Hcr Home Care

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: This Element is not met as evidenced by: Based on a review of 6 patient records, the agency’s complaint log, and interviews with the Chief Nursing Officer and Regional Director of Patient Services (DPS), it was determined in 1 patient record (patient #5) the agency failed to have an effective process in place to ensure that all complaints related to patient care are documented, investigated, and resolved. Evidence as follows: Patient #5 was admitted to the agency on 04/22/24 with diagnoses that included surgical aftercare following surgery of the circulation system, type 1 diabetes, heart failure, chronic obstructive pulmonary disease, and atrial fibrillation. An agency Client Episode Coordination note dated 05/06/24, indicated the agency received call from a hospital case manager that stated the patient had voiced “some concerns” about not hearing from agency nursing staff “on visits.” The note continues as follows: - 05/07/24, 8:57 a.m., telephone call to patient’s cell number. Left voice mail “that we received information that they were unhappy with some of the home care, left VM to call back regarding issues.” - On 05/07/24, 9:30 a.m. “I called the patient’s hospital room but no answer.” - On 05/07/24, 10:35 a.m., telephone call to the the spouse’s cell phone and left a voice mail to call back regarding issues. - 05/07/24 2:17 p.m., called patient’s cell phone again, left voice mail. A note dated 05/08/24 included more attempts to reach the patient: - 05/08/24 9:57 a.m., telephone call to the patient’s cell phone, and left another message. - 05/08/24 11:32 a.m., telephone call to spouse, and left voice mail to return call. - 05/08/24, 1:55 p.m., received a call from patient’s relative. Discussed issues with home care and expectations. Reviewed the services to be provided and what a home care visit looks like. The relative felt that the patient and caregiver “didn’t really know what home care was, and their expectations of what it was.” The relative stated they would be speaking to the patient and caregiver to explain. On 06/21/24, the Complaint Log for the past 4 months was requested and received during the entrance conference. A review of the Complaint Log from 2/1/24-6/13/24 revealed that patient #6’s complaint was not entered in the log. The agency’s “Patient Concerns/Grievances” policy, revised 01/2021, included: - All HCR staff are responsible for notifying the Clinical Manager or his/her designee. - The Clinical Manager or his/her designee is responsible for investigating all patient complaints - A summary log will be retained by the Director of Patient Services. The agency failed to log, investigate, and follow policy when the complaint was received. On 06/21/24 at 2:15 p.m., the surveyor reviewed the above records with the Chief Nursing Officer, Director of Patient Services, and Clinical Managers. They acknowledged the findings and provided no additional information. Failure to track, investigate and resolve complaints has the potential for unmet patient needs and possible negative patient outcomes.”

“Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: This Standard is not met as evidenced by: Based on clinical record review, observational home visits, and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Managers (CM), it was determined for 5 of 18 patients (patients #1, 3, 12, 13, and 17) the agency failed to ensure initial comprehensive nursing assessments were of sufficient scope to ensure all patient needs were identified. Evidence as follows: Patient #12 was admitted to the agency on 10/04/23 with diagnoses of urinary symptoms, hyperkalemia, chronic kidney disease, benign prostatic hypertrophy, and congestive heart failure. On 10/04/23 the skilled nurse (SN) visited the patient for the initial assessment and failed to perform a comprehensive assessment of pain management. The 10/04/23 to 12/02/23 Home Health Certification and Plan of Care included the following: -Acetaminophen 500 mg three times a day as needed (PRN) for pain. -Lidocaine 4% patch every 12 hours PRN for back pain, on 12 hours off 12 hours. The SN documented the patient currently had 4 out of 10 aching pain to the right hip. The SN failed to assess pain throughout the day, what worsened pain and what relieved pain. The SN documented the patient was taking acetaminophen three times a day and failed to document the dosage of the medication and effectiveness. The SN failed to assess if the patient was using the lidocaine patch, the location of use and effectiveness of the intervention. On 11/14/23 at 2:45 p.m. the record was reviewed with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Patient #17 was admitted to the agency 04/27/23 with diagnoses including type 2 diabetes with foot ulcer, non-pressure chronic ulcer of left heel and mid-foot, and osteomyelitis. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for Increase in Number of Pressure Ulcers and Discharged to the Community with an Unhealed Stage II Pressure Ulcer. The 04/27/23 Certification and Plan of Care, and subsequent orders, included skilled nurse (SN) visits 2-3 times weekly to provide wound care and assessment. On 05/01/23 the SN documented wound measurements as 13 cm (length) x 12.2 cm (width) x 0.8 (depth). On 05/08, 05/19, 05/22, and 05/31/23 the SN documented in the Wound Record Report the reason wound measurements were not taken as “Worldview” (a software program to capture wound photos and measurements). On 05/08 wound photos were taken that did not capture measurements; there were no wound photos or measurements present in the record from 05/19 or 05/22/23. On 05/31/23 wound photos included measurements as 16 cm x 12.4 cm x 0.1 cm. On 06/05/23 the SN documented the wound measured 14 cm x 13 cm x 2.5 cm, there was no documentation related to the significant increase in depth. On 11/13/23 the surveyor reviewed the undated agency policy “WOUNDS” which stated, “Wounds should be measured a minimum of once per week or if there is a significant change in wound status.” From 05/01/23 through 05/31/23 the SN failed to assess wound measurements per agency policy. On 11/13/23 at 1 p.m. the above record was reviewed with Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Patient #13 was admitted to the agency on 04/12/23 with diagnoses including type 2 diabetes, end-stage renal disease, retinopathy, depression, and cerebral vascular accident (stroke). The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for Hyper/Hypoglycemia. Nursing The Home Health Certification and Plan of Care (POC) dated 04/18/23 included the following: - skilled nurse (SN) for instruction/reinforcement of diabetes management, including diet, skincare, foot care, and medications to manage blood sugar. Patient/Caregiver blood glucose testing. The patient’s primary care provider’s office notes dated 04/06/23 included the patient was having problems managing diabetes due to poor fine motor skills and retinopathy (poor vision) and will try to use a sensor to monitor blood sugar but will have to evaluate whether the screen of the phone is able to be seen consistently. The patient stated the screen of the glucometer is not able to be consistently seen. Medications included: - lantus insulin 100u/ml, 14 units at bedtime - Humalog kwikpen (U-100) insulin, use 2 times daily with breakfast and dinner 70 - 90 6u, 91 - 130 8u, 131 - 150 10u, 151- 200 12u, ...351 - 400 20u. - Baqsimi 3mg/actuation nasal spray 1 spray in nostril as needed for low blood sugar. Maximum daily dose of one spray. On 04/18/23, the SN visited for the initial assessment of the patient and documented the patient lived alone and had decreased vision, which made blood sugar testing difficult. A note indicated the patient was to be assessed on 04/20/23 for a talking glucometer. The SN documented that blood sugar was elevated during the visit and also spoke to the physician’s office staff to obtain the Humalog sliding scale for twice-daily use. The SN failed to assess if the patient could test the blood sugar independently with limited vision and to assess the availability of the caregiver. There was no evidence the SN ensured the patient could see the sliding scale, use the Humalog pen, and interpret the sliding scale with impaired vision. On 04/21/23, the SN visited and found the range of blood sugar readings from the glucometer 216 - 455. The SN documented that “ the 455 is after not taking the insulin as prescribed because the patient stated they were too tired.” The SN documented the patient’s remarks from the visit as, sometimes I get tired and don’t take the Lantus, and also documented the patient hadn’t tested the blood glucose that day; no reason for not testing was noted. The SN failed to assess if the patient was capable of testing the blood sugar independently or if the caregiver had been available to assist the patient with testing and medications. On 04/28/23, the SN visited and determined the patient was now testing and using the sliding scale 3 times daily instead of the previously ordered 2 times daily. The SN notified the physician’s office and updated the order. There was no evidence the SN discussed with the physician’s office or patient the amount of Humalog insulin on hand or the increased amount that would be required to ensure the patient would have enough insulin for the new, 3 times per day order. The discharge note dated 06/09/23 included the patient sought emergent care for hyperglycemia without hospital admission and that the patient had “run out of insulin.” Social Work The patient’s primary care provider’s office notes dated 04/06/23 included in the agency referral indicated “Home Care referral to be initiated. SW assessment would be helpful d/t current social situation and depression.” On 04/18/23, the SW included in the start of care narrative note social work to evaluate for life alert services in the home. The 04/18/23 POC included the referral for medical social services, effective 04/23/23, once a week for 2 weeks to evaluate and assess social and emotional factors related to the client’s illness, need for care, response to treatment and adjustment to care to be followed by collaboration with the physician and nurse to develop a plan of care. The POC also included an antidepressant, duloxetine 30mg capsule daily. The reason for the referral listed on the POC was an evaluation of additional resources that may be available in the home, long-term care, and blister packs. On 04/25/23, the social worker (SW) visited the patient and documented emotional findings that the patient had anxiety, a pre-existing psychiatric diagnosis. In the narrative note from the visit, neither the patient’s emotional findings, anxiety, or depression were documented. The SW failed to assess the patient’s anxiety, depression, or need for life alert. On 11/13/23 at 1 p.m., the above record was reviewed with the Administrator, DPS, and Clinical Managers. They acknowledged the findings and provided no additional information. Failure of the agency staff to perform a comprehensive assessment of the patients may result in unmet patient needs and negative patient outcomes.”

“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 patient records, observational home visits and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Managers, it was determined in 4 of 18 patient records, (patients #3, 8, 14, and 17) that clinical staff failed to provide care as ordered by the physician. Evidence as follows: Patient #17 was admitted to the agency 04/27/23 with diagnoses including type 2 diabetes with foot ulcer, non-pressure chronic ulcer of left heel and mid foot, and osteomyelitis. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for Increase in Number of Pressure Ulcers and Discharged to the Community with an Unhealed Stage II Pressure Ulcer. On 05/18/23 the physician ordered “Skilled nurse to change Blastix cream with Adaptic, gauze, abdominal pad and secure with Kerlix on Monday, Wednesday and Friday.” The SN visited to provide wound care on Friday 5/19 and Monday 5/22; the patient was scheduled to be seen in the wound clinic on 05/24/23. On Friday 05/26/23 the skilled nurse visited the patient, documented wound care performed per physician orders, and the wound had a faint odor. On 05/31/23 the on-call RN documented the patient called and stated he received no visit that day and his dressing was saturated; the SN visited to complete wound care that evening 9:25-10:11 p.m. On 11/13/23 at 1 P.M., during record review, the surveyor asked why no visit occurred between 05/26 and 05/31/23. On 11/15/23 the DPS provided the surveyor a verbal order, dated 05/23/23, to reduce nursing visits to 2 times for the week of 05/28/23 due to the holiday. The DPS stated it was common practice for the agency to contact the physician to reduce frequency of visits to accommodate holidays. Review of the order revealed the LPN who wrote the order documented they left a detailed message for the nurse at physician’s office. There was no evidence the writer received authorization in advance for the verbal order, the order was signed by the physician on 06/01/23. Frequency of home health services should be based upon clinical need, and the physician ordered plan of care, not on the availability of agency staff. Patient #14 was admitted to the agency on 01/06/23 with diagnoses including type 2 diabetes and end stage renal disease. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for Emergent Care for Hypo/Hyperglycemia and Development of Urinary Tract Infection. On 01/06/23 the skilled nurse documented in the comprehensive assessment the patient had an AV fistula (access for dialysis) in left arm. The 01/06/23 Certification and Plan of Care (POC) included no blood pressure left arm. -On 01/06/23 and 01/20/23, the physical therapist documented BP in left arm. -On 01/13/23 and 01/16/23 the occupational therapist documented BP in left arm. The 01/06/23 POC included patient/caregiver check blood sugars 4 times daily and as needed using Dexcom scanner. -On 01/11/23 the physical therapist visited the patient and documented physician orders do not include blood glucose testing On 11/13/23 at 1 p.m. the record was reviewed with Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Patient #10 was admitted to the agency on 03/21/23 with diagnoses of kidney failure, congested heart failure, chronic obstructive pulmonary disease, and anemia. Home Health Certification and Plan of Care (POC) dated 09/17/23 ordered the patient to demonstrate proficiency switching from daytime catheter leg bag to large drainage bag. SN failed to: - Ensure demonstration and observe return demonstration by patient and CG. -Ensure infection control practices were followed correctly. - Ensure written instructions were left in the home. On 11/13/23 at 1:00 p.m. the surveyor reviewed the above records with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Patient #4 was admitted to the agency on 02/24/23 with diagnoses of stage 4 pressure ulcers to gluteal and sacral areas, sclerosis, paraplegia and cystostomy. The 10/16/23 certification period had ordered for the skilled nurse to administer bladder irrigation with 60 ml sterile water as needed for occlusion to the supra pubic catheter. On 11/08/23 at 10 a.m. the surveyor conducted a home visit with skilled nurse and caregiver present. During the visit the caregiver reported to the nurse that he had increased the frequency with supra pubic irrigation from 2 times a day to 3 times a day due to frequent blockages. On 11/09/23 the agency provided a policy tilted Standard of Care Documentation Protocol dated 3/2022. The plan of care must include an order to allow patient/ or caregiver to perform the intervention and to indicate the nurse is to teach as well as perform the intervention as needed, this included Foley/suprapubic catheters. The SN failed to: - obtain an order for the caregiver to perform task On 11/13/23 at 1:00 p.m. the surveyor reviewed the above records with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Failure to perform adequate assessments for changes in patient condition, notify the physician, and update the plan of care as needed, has the potential for unmet patient needs, and possible negative patient outcomes. Home Visit (HV) 1. Patient #3 was admitted to the agency on 10/27/23 with diagnoses that included acute kidney failure, type 1 diabetes, osteomyelitis, sepsis, congestive heart failure (CHF), and cellulitis of the left lower limb. Wound Care The Home Health Certification and Plan of Care (POC) dated 10/27/23 included wound care orders as follows: - wound care to left great toe and 2nd toe surgical wound; cleanse area with normal saline and pat dry. Apply wet to dry dressing and secure with kerlix (stretchy gauze); change daily. On 11/07/23 at 10:30 a.m., the surveyor conducted an HV and observed the skilled nurse (SN) perform wound care to the left great toe and 2nd toe as follows: - the wound was cleansed with Hibiclens - sterile packing was moistened with saline and packed into the wounds with a sterile cotton-tipped applicator - covered with gauze pad - wrapped with kerlix and secured The SN failed to follow the wound care orders. Daily Weight The POC included an order to check weight daily and call physician for weight gain greater than or equal to 3 pounds in a day or 5 pounds in a week. During the HV, the SN asked the patient’s caregiver (CG) how the weights had been. The CG responded that they could not obtain the weight as the patient was “too unsteady” to stand safely on the scale, even with the walker and assistance. The patient had returned home from the hospital on 10/27/23 and missed 10 daily weights. The patient was unsteady, and the caregiver voiced concern about the patient falling. The SN assisted the patient to get onto the scale and logged the weight. On 11/13/23 at 1:00 p.m., the findings were reviewed with the Administrator, DPS, and CM, who acknowledged the findings and provided no additional information. 2. Patient #10 was admitted to the agency on 03/21/23 with diagnoses of kidney failure, congested heart failure, chronic obstructive pulmonary disease, and anemia. The 10/13/23 hospital discharge instruction documented the patient had been admitted to the hospital on 10/08/23 with the diagnosis of hematochezia (rectal bleeding) and was discharged on 10/13/23 with an indwelling catheter. The 10/13/23 discharge instructions for the medication spironolactone (a diuretic, or fluid reducer) 1- 25mg tablet on Monday, Wednesday, and Friday and was a change from daily administration. The 10/20/23 resumption of care order documented spironolactone 1- 25mg tablet daily. There was no evidence of a supplemental order with a medication change after the patient had been discharged from the hospital. The skilled nurse failed to accurately update the plan of care and reconcile the medications. On 11/13/23 at 1:00 p.m., the surveyor reviewed the above records with the Administrator, DPS, and CM. They acknowledged the findings and provided no additional information. 3. Patient #8 was admitted to the agency on 11/03/23 with diagnoses of fracture of the right pubis/orthopedic aftercare, pressure ulcer of the right buttock, fracture of the first lumbar vertebrae, history of falls, type 2 diabetes, and rheumatoid arthritis. On 11/03/23, the skilled nurse (SN) visited and documented the patient had a pain level of “7”. The Home Health Certification and Plan of Care (POC) included parameters for pain to notify the physician if the pain was greater than 6 on a 1- 10 scale. There was no evidence the SN notified the physician the patient’s pain was greater than 6. On 11/14/23 at 2:00 p.m., the findings were reviewed with the Administrator, DPS, and CM, who acknowledged the findings and provided no additional information. Failure to provide care as outlined in the physician’s orders has the potential for unmet patient needs and negative outcomes for the patient population.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on 7 observational home visits, review of agency policies and procedures, and interviews with the Administrator, Director of Patient Services (DPS), and Clinical Managers (CM), it was determined during 1 of 7 visits (patient #3), the skilled nurse (SN) failed to follow accepted standards of infection control practices. Evidence as follows: Home Visit (HV) Patient #3 was admitted to the agency on 10/27/23 with diagnoses of acute kidney failure, type 1 diabetes, osteomyelitis, sepsis, congestive heart failure (CHF), and cellulitis of the left lower limb. On 11/07/23 at 10:30 a.m., the surveyor conducted an observational HV and observed the SN violate infection control as follows: Peripherally Inserted Central Catheter (PICC) During the HV, the skilled nurse (SN) performed a PICC dressing change. The surveyor observed the following: - The SN failed to perform hand hygiene after removing the soiled dressing and doffing gloves. - The SN dropped items on the floor and balanced on the carpet with an ungloved hand to pick them up. No hand hygiene was performed after touching the floor. - The SN lifted the chlorhexidine swab pack from the dressing change kit and placed it on the sterile field with the same ungloved hand that had touched the floor, thus contaminating the outside of the swab package and the sterile field. - The SN donned the sterile gloves without performing hand hygiene. The pack of chlorhexidine swabs was then handled with the sterile gloved hands, thus contaminating the sterile gloves. - With the PICC open and unsecured, the SN obtained the sterile measuring tape and measured the circumference of the patient’s upper arm, contaminating the measuring tape. When measuring complete, the SN ran a sterile glove down the length of the tape, re-contaminating the sterile glove. - The patient’s masked face was turned toward the insertion site during the procedure. The surveyor reviewed the agency’s undated PICC policy which included: - instruct patient to turn the head away from the site during the procedure and have the patient don a mask - after discarding the soiled dressing and securement device, remove gloves, perform hand hygiene, and don sterile gloves Wound Care The patient’s wound care orders indicated daily dressing changes to the left great toe and 2nd toe. The surveyor observed the following: - After using a mobile device to photograph the wound, the SN doffed gloves and donned gloves without hand hygiene in between; this procedure was completed twice when the photograph was repeated. The agency’s undated Wounds policy and procedure included performing hand hygiene after doffing soiled gloves and prior to donning clean gloves. The agency’s policies were consistent with the Centers for Disease Control Hand Hygiene Guidance, which states: The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - immediately before touching a patient - before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices - before moving from work on a soiled body site to a clean body site on the same patient - after touching a patient or the patient’s immediate environment - after contact with blood, body fluids, or contaminated surfaces - immediately after glove removal Reference: https://www.cdc.gov/handhygiene/providers/guideline.html On 11/13/23 at 1:00 p.m., the findings were reviewed with the Administrator, DPS, and CM, who acknowledged the findings and provided no additional information. Failure to ensure the SN is oriented to agency policies and procedures regarding standard precautions for the prevention and transmission of infectious agents has the potential for unmet patient needs and possible negative patient outcomes.”

“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 review of 2 clinical records for patients receiving home health aide (HHA) service (patients #9 and 11) and interviews with the Administrator, Director of Patient Service (DPS), and Clinical Managers CM), it was determined in both records, the skilled nurse (SN) failed to develop complete and accurate aide written instructions. Evidence as follows: Patient #11 was admitted to the agency on 06/12/23 with diagnoses of lymphedema, chronic wounds to lower legs, and congestive heart failure. On 10/06/23 the SN visited the patient for the recertification assessment and documented the patient had nonpitting edema and chronic wounds to both lower legs. The SN performed wound care including Aquacel AG to the wound beds and two layers of Coban (compression) wrap. The SN documented the patient was encouraged to elevate legs, The 10/10/23-12/08/23 Home Health Certification and Plan of Care included orders for dressing change weekly and home health aide twice weekly to assist with personal care. Medications included ammonium lactate 12% lotion topically daily to legs. The 10/10/23 home health aide care plan was incomplete as follows: -The aide instructions included assist with Bath/Shower as needed every visit, and shampoo hair in shower every visit. -The care plan failed to include instructions regarding the lower leg dressings to include removing or covering for showers and changes to report to the nurse such as increased drainage or dislodgement. -The care plan failed to include instructions for management of edema including elevation of legs. -The care plan instructions included lotion to arms, legs, back every visit and failed to identify the type of lotion, such as the lotion listed in the medications. On 11/14/23 at 2:45 p.m. the surveyor reviewed the record with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Patient #9 was admitted to the agency on 10/12/23 with diagnoses of urinary tract infection, sepsis, history of kidney transplant, presence of suprapubic urinary catheter, hypertension with orthostatic hypotension, squamous cell carcinoma of the right temple and eye, blindness to left eye and sleep apnea. On 10/12/23 the SN visited the patient for the start of care assessment and documented the patient was dependent for activities of daily living (ADLs) including with bathing, dressing and toileting and was unable to transfer, stand or walk without assistance of two people and the patient had a suprapubic catheter. The 11/05/23 aide care plan included complete assistance with a sponge bath at every visit and failed to include any instructions regarding care of the urinary catheter. On 11/14/23 at 2:45 p.m. the surveyor reviewed the record with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Failure to ensure that home health aide care plans are complete has the potential for unmet patient needs.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on a review of clinical records, observational home visits and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Managers (CM), it was determined in 2 of 18 records, (patients #5 and 10) the skilled nurse (SN) failed to perform comprehensive medication reviews. Evidence as follows: Patient #10 was admitted to the agency on 03/21/23 with diagnoses of kidney failure, congested heart failure, chronic obstructive pulmonary disease, and anemia. The 10/13/23 hospital discharge instruction documented the patient had been admitted to the hospital on 10/08/23 with the diagnosis of hematochezia (rectal bleeding) and was discharged on 10/13/23 with an indwelling catheter. The 10/13/23 discharge instructions for the medication spironolactone (a diuretic, or fluid reducer) 1- 25mg tablet on Monday, Wednesday, and Friday and was a change from daily administration. The 10/20/23 resumption of care order documented spironolactone 1- 25mg tablet daily. There was no evidence of a supplemental order with a medication change after the patient had been discharged from the hospital. The skilled nurse failed to accurately update the plan of care and reconcile the medications. On 11/13/23 at 1:00 p.m., the surveyor reviewed the above records with the Administrator, DPS, and CM. They acknowledged the findings and provided no additional information. Home Visit (HV) Patient #5 was admitted to the agency on 09/15/23 with diagnoses of surgical amputation of the toes, type 2 diabetes with peripheral angiopathy, atherosclerosis, paroxysmal atrial fibrillation, coronary heart disease, congestive heart failure, and anemia. The Home Health Certification and Plan of Care (POC) dated 09/15/23 included furosemide (a diuretic) 1 - 40mg tablet twice daily. On 11/08/23 at 12:00 p.m., the surveyor conducted an observational HV with the skilled nurse (SN). During the visit, the SN reviewed the patient’s medication bottles and compared them to the physician’s orders on the POC. The patient’s furosemide bottle label ordered 1- 40mg tablet daily. The patient stated, “I take that one once daily, just like it says.” The patient’s weight had increased by 18 pounds from the start of care on 09/15/23 to the date of the HV. The SN called the physician’s office during the visit to report the weight gain, clarify the order, and schedule a visit with the patient’s physician. The SN had also reported a 10# weight gain to the physician on 10/23/23. The agency Medication Reconciliation Protocol dated 01/2022 included: - medication reconciliation is required at every in-home patient visit - compare the current medication orders and medication labels in the home and patient report of how medications are taken The POC included an order for Baqsimi (a fast-acting blood sugar elevator) 3mg/actuation nasal spray, 1 spray, as needed, into each nostril as needed for hypoglycemia. The patient stated that medication was “out in my truck, I think,” and was never reconciled before the completion of the visit. The SN failed to reconcile the medications between the start of care and the HV. On 11/13/23 at 1 p.m., the above record was reviewed with the Administrator, DPS, and CM. They acknowledged the findings and provided no additional information. Home Visit (HV) Patient # 3 was admitted to the agency on 10/27/23 with diagnoses of acute kidney failure, type 1 diabetes, osteomyelitis, sepsis, congestive heart failure (CHF), and cellulitis of the left lower limb. On 11/07/23, the surveyor conducted an observational HV and reviewed the medications with the patient and caregiver afterward. The Home Health Certification and Plan of Care (POC) included: - multivitamin 1 tablet daily - nitroglycerin 0.4 mg sublingual tab every 5 minutes as needed for chest pain, maximum daily dose 3 tablets - senna plus 8.6mg - 50mg capsule, 2 caps at bedtime A review of the patient’s medication and an interview with the patient and caregiver revealed the following: - the patient took women’s multivitamin gummies, 2 pieces daily - the Senna Plus was PRN or as-needed only - the nitroglycerin vial was stored in the refrigerator and, after examination, found to have expired 02/2020 and, per the caregiver, had not been checked On 11/13/23 at 1 p.m., the above record was reviewed with the Administrator, DPS, and Clinical Managers. They acknowledged the findings and provided no additional information. Failure to perform complete and accurate medication reviews could lead to patients potentially taking medications inconsistent with the physician’s intentions and possible negative patient outcomes.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on a review of clinical records, observational home visits, and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Managers (CM), it was determined in 1 out of 18 records (patient #10) the skilled nurse (SN) failed to assess the patient within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more. Evidence as follows: Patient #10 was admitted to the agency on 03/21/23 with diagnoses of kidney failure, congestive heart failure, chronic obstructive pulmonary disease, and anemia. On 10/08/23 the patient was admitted to the hospital with the diagnosis of hematochezia (blood in the stool) and was discharged on 10/13/23 (a Friday) with an indwelling urinary catheter. On 10/14/23 at 10:25 a.m., the on-call RN documented on the Patient Information Report the patient’s caregiver called the agency to report the patient was home from the hospital and the patient’s catheter was leaking. The on-call RN documented the resumption of care (ROC) visit was scheduled to occur 10/17/23 and directed the caregiver to take the patient to the emergency room if they were having problems with the catheter. The agency failed to appropriately address the patient’s acute need, and failed to complete the ROC assessment within 48 hours of the patient’s return home from the hospital. There was no evidence the physician was notified and approved of the delayed resumption of care. On 11/13/23 at 1 p.m. the above findings were reviewed with the Administrator, DPS and CM. The CM stated it was agency practice not to make a visit for acute issues until after the ROC was complete, and that ROCs are not scheduled during the weekend because nursing staff work Monday through Friday. The Administrator later told the surveyor there are nursing staff on-call who can visit a patient and complete the ROC during the weekend. Failure to perform a resumption of care assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes, and left this patient without needed home care services resulting in an unnecessary emergency room visit.”

“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 a review of clinical records, observational home visits, and interviews with the Director of Patient Services (DPS) and Clinical Manager, it was determined in 3 of 18 records (patients #1, 4 and 14) the agency failed to develop complete and accurate plans of care that were individualized to address the total needs of the patients. Evidence as follows: Patient #14 was admitted to the agency on 01/06/23 with diagnoses including type 2 diabetes and end stage renal disease. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for Emergent Care for Hypo/Hyperglycemia and Development of Urinary Tract Infection. The 01/06/23 Certification and Plan of Care (POC) included patient/caregiver check blood sugars 4 times daily and as needed using Dexcom scanner. On 01/06/23 the skilled nurse documented in the comprehensive assessment a random blood glucose of 252, with a range of 100 to 450. -The POC failed to include the acceptable range of blood glucose including parameters for when to notify the physician. On 11/13/23 at 1 p.m. the above record was reviewed with Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Home Visit (HV) Patient #4 was admitted to the agency on 02/24/23 with diagnoses of stage 4 pressure ulcers to gluteal and sacral sites, multiple sclerosis, paraplegia and cystostomy. The 10/16/23 certification period had ordered for the skilled nurse to administer bladder irrigation with 60 ml sterile water as needed for occlusion to the supra pubic catheter. On 11/08/23 at 10 a.m. the surveyor conducted an observational HV with skilled nurse and caregiver present. During the HV, the caregiver reported to the nurse they needed to irrigate the patient’s supra-pubic catheter more frequently due to more frequent blockages. On 11/09/23 the agency provided a policy Standard of Care Documentation Protocol, dated 3/2022 included; plan of care must include an order to allow patient or caregiver to perform the intervention and to indicate the nurse is to teach as well as perform the intervention as needed. The SN failed to: - Report finding of increased need for irrigation in the home to the physician. - Teach caregiver supra-pubic irrigation treatment including use of equipment. - Establish if caregiver is correctly performing the treatment by a return demonstration. - Provide evidence that written directives were left in the home for reference when skilled nurse in not present. On 11/13/23 at 1:00 p.m., the surveyor reviewed the above records with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Failure to perform adequate assessments for changes in patient condition, notify the physician, and update the plan of care as needed, has the potential for unmet patient needs, and possible negative patient outcomes. Failure to ensure the development of complete and accurate plans of care to meet the needs of the patients may result in negative patients outcomes.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on review of patient records, observational home visits, and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Managers (CM), it was determined for 2 out of 18 patients (patients #9 and 14) agency staff failed to provide coordinated care to meet the needs of the patients. Evidence as follows: Patient #14 was admitted to the agency on 01/06/23 with diagnoses including type 2 diabetes and end stage renal disease. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for Emergent Care for Hypo/Hyperglycemia and Development of Urinary Tract Infection. The agency staff failed to coordinate care as follows: NURSING SERVICES/DIABETES MANAGEMENT The 01/06/23 Certification and Plan of Care (POC) included: -patient/caregiver check blood sugars 4 times daily and as needed using Dexcom scanner -NovoLog FlexPen (rapid acting insulin) 3 times daily per sliding scale (insulin dosage dependent on blood glucose readings) and size of meals On 01/06/23 the skilled nurse (SN) documented the patient’s caregiver/spouse provided 24/7 care, checked blood glucose (BG), injected insulin, and administered medications. On 01/12/23 the SN documented in “coordination notes” they called the physician to inform them the 01/13/23 SN visit would be by phone and normal in-home scheduled visits would resume going forward. On 01/13/23 the SN documented they left a message on the patient’s machine with callback information. -There was no evidence the 01/13/23 telephone visit occurred. The SN failed to coordinate with the case manager or patient to reschedule and failed to notify the physician the visit did not occur. On 01/16/23 the occupational therapist (OT) documented regarding BG “patient declines taking today”, and on 01/18 “refuses to take today.” The OT did not document when BG was last checked or range of recent BGs. On 01/18/23 the OT documented they communicated with the social worker (SW) and SN, however there was no evidence the above information regarding BG testing was communicated to the case manager or physician. On 01/20/23 the SN visited, and documented patient’s son was present during visit and the primary caregiver remained in hospital. The son stated he didn’t know if anyone had checked the patient’s blood sugars, the patient stated they checked them at dialysis. The son demonstrated proficiency and independence, blood sugar was 346, the patient hadn’t been getting correct insulin dosages. The SN reviewed the sliding scale with caregiver, notified MD office, and set up the Dexcom sensor and showed caregiver how to use it. -The SN failed to coordinate with the family to determine whether the CG instructed during the visit was available for monitoring BG 4 times daily and administering insulin 3 times daily as ordered. On 01/23/23 the OT documented regarding BG, “patient does not remember but took 6 units meaning blood sugar between 201 and 250.” The OT did not document who (patient or what CG) checked the BG and administered insulin. On 01/25 and 01/26/23 the SN documented leaving a message for the patient and receiving a call back stating client was unavailable due to scheduled dialysis that day and medical appointments the following day. -The SN failed to coordinate a rescheduled visit. -On 01/27/23 the OT documented patient declined BG testing and failed to communicate this information to the case manager or physician. On 02/01/23 the OT visited and documented “Patient speech more slurred/difficult to understand than normal and patient appears with increased confusion and increased lethargy. Patient reports not taking blood sugar today. After bringing patient diabetic supplies patient reports not knowing how to do on own as wife, who is currently hospitalized, usually does it. Patient son present midway through session and was able to take blood sugar with sugars running very high at 543. Call made to (physician) office who recommend patient goes to ER for follow up due to dangerously high level.” INTERDISCIPLINARY COMMUNICATION/24/7 SUPERVISION On 01/06/23 the skilled nurse (SN) documented that the patient “requires 24 hour care and supervision”, and that the caregiver / wife was overwhelmed and requested a social work referral for more help. On 01/18/23 the OT documented in client coordination notes to call son at (telephone number) for scheduling if unable to reach patient. On 01/18/23 the SW documented a missed visit due to “patient states that his wife has been in the hospital since Sunday and that he is unable/not willing to come to the door today. Moving visit to next week.” -The SW failed to communicate this information to agency team members or coordinate with the family to ensure that the patient was safe at home given the need for 24/7 supervision. -The social worker documented that the MD office was notified, however the corresponding “order” reflected only notification of a missed /rescheduled visit. Coordination notes documented case conferences occurred on 01/16/23 and 01/27/23, both documented “no concerns/complaints identified at this time” and failed to address/coordinate: -whether the patient had 24/7 supervision -whether there was a caregiver available to monitor BG 4 times daily and administer insulin per sliding scale -need for and lack of aide services SCHEDULE COORDINATION/COORDINATION WITH DIALYSIS CLINIC On 01/06/23 the skilled nurse (SN) documented that the patient had dialysis every Tuesday, Thursday, and Saturday. On 01/18 the patient declined a physical therapy visit, and on 01/19/23 declined visits from PT and nursing who documented he had dialysis that day (Tuesday). On 01/25 and 01/26/23 the SN documented leaving a message for the patient and receiving a call back stating client was unavailable due to scheduled dialysis that day and medical appointments the following day. -The team failed to coordinate their visits according to the patient’s scheduled dialysis appointments. On 01/20/23 the SN visited, and documented patient’s son stated he didn’t know if anyone had checked the patient’s blood sugars, the patient stated they checked them at dialysis. -The SN failed to coordinate with the providers at the dialysis clinic to obtain information regarding their blood glucose monitoring. AIDE SERVICES On 01/13/23 the OT documented a request for aide services beginning as soon as possible three days per week. A “coordination notes-follow-up comment” dated 01/17/23 documented “aide schedule to follow once available” and “clinician notified of denial via e-mail. -There was no evidence of any additional agency coordination to secure aide services. On 11/13/23 at 1 p.m. the record was reviewed with Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. On 11/15/23 the surveyor interviewed the DPS regarding the frequency of scheduled SN visits and missed visits. The DPS stated that SN visits after the start of care were intended/scheduled to occur twice weekly for 2 weeks, then once weekly for 4 weeks, and that the agency did not document them as missed visits because the scheduler deleted the visits rather than noting them as missed. The surveyor requested any interagency documentation regarding attempts to secure aide service for the patient, no further information was provided. Patient #9 was admitted to the agency on 10/12/23 with diagnoses of urinary tract infection, sepsis, history of kidney transplant, presence of suprapubic urinary catheter, hypertension with orthostatic hypotension, squamous cell carcinoma of the right temple and eye, blindness to left eye and sleep apnea. The agency failed to coordinate care to meet needs. Urinary Catheter The 10/10/23 hospital summary revealed the patient was hospitalized for sepsis with acute encephalopathy due to complicated urinary tract infection and orbital cellulitis. On 10/12/23 the SN visited the patient for the start of care assessment and documented the patient had a suprapubic catheter. On 11/05/23 the SN documented in the resumption of care (ROC) note the catheter was draining light yellow urine with a small amount of mucous. On 11/07/23 at 8:20 a.m. the on-call SN documented the caregiver reported the patient was not passing urine through the catheter and the adult briefs were wet. The caregiver reported the tube was untwisted and urine began flowing into the bag and was cloudy. The on-call nurse encouraged extra fluids and documented informing the case manager via email. On 11/07/23 at 2:49 p.m. the SN visited the patient and documented the catheter was draining and urine was clear. There was no mention of previous issue with the urine being blocked and any education regarding prevention of further issues. On 11/08/23 at 8:28 a.m. the on-call nurse documented receiving a call from the caregiver reporting the catheter was clogged, some urine was leaking into the bag, but most was draining into the adult briefs. On 11/08/23 at 12:50 p.m. the supervisor documented in a late entry note calling the caregiver that morning and informing the caregiver they were working on finding a nurse to make a prn visit and had not been able to yet. The supervisor documented the caregiver stated, “I need someone sooner than later”, the patient could hardly stay awake, and the caregiver needed help. The agency failed to coordinate to ensure the patient, who had a history of a kidney transplant, was seen timely to address urinary retention and prevent a visit to the hospital. Over 4 hours passed until the patient was advised to go to the hospital. On 11/08/23 at 12:51 p.m. the DPS documented the caregiver reported the patient was lethargic, not eating and drinking, and had gotten worse over the last few days and requesting a nurse come out and see the patient. Urine output was low and the DPS instructed the caregiver to go to the emergency department (ED) for evaluation. The 11/08/23 ED report revealed the patient had presented to the department with weakness, the suprapubic catheter was found to be kinked and once corrected, the patient had 900 cc of urine from the catheter. The patient returned home on 11/09/23 with an order for an antibiotic. Personal Care On 10/12/23 the SN visited the patient for the start of care assessment and documented the patient was dependent for activities of daily living (ADLs) including with bathing, dressing and toileting and was unable to transfer, stand or walk without assistance of two people. The SN documented the caregiver was available 24 hours a day 7 days a week but had become overwhelmed and another family member assisted as needed on evenings and weekends, and a home health aide was needed. The SN documented the patient was looking for private paid assistance with ADLs. The 10/12/23 to 12/10/23 Home Health Certification and Plan of Care orders included home health aide (HHA) effective 10/22/23 to provide personal care 2 times a week for one week. The 11/05/23 ROC orders included HHA 2 times weekly for two weeks. On 11/07/23 the social worker (MSW) documented the patient was paying privately for aide service a couple of days a week to assist with personal care and the MSW referred the patient to the office of aging for personal care services. There was no evidence of coordination to initiate HHA services through the agency. On 11/13/23 the surveyor requested aide documentation, and none was provided. On 11/14/23 at 2:45 p.m. the record was reviewed with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Failure to coordinate patient care has the potential for unmet patient needs, and possible negative patient outcomes.”