Cattaraugus County Department of Health Chha

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on clinical record review and interview with agency staff for one (1) of two (2) patients (Patient #2), receiving Home Health Aide services, the agency failed to develop an aide care plan of sufficient scope to meet the patient’s needs. Specifically, the aide care plan lacked instruction to the aide regarding bleeding precautions for patients at risk for bleeding. Failure to develop aide plans of care that are of sufficient scope to meet the patient’s needs has the potential to place patients at risk for inadequate or inappropriate care. Patient #2 - This 71-year-old patient with diagnoses that include osteoarthritis of right knee, status post knee replacement, and attention to surgical dressings and sutures was admitted to the agency on 10/08/2024. Review of the Home Health Certification and Plan of Care for certification period 10/08/2024 to 12/06/2024 revealed the following orders: - Anti-coagulant precautions; - Current use of aspirin; and - Aspirin 81 milligrams, twice daily by mouth. Review of the Home Health Aide Care Plan lacked documented evidence of safety measures for patients at risk for bleeding. During interview on 10/18/2024 at 02:11 PM, the Community Health Nurse stated the aide plan of care does not include this instruction, but it can be added.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on clinical record review and interview with agency staff for one (1) of two (2) patients (Patient #1), receiving Home Health Aide services, the agency failed to ensure the Home Health Aide follows the aide plan of care for completion of assigned tasks. Failure to ensure the Home Health Aide follows the aide plan of care and provides services in accordance with the respective plan of care has potential for unmet patient needs and negative patient outcomes. Patient #1 - This 65-year-old patient with diagnoses that include lumbar stenosis with neurogenic claudication, lumbosacral spondylosis, and metastatic cancer was admitted to the agency on 09/03/2024. Review of the Home Health Aide Care Plan dated 09/08/2024 revealed the Home Health Aide was assigned the following tasks: - Report all changes in patient condition or refusals of care to the agency; - Personal hygiene/grooming (no frequency specified); - Sponge bath/assist – sponge bath/patient does not have a downstairs shower and unable to get upstairs (no frequency specified); - Skin care (no frequency specified); - Comb/brush hair (no frequency specified); - Shampoo hair at sink (no frequency specified); - Oral care (no frequency specified) - Dressing/undressing/assist (no frequency specified); - Elimination, toilet (no frequency specified); - Incontinent care, adult diapers (no frequency specified); - Mobility/transfer (no frequency specified); - Walker/supervise/assist (no frequency specified); - Transfer/self/supervise/assist (no frequency specified); - Exercise program per Physical Therapy (no frequency specified) - Prepare snack – or meal if there at mealtime and time allows encourage frequent meals/healthy snacks and frequent fluids (no frequency specified); - Encourage patient to carry phone until gets life alert (no frequency specified); and - Medication – self administration, patient sets up med tray, remind patient to take. Review of the aide time and activity sheet revealed the following instructions and documentation codes: - “The Home health Aide is to perform only those activities listed on the care plan for this patient. Report all REFUSALS of care to the agency…”; - (check mark) = performed; - (R) = Refused; - (-) = Not applicable that day; and - All tasks on the care plan must be addressed on Home Health Aide worksheet each visit. Review of the aide time and activity sheet dated 09/09/2024 revealed the aide documented a line with an arrow through the entire Monday column. It is unclear what the aide did on this day. During interview on 10/18/2024 at 01:49 PM, the Community Health Nurse stated the aide did not complete any tasks on this day because when the aide arrived at the patient’s home the patient refused the visit. The Community Health Nurse stated that the aide should have used the codes listed on the sheet to document the patient’s refusal. Review of the aide time and activity sheets dated 09/13/2024, 9/17/2024, 09/20/2024, 09/27/2024, 10/10/2024, and 10/11/2024 revealed the aide documented the patient refused hair care, dressing/undressing, transferring, and/or showering. Review of the patient care record from 09/13/2024 to 10/14/2024 lacked documented evidence the aide reported all changes in patient condition or refusals of care to the agency as instructed on the aide plan of care. During interview on 10/18/2024 at 01:51 PM, the Community Health Nurse stated showers are not an assigned task and should never have been offered/refused. The Community Health Nurse stated that it has not been the agency’s practice to assign frequencies to individual tasks and that it is implied that it should be done/offered at each visit. Lastly the Community Health Nurse stated that historically, notification of refusals is only expected when the patient refuses all care, not individual tasks.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on review of clinical records and interviews with agency staff for five (5) of seventeen 17) patients (Patient #s: 1, 2, 8, 12, and 16), the agency failed to provide services in accordance with physician orders and the Plan of Care (POC). The issues are: - The Physical Therapist failed to follow the plan of care and obtain vital signs. - The Skilled Nurse failed to follow the plan of care and obtain a weight. - The Skilled Nurse failed to follow the plan of care and obtain a blood glucose. - The agency failed to provide Home Health Aide services in accordance with the physician orders/ plan of care. - The Skilled Nurse failed to follow the plan of care and obtain a pulse oximetry level. Failure to ensure patient care is provided in accordance with physician orders and the plan of care has the potential for patients to receive poor care and for health care needs to go unmet. Patient #1 – This 54-year-old patient with diagnoses that include hemiparesis affecting right side as late effect of a cerebrovascular accident, decreased functional mobility, and hypertensive heart disease with congestive heart failure was admitted to the agency on 11/14/2023. Review of the Supplemental Orders from 11/16/2023 to 11/19/2023 revealed the Physical Therapist was to assess vital signs (blood pressure, heart rate, respiratory rate) at each session. Review of the Physical Therapy with Treatment Routine visit dated 11/16/2023 lacked documented evidence the Physical Therapist obtained vital signs as specified in the plan of care. During interview on 12/11/2023 at 09:30 AM, the Physical Therapist stated, “Possibly I missed one.” Patient #2 – This 75-year-old patient with diagnoses that include chronic obstructive pulmonary disease, non-Hodgkin’s lymphoma, and type 2 diabetes with peripheral neuropathy was admitted to the agency on 11/01/2023. Review of the Physician’s Orders/Plan of Care from 11/01/2023 to 12/30/2023 revealed the Skilled Nurse was to obtain a weight with each visit. Review of the Skilled Nurse Routine visit dated 11/14/2023 lacked documented evidence the Skilled Nurse obtained a weight as specified in the plan of care. During interview on 12/06/2023 at 09:45 AM, the Supervising Community Health Nurse stated she spoke with the Skilled Nurse who completed the visit on this day and she stated that the Skilled Nurse stated that she checked the patient’s log and documented the weight was stable, but she did not document an actual number. Patient #8 - This 67-year-old patient with diagnoses that include encounter for prosthetic gait training, history of below-knee amputation of right lower extremity, type 2 diabetes mellitus with peripheral angiopathy was admitted to the agency on 11/22/2023. Review of the Physician’s Orders/Plan of Care from 11/22/2023 to 01/20/2024 revealed the Skilled Nurse was to instruct the patient/caregiver how to perform home glucose monitoring until the patient/caregiver is competent or it is determined the patient/caregiver is unable to learn, the patient is to test daily, and notify the medical doctor or nurse practitioner if the blood glucose is less than 40 or greater than 400 milligrams per deciliter. Review of the Skilled Nurse Routine visit on 11/28/2023 lacked documented evidence the Skilled Nurse obtained a blood glucose as specified in the plan of care. During interview on 12/13/2023 at 09:15 AM, the Community Health Nurse stated he did not document the blood glucose on this day, but he knows the patient is compliant and is testing. Patient #16 - This 69-year-old patient with diagnoses that include chronic obstructive pulmonary disease, hypertensive heart disease with congestive heart failure, and chronic venous insufficiency was admitted to the agency on 02/17/2023. Review of the Supplemental Orders from 05/21/2023 to 05/21/2023 revealed that the home health aide is to provide services one (1) time a week for the four (4) weeks. Review of the clinical record from 05/21/2023 to 07/27/2023 (date of discharge) lacked documented evidence of one home health aide visit the week of 05/28/2023 to 06/23/2023. The agency failed to provide home health aide services in accordance with the physician orders/ plan of care. During interview on 12/13/2023 at 10:17 AM, the Community Health Nurse stated there is no documentation of the missed aide visit. Patient #12- This 65- year-old patient with diagnoses that include delayed surgical wound healing, status post amputation of lesser toe of left foot, and type 2 diabetes mellitus with peripheral artery disease was admitted to the agency on 11/11/2023. Review of the Physician’s Orders/Plan of Care from 11/11/2023 to 01/09/2024 revealed the Skilled Nurse is to obtain a pulse oximetry at each visit for chronic obstructive pulmonary disease and congestive heart failure. Review of Skilled Nurse Routine Visit dated 11/23/2023 lacked documented evidence a pulse oximetry was obtained. During an interview on 12/13/2023 at 10:51 AM, the Community Health Nurse stated that the pulse oximetry was not obtained during the visit.”

“Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This Standard is not met as evidenced by: Based on review of clinical records and staff interview for one (1) of seventeen (17) patients (Patient # 16), the agency failed to ensure the Plan of Care was updated and revised to reflect the patient’s current status. Specifically, the plan of care lacked orders to discontinue wound care to healed wounds. Failure to ensure the plan of care is updated and revised has the potential to result in negative patient outcomes. Patient #16 - This 69-year-old patient with diagnoses that include chronic obstructive pulmonary disease, hypertensive heart disease with congestive heart failure, and chronic venous insufficiency was admitted to the agency on 02/17/2023. Review of the Physician’s Orders/Plan of Care from 06/17/2023 to 08/15/2023 revealed the following orders: - Wound Care #1 left lower leg anterior: cleanse with soap and water, apply silver alginate to wound bed, apply Unna boot, secure with Coban weekly by Skilled Nurse/wound clinic. - Wound Care #3 left lower posterior leg proximal: cleanse with soap and water, apply silver alginate to wound bed, apply Unna boot, secure with Coban weekly by Skilled Nurse/wound clinic. Review of the Skilled Nurse – Nursing (Outcome and Assessment Information Set) Routine Visit dated 06/21/2023 revealed the Registered Nurse documented the following: - Wound #1 left leg anterior: healed, and - Wound #3 left lower posterior leg proximal: healed. Review of the patient care record from 06/21/2023 to 07/27/2023 (date of discharge) lacked documented evidence of an order to discontinue wound care to healed wounds #1 and #3. During interview on 12/13/2023 at 10:05 AM stated that the Registered Nurse ended them, no order was generated to discontinue them, and she is not sure what happened. The Community Health Nurse stated that at this time they were having electronic medical record system issues. The Community Health Nurse stated that if they were not having computer problems a discontinuation order should have been sent.”

“Supervision of home health aides CFR(s): 484.80(h) Standard: Supervision of home health aides. This Standard is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for two (2) of seven (7) patients receiving Home Health Aide services (Patient #’s 2 and 17), the agency failed to ensure the Skilled Nurse or Therapist orients the Home Health Aide to the aide care plan prior to rendering patient services. Failure to ensure the Home Health Aide is oriented to the aide care plan, places patients at risk for unmet needs. Patient #2 – This 75-year-old patient with diagnoses that include chronic obstructive pulmonary disease, non-Hodgkin’s lymphoma, and type 2 diabetes with peripheral neuropathy was admitted to the agency on 11/01/2023. Review of the Supplemental Orders from 11/26/2023 to 11/26/2023 revealed an order for an aide to visit one (1) time a week for five (5) weeks. Review of the Home Health Aide/Personal Care Aide Activity Sheet dated 11/29/2023 revealed this was the first Home Health Aide service visit provided to the patient. Review of the clinical record lacked documented evidence of the Home Health Aide was oriented to the plan of care either by telephone or in person for the 11/29/2023 initial Home Health Aide visit. During interview on 12/13/2023 at 03:05 PM, the Community Health Nurse stated she was not able to find documentation of an initial aide placement. Patient #17 - This 94-year-old patient with diagnoses that include recurrent urinary tract infection, type 2 diabetes with chronic kidney disease, and hypertension with renal disease was admitted to the agency on 04/04/2023. Review of the Supplemental Orders from 04/11/2023 to 04/18/2023 revealed an order for an aide (no frequency specified). Review of the Home Health Aide/Personal Care Aide Activity Sheet dated 04/19/2023 revealed this was the first Home Health Aide service visit provided to the patient. Review of the clinical record lacked documented evidence of the Home Health Aide was oriented to the plan of care either by telephone or in person for the 04/19/2023 initial Home Health Aide visit. During interview on 12/13/2023 at 02:45 PM, the Community Health Nurse stated the order generated on 04/11/2023 did not contain a frequency for which the aide was to visit, but the frequency was confirmed with the doctor and a new order was generated on 05/11/2023 with a frequency of two (2) times per week for four (4) weeks. The Community Health Nurse stated that the patient refused aide services at the start of care, but she changed her mind around 04/11/2023 and that is when the initial order was sent. The Community Health Nurse stated that she could not find documentation of an introductory aide placement.”

“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 review of clinical records and interviews with staff, for eight (8) of seventeen (17) patients (Patient #’s : 1, 2, 5, 9, 11, 15, 16, and 17) the agency failed to ensure all documentation is legible, clear, complete, consistent, and appropriately authenticated, dated, and timed, in accordance with accepted standards of practice. Failure to ensure documentation is legible, clear, complete, and appropriately authenticated has the potential for patients to receive care from unlicensed staff. Patient #11 - This 64-year-old patient with diagnoses that include acute metabolic encephalopathy, acute cystitis, and anxiety was admitted to the agency on 11/17/2023. Review of the Charts/Clinical Note dated 11/14/2023 revealed the note was electronically signed by Employee O (a Community Health Nurse) but the signature lacked credentials. The agency failed to ensure documentation is appropriately authenticated in accordance with accepted standards of practice. During interview on 12/11/2023 at 01:00 PM, Employee O stated she is the Clinical Intake Registered Nurse, and her note is missing her credentials. Patient #1 – This 54-year-old patient with diagnoses that include hemiparesis affecting right side as late effect of a cerebrovascular accident, decreased functional mobility, and hypertensive heart disease with congestive heart failure was admitted to the agency on 11/14/2023. Review of the Physician’s Orders/Plan of Care from 11/14/2023 to 01/12/2024 revealed an order for an aide one (1) time a week for six (6) weeks. Review of the Home Health Aide/Personal Care Aide Activity Sheet dated 11/30/2023 lacked documented evidence of the caregiver’s discipline. The agency failed to ensure documentation is appropriately authenticated in accordance with accepted standards of practice. Patient #2 – This 75-year-old patient with diagnoses that include chronic obstructive pulmonary disease, non-Hodgkin’s lymphoma, and type 2 diabetes with peripheral neuropathy was admitted to the agency on 11/01/2023. Review of the Supplemental Orders from 11/26/2023 to 11/26/2023 revealed an order for an aide one (1) time a week for five (5) weeks. Review of the Home Health Aide/Personal Care Aide Activity Sheet dated 11/29/2023 lacked documented evidence of the caregiver’s discipline. The agency failed to ensure documentation is appropriately authenticated in accordance with accepted standards of practice. Patient #9 - This 92-year-old patient with diagnoses that include urinary tract infection, hallucinations, and generalized anxiety disorder was admitted to the agency on 11/13/2023. Review of the Physician’s Orders/Plan of Care from 11/13/2023 to 01/11/2024 revealed an order an aide one (1) time a week for two (2) weeks. Review of the Home Health Aide/ Personal Care Aide Activity Sheet dated 11/30/2023 lacked documented evidence of the caregiver’s discipline. The agency failed to ensure documentation is appropriately authenticated in accordance with accepted standards of practice. Patient #16 - This 69-year-old patient with diagnoses that include chronic obstructive pulmonary disease, hypertensive heart disease with congestive heart failure, and chronic venous insufficiency was admitted to the agency on 02/17/2023. Review of the Physician’s Orders/Plan of Care from 04/18/2023 to 06/16/2023 revealed an order for an aide one (1) time a week for five (5) weeks. Review of the Home Health Aide/ Personal Care Aide Activity Sheets dated 04/20/2023, 04/27/2023, 05/04/2023, and 05/18/2023 lacked documented evidence of the caregiver’s discipline. The agency failed to ensure documentation is appropriately authenticated in accordance with accepted standards of practice. Patient #17 - This 94-year-old patient with diagnoses that include recurrent urinary tract infection, type 2 diabetes with chronic kidney disease, and hypertension with renal disease was admitted to the agency on 04/04/2023. Review of the Supplemental Orders from 04/11/2023 to 04/18/2023 revealed an order for an aide (no frequency specified). Review of the Supplemental Orders from 05/08/2023 to 05/14/2023 revealed an order for an aide two (2) times a week for four (4) weeks. Review of the Home Health Aide/Personal Care Aide Activity Sheets dated 04/19/2023, 05/13/2023, 05/17/2023, 05/20/2023, 05/23/2023, 05/27/2023, 05/31/2023, 06/03/2023, and 06/06/2023 lacked documented evidence of the caregiver’s discipline. The agency failed to ensure documentation is appropriately authenticated in accordance with accepted standards of practice. During interview on 01/02/2023 at 10:28 AM, the Director of Patient Services stated the aide’s credentials are probably missing on all of the time sheets. Patient #5 – This 87-year-old patient with diagnoses that include fracture of shaft of right humerus, status post open reduction internal fixation, and attention to surgical dressings or sutures was admitted to the agency on 11/21/2023. Review of the HHA/PCA Activity Sheet dated 11/28/2023 to 12/02/2023 revealed the aide’s credentials are not documented. The agency failed to ensure documentation by staff is authenticated in accordance with accepted standards of practice. During an interview on 01/02/2024 at 10:24 AM, the Director of Patient Services stated credentials should be included with the signature. Patient #15 This 97- year-old patient with diagnoses osteoarthritis involving multiple joints on both sides of the body, immobility, and pressure injury of coccygeal region, stage 2 was admitted on 01/14/2023. A. Review of the HHA/PCA Activity Sheet dated 11/28/2023 to 12/02/2023 revealed the aide’s credentials are not documented. The agency failed to ensure documentation by staff is authenticated in accordance with accepted standards of practice. During an interview on 01/02/2024 at 10:24 AM, the Director of Patient Services stated credentials should be included with the signature. B. Review of the HHA/PCA Activity Sheet revealed the timeframe for the aide task documentation is documented as 02/ /2023 to 02/11/2023. The date is incomplete. The agency failed to ensure all forms are complete. During an interview on 12/13/2023 at 10:22 AM, the Director of Patient Services stated dates should be completed.”

“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 review of clinical records and staff interview for six (6) of seventeen (17) patients (Patient #s: 1, 2, 4, 6, 9 and 17), the agency failed to ensure the Registered Nurse conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient’s return home, or on the physician-ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. Patient #1 – This 54-year-old patient with diagnoses that include hemiparesis affecting right side as late effect of a cerebrovascular accident, decreased functional mobility, and hypertensive heart disease with congestive heart failure was admitted to the agency on 11/14/2023. Review of the Rehabilitation Discharge Summary (referral) revealed that the patient was referred to the agency on 11/08/2023. Review of the Skilled Nursing Outcome and Assessment Information Set Start of Care revealed the initial assessment was completed on 11/14/2023, six (6) days after the patient was referred to the agency for services. Review of the clinical record lacked documented evidence of a physician’s order to delay the start of care until 11/14/2023. During interview on 12/13/2023 at 03:35 PM, the Supervising Community Health Nurse stated “we missed the twenty-four (24) hour mark,” and she “remembers the patient delayed the start for some reason, but it is not documented.” Patient #2 – This 75-year-old patient with diagnoses that include chronic obstructive pulmonary disease, non-Hodgkin’s lymphoma, and type 2 diabetes with peripheral neuropathy was admitted to the agency on 11/01/2023. Review of the Home Care Intake (referral) revealed that the patient was referred to the agency on 10/28/2023. Review of the Skilled Nursing Outcome and Assessment Information Set Start of Care revealed the initial assessment was completed on 11/01/2023, four (4) days after the patient was referred to the agency for services. Review of the clinical record lacked documented evidence of a physician’s order to delay the start of care until 11/01/2023. During interview on 12/13/2023 at 11:05 AM, the Supervising Community Health Nurse stated “we missed the twenty-four (24) hour window, conversations were had regarding the cause of the delay, and these conversations were not documented.” Patient #4 – This 56 -year-old patient with diagnoses that include glioma of the brain, status post craniotomy, and developmental delay was admitted to the agency on 11/28/2023. Review of the Discharge Summary (referral) revealed that the patient was referred to the agency on 11/24/2023. Review of the Skilled Nursing Outcome and Assessment Information Set Start of Care revealed the initial assessment was completed on 11/28/2023, four (4) days after the patient was referred to the agency for services. Review of the clinical record lacked documented evidence of a physician’s order to delay the start of care until 11/28/2023. During interview on 12/13/2023 at 01:30 PM, the Supervising Community Health Nurse stated “We pride ourselves in getting in within the twenty-four (34) hour window.” The Supervising Community Health Nurse stated delays are being talked about, but clinicians are not documenting the cause of the delay, or the conversations had. Patient #6 – This 88-year-old patient with diagnoses that include osteoarthritis, hypertensive heart disease with congestive heart failure was admitted to the agency on 11/14/2023. Review of the Primary Care Center Referral revealed that the patient was referred to the agency on 11/10/2023. Review of the Skilled Nursing Outcome and Assessment Information Set Start of Care revealed the initial assessment was completed on 11/14/2023, four (4) days after the patient was referred to the agency for services. Review of the clinical record lacked documented evidence of a physician’s order to delay the start of care until 11/14/2023. During interview on 12/13/2023 at 01:30 PM, the Supervising Community Health Nurse stated “We pride ourselves in getting in within the twenty-four (24) hour window.” The Supervising Community Health Nurse stated delays are being talked about, but clinicians are not documenting the cause of the delay, or the conversations had. Patient #9 - This 92-year-old patient with diagnoses that include urinary tract infection, hallucinations, and generalized anxiety disorder was admitted to the agency on 11/13/2023. Review of the Emergency Room Referral revealed that the patient was referred to the agency on 11/08/2023. Review of the Skilled Nursing Outcome and Assessment Information Set Start of Care revealed the initial assessment was completed on 11/13/2023, five (5) days after the patient was referred to the agency for services. Review of the clinical record lacked documented evidence of a physician’s order to delay the start of care until 11/13/2023. During interview on 12/13/2023 at 03:30 PM, the Community Health Nurse stated “We did not get in to open the patient within twenty-four (24) hours of the referral.” Patient #17 - This 94-year-old patient with diagnoses that include recurrent urinary tract infection, type 2 diabetes with chronic kidney disease, and hypertension with renal disease was admitted to the agency on 04/04/2023. Review of the General Clinic Note (referral) revealed that the patient was referred to the agency on 03/29/2023. Review of the Skilled Nursing Outcome and Assessment Information Set Start of Care revealed the initial assessment was completed on 04/04/2023, six (6) days after the patient was referred to the agency for services. Review of the clinical record lacked documented evidence of a physician’s order to delay the start of care until 04/04/2023. During interview on 12/13/2023 at 01:30 PM, the Supervising Community Health Nurse stated “We pride ourselves in getting in within the twenty-four (24) hour window.” The Supervising Community Health Nurse stated delays are being talked about, but clinicians are not documenting the cause of the delay, or the conversations had.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on clinical record review and staff interview for three (3) of seventeen (17) patients (Patient #s: 2, 6, and 8) the agency failed to ensure that a comprehensive assessment consistent with the patient’s needs was performed within five (5) calendar days after the start of care. The issues are: - Physical Therapy failed to complete a comprehensive assessment within five (5) days of the start of care. - Occupational Therapy failed to complete a comprehensive assessment within five (5) days of the start of care. Failure to ensure a comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. Patient #2 – This 75-year-old patient with diagnoses that include chronic obstructive pulmonary disease, non-Hodgkin’s lymphoma, and type 2 diabetes with peripheral neuropathy was admitted to the agency on 11/01/2023. Review of the agency’s undated Home Care Intake Form revealed the patient was admitted to rehabilitation on 09/26/2023 and discharged from rehabilitation to home on 10/28/2023 with a referral for the following services: Skilled Nursing, Physical Therapy, Occupational Therapy and Home Health Aide. Review of the Physician’s Orders/Plan of Care from 11/01/2023 to 12/30/2023 revealed the order for an Occupational Therapy evaluation. Review of the Occupational Therapy Initial Visit dated 11/10/2023 revealed the Occupational Therapy evaluation was completed nine (9) days after the start of care. The Occupational Therapist failed to complete a comprehensive assessment of the patient within five (5) calendar days after the start of care. Patient #6 – This 88-year-old patient with diagnoses that include osteoarthritis, hypertensive heart disease with congestive heart failure was admitted to the agency on 11/14/2023. Review of the Primary Care Center Referral dated 11/10/2023 revealed a referral for a Physical Therapy Evaluation. Review of the Physician’s Orders/Plan of Care from 11/14/2023 to 01/12/2024 revealed the order for a Physical Therapy evaluation. Review of the Physical Therapy Initial Visit dated 11/20/2023 revealed the Physical Therapy evaluation was completed six (6) days after the start of care. The Physical Therapist failed to complete a comprehensive assessment of the patient within five (5) calendar days after the start of care. Patient #8 - This 67-year-old patient with diagnoses that include encounter for prosthetic gait training, history of below-knee amputation of right lower extremity, type 2 diabetes mellitus with peripheral angiopathy was admitted to the agency on 11/22/2023. Review of the Primary Care Center Order Form dated 11/20/2023 revealed a referral for a Physical Therapy Evaluation. Review of the Physician’s Orders/Pan of Care from 11/22/2023 to 01/20/2024 revealed the order for a Physical Therapy evaluation. Review of the Physical Therapy Initial Visit dated 11/28/2023 revealed the Physical Therapy evaluation was completed six (6) days after the start of care. The Physical Therapist failed to complete a comprehensive assessment of the patient within five (5) calendar days after the start of care. During interview on 12/11/2023 at 12:05 PM, the Supervising Community Health Nurse stated Physical Therapy and Occupational Therapy have ten (10) days from the start of care to get in and develop the plan of care, and this time frame was met. The Supervising Community Heath Nurse stated this is the agency’s policy and the agency has been following this policy all along.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on review of clinical records and staff interviews for two (2) of seventeen (17) patients (Patient #s 7 and 16) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients. The issues are: The plan of care lacked a maximum daily dose of Acetaminophen. The plan of care lacked a frequency for weights. Failure to develop a complete and accurate plan of care that is comprehensive and addresses patient needs has the potential to result in patient harm. Patient #16 - This 69-year-old patient with diagnoses that include chronic obstructive pulmonary disease, hypertensive heart disease with congestive heart failure, and chronic venous insufficiency was admitted to the agency on 02/17/2023. Review of the Physician’s Orders/Plans of Care from 02/17/2023 to 04/17//2023, 04/18/2023 to 06/16/2023, and 06/17/2023 to 08/15/2023 revealed an order to instruct in weight monitoring and recordkeeping. The plan of care lacked a frequency for when to obtain weights. During interview on 12/11/2023 at 09:45 AM, the Community Health Nurse stated there is no frequency specified on the initial plan of care or subsequent plans of care and there should be. Patient #7 - This 60-year-old patient with diagnoses that include non-healing wound of amputation stump, infection of left below knee amputation, and atherosclerosis of native artery of both lower extremities was admitted to the agency on 10/27/2023. Review of the Office Visit Note dated 10/20/2023 revealed the patient was discharged home on the following medication: Acetaminophen 325 milligrams, two (2) tablets by mouth, every six (6) hours as needed for general discomfort or fever, maximum daily does 3.5 grams per twenty-four (24) hours. Review of the Physician’s Orders/Plan of Care from 10/27/2023 to 12/25/2023 revealed an order for Acetaminophen 325 milligrams, two (2) tablets by mouth, every six (6) hours as needed for general discomfort or fever. The order lacks a maximum daily dose and is inconsistent with what is ordered on the Office Visit Note dated 10/20/2023. The plan of care lacked a maximum daily dose of Acetaminophen. During interview on 12/13/2023 at 03:30 PM, the Supervising Community Health Nurse stated that it is not the agency’s practice to include maximum daily doses of Tylenol on every plan of care. The Supervising Community Health Nurse stated that in this case because the maximum daily dose was specified on the office visit note, it should have been included on the 485 and it was not.”

“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 review of clinical records and interviews with agency staff, for four (4) of seventeen (17) patients (Patient #s: 1, 2, 16, and 17), the agency failed to ensure drugs and treatments are administered in accordance with physician orders. The issues are: - The Registered Nurse failed to obtain an order for the administration of a B12 injection. - The Physical Therapist failed to obtain an order for a flutter valve. - The Registered Nurse failed to obtain an order for durable medical equipment. - The agency failed to obtain an order for Tylenol. - The agency failed to obtain an order for Benadryl. Failure to administer drugs and treatments without a physician’s order has the potential to result in poor quality of care. Home Visit Patient #2 – This 75-year-old patient with diagnoses that include chronic obstructive pulmonary disease, non-Hodgkin’s lymphoma, and type 2 diabetes with peripheral neuropathy was admitted to the agency on 11/01/2023. During an observational home visit conducted on 11/30/2023 at 11:20 AM, the surveyor observed the Physical Therapist instruct the patient on the use of a flutter valve. Review of the patient care record from 11/30/2023 to 12/13/2023 (date of interview) lacked an order for a flutter valve to include the frequency of use. The Physical Therapist failed to obtain an order for a flutter valve. During interview on 12/13/2023 at 03:05 PM, the Supervising Community Health Nurse stated there is no order for a flutter valve and if the patient has one there should be an order. Patient #1 – This 54-year-old patient with diagnoses that include hemiparesis affecting right side as late effect of a cerebrovascular accident, decreased functional mobility, and hypertensive heart disease with congestive heart failure was admitted to the agency on 11/14/2023. Review of the Physician’s Orders/Plan of Care from 11/14/2023 to 01/12/2024 revealed an order for Cyanocobalamin Injection (B12) 1000 micrograms per milliliter injection; patient to administer intramuscularly on the 19th of every month. Review of the Charts/Clinical Note dated 11/28/2023 (six days after the B12 injection was due to be administered) revealed the RN documented “Skilled Nurse administered monthly B12 injection per patient request to right upper extremity.” Review of the patient record from 11/28/2023 to 12/11/2023 (date of interview) lacked an order for the Registered Nurse to administer the B12 injection, to include permission for the late administration and the new date for the future monthly injections. The Registered Nurse failed to obtain an order for the administration of a B12 injection. During interview on 12/11/2023 at 10:00 AM, the Community Health Nurse stated she forgot to add into her note that she called the doctor to get permission to administer the injection because the patient had missed her injection the week before due to her stroke and weakness. Patient #16 - This 69-year-old patient with diagnoses that include chronic obstructive pulmonary disease, hypertensive heart disease with congestive heart failure, and chronic venous insufficiency was admitted to the agency on 02/17/2023. Review of the Charts/Clinical Note dated 05/23/2023 revealed the Skilled Nurse documented the “patient is sitting in inflatable cushion on chair.” Review of the patient care record from 05/23/2023 to 07/27/2023 (date of discharge) lacked an order for durable medical equipment to include an inflatable cushion. The Registered Nurse failed to obtain an order for durable medical equipment. During interview on 12/11/2023 at 11:53 AM, the Community Health Nurse stated she does not know when it was obtained but the patient was sitting on it at the time of her visit. The Community Health Nurse stated that an order should have been generated for the inflatable cushion and added under general clinical. Patient #17 - This 94-year-old patient with diagnoses that include recurrent urinary tract infection, type 2 diabetes with chronic kidney disease, and hypertension with renal disease was admitted to the agency on 04/04/2023 and discharged on 06/07/2023. Review of the Charts/Clinical Notes dated 05/08/2023 and 05/09/2023 the Physical Therapist documented the patient has taken 1000 milligrams of Tylenol PM and 50 milligrams of Benadryl for pain. Review of the Charts/Clinical Note dated 05/09/2023 revealed the Registered Nurse documented the patient’s granddaughter gave her Tylenol PM for sleep. Review of the Charts/Clinical Notes dated 05/12/2023, 05/15/2023, 05/19/2023, 05/22/2023, 05/26/2023 revealed the Physical Therapist documented the patient has taken 1000 milligrams of Tylenol. Review of the Charts/Clinical Note dated 11/30/2023 (approximately 5 months after the patient was discharged from the agency) revealed the Physical Therapist documented the following: Late entry – provider updated patient took Tylenol PM 1000 milligrams and 50 milligrams due to pain, verbal orders obtained, and nursing updated. Review of the patient care record from 05/08/2023 to 06/07/2023 (date of discharge) lacked an order for Tylenol and Benadryl. The Physical Therapist failed to obtain an order for Tylenol and Benadryl. During interview on 12/13/2023 at 02:51 PM, the Community Health Nurse stated there are no orders for Tylenol or Benadryl. The Community Health Nurse stated that this issue was identified when they were pulling the records together for the survey, and this is why the Physical Therapist wrote a late entry note and contacted the physician.”

“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 review of clinical records and interviews with agency staff, for three (3) of seventeen (17) patients (Patient #’s 1, 16, and 17) the agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest that the Plan of Care may need to be altered. The issues are: - The Registered Nurse failed to notify the physician of a change in the patient’s bowel function. - The Registered Nurse failed to notify the physician of a change in the patient’s genitals. - The Occupational Therapist failed to notify the physician of the patient’s complaints of abdominal pain, nausea, headache, and need for a urinalysis. - The Registered Nurse failed to notify the physician of the patient’s non-compliance with oxygen use. - The Registered Nurse failed to notify the physician of the patient’s hypertension. - The Registered Nurse failed to notify the physician of the patient’s desaturation with activity and rest. - Failure to promptly notify the physician to changes in the patient’s condition or needs that may suggest that outcomes are not being achieved and/or the Plan of Care should be altered has the potential to result in unmet patient needs and negative patient outcomes. Home Visit Patient #1 – This 54-year-old patient with diagnoses that include hemiparesis affecting right side as late effect of a cerebrovascular accident, decreased functional mobility, and hypertensive heart disease with congestive heart failure was admitted to the agency on 11/14/2023. Review of the Hospital Discharge instructions dated 11/08/2023 revealed the following: - Medical problems: C. difficile diarrhea, and - Instructions to stop the following medications: Ceftriaxone 1 gram intravenous daily and Vancomycin HCl 125 milligram capsule by mouth, four (4) times daily. Review of the Physician’s Orders/Plan of Care from 11/14/2023 to 01/12/2024 revealed the following diagnosis: History of Clostridioides difficile colitis with a start date of 11/14/2023. Review of the Skilled Nurse – Nursing (Outcome and Assessment Information Set) – Start of Care – further visits planned dated 11/14/2023 revealed the Skilled Nurse documented the following: - The patient very rarely or never has bowel incontinence; - Last bowel movement 11/14/2023; and - Abdomen soft, non-tender active bowel sounds in all four quadrants, regular bowel pattern, normal stool, and abdomen not distended. Review of the Physical Therapy with Treatment (Outcome and Assessment Information Set) Routine Visit dated 11/16/2023 revealed the Physical Therapist documented there is no change in bowel function from the patient’s norm. Review of the Skilled Nurse (Outcome and Assessment Information Set) Routine Visits dated 11/16/2023 revealed the Skilled Nurse documented the following: - Last bowel movement 11/15/2023, and - Abdomen soft, non-tender active bowel sounds in all four quadrants, regular bowel pattern, normal stool, and abdomen not distended. Review of the Skilled Nurse (Outcome and Assessment Information Set) Routine Visits dated 11/20/2023 the Skilled Nurse documented the following: - Last bowel movement 11/19/2023, and - Abdomen soft, non-tender active bowel sounds in all four quadrants, regular bowel pattern, normal stool, and abdomen not distended. Review of the Charts/Clinical Notes dated 12/01/2023 revealed the Physical Therapist documented he received a text message from the patient requesting to forego physical therapy on that day due to gastrointestinal disturbance. Additionally, the Physical Therapist documented he would follow up with the patient on Monday, he contacted the nurse regarding the missed visit and gastrointestinal disturbance, and he made a phone call to the patient’s physician regarding the missed visit. Review of the patient care record from 12/01/2023 to 12/11/2023 (date of interview) lacked documented evidence the Registered Nurse notified the physician of the change in the patient’s bowel function. The agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest that the POC may need to be altered. During interview on 12/11/2023 at 09:50 AM, the Community Health Nurse stated that the patient has occasional incontinence and diarrhea. The Community Health Nurse stated the diarrhea did not come to light until the 12/01/2023 contact with the Physical Therapist. Additionally, the Community Health Nurse stated that when she visited the patient on 12/06/2023 the patient was back to her normal function, and she attributed the diarrhea to her weight loss medications which she recently stopped taking. Lastly, the Community Health Nurse stated that because the patient has a history of occasional incontinence and diarrhea, and because she had resumed her normal bowel function on 12/06/2023, she did not feel she need to contact the physician regarding the diarrhea reported to the Physical Therapist on 12/01/2023. Patient #17 - This 94-year-old patient with diagnoses that include recurrent urinary tract infection, type 2 diabetes with chronic kidney disease, and hypertension with renal disease was admitted to the agency on 04/04/2023. A. Review of the Skilled Nurse (Outcome and Assessment Information Set) Routine Visit dated 04/11/2023 revealed the Skilled Nurse documented the patient’s caregiver reports the patient has a red and excoriated labia – possible yeast infection. Review of the patient care record from 04/11/2023 to 06/07/2023 (date of discharge) lacked documented evidence the Registered Nurse notified the patient’s physician of the change in the patient’s genitals. The agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest that the POC may need to be altered. During interview on 12/13/2023 at 12:15 PM, the Community Health Nurse stated he documented in his chart clinical note that he notified the nurse at the patient’s primary care office, and she was in a agreement, but he did not document specifically what he notified the nurse about. The Community Health Nurse stated that there is nothing specific to the labia discussed in his clinical note. B. Review of the Charts/Clinical Note dated 04/19/2023 revealed the Occupational Therapist documented the following: “Reports have stomachache and nausea, and headache with doctor notified by family and urine specimen to be obtained…” Review of the patient care record from 04/19/2023 to 06/07/2023 (date of discharge) lacked documented evidence the Occupation Therapist notified the patient’s physician of the abdominal pain, nausea, headache, and need for a urinalysis. The agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest that the POC may need to be altered. During interview on 12/11/2023 at 12:45 PM, the Occupational Therapist stated if it is not written down, she did not communicate with the physician. The Occupational Therapist stated she assumed that because the patient’s daughter was Registered Nurse the daughter was going to get the urine sample and bring it in. Patient #16 - This 69-year-old patient with diagnoses that include chronic obstructive pulmonary disease, hypertensive heart disease with congestive heart failure, and chronic venous insufficiency was admitted to the agency on 02/17/2023. A. Review of the Charts/Clinical Note dated 03/27/2023 revealed the Physical Therapist documented he contacted the Community Health Nurse to inform him of the patient’s hypertension (no value documented) and continued oxygen desaturation with activity (no value documented). Review of the patient care record from 03/27/2023 to 07/27/2023 (date of discharge) lacked documented evidence the Registered Nurse notified the physician of the patient’s hypertension or desaturations. The agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest that the POC may need to be altered. During interview on 12/13/2023 at 10:50 AM, the Community Health Nurse stated he does not remember what the values were that were reported to him or if there was physician follow up, but the Community Health Nurse stated the patient was fine the following day. B. Review of the Physician’s Orders/Plan of Care from 02/17/2023 to 04/17/2023 revealed an order for oxygen 2-4 liters per minute via nasal cannula, continuously. Review of the Skilled Nurse – Nursing (Outcome and Assessment Information Set) Routine visit dated 02/24/2023 revealed the Skilled Nurse documented the following: - The patient’s oxygen saturation is 91% without oxygen at rest. - Respiratory: continuous oxygen use, via nasal cannula, 2 – 4 liters per minute. Review of the Charts/Clinical Notes dated 02/24/2023 revealed the Registered Nurse documented that the patient reports compliance with inhaler, oxygen, and continuous positive airway pressure use. The documentation is inconsistent regarding the patient’s oxygen usage. Review of the Physician’s Orders/Plan of Care from 04/18/2023 to 06/16/2023 revealed an order for oxygen 2-4 liters per minute via nasal cannula, continuously. Review of the Skilled Nurse – Nursing (Outcome and Assessment Information Set) Routine visit dated 04/25/2023 revealed the Skilled Nurse documented the following: - The patient’s oxygen saturation is 93% without oxygen at rest. - Respiratory: continuous oxygen use, via nasal cannula, 2 – 4 liters per minute. Review of the Charts/Clinical Notes dated 04/25/2023 revealed the Registered Nurse documented that the patient reports compliance with inhaler, oxygen, and continuous positive airway pressure use. The documentation is inconsistent regarding the patient’s oxygen usage. Review of the patient care record lacked documented evidence the Registered Nurse notified the physician of the patient’s non-compliance with oxygen use. During interview on 12/12/2023 at 09:15 AM, the Community Health Nurse stated at the time of these visits the patient was not wearing her oxygen. The Community Health Nurse explained that the patient would take it off and needed to be reminded to put it back on. Lastly, the Community Health Nurse stated he did not notify the doctor of the patient’s non-compliance following either visit. The agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest that the POC may need to be altered.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on review of clinical records and interviews with agency staff, two (2) of seventeen (17) clinical records (Patient #’s 16 and 17) lacked documented evidence of ongoing interdisciplinary assessments and coordination between skilled professionals to ensure the development and implementation of a plan of care that meets the patient’s rehabilitation needs and goals. The issues are: The Occupational Therapist failed to communicate to the Registered Nurse the patient’s need for a urinalysis and complaints of abdominal pain, nausea, and headache. The Physical Therapist failed to communicate to the Registered Nurse that the patient had developed lower extremity weeping. Failure to ensure there are ongoing interdisciplinary assessments and communication has the potential for negative patient outcomes. Patient #16 - This 69-year-old patient with diagnoses that include chronic obstructive pulmonary disease, hypertensive heart disease with congestive heart failure, and chronic venous insufficiency was admitted to the agency on 02/17/2023. Review of the Skilled Nurse – Nursing (Outcome and Assessment Information Set) - Start of Care – further visits planned dated 02/17/2023 revealed the Registered Nurse documented the patient has bilateral lower extremity pitting edema (no weeping documented). Review of the Physical Therapy (Outcome and Assessment Information Set) Initial Visit dated 02/21/2023 revealed the Physical Therapist documented the patient has bilateral lower extremity edema with weeping. Review of the clinical record from 02/21/2023 to 07/27/2023 (date of discharge) lacked documented evidence of ongoing interdisciplinary assessments and communication between the skilled professionals regarding the patient’s lower extremity weeping. During interview on 12/11/2023 at 03:10 PM, the Physical Therapist stated he calls all nurses on the day he sees the patient and talks with them about what he sees. The Physical Therapist stated that if he documented the contact, it would be in a c or n note, or possibly in his comments. Lastly, the Physical Therapist stated that possibly, on this day, he did not put the details in his note. Patient #17 - This 94-year-old patient with diagnoses that include recurrent urinary tract infection, type 2 diabetes with chronic kidney disease, and hypertension with renal disease was admitted to the agency on 04/04/2023. Review of the Charts/Clinical Note dated 04/19/2023 revealed the Occupational Therapist documented the following: “Reports have stomachache and nausea, and headache with doctor notified by family and urine specimen to be obtained…” Review of the clinical record from 04/19/2023 to 06/07/2023 (date of discharge) lacked documented evidence of ongoing interdisciplinary assessments and communication between the skilled professionals regarding the patient’s abdominal pain, nausea, headache, and need for a urinalysis. During interview on 12/11/2023 at 12:50 PM, the Occupational Therapist stated if she communicated with the nurse, she would have put in a communication note. The Occupational Therapist stated that if there is not a communication note in the patient record, she may not have communicated the patient’s complaints or need for urinalysis to the nurse.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for seven (7) of seventeen (17) patients (Patient #’s: 2, 9, 10, 11, 15, 16, and 17), the agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes. The issues are: - Documentation is inconsistent regarding the patient’s use of a back brace. - Documentation is inconsistent regarding a delay in the Home Health Aide start date. - Documentation is inconsistent regarding the patient’s urinary tract infection. - Documentation is inconsistent regarding the patient’s use of life alert. - Documentation is inconsistent regarding the patient’s use of oral medications at discharge. - Documentation of pulse oximetry parameters is inconsistent with standards. - Documentation of the patient’s height is inconsistent. - Documentation of a wound assessment is inconsistent with the clinician’s responsibilities. Failure to prepare or document complete clinical and accurate progress notes has the potential for unmet patient needs. Patient #11 - This -year-old patient with diagnoses that include acute metabolic encephalopathy, acute cystitis, and anxiety was admitted to the agency on 11/17/2023. Review of the Physician’s Orders/Plan of Care from 11/17/2023 to 01/15/2023 revealed an order for the patient to apply a back brace when up and moving around. Review of the Supplemental Orders from 11/21/2023 to 11/26/2023 (the Physical Therapy Plan of Care) lacked documented evidence of an order for the utilization of a back brace while up and moving around. Review of the Skilled Nurse Start of Care visit dated 11/17/2023 and Skilled Nurse Routine visits dated 11/21/2023 and 11/30/2023 lacked documented evidence the patient was wearing the back brace while up and moving around. Review of the Physical Therapy Initial Visit dated 11/21/2023 lacked documented evidence the patient was wearing the back brace while up and moving around. During interview on 12/11/2023 at 10:15 AM, the Physical Therapist stated he has never seen a back brace in the home, and if the patient had a back brace, he would have added it to the patient’s care plan after speaking with the patient’s physician. During interview on 12/11/2023 at 01:17 PM, the Community Health Nurse stated the patient had it on at the time of her visit and the patient was compliant with its use. The documentation is inconsistent. It is unclear of the patient has a back brace and if the patient is wearing the back brace while up and moving around. Patient #2 – This 75-year-old patient with diagnoses that include chronic obstructive pulmonary disease, non-Hodgkin’s lymphoma, and type 2 diabetes with peripheral neuropathy was admitted to the agency on 11/01/2023. Review of the Home Care Intake received 10/26/2023 revealed an order for Home Health Aide services. Review of the Physician’s Orders/Plan of Care from 11/01/2023 to 12/30/2023 lacked documented evidence of an order for a Home Health Aide. Review of the Supplemental Orders from 11/22/2023 to 12/16/2023 revealed an order for an aide to assist with personal hygiene/grooming, dressing, elimination, mobility/transfers, nutrition/hydration, special observations, and precautions (notify Skilled Nurse of shortness of breath, skin breakdown), and home management. The order lacked documented evidence of a frequency in which the aide was to visit. Review of the Supplemental Orders from 11/26/2023 to 11/26/2023 revealed an order for an aide to visit one (1) time a week for five (5) weeks. Review of the patient care record from 11/01/2023 to 11/30/2023 revealed the aide’s initial visit occurred on 11/29/2023 (twenty-eight (28) days after the patient’s start of care). During interview on 12/13/2023 at 11:05 AM, the Supervising Community Health Nurse stated the aide was referred at the start of care but did not start until 11/29/2023 due to the patient’s request for services to start after the holiday. The Supervising Community Health Nurse stated that this conversation regarding the patient’s request is not documented in the patient record. The documentation is inconsistent. It is unclear why the aide services were not initiated at start of care as ordered on the home care referral. Patient #9 - This 92-year-old patient with diagnoses that include urinary tract infection, hallucinations, and generalized anxiety disorder was admitted to the agency on 11/13/2023. Review of the Face-to-Face Encounter dated 11/08/2023 revealed the patient was discharged home with a prescription for Nitrofurantoin Macrocrystal 100 milligram capsule, take one capsule by mouth two (2) times per day, dispense 20 capsules (no indication specified). Review of the Physician’s Orders/Plan of Care from 11/13/2023 to 01/11/2023 revealed the following: - Primary diagnosis: Urinary Tract Infection - Assess temperature each visit (patients with wound, intravenous catheters, catheters, invasive procedures, infectious process) - Assess for signs and symptoms of urinary tract infection each visit…Instruct patient/caregiver in signs and symptoms of urinary tract infection until verbalizes understanding. - Acute care hospitalization risks…Urinary tract infection - Emergency care risks…Urinary tract infection - Nitrofurantoin Macrocrystal by mouth capsule 100 milligrams, twice daily for ten days. Review of the Charts/Clinical Note dated 11/13/2023 revealed the Registered Nurse documented the following: “diagnosed with urinary tract infection…patient was given Nitrofron rx at ER (for UTI)…” Review of the Skilled Nurse - Nursing Start of Care – further visits planned – dated 11/13/2023 revealed the Skilled Nurse documented the following genitourinary system review: - Patient has been treated for urinary tract infections within the past fourteen (14) days, and - Patient is currently being treated for frequent infections. Review of the Skilled Nurse – Nursing Routine Visits dated 11/16/2023 and 11/21/2023 revealed the Skilled Nurse documented the patient does not have frequent genitourinary infections. Review of the Skilled Nurse – Nursing – Discharge from Agency dated 11/30/2023 revealed the Skilled Nurse documented the patient has not been treated for a urinary tract infection within the past fourteen (14) days. The Skilled Nurse failed to ensure the clinical note accurately reflects the patient’s current status regarding the presence of a urinary tract infection. During interview on 12/11/2023 at 11:00 AM, the Community Health Nurse stated the clinicians have other options besides yes or no. The Community Health Nurse stated that the nurse could have selected the option “currently being treated.” Additionally, the Community Health Nurse stated that the clinician may have calculated her response based on the date the patient was discharged from the hospital (11/08/2023), and not from the date that the patient finished the antibiotics (11/18/2023). The Community Health Nurse stated that if the nurse had calculated her response based on the date the patient finished the antibiotics (11/18/2023), then the answer to the question at discharge should have been yes. Lastly, the Community Health Nurse stated it is difficult to speak to why the nurse selected what she selected, and the nurse is not available to interview. Patient #16 - This 69-year-old patient with diagnoses that include chronic obstructive pulmonary disease, hypertensive heart disease with congestive heart failure, and chronic venous insufficiency was admitted to the agency on 02/17/2023. Review of the Charts/Clinical Note date 02/17/2023 revealed the Registered Nurse documented the patient denies burning, does report some frequency and an increase in incontinence reports a urine sample was dropped off yesterday, and the nurse called the doctor for results, and they are still pending. Review of the Skilled Nurse – Nursing (Outcome and Assessment Information Set) Routine Visit dated 02/22/2023 revealed the Registered Nurse documented the following: “Frequent Infections: Currently being treated.” Review of the Charts/Clinical Note dated 02/22/2023 revealed the Registered Nurse documented the patient reports new antibiotic due to a urinary tract infection and to see the medication screen for new details of new prescription in the home. Review of the Skilled Nurse – Nursing (Outcome and Assessment Information Set) Routine Visit dated 02/24/2023 revealed the Registered Nurse documented the following: “Frequent Infections: No.” Review of the Skilled Nurse – Nursing (Outcome and Assessment Information Set) Routine Visit dated 02/28/2023 revealed the Registered Nurse documented the following: “Frequent Infections: Currently being treated.” Review of the Skilled Nurse – Nursing (Outcome and Assessment Information Set) Routine Visits dated 03/03/2023 and 03/10/2023 revealed the Registered Nurse documented the following: “Frequent Infections: No.” Review of the Skilled Nurse – Nursing (Outcome and Assessment Information Set) Routine Visit dated 03/14/2023 revealed the Registered Nurse documented the following: “Frequent Infections: Currently being treated.” Review of the Supplemental Orders from 03/17/2023 to 03/17/2023 revealed an order for Nitrofurantoin Macrocrystal capsule 100 milligrams by mouth twice daily for seven (7) days. The documentation is unclear as to whether the patient has frequent urinary tract infections and/or if the patient is currently being treated for a urinary tract infection. During interview on 12/13/2023 at 09:30 AM, the Community Health Nurse stated the antibiotic was initiated on 02/20/2023 with an end date of 02/27/2023. The Community Health Nurse stated the patient was being treated for a urinary tract infection on 02/22/2023, 02/24/2023, and 02/28/2023. The Community Health Nurse stated that he may have selected the incorrect box at the 02/24/2023 visit. Additionally, the Community Health Nurse stated that on 03/14/2023 he is not sure if he missed clicked, but he knows he called the doctor about Nystatin; however, he was not sure if the urinary tract infection started on 03/14/2023 or when the order was placed by another Community Health Nurse following his visit on 03/17/2023. Lastly, the Community Health Nurse stated that the patient was not being treated for a urinary tract infection at the time of his visit on 03/10/2023. Patient #17 - This 94-year-old patient with diagnoses that include recurrent urinary tract infection, type 2 diabetes with chronic kidney disease, and hypertension with renal disease was admitted to the agency on 04/04/2023. A. Review of the Skilled Nurse (Outcome and Assessment Information Set) Start of Care – further visits planned visit dated 04/04/2023 revealed the Registered Nurse documented the patient declines referral/use of Lifeline/Emergency device. Review of the Physical Therapy with Treatment (Outcome and Assessment Information Set) Initial Visit dated 04/06/2023 revealed the Physical Therapist documented the patient has a Lifeline/Emergency Device to call for help. The documentation is unclear as to whether the patient does or does not use Lifeline/Emergency Device. During interview on 12/13/2023 at 10:30 AM, the Physical Therapist stated the patient has Life Alert. B. Review of the General Clinic Note (Physician) dated 03/29/2023 revealed the following: - The patient was hospitalized for a urinary tract infection in January; - Urinalysis large leukocytes and blood. Will start antibiotics…; - Recurrent urinary tract infection; and - Orders: Cefuroxime 250 milligrams tablet, by mouth, twice daily for seven (7) days. Review of the Physician’s Orders/Plan of Care from 04/04/2023 to 06/02/2023 revealed the following: - Diagnosis: Recurrent urinary tract infection - Assess temperature each visit (patients with wounds, intravenous catheters, catheters, invasive procedure, infectious process) - Assess for urinary tract infection each visit and instruct patient/caregiver in signs and symptoms of urinary tract infections. - Ciprofloxacin Hydrochloride 500 milligram tablet, by mouth, twice daily for seven (7) days. Review of the Skilled Nurse – Nursing (Outcome and Assessment Information Set) – Start of Care – further visits planned dated 04/04/2023 revealed the Registered Nurse documented the patient is currently being treated for frequent genitourinary infections. Review of the Charts/Clinical Note dated 04/04/2023 revealed the Registered Nurse documented the following: - Referred to the agency for home health services by primary care physician related to urinary tract infection: - No signs and symptoms of urinary tract infection present at this time; patient is currently on an antibiotic for a urinary tract infection. - The Cefuroxime that is on the referral has been discontinued, the patient has a new script bottle in the home for Cipro 500 milligrams every twelve hours for seven (7) days. Review of the Skilled Nurse (Outcome and Assessment Information Set) Routine Visit dated 04/18/2023 revealed the Registered Nurse documented the patient does not have frequent urinary tract infections. The documentation is unclear as to whether the patient has frequent urinary tract infections and/or if the patient is currently being treated for a urinary tract infection. During interview on 12/13/2023 at 12:35 PM, the Registered Nurse stated he possibly mis-clicked the box and the patient was done being treated for the urinary tract infection on the 18th. C. Review of the Physician’s Orders/Plan of Care from 06/03/2023 to 08/01/2023 revealed the patient as taking the following oral medications: - Lovastatin; - Furosemide; - Klonopin; and - Paxil Review of the Outcome and Assessment Information Set Only – Discharge from agency dated 06/07/2023 revealed the Registered Nurse documented “not applicable - no oral medications prescribed.” The documentation is inconsistent. It is unclear if the patient was taking oral medication at time of discharge. During interview on 12/13/2023 at 02:35 PM, the Community Health Nurse stated the nurse completing the discharge should have selected item #3, not not applicable. Patient #10- This 66- year-old patient with diagnoses that include chronic obstructive pulmonary disease exacerbation, acute exacerbation of chronic obstructive airways disease with asthma, and left lower lobe pneumonia was admitted to the agency on 11/21/2023. A.) Review of Skilled Nursing Start of Care note dated 11/21/2023 revealed the patient utilizes continuous supplemental oxygen at a rate of 3 liters per minute, delivered via nasal cannula. Review of the Physician’s Orders/Plan of care from 11/21/2023 to 01/19/2024 revealed an order for the Skilled Nurse to notify the physician is the patient’s pulse oximetry is less than “09%.” The ordered parameter for pulse oximetry notification is inconsistent with acceptable clinical practices. During an interview on 12/12/2023 at 02:11 PM, the Community Health Nurse stated that the ordered parameter for the pulse oximetry was entered incorrectly. The parameter should be less than 90 %. B.) Review of the Skilled Nursing Start of Care dated 11/21/2023 revealed the nurse documented the patient’s height under General Systems Review/Clinical Monitoring…Measurements as 58.0 inches. In the General Systems Review/Nutrition portion of the assessment, the Skilled Nurse documented the patient’s height as 67 inches. The documentation is inconsistent. During an interview on 12/12/2023 at 02:05 PM, the Community Health Nurse stated that the documentation of the patient’s height was documented incorrectly. Patient #15 This 97- year-old patient with diagnoses osteoarthritis involving multiple joints on both sides of the body, immobility, and pressure injury of coccygeal region, stage 2 who was admitted to the agency on 03/17/2023. Review of Speech Language Pathologist Routine Visit dated 03/04/2023 General systems review/skin/incision/wound revealed: - Site location: specify location: #1 right heel (09/16/2022), present on start of care. - Type: pressure ulcer - Pressure ulcer stage: unstageable - Healing: not healing - Wound measurement: not measured - Incision/wound tissue observed: pink, other: scab/thick skin - Surrounding tissue: erythema - Wound margins: tunneling absent, undermining absent - Drain site and type: none - Drainage: none - Dressing changed this visit: no - Site location: specify location: #2 left heel (09/16/2022) - Type: Pressure ulcer - Pressure ulcer stage: unstageable - Healing: not healing - Wound measurement: not measured - Incision/wound tissue observed: pink, other: scab/thick skin - Surrounding tissue: erythema - Wound margins: tunneling absent, undermining absent - Drain site and type: none - Drainage: none - Dressing changed this visit: No - Site location: specify location: #3 coccyx (09/16/2022) Re-opened 02/15/2023. - Type: pressure ulcer - Pressure ulcer stage: stage 2 - Healing: healing by secondary intent - Wound measurement: not measured - Incision/wound tissue observed: pink - Surrounding tissue: intact - Wound margins: tunneling absent, undermining absent - Drain site and type: none - Drainage: none - Dressing changed this visit: No - Site location: specify location: #4 right lateral lower extremity (01/25/2023) - Type: skin tear - Healing: not healing - Wound measurement: not measured - Incision/wound tissue observed: pink, beefy, red - Surrounding tissue: intact - Wound margins: tunneling absent, undermining absent - Drain site and type: none - Drainage: serosanguinous - Drainage amount: small - Dressing changed this visit: No It is unclear whether the Speech Language Pathologist actually assessed the patient’s wounds. During an interview on 12/13/2023 at 10:19 AM, the Community Health Nurse stated that when the Speech Language Pathologist opened the assessment to document on the patient, portions of the wound assessment pulled into the visit template. The pathologist should have selected the option of “N/A” at the time, which would have allowed the pathologist to bypass the need to document a wound assessment. In this situation the pathologist did not select N/A and was required to input a wound assessment.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on review of clinical records, agency policies and procedures, and interview with agency staff, for six (6) of seven (7) patients receiving Home Health Aide Services (Patient #’s: 1, 2, 5, 9, 16, and 17), the agency failed to ensure the Home Health Aide provides services as directed on the aide plan of care. Failure to follow the Plan of Care has the potential to result in inadequate care. Review of the agency’s policy entitled “Home Health Aide Services” last reviewed 08/2021 revealed the following: “Documentation 1. Home Health Aide /Personal Care Aide activity sheet-document all tasks that have been completed while in the home, while following the Plan of Care…” Patient #1 – This 54-year-old patient with diagnoses that include hemiparesis affecting right side as late effect of a cerebrovascular accident, decreased functional mobility, and hypertensive heart disease with congestive heart failure was admitted to the agency on 11/14/2023. Review of the Physician’s Orders/Plan of Care from 11/14/2023 to 01/12/2024 revealed an order for an aide one (1) time a week for six (6) weeks. Review of the Home Health Aide Care Plan with a start date of 11/14/2023 and an end date of 01/14/2023 revealed the plan of care directs the aide to perform the following tasks: - Length of visit – one (1) hour - Frequency – Once weekly - Report all changes in patient condition or refusal of care to the agency. - Personal hygiene/Grooming - Shower/assist every visit. - Comb/brush hair as needed. - Shampoo hair every visit - Dressing/undressing/assist as needed. - Incontinent care/bladder as needed. - Adult diapers - Mobility/transfer – walker/assist. - Weight (record) – each visit and record - Standard and fall precautions. - Home management as time allows. A. Review of the Home Health Aide/ Personal Care Aide Activity Sheet for week of 11/26/2023 to 12/02/2023 revealed the aide completed the following task that was not on the aide care plan: skin care. The agency failed to ensure the aide follows the plan of care. B. Review of the Home Health Aide/Personal Care Aide Activity Sheet for week of 11/26/2023 to 12/02/2023 lacked documented evidence that the aide obtained a weight as assigned on the plan of care. The agency failed to ensure the aide follows the plan of care. Patient #2 – This 75-year-old patient with diagnoses that include chronic obstructive pulmonary disease, non-Hodgkin’s lymphoma, and type 2 diabetes with peripheral neuropathy was admitted to the agency on 11/01/2023. Review of the Supplemental Orders from 11/22/2023 to 12/16/2023 revealed an order for an aide to assist with personal hygiene/grooming, dressing, elimination, mobility/transfers, nutrition/hydration, special observations, and precautions (notify Skilled Nurse of shortness of breath, skin breakdown), and home management. The order lacked documented evidence of a frequency in which the aide was to visit. Review of the Supplemental Orders from 11/26/2023 to 11/26/2023 revealed an order for an aide to visit one (1) time a week for five (5) weeks. Review of the Home Health Aide Care Plan with a start date of 11/27/2023 and no end date of “ongoing” revealed the plan of care directs the aide to perform the following tasks: - Length of visit – one (1) hour - Frequency – Once weekly - Report all changes in patient condition or refusal of care to the agency. - Assist with shower. - Skin care per patient preference - Comb/brush hair - Shampoo hair when requested. - Shave upon request - Oral care each visit - Dressing/undressing/assist - Elimination – toilet, adult diapers - Mobility/transfer – walker/supervise. - Nutrition/hydration – home delivered meals. - Weight (record) – patient weighs self daily and records. - Notify Skilled Nurse of shortness of breath, skin breakdown. - Medication – self-administer, remind patient to take, pill packs from pharmacy on kitchen counter. - Oxygen precautions – 2 liters per minute via nasal cannula continuous - Standard and fall precautions. - Home management after personal care if time allows. A. Review of the Home Health Aide/ Personal Care Aide Activity Sheet for week of 11/26/2023 to 12/02/2023 revealed the aide completed the following task that was not on the aide care plan: sponge/bed bath. The agency failed to ensure the aide follows the plan of care. B. Review of the Home Health Aide/Personal Care Aide Activity Sheet for week of 11/26/2023 to 12/02/2023 lacked documented evidence that the aide offered medication reminders as assigned on the plan of care. The agency failed to ensure the aide follows the plan of care. Patient #9 - This 92-year-old patient with diagnoses that include urinary tract infection, hallucinations, and generalized anxiety disorder was admitted to the agency on 11/13/2023. Review of the Physician’s Orders/Plan of Care from 11/13/2023 to 01/11/2024 revealed an order for an aide one (1) time a week for two (2) weeks to start 11/26/2023. Review of the Home Health Aide Care Plan with a start date of 11/26/2023 and an end date of 12/09/2023 revealed the plan of care directs the aide to perform the following tasks: - Length of visit – one (1) hour - Frequency – Once weekly - Report all changes in patient condition or refusal of care to the agency. - Personal hygiene/grooming - Sponge bath/assist - Shower/assist. - Shower bench - Skin care assist in application of barrier cream to coccyx area - Comb/brush hair - Shampoo hair - Oral care - Dressing/undressing/assist - Elimination – toilet, adult diapers - Incontinent care/bladder - Mobility/transfer – walker/supervise, cane supervise. - Transfer/self/supervise. - Transfer/assist - Exercise program per physical therapy - Nutrition/hydration – home delivered meals. - Prepare supper. - Encourage fluids. - Miscellaneous tasks – make sure patient is wearing life alert. - Special Observations and Precautions – call for increased pain/uncontrolled anxiety, call for signs and symptoms of skin breakdown, has blanchable redness on buttocks. - Medication – self-administer, remind patient to take. - Standard and fall precautions. - Home management as time allows. - Special instructions – patient has history of hallucinations at night, reassure that they are not real. A. Review of the Home Health Aide/ Personal Care Aide Activity Sheet for week of 11/28/2023 to 12/02/2023 revealed the aide completed the following task that was not on the aide care plan: change catheter bag. The agency failed to ensure the aide follows the plan of care. B. Review of the Home Health Aide/ Personal Care Aide Activity Sheet for week of 11/28/2023 to 12/02/2023 revealed the aide offered and the patient refused to have the aide prepare breakfast and lunch, but the aide prepared a snack. The preparation of breakfast, lunch and snack was not on the aide care plan. The agency failed to ensure the aide follows the plan of care. C. Review of the Home Health Aide/Personal Care Aide Activity Sheet for week of 11/28/2023 to 12/02/2023 lacked documented evidence that the aide ensured the patient was wearing life alert as assigned on the plan of care. The agency failed to ensure the aide follows the plan of care. Patient #16 - This 69-year-old patient with diagnoses that include chronic obstructive pulmonary disease, hypertensive heart disease with congestive heart failure, and chronic venous insufficiency was admitted to the agency on 02/17/2023. Review of the Physician’s Orders/Plan of Care from 04/18/2023 to 06/16/2023 revealed an order for an aide one (1) time a week for five (5) weeks. Review of the Home Health Aide Care Plan with a start date of 04/14/2023 and an end date of 08/15/2023 revealed the plan of care directs the aide to perform the following tasks: - Length of visit – one (1) hour - Frequency – Once weekly - Report all changes in patient condition or refusal of care to the agency. - Personal hygiene/grooming - Sponge bath/assist or shower each visit. - Shower/assist or sponge bath each visit - Shower bench - Skin care: report any redness or open areas to case manager. - Comb/brush hair: set up assist with each visit. - Shampoo hair with each shower - Oral care encourage each visit. - Dressing/undressing/assist - Elimination: toilet, offer each visit - Peri care with each toileting - Adult diapers: wears pads - Mobility/transfer – walker/assist - Transfer/assist - Turn and position: encourage every two (2) hours. - Medication – family prepares, patient is independent. - Oxygen precautions: oxygen 2 – 4 liters at all times via nasal cannula - Standard and fall precautions. - Home management as time allows. A. Review of the Home Health Aide/ Personal Care Aide Activity Sheets for weeks of 04/18/2023 to 04/22/2023, 04/25/2023 to 04/29/2023, 05/04/2023 to 05/06/2023, and 05/20/2023 revealed the aide completed the following task that was not on the aide care plan: range of motion/home exercise plan. The agency failed to ensure the aide follows the plan of care. B. Review of the Home Health Aide/ Personal Care Aide Activity Sheets for weeks of 04/18/2023 to 04/22/2023, 04/25/2023 to 04/29/2023, 05/04/2023 to 05/06/2023, and 05/20/2023 revealed the aide completed the following task that was not on the aide care plan: assist with medications. The agency failed to ensure the aide follows the plan of care. C. Review of the Home Health Aide/ Personal Care Aide Activity Sheets for weeks of for weeks of 04/18/2023 to 04/22/2023, 04/25/2023 to 04/29/2023, and 05/04/2023 to 05/06/2023 revealed the aide completed or offered and the patient refused to have the aide prepare breakfast, lunch, dinner, or a snack. The preparation of breakfast, lunch and snack was not on the aide care plan. Review of the Home Health Aide/ Personal Care Aide Activity Sheet for week of 05/16/2023 to 05/20/2023 revealed the aide offered and the patient refused to have the aide prepare breakfast, lunch, and dinner. The preparation of breakfast, lunch, and dinner was not on the aide care plan. The agency failed to ensure the aide follows the plan of care. Patient #17 - This 94-year-old patient with diagnoses that include recurrent urinary tract infection, type 2 diabetes with chronic kidney disease, and hypertension with renal disease was admitted to the agency on 04/04/2023. Review of the Supplemental Orders from 04/11/2023 to 04/18/2023 revealed an order for an aide (no frequency specified). Review of the Supplemental Orders from 05/08/2023 to 05/14/2023 revealed an order for an aide two (2) times a week for four (4) weeks. Review of the Home Health Aide Care Plan with a start date of 05/09/2023 and an end date of 06/02/2023 revealed the plan of care directs the aide to perform the following tasks: - Length of visit – one (1) hour - Frequency – two (2) times per week - Report all changes in patient condition or refusal of care to the agency. - Personal hygiene/grooming - Bed bath/assist if patient is not safe (weak) to get to shower. - Shower/assist - Comb/brush hair - Shampoo hair - Oral care - Dressing/undressing/assist - Elimination: toilet - Peri care - Incontinent care/bladder - Adult diapers - Mobility/transfer - Cane/assist - Walker/assist - Transfer/assist - Gait belt - Encourage ambulation. - Turn and position: encourage repositioning every one (1) to two (2) hours - Exercise program per Physical Therapy - Exercise program per Occupational Therapy - Standard and fall precautions. - Home management - Special instructions: patient has stage 2 pressure ulcers to gluteal cleft and left buttock. Desitin applied by family. A. Review of the Home Health Aide and Personal Care Aide Activity sheets for weeks 04/18/2023 to 04/22/2023, 05/09/2023 to 05/13/2023, 05/23/2023 to 05/27/2023, and 06/06/2023 revealed the aide completed the following task that was not on the aide care plan: assistance with medication. The agency failed to ensure the aide follows the plan of care. B. Review of the Home Health Aide/ Personal Care Aide Activity Sheets for weeks of 04/18/2023 to 04/22/2023, 05/16/2023 to 05/20/2023, 05/23/2023 to 05/27/2023, 05/31/2023 to 06/03/2023, and 06/06/2023 to 06/10/2023 revealed the aide offered and the patient refused to have the aide prepare breakfast, lunch, and dinner. The preparation of breakfast, lunch, and dinner was not on the aide care plan. The agency failed to ensure the aide follows the plan of care. During interview on 01/02/2023 at 10:17 AM, the Director of Patient Services stated “we know aide documentation is a problem.” The Director of Patient Services stated aide documentation is something “we struggle with every time the surveyors are here.” The Director of Patient Services stated “we will just continue to work with and educate the aides with hopes to improve in this area in the future.” Patient #5 – This 87-year-old patient with diagnoses that include fracture of shaft of right humerus, status post open reduction internal fixation, and attention to surgical dressings or sutures was admitted to the agency on 11/21/2023. Review of the agency policy titled “Home Health Aid Services” last reviewed 08/2021 revealed: “1. Home Health Aid/Personal Care Assistant activity sheet- document all tasks that have been completed while in the home, while following the plan of care.” Review of the Physician’s Orders/Plan of Care from 11/21/2023 to 01/19/2024 revealed an order for Aide services effective 11/26/2023 one (1) time a week for eight (8) weeks for assistance with personal care and activities of daily living. Review of Home Health Aide Care Plan Interventions dated 11/26/2023 to “discharge from CCHD” revealed the following tasks were assigned for the Home Health Aide to complete: - Personal Hygiene/Grooming at each visit - Sponge bath/assist at each visit - Skin care at each visit - Comb/brush hair at each visit - Shampoo hair at each visit - Shave if needed - Oral care at each visit - Dressing at each visit - Elimination as needed - Peri care at each visit - Adult diapers assist as needed - Mobility/transfer as needed - Walker/supervise as needed - Nutrition/hydration as needed - Prepare breakfast as time allows - Prepare lunch as time allows - Prepare supper as time allows - Clean bathroom as time allows - Clean kitchen as time allows - Clean living area as time allows - Laundry as time allows - Garbage as time allows - Home Management Review of the Home Health Aide/Personal Care Assistant Activity Sheet week of 11/28/2023 thru 12/02/2023 revealed the Home Health Aid assisted with medications. The agency failed to ensure the Home Health Aide followed the plan of care. During an interview on 01/02/2024 at 10:17 AM, the Director of Patient Services stated it always seems to be a struggle, we need to work with the aides more on tasks assigned and not doing and doing tasks that are not assigned.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on review of clinical records, agency policies and procedures, and staff interview, for seventeen (17) of seventeen (17) patients (Patient #s: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17), the agency failed to follow agency policies and procedures, current clinical practice guidelines and accepted professional standards when providing services. Specifically, palliative care needs were not assessed per agency policy, the home health aide failed to document and report changes in the patient’s condition per agency policy, and documentation of a wound was not in accordance with agency policy. Failure to follow agency policies and procedures and ensure compliance with accepted professional standards has the potential to result in unmet patient needs and inadequate care. 1. Review of agency policy entitled “Home Health Aide Services” last reviewed 08/2021 revealed the following: “Documentation: 3. If you have identified a change while caring for a patient refer to the back of the activity sheet…” Home Visit Patient #1 – This 54-year-old patient with diagnoses that include hemiparesis affecting right side as late effect of a cerebrovascular accident, decreased functional mobility, and hypertensive heart disease with congestive heart failure was admitted to the agency on 11/14/2023. Review of the Hospital Discharge instructions dated 11/08/2023 revealed the following: - Medical problems: C. difficile diarrhea, and - Instructions to stop the following medications: Ceftriaxone 1 gram intravenous daily and Vancomycin HCl 125 milligram capsule by mouth, four (4) times daily. Review of the Physician’s Orders/Plan of Care from 11/14/2023 to 01/12/2024 revealed the following diagnosis: History of Clostridioides difficile colitis with a start date of 11/14/2023. Review of the Skilled Nurse – Nursing (Outcome and Assessment Information Set) – Start of Care – further visits planned dated 11/14/2023 revealed the Skilled Nurse documented the following: - The patient very rarely or never has bowel incontinence; - Last bowel movement 11/14/2023; and - Abdomen soft, non-tender active bowel sounds in all four quadrants, regular bowel pattern, normal stool, and abdomen not distended. Review of the Physical Therapy with Treatment (Outcome and Assessment Information Set) Routine Visit dated 11/16/2023 revealed the Physical Therapist documented there is no change in bowel function from the patient’s norm. Review of the Skilled Nurse (Outcome and Assessment Information Set) Routine Visits dated 11/16/2023 revealed the Skilled Nurse documented the following: - Last bowel movement 11/15/2023, and - Abdomen soft, non-tender active bowel sounds in all four quadrants, regular bowel pattern, normal stool, and abdomen not distended. Review of the Skilled Nurse (Outcome and Assessment Information Set) Routine Visits dated 11/20/2023 the Skilled Nurse documented the following: - Last bowel movement 11/19/2023, and - Abdomen soft, non-tender active bowel sounds in all four quadrants, regular bowel pattern, normal stool, and abdomen not distended. Review of the Home Health Care Plan (aide care plan) dated 11/14/2023 revealed the Home Health Aide is instructed to report all changes in patient condition or refusal of care to the agency. Review of page two of the Home Health Aide/Personal Care Aide Activity Sheet revealed the following instructions: “Report all changes in patient condition or falls to the agency…Narratives are only to be used for changes in patient condition…” During an observational home visit conducted on 11/30/2023 at 09:15 AM, the surveyor observed the patient inform the aide that she has had diarrhea for the past couple days. Additionally, the surveyor observed dried stool on the front of the toilet. Review of the Home Health Aide/Personal Care Aide Activity Sheet, pages one and two, dated 11/30/2023 (the initial aide visit) lacked documented evidence the aide documented or reported the patient’s diarrhea (change in patient condition). The Home Health Aide failed to follow agency policy for documenting and reporting changes in patient condition. During interview on 12/11/2023 at 10:00 AM, the Supervising Community Health Nurse stated the aide should have written the problem on the back of her aide time and activity sheet so that it could have been followed up on. The Supervising Community Health Nurse stated that the back of this aide time and activity sheet is blank, and the aide did not report as she should have. 2. Review of the agency policy entitled “Palliative Care” last reviewed 08/2023 revealed: “6.1 All home care patients with an advanced life-limiting condition or illness will be assessed upon admission for the need for palliative care.” Patient #1 – This 54-year-old patient with diagnoses that include hemiparesis affecting right side as late effect of a cerebrovascular accident, decreased functional mobility, and hypertensive heart disease with congestive heart failure was admitted to the agency on 11/14/2023. Review of the patient care record from 11/14/2023 to 12/06/2023 lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #2 – This 75-year-old patient with diagnoses that include chronic obstructive pulmonary disease, non-Hodgkin’s lymphoma, and type 2 diabetes with peripheral neuropathy was admitted to the agency on 11/01/2023. Review of the patient care record from 11/01/2023 to 11/30/2023 lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #3 – This 89-year-old patient with diagnoses that include diverticulosis, gastrointestinal diverticular bleed, and severe protein – calorie malnutrition was admitted to the agency on 11/17/2023. Review of the patient care record from 11/17/2023 to 12/04/2023 lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #4 – This 56 -year-old patient with diagnoses that include glioma of the brain, status post craniotomy, and developmental delay was admitted to the agency on 11/28/2023. Review of the patient care record from 11/28/2023 to 12/01/2023 lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #6 – This 88-year-old patient with diagnoses that include osteoarthritis, hypertensive heart disease with congestive heart failure was admitted to the agency on 11/14/2023. Review of the patient care record from 11/14/2023 to 12/06/2023 lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #7 - This 60-year-old patient with diagnoses that include non-healing wound of amputation stump, infection of left below knee amputation, and atherosclerosis of native artery of both lower extremities was admitted to the agency on 10/27/2023. Review of the patient care record from 10/27/2023 to 12/04/2023 lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #8 - This 67-year-old patient with diagnoses that include encounter for prosthetic gait training, history of below-knee amputation of right lower extremity, type 2 diabetes mellitus with peripheral angiopathy was admitted to the agency on 11/22/2023. Review of the patient care record from 11/22/2023 to 11/28/2023 lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #9 - This 92-year-old patient with diagnoses that include urinary tract infection, hallucinations, and generalized anxiety disorder was admitted to the agency on 11/13/2023. Review of the patient care record from 11/13/2023 to 11/30/2023 (date of discharge) lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #11 - This 64-year-old patient with diagnoses that include acute metabolic encephalopathy, acute cystitis, and anxiety was admitted to the agency on 11/17/2023. Review of the patient care record from 11/17/2023 to 11/30/2023 lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #13 - This 70-year-old patient with diagnoses that include fracture of the distal end of right femur, periprosthetic fracture around prosthetic knee, and type 2 diabetes was admitted to the agency on 07/06/2023. Review of the patient care record from 07/06/2023 to 07/18/2023 (date of discharge) lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #14 - This 98-year-old patient with diagnoses that include acute sinusitis, stage 2 pressure injury of coccygeal region, and failure to thrive was admitted to the agency on 04/27/2023. Review of the patient care record from 04/27/2023 to 05/02/2023 (date of discharge) lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #16 - This 69-year-old patient with diagnoses that include chronic obstructive pulmonary disease, hypertensive heart disease with congestive heart failure, and chronic venous insufficiency was admitted to the agency on 02/17/2023. Review of the patient care record from 02/17/2023 to 07/27/2023 (date of discharge) lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #17 - This 94-year-old patient with diagnoses that include recurrent urinary tract infection, type 2 diabetes with chronic kidney disease, and hypertension with renal disease was admitted to the agency on 04/04/2023. Review of the patient care record from 04/04/2023 to 06/07/2023 (date of discharge) lacked documented evidence of a palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. During interview on 12/11/2023 at 09:00 AM, the Supervising Community Health Nurse stated conversations regarding palliative care assessments happen with patients that are appropriate, however documentation of these assessments/conversations has not been an agency practice. Review of the agency policy entitled “Palliative Care” last reviewed 08/2023 revealed: “6.1 All home care patients with an advanced life-limiting condition or illness will be assessed upon admission for the need for palliative care.” Patient #5 – This 87-year-old patient with diagnoses that include fracture of shaft of right humerus, status post open reduction internal fixation, and attention to surgical dressings or sutures was admitted to the agency on 11/21/2023. Review of the patient care record from 11/21/2023 to 11/28/2023 lacked documented evidence of palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #10- This 66- year-old patient with diagnoses that include chronic obstructive pulmonary disease exacerbation, acute exacerbation of chronic obstructive airways disease with asthma, and left lower lobe was admitted to the agency on 11/21/2023. Review of the patient care record from 11/21/2023to 11/28/2023 lacked documented evidence of palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #12- This 65- year-old patient with diagnoses delayed surgical wound healing, status post amputation of lesser toe of left foot, and type 2 diabetes mellitus with peripheral artery disease was admitted to the agency on 11/11/2023. Review of the patient care record from 11/11/2023 to 11/30/2023 lacked documented evidence of palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. Patient #15 This 97- year-old patient with diagnoses osteoarthritis involving multiple joints on both sides of the body, immobility, and pressure injury of coccygeal region, stage 2 who was admitted to the agency on 03/17/2023. A. Review of the patient care record from 3/17/2023 to 4/14/2023 (date of discharge) lacked documented evidence of palliative care assessment. The Home Health Agency failed to follow agency policy for palliative care assessment. During an interview on 12/13/2023 at 10:42 AM, the Supervising Community Health Nurse stated that this is a global issue, missing across all patient charts. B. Review of Pressure Ulcer/Wound Assessment Policy last reviewed 08/2022 revealed “Tertiary Intention (AKA) delayed primary) wounds are left open deliberately for several days until the potential complication has resolved, then wound edges are brought together 2. Reassessment: B. It is not appropriate to reverse stage a pressure wound.” Review of Skilled Nursing Start of Care Routine Visit 01/04/2023 General Systems Review/Skin/Incision/Wound revealed #1 Right Heel (09/16/2022) Pressure Ulcer Stage: 2; #2 Left Heel (09/16/2022) Pressure Ulcer Stage: 2. Review of Skilled Nursing Routine Visit 04/05/2023 revealed 2023 under General Systems Review/Skin/Incision/Wound revealed #1 Right Heel (09/16/2022) Pressure Ulcer Stage: 1; #2 Left Heel (09/16/2022) Pressure Ulcer Stage: 1; #3 Coccyx Pressure Ulcer Stage:2. The agency failed to follow their Pressure Ulcer/Wound Assessment Policy. During an interview on 12/13/2023 at 02:14 PM, the Community Health Nurse stated that information was sent to the clinicians in the beginning of the year that pressure ulcer wounds cannot be backstaged.”