM, the Human Resources (HR) Manager confirmed the findings and revealed Employee 4 functioned as MSW and not a Social Services Assistant. Employee 4 completed and signed the Medical Social Services Evaluation Form dated 03/04/2024 and Medical Social Services Revisit Note dated 03/07/2024 for Patient 4. Employee 4 signed both documents as the Medical Social Worker.”

“Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to maintain patient privacy and protect patient information obtained electronically for 1 of 7 patients (Patient #6). The deficient practice placed the patient at risk for unauthorized access to patient information. Findings include: Patient 6 (P6) On 08/01/2023, the agency admitted Patient 6 with stage II pressure ulcer of the right buttocks. The agency continuously recertified P6 through 05/26/2024. On 03/06/2024, the Clinical Manager documented a communication note revealing the following: The Home Health Aide (HHA) contacted the agency’s office to report P6 had multiple pressure ulcers on the sacrum, buttocks, heel and mid-back. The HHA sent pictures via e-mail. On 05/03/2024 at 10:15 AM, the HHA indicated the wound pictures were sent to the Clinical Manager with a personal phone. After the phone call, the Clinical Manager verbalized the HHA texted the wound pictures from a personal phone to a receiving personal phone. The Clinical Manager then e-mailed them to the agency’s e-mail account where they were printed out and placed into P6’s clinical record. The Clinical Manager showed the Inspector the wound pictures, which were still currently on the Clinical Manager’s phone and not deleted. On 05/03/2024 at 2:45 PM, the Director of Nursing indicated the agency handed out I-pads to all clinicians after the previous recertification survey in April 2021. The I-pad could have been used to take the pictures and then brought to the office to download and print the pictures and or upload them into the electronic clinical record. Clinicians should not use personal electronic devices to photograph patients’ wounds. The Administrator verbalized the agency did not have any policy more specific to photographing patients’ wounds and placing them in the clinical record. Responsibility #15 of the Clinical Manager’s signed job description, dated 03/11/2015, revealed the Clinical Manager observed confidentiality and safeguarded all patient related information. Procedure #7 of the Information Confidentiality, Security and Data Integrity policy revealed the agency would monitor staff compliance with confidentiality, privacy and security. Information from monitoring activities and new advancements in technology would be used by leaders to improve confidentiality, privacy and security.”

“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 interview, record review and document review, the facility failed to ensure the correct state toll free home health telephone hotline number was provided and posted conspicuously in the home health folder maintained for 3 of 3 patient home visits conducted (Patient 1, 2, and 3). The deficient practice had the potential for the patients not having access or forum where the patients could file complaints about the agency. Patient 1 (P1) P1 was admitted on 06/03/2023, with diagnoses including atherosclerosis, cerebral aneurysm and hypertension. On 04/30/2024 at noon, during a home visit with P1, the patient expressed unawareness of the state toll free home health telephone hotline number. P1 identified the physical therapist and nurse as the assigned caregivers for home visits. Review of P1’s home health folder revealed the state toll free home health telephone hotline number was listed on a sticker on the folder; however, the inspector verified the listed number was incorrect. On 05/02/2024 in the afternoon, the Director of Nursing confirmed the findings and acknowledged the label sticker attached to the front of the home health folder should have contained the correct state toll free home health telephone hotline number. Patient 2 (P2) P2 was admitted on 01/27/2024, with diagnoses including Covid-19 and pneumonia. On 04/30/2024 at 2:30 PM, during a home visit with P2, the patient expressed unawareness of the state toll free home health telephone hotline number. P2 identified the nurse as the assigned caregiver for home visits. Review of P2’s home health folder revealed the state toll free home health telephone hotline number was listed on a sticker on the folder; however, the inspector verified the listed number was incorrect. On 05/02/2024 in the afternoon, the Director of Nursing confirmed the findings and acknowledged the label sticker attached to the front of the home health folder should have contained the correct state toll free home health telephone hotline number. Findings include: The agency’s policy titled Patient Bill of Rights and Responsibilities dated February 2024, documented the patients had the right to be advised of the telephone number and hours of operation of the state’s Home Health Agency hotline which received complaints or questions about local home care agencies. Patient 3 (P3) P3 was admitted on 01/02/2024, with diagnoses including dementia and chronic kidney disease. On 04/30/2024 at 2:30 PM, during a home visit with P3, the patient indicated not being aware of the state toll free home health telephone hotline number. P3 indicated calling the Registered Nurse (RN) for the patient’s questions or concerns. P3 showed the RN’s telephone number written at the label sticker attached to the home health folder maintained in the patient’s home. Review of P3’s home health folder revealed the state toll free home health telephone hotline number was not conspicuously listed or included in the folder. On 04/30/2024 at 3:12 PM, the RN confirmed the findings and acknowledged the label sticker attached to the front of the home health folder should have contained the state toll free home health telephone hotline number.”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure it followed up with a recommendation to report patient neglect and then inadvertently neglected a patient by failing to assess, refer, order and administer wound care treatment in a timely manner for 1 of 7 patients (Patient 6). The failed practice placed the patient at risk for continued potential abuse or neglect. Findings include: Patient 6 (P6) On 08/01/2023, the agency admitted Patient 6 with Stage ll pressure ulcer of the right buttocks. The agency continuously recertified P6 up through the current recertification period of 01/28/2024 to 03/27/2024. The following physical therapy progress notes documented P6 was not being kept clean and dry and was repeatedly found to be full of bladder/bowel residue from thighs to upper back with foul odor upon arrival for a physical therapy visit: 09/22/2023, 09/29/2023, 10/06/2023, 10/20/2023, 11/08/2023, 11/18/2023 and 11/25/2023. On 01/26/2024, the agency recertified P6 without skilled nursing due to the spouse’s refusal. Only physical therapy visits were ordered. The following physical therapy progress notes documented P6 was not being kept clean and dry and was repeatedly found to be full of bladder/bowel residue from thighs to upper back with foul odor upon arrival for a physical therapy visit: 02/13/2024, 02/16/2024, 02/23/2024, 02/26/2024, 03/04/2024, 03/08/2024, 03/12/2024, 03/19/2024 and 03/25/2024. On 02/16/2024 at 3:28 PM, the Clinical Manager had documented a communication note with the following: The Physical Therapist reported to the office a decline in patient condition with the spouse in denial of needing skilled nursing assistance. P6 was found in bed soaked with stool from the thighs to the upper back. P6 had rashes already. Spouse continued to refuse nursing as well as social services referral. Spouse was reported to have possible mental health issues as well. The agency office was recommending a referral to elder protective services but would contact the primary care physician for an opinion. The clinical record lacked documented evidence the agency followed through with a referral to elder protective services, received a reply from the primary care physician or followed up with the primary care physician. On 02/23/2024 at 10:20 AM, the Clinical Manager documented a physician order reordering skilled nursing visit frequencies for a nurse and home health aide. Within the order, the Clinical Manager noted a home visit wound doctor examined P6 and ordered wound care treatment. On 03/06/2024, the Clinical Manager documented a communication note revealing the following: The Home Health Aide (HHA) contacted the agency’s office to report P6 had multiple pressure ulcers on the sacrum, buttocks, heel and mid-back. On 03/08/2024, a registered nurse documented a skilled nursing visit (for the first time in three weeks since the Physical Therapist first reported rashes on 02/16/2024) during which the following was documented: Patient 6 suffered from multiple decubitus ulcers, was bedbound and was incontinent of bladder and bowel. High risk for skin breakdown. Caregiver had already performed wound care. Dressings dry and intact. Wound Nurse Practitioner to visit to assess and order treatment on 03/11/2024. On 03/11/2024, a Wound Nurse Practitioner (WNP) assessed the patient at home and documented the spouse as stating all the wounds started two weeks prior. The WNP ordered wound treatment. Between 02/23/2024 and 03/11/2024, the clinical record lacked documented evidence of any orders for wound care treatment. On 05/02/2024 in the late afternoon, the Clinical Manager in question (referencing the documented order dated 02/23/2024) indicated there was another wound provider who came to P6’s home, separate from the company who started on 03/11/2024, although there was no documented evidence of it. The Clinical Manager did not have an answer as to why orders were not followed up on for wound care or for why a decision was not made for a referral to elder protective services, aside from the spouse allowed skilled nursing to begin conducting visits again. Despite the Director of Nursing’s efforts over two days (05/02-03/2024), the agency was unable to reconcile if any other home visit provider conducted a wound referral visit and ordered wound treatment prior to 03/11/2024. On 05/02/2024 at 4:20 PM and in a written statement at 10:41 AM on 05/03/2024, P6’s primary care Physician indicated there was no wound care referral order for a home visit doctor or for any wound care treatment. The Physician further indicated the home health agency was responsible for covering wound care generally with third party wound referrals. The Primary Care Physician indicated in reference to the elder protective referral that the agency should make that referral if warranted. Providers from the Primary Care Physician’s office did not see the neglect the Physical Therapist described. On 05/02/2024 at 4:45 PM, the Registered Nurse, who documented the skilled nursing note dated 03/08/2024, indicated the spouse would not allow clinicians to examine wounds if wound care was done for the day prior to a visit. The Registered Nurse was not aware of what wound care orders were current at that time, if any. The Registered Nurse only conducted visits in March 2024 and did not see the neglect the Physical Therapist had described. On 05/02/2024 at 5:10 PM, the Home Health Aide verbalized only seeing one instance of P6 lying in incontinent residue upon conducting a home visit. The Clinical Manager documented a wound care doctor visit with wound care orders, but there were no specified wound care orders or wound care doctor visit documented as of 02/23/2024. Due to missed visits, a registered nurse did not conduct a skilled nursing visit until 03/08/2024. The Clinical Manager and the registered nurse failed to follow-up to clarify and document what wound care orders were current, if any. Nobody knew what wound care the spouse provided, until the WNP conducted a visit and ordered treatment on 03/11/2024. On 03/31/2024 in the afternoon, the spouse found P6 deceased in bed, later confirmed by emergency medical services advised by the agency. On 05/03/2024 at 2:50 PM, the Director of Nursing indicated elder protective services should have been called in real time, and agency staff needed reinforcement of mandatory reporter obligations. An in-service training documenting elder abuse was last presented 11/18/2021. There was no documented evidence the training included the state’s mandatory reporter law. Procedure #4 of the Identifying and Reporting Possible Victims of Alleged/Suspected Abuse, Neglect or Exploitation policy revealed criteria to identify elder neglect or abuse included inadequate supervision with resulting effect on provision of bathing and toileting. Procedure #7 of the Identifying and Reporting Possible Victims of Alleged/Suspected Abuse, Neglect or Exploitation policy revealed staff would immediately report an assessment of patient’s condition which might indicate neglect to the Director of Clinical Services, who would assign a supervisor to assess the patient for abuse, neglect and/or exploitation. Procedure #8 of the Identifying and Reporting Possible Victims of Alleged/Suspected Abuse, Neglect or Exploitation policy revealed the Director of Clinical Services would communicate assessment findings to the physician and the appropriate agency according to state regulations/laws. Procedure #10 of the Identifying and Reporting Possible Victims of Alleged/Suspected Abuse, Neglect or Exploitation policy revealed agency staff received ongoing education regarding state laws regarding the reporting of possible victims of abuse, neglect or exploitation. Procedure #2 of the Nursing Services policy revealed professional nursing service will be provided by a registered nurse and include initiating the plan of care and revising as necessary, coordination of services, referrals to other services as needed, informing the physician/practitioner and other staff of changes in the patient’s needs and evaluating the effectiveness and outcomes of care. Procedure #2 of the Coordination Of Patient Care policy revealed the Director of Clinical services made patient and personnel assignments and provided oversight of all patient care services. Oversight included: Coordinating patient care, coordinating referrals, ensuring that patient needs were continually assessed and ensuring the development, implementation and updates of the individualized plan of care.”

“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 observation, interview, record review and document review, the agency failed to ensure the comprehensive assessment included an accurate patient medication record for 2 of 7 sampled patients (Patient 3 and 6). The deficient practice had the potential for failing to provide an effective medication management for the patients. Patient 6 (P6) P6 was admitted on 08/01/2023, with a diagnosis of stage II pressure ulcer of the right buttocks. On 08/01/2023, the plan of care (and each plan of care for subsequent recertification periods) revealed a skin protectant ordered. The skin protectant was not identified on any of the plans of care. Skilled nursing visits identified unnamed skin protectant or Calmoseptine was applied to P6, including 10/20/2023, 12/08/2023, 12/15/2023, 12/29/2023 and 01/12/2024. Each of the five medication profiles for the respective recertification episodes lacked documented evidence of any skin protectant. On 05/03/2024 at 2:50 PM, the Director of Nursing confirmed the findings and explained the nurses were expected to reconcile the patient’s medications every skilled nursing visit. Findings include: The agency’s policy titled Medication Reconciliation dated February 2024, documented the agency would reconcile patient’s medications at the time of admission and on an ongoing basis. Medications ordered while the patient was receiving care would be compared to the medication list/profile. The medication list/profile would be updated with each new or changed medication. The patient’s medication list in the home would also be updated. Patient 3 (P3) P3 was admitted on 01/02/2024, with diagnoses including dementia and chronic kidney disease. The physician’s order dated 02/27/2024, included the following: - Flonase Allergy Relief 50 microgram (mcg)/actuation nasal spray, one spray each nostril once a day - Capsaicin 0.075% topical cream, apply a small amount to affected area twice per day as needed for pain - Lidocaine Hydrochloride (HCl) topical solution, apply sparingly to affected area twice per day as needed for pain - Diclofenac Sodium 1% topical gel, apply four grams to affected area twice per day as needed for pain. Do not apply more than eight grams daily to any one affected joint of the lower extremities. Do not exceed a total dose of 32 grams daily over all joints. The above-mentioned medications were included in the Patient Medication Profile for P3’s recertification period from 03/02/2024 to 04/30/2024. On 04/30/2024 at 2:30 PM, during a home visit with P3, a reconciliation of the patient’s home medications with the Patient Medication Profile was conducted with the Registered Nurse (RN). The four medications mentioned above could not be located in the patient’s home. On 04/30/2024 at 2:42 PM, P3 indicated not taking Flonase nasal spray and had been using Ipratropium Bromide nasal spray instead. P3 showed the nasal spray (Ipratropium Bromide 21 mcg) which the patient was taking three times a day as needed for runny nose. On 04/30/2024 at 3:15 PM, the RN confirmed the four medications mentioned above were included in P3’s Patient Medication Profile and could not be located in the patient’s home. The RN revealed the patient had stopped using the pain cream. The RN indicated Flonase Allergy Relief was ordered to be taken daily but was not available in the patient’s home. The RN explained P3’s Ipratropium Bromide 21 mcg was ordered on 03/12/2024. The RN acknowledged P3’s medication profile should have been reconciled. On 05/01/2024 at 9:30 AM, the Director of Nursing (DON) explained the nurses were expected to reconcile the patient’s medications every skilled nursing visit. The DON indicated P3 should have all the medications as ordered or the RN could have obtained a physician’s order to discontinue the medications the patient had stopped taking.”

“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 interview, record review and document review, the agency failed to ensure wound care treatment orders were followed for 2 of 7 sampled patients (Patient 4 and 6); and failed to provide documented evidence the catheter drainage bag was changed weekly as ordered for 1 of 7 sampled patients (Patient 5). The deficient practice had the potential for the patients’ wound progression and development of an infection. Patient 6 (P6) P6 was admitted on 08/01/2023, with a diagnosis of Stage II pressure ulcer of the right buttocks. On 08/01/2023, the plan of care revealed skilled nursing to perform wound care twice weekly and as needed. The plan of care showed skilled nursing visits ordered twice weekly for two weeks and then weekly for seven weeks. The clinical record contained documented evidence the wound was healed and wound care ended as of a weekly skilled nursing visit dated 09/22/2023. The clinical record lacked documented evidence twice weekly skilled nursing visits were conducted after 08/11/2023. The clinical record lacked documented evidence the wound care visit frequency was changed, discontinued or otherwise modified to be in sync with the overall skilled nurse visit frequency. On 05/03/2024 at 2:50 PM, the Director of Nursing confirmed the findings. Findings include: The agency’s policy titled Plan of Care – CMS #485 and Physician/Practitioner Orders dated February 2024, documented care and services would be provided according to physician/practitioner orders. Drug, services and treatments were administered by staff only as ordered by the physician/practitioner. Patient 4 (P4) P4 was admitted on 03/03/2024, with diagnoses including chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity and chronic kidney disease. The physician’s order dated 03/12/2024, documented discontinue previous wound care order. Start new wound care treatment: Skilled Nursing (SN) to perform and teach patient/patient caregiver re: Wound care to both lower legs every visit as follows: Cleanse wound with cleanser (use Dakin’s solution) and pat dry with dry gauze. Apply Bactroban to wound bed. Cover with absorbent pad dressing as needed for soiled and loose dressing and wrap with rolled gauze followed by self-adhesive bandage (Coflex) twice weekly and as needed. Secure dressing with tape as needed. The Skilled Nursing Visit Note dated 03/16/2024, 03/21/2024, and 03/23/2024, documented the following wound care provided to P4: - Wound care to left lower extremity every visit as follows: Cleanse wound with cleanser (use Dakin’s solution) and pat dry with dry gauze. Apply Mupirocin 2% Cream (Bactroban) to wound bed followed by oil emulsion gauze as needed. Cover with absorbent pad dressing as needed for soiled and loose dressing and wrap with rolled gauze followed by self-adhesive bandage (Coflex). The Skilled Nursing Visit Note for the above-mentioned three SN visit dates lacked documented evidence the wound care treatment was provided per the physician’s order dated 03/12/2024. On 05/01/2024 at 2:03 PM, the Director of Nursing (DON) confirmed the findings and explained the wound care treatment provided on 03/16/2024, 03/21/2024, and 03/23/2024 was from the previous physician’s order and was discontinued on 03/12/2024. The DON indicated the nurse should have provided wound care treatment to P3’s both lower legs instead of left lower extremity only. The DON revealed an oil emulsion gauze should not have been applied. The DON acknowledged the wound care treatment order was not followed. Patient 5 (P5) P5 was admitted on 12/18/2023, with diagnoses including pressure ulcers and paraplegia. The physician’s order dated 02/12/2024, documented the coude’ (a curved tip of slightly angled catheter) Foley catheter care including skilled nursing (SN) to change 2,000 milliliter (ml) urinary bedside drainage bag weekly and as needed for soiling. Patient’s spouse may perform urinary drainage bag changes on days SN was not visiting. P5’s medical record lacked documented evidence the urinary bedside drainage bag was changed weekly per the physician’s order during the following weeks: - Week of 02/25/2024 (SN visit done on 02/25/2024 and 03/01/2024.) - Week of 03/03/2024 (SN visit done on 03/05/2024 and 03/07/2024.) - Week of 03/24/2024 (SN visit done on 03/25/2024 and 03/30/2024.) - Week of 03/31/2024 (SN visit done on 04/01/2024 and 04/06/2024.) - Week of 04/07/2024 (SN visit done on 04/08/2024 and 04/13/2024.) On 05/02/2024 at 9:38 AM, the DON confirmed the findings and acknowledged the nurses were expected to provide the Foley catheter care as ordered. The DON explained the nurses should have changed P5’s urinary drainage bag weekly as ordered and documented the interventions provided in the narrative notes section of the SN Visit Note.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure a nurse captured clinical information and entered it into the clinical record with an accurate time of day for 1 of 7 patients (Patient #6). Findings include: Patient 6 (P6) On 08/01/2023, the agency admitted Patient 6 with pressure ulcer of the right buttocks. The agency continuously recertified P6 through 05/26/2024. On 03/06/2024, the Clinical Manager documented a communication note revealing the following: The Home Health Aide (HHA) contacted the agency’s office to report P6 had multiple pressure ulcers on the sacrum, buttocks, heel and mid-back. The HHA had sent pictures via e-mail. On 05/02/2024 at 5:10 PM, the HHA indicated the wound pictures were sent to the Clinical Manager with a personal phone. Upon examination of the communication note, the HHA contacted the Clinical Manager at 10:35 AM on 03/06/2024, but the HHA visit occurred at 1:30 PM on 03/06/2024. The previous HHA visit was documented on 03/01/2024. In order to determine the accuracy of when the wound pictures were taken, the HHA was contacted again. On 05/03/2024 at 10:15 AM, the HHA was unable to recall if the wound pictures were taken at the earlier visit or not. After the interview, the Clinical Manager showed the Inspector the original personal phone message received from the HHA with the wound pictures at 11:21 AM on 03/06/2024, confirming the finding of misidentifying the time of day for the communication note. Procedure #1 of the Medical Record Content policy revealed all entries in the patient record must also be timed.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure a patient’s wounds were identified, documented, received a provider referral and ordered care and treatment in a timely manner for 1 of 7 patients (Patient 6). The deficient practice placed the patient at risk for worsening wounds or infection. Findings include: Patient 6 (P6) On 08/01/2023, the agency admitted Patient 6 with pressure ulcer of the right buttocks. The agency continuously recertified P6 up through the current recertification period of 01/28/2024 to 03/27/2024. On 02/23/2024 at 10:20 AM, a Clinical Manager documented a physician order reordering skilled nursing visit frequencies for a nurse and home health aide. Within the order, the Clinical Manager noted a home visit wound doctor examined P6 and ordered wound care treatment. On 03/06/2024, the Clinical Manager documented a communication note revealing the following: The Home Health Aide (HHA) contacted the agency’s office to report P6 had multiple pressure ulcers on the sacrum, buttocks, heel and mid-back. On 03/08/2024, a registered nurse documented a skilled nursing visit during which the following was documented: Patient 6 suffered from multiple decubitus ulcers, was bedbound and was incontinent of bladder and bowel. High risk for skin breakdown. Caregiver had already performed wound care. Dressings dry and intact. Wound Nurse Practitioner to visit to assess and order treatment on 03/11/2024. On 03/11/2024, a Wound Nurse Practitioner (WNP) assessed the patient at home and documented the spouse as stating all the wounds started two weeks prior. The WNP ordered wound treatment. Between 02/23/2024 and 03/11/2024, the clinical record lacked documented evidence of any orders for wound care treatment. On 05/02/2024 in the late afternoon, the Clinical Manager in question (referencing the documented order dated 02/23/2024) indicated there was another wound provider who came to P6’s home, separate from the company who started on 03/11/2024. Despite the Director of Nursing’s efforts over two days (05/02-03/2024), the agency was unable to reconcile if any other home visit provider conducted a wound referral visit and ordered wound treatment prior to 3/11/2024. On 05/02/2024 at 4:20 PM and in a written statement at 10:41 AM on 05/03/2024, P6’s primary care Physician indicated there was no wound care referral order for a home visit doctor or for any wound care treatment from her office. The Physician further indicated the home health agency was responsible for covering wound care generally with third party wound referrals. On 05/02/2024 at 4:45 PM, the Registered Nurse, who documented the skilled nursing note dated 03/08/2024, indicated the spouse would not allow clinicians to examine wounds if wound care was done for the day prior to a visit. The Registered Nurse was not aware of what wound care orders were current at that time, if any. The Clinical Manager documented a wound care doctor visit with wound care orders, but there were no specified wound care orders documented as of 02/23/2024. Due to missed visits, a registered nurse did not conduct a skilled nursing visit until 03/08/2024. The Clinical Manager and the registered nurse failed to follow-up to clarify and document what wound care orders were current, if any. Nobody knew what wound care the spouse provided, until the WNP conducted a visit and ordered treatment on 03/11/2024. Procedure #2 of the Nursing Services policy revealed professional nursing service will be provided by a registered nurse and include initiating the plan of care and revising as necessary, coordination of services, referrals to other services as needed, informing the physician/practitioner and other staff of changes in the patient’s needs and evaluating the effectiveness and outcomes of care. Procedure #2 of the Coordination Of Patient Care policy revealed the Director of Clinical services made patient and personnel assignments and provided oversight of all patient care services. Oversight included: Coordinating patient care, coordinating referrals, ensuring that patient needs were continually assessed and ensuring the development, implementation and updates of the individualized plan of care.”