Twin Tier Home Health, Inc.

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard 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, Clinical Managers, and patients, it was determined in 6 of 17 records (patients #1, 2, 7, 9, 10, and 17) the agency failed ensure patients received the home health services that were written in the individualized plan of care. Evidence as follows: 1. Patient #17 was chosen from an Internet Quality Improvement & Evaluation System (iQIES) Potentially Avoidable Event Report for hospitalization related to hypo/hyperglycemia. The patient was admitted to the agency on 07/13/23 with diagnoses that included complication of procedure (amputation of left 5th toe), acute osteomyelitis left ankle and foot, cellulitis of the left lower limb, type 2 diabetes with diabetic neuropathy, hypertension, and major depressive disorder. On 07/13/24, the skilled nurse visited the patient for the initial assessment and developed the plan of care. During the visit, the patient developed symptoms of hypoglycemia with a glucose reading of 39. The nurse administered glucose tablets which temporarily corrected the glucose to 80, however, the patient again became symptomatic and the glucose reading again was in the 30s. 911 was called and the patient was transported to the emergency department. The Home Health Plan of Care dated 07/13/24-09/10/23 included the following; - Insulin glargine, (long acting) inject 30 units every day at bedtime - Insulin lispro, (short acting) inject 10 units twice daily at 10:00 a.m., and 6:00 p.m. - patient to perform blood sugar testing twice daily, after breakfast and after dinner - ensure that glucometer is operational, and that patient has sufficient testing supplies - patient will be obtaining a new glucometer from the Endocrinology office 07/14/23 - taxing effort to leave home - relies on public transportation or another relative / neighbor to drive The 07/13/24 initial assessment included; - “pt. reports [they] already called endocrinology today regarding getting a new script for glucometer and test strips, as [they] ran out during the [SOC] visit today The 07/14/23 visit notes included: - client has not been able to pick up glucometer test strips - unable to specify how much glargine was taken last night, and took 8 units this am The 07/16/24 visit notes included: - vital signs stable, no strips for (blood glucose) monitoring, denies signs and symptoms of hypo or hyperglycemia The 07/18/23 visit notes included: - Client has still not been able to pick up [their] chemstrips, and monitoring equipment at pharmacy - barriers to goal attainment and what we are doing to address them - “none” The 07/20/23 visit notes included: - chemstrip blood glucose reading 247 From 07/14/23 to the date the patient obtained the testing equipment (between 07/18 and 7/20/23), there was no evidence the agency staff notified the physician the blood glucose was not able to be tested as ordered, or assisted the patient to develop a plan to obtain the equipment from the pharmacy. On 08/01/24 at 3:00 p.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. Home Visit 2. Patient #2 was admitted to the agency on 06/27/24 with diagnoses of multiple sclerosis, cerebrovascular accident (stroke), expressive aphasia, and hypertension. The 06/27/24-08/25/24 “Home Health Plan of Care” included: - social work: 1 visit x 1 week (for evaluation) dates, 06/30-07/06/24 - speech language: 1 visit x 1 week (for evaluation), 06/30-07/06/24 On 06/27/24 the skilled nurse saw the patient for an initial visit and documented the patient “has slow speech and word find issues”, the patient is “forgetful”, and their BIMS (brief interview for metal status) score was 10 (moderately impaired). The social worker visited the patient for an initial evaluation on 07/12/24 (10 business days after admission) and the speech language therapist visited the patient for an initial evaluation on 07/16/24 (12 business days after admission). On 08/01/24 the surveyor requested the policies for professional staff. The “Medical Social Services” and “Speech Language Pathology Services” policies, both dated 05/2023, included, services are “generally provided within 7 business days of the physician’s orders.” The agency failed to ensure the patient was evaluated timely by social week and speech language pathology per the plan of care. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers. They acknowledged the findings and provided no additional information. Home Visit 3. Patient #1 was admitted to the agency with diagnoses of malnutrition, peritoneal cancer, mucinous adenocarcinoma (cancer) within the digestive system, and history of partial small bowel obstruction. The 06/26/24-08/25/24 Home Health Plan of Care included with each central catheter dressing change, the skilled nurse was to measure the arm circumference 7 cm above the central catheter. On 07/31/24 at 10:00 a.m., the surveyor completed a home visit with the skilled nurse. During the visit, the surveyor observed the nurse perform a central catheter dressing change and noted the nurse failed to measure the arm circumference as ordered in the plan of care. The surveyor reviewed documentation of 6 additional skilled nurse intravenous visits between 06/27 and 07/24/24 and failed to include arm circumference in 4 of 6 visits. On 08/01/24 the surveyor requested the central catheter policy. The 05/2017 “Infusion Therapy-Peripherally Inserted Central Catheter Maintenance and Management…” policy states, dressing change procedure, the skilled nurse is to “measure arm circumference at 7 cm above the insertion site. Measure on bare skin and compare with last measurement. Notify MD of increase greater than 2 cm.” On 08/01/24 at 3:00 p.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. 4. Patient #10 was admitted to the agency 07/19/24 with diagnoses that included hypokalemia (low potassium), history of coronary artery bypass surgery, peripheral arterial disease, and hypothyroidism. The Home Health Plan of Care dated 07/19/24-09/16/24 included speech language pathology, 1 visit every week for 1 week, dates 07/22/24 to 07/27/24. On 07/31/24, the speech language pathologist created a missed visit note to the physician and care team which included: - patient called this week to say not feeling well and wanted to cancel today’s evaluation - other appointments were offered this week but patient declined - patient wants the visit the week the clinician returns on the week of 08/12/24, but the patient may not be receiving services at that time On 08/01/24 the surveyor requested the policies for professional staff. The “Speech Language Pathology Services” policy, dated 05/2023, included, services are “generally provided within 7 business days of the physician’s orders.” On 08/01/24 during record review the Clinical Manager stated “the SLP is going on vacation.” The speech pathologist failed to coordinate with the care team to determine if another speech pathologist could evaluate the patient. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. 5. Patient #7 was admitted to the agency 06/01/24 with diagnosis including multiple sclerosis, pressure ulcer of the sacrum, suprapubic catheter, and frequent urinary tract infections. The agency failed to provide all services as per the physician ordered referral. Home Health Aide Referral The 05/24/24 referral included the following disciplines: skilled nursing, physical therapy, occupational therapy, and home health aide. There was no evidence in the record the patient was ever offered or declined a home health aide, no communication notes or other evidence of agency discussion or consideration regarding a home health aide, and no communication with the physician that the agency did not/was unable to provide an aide for this patient. 07/31/24 at 9:30 a.m. the surveyor completed an observational home visit. Following the visit the surveyor interviewed the patient and caregiver regarding the disciplines providing services. The surveyor asked whether a home health aide was offered or provided by the agency. The caregiver stated they were “not aware that was an option,” to which the patient nodded and agreed. They further stated it was difficult for the caregiver (spouse) to provide all the care, and that the Medicaid program that allows payment to caregivers excludes spouses as paid caregivers. Edema Measurements The 06/01/24 Home Health Plan of Care included an intervention for all skilled disciplines to assess edema every visit. The intervention included “Measure arch of foot, above malleolus, and calf at 31 cm up from heel.” Edema measurements were obtained at the start of care on 06/01/24 and at the recertification visit on 07/29/24. From 06/01-07/29/24 the patient was being visited by nursing 2-3 times per week; and from 06/01-06/29/24 the patient was also being visited by physical therapy 1-2 times weekly. From the start of care 06/01/24, through recertification on 07/29/24, the visiting nurses and physical therapists failed to follow the plan of care to obtain edema measurements. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information at that time. On 08/02/24 at 11:00 a.m., during a second record review, the surveyor asked the nurse who completed the initial comprehensive assessment (current clinical manager) whether they had any recall of the referral including a home health aide, or whether that was ever offered/discussed; the nurse was unable to recall. 6. Patient #9 was admitted to the agency 07/22/24 with diagnoses including endocarditis, atrial fibrillation, and edema. The 07/22/24 Home Health Plan of Care included an aide visit to occur one time between 07/22-07/27/24, then two times per week for eight weeks from 07/28-09/19/24. On 07/30/24 the social worker visited the patient and documented they encouraged the caregiver to obtain aides, they were informed about private hire and agency aides, and a telephone call was placed to an organization that helps seniors. As of 08/02/24, during the survey, 2-3 visits should have occurred per the plan of care orders and no visits had occurred. There was no evidence of agency communication regarding why no aide visits had been scheduled or occurred, and no evidence the physician was notified aide services were not provided as ordered. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. On 08/01/24 the surveyor reviewed the agency policy titled “Home Health Aide Services”, revised 06/2024, which included, “Aide service is generally provided within five days of the initial request.” On 08/01/24 at 3:00 p.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. In the above 2 examples, the agency failed to provide home health aide services in accordance with their policy and the patient’s plan of care. Failure to ensure the services in the plans are provided to patients as ordered has the potential to result in negative outcomes for the agency’s entire 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 with clinicians, review of agency policies and procedures, and interviews with the Administrator/Director of Patient Services and Clinical Managers, it was determined during 2 of 7 visits (patients #5 and 7), the clinician failed to follow accepted standards of infection control practices. Evidence as follows: Home Visit Patient #5 was admitted to the agency on 06/13/24 with diagnoses of chronic venous hypertension with ulcer of bilateral lower extremity, stage 2 pressure ulcer of left buttock, hypertensive heart disease with heart failure, and type 2 diabetes. On 7/31/24, the surveyor completed an observational home visit with the skilled nurse where the nurse performed wound care to the patient’s right lower extremity. The skilled nurse removed the old dressing, discarded their gloves, and performed hand hygiene before applying a new pair of gloves. The surveyor observed a yellow, sloughy exudate on the wound. After the visit, the nurse documented the wound had a large amount red, serosanguinous, and tan drainage. The skilled nurse then applied normal saline to gauze and patted the wound to cleanse it; then used new gauze to pat the wound dry. The saline had soaked through the original gauze and was in constant contact with the skilled nurse’s glove while cleansing the wound. After cleansing the wound, the skilled nurse did not doff the soiled gloves and proceeded to apply the new, clean dressing without donning clean gloves. On 08/01/24, the surveyor reviewed the agency policy “Integumentary – Application of Wound Dressing”, revised 03/2024 which included, “if gloves become contaminated or a significant amount of cleaning solution has touched gloves; remove and discard gloves in appropriate container.” The skilled nurse failed to follow agency policy and change gloves when they had a large amount of cleaning solution on them, which could lead to possible cross-contamination and potential negative outcomes for the patient. On 08/02/24 at 11:00 a.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers 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 Visit 1. Patient #7 was admitted to the agency 06/01/24 with diagnosis including multiple sclerosis, pressure ulcer of the sacrum, suprapubic catheter, and frequent urinary tract infections. On 07/31/24 at 9:30 a.m. the surveyor completed an observational home visit with the nurse to change a wound VAC dressing (vacuum-assisted closure of a wound is a type of therapy to help wounds heal). Throughout the visit and wound care procedure the patient was in a hospital style bed in their living room. The surveyor observed the nurse remove the soiled dressing, walk into the kitchen with the soiled dressing in their hands, and return to the living room with the lined kitchen trashcan. The nurse disposed of the soiled dressing in the trashcan which the surveyor observed to be approximately 3/4 full. The skilled nurse proceeded with the dressing change and each time they changed their gloves they turned the gloves inside out and set them on a small folding table next to the foot of the patient’s bed. When the nurse completed the dressing change, they gathered all of the dirty gloves and discardable items from the dressing change, and placed those directly into the kitchen garbage can on top of soiled dressing. 07/31/24, at approximately 12 noon, the surveyor requested the agency policies for dressing change, including trash disposal. The policy “Integumentary – Application of Wound Dressing”, dated 03/2024, included at the conclusion of dressing change “Wearing gloves, discard soiled supplies in plastic bag, tie closed and place in patient trash bag.” The skilled nurse failed to follow agency policy for disposal of soiled supplies/infection control. On 08/01/24 at 3:00 p.m., the findings were reviewed with the Administrator/Director of Patient Services and Clinical Managers. They acknowledged the findings and provided no additional information. Home Visit 2. Patient #5 was admitted to the agency on 06/13/24 with diagnoses of chronic venous hypertension with ulcer of bilateral lower extremity, stage 2 pressure ulcer of left buttock, hypertensive heart disease with heart failure, and type 2 diabetes. On 7/31/24, the surveyor completed an observational home visit with the skilled nurse to perform wound care to the patient’s right lower extremity. The skilled nurse removed the old dressing, discarded their gloves, and performed hand hygiene before applying a new pair of gloves. The surveyor observed a yellow, sloughy exudate on the wound. The skilled nurse opened a gauze pad, placed the pad on the open package, and saturated the gauze with normal saline. The nurse then cleansed the wound with a patting motion using the saline soaked gauze and their entire gloved hand, then used new gauze to pat the wound dry. After cleansing the wound, the skilled nurse did not remove the then soiled gloves, and proceeded to apply the clean dressing without putting on clean gloves. After the visit, the surveyor reviewed the nurse’s wound care documentation dated 07/31/24 which included the wound had a large amount of red, serosanguinous, and tan drainage. On 08/01/24, the surveyor reviewed the agency policy “Integumentary – Application of Wound Dressing”, revised 03/2024 which included, “if gloves become contaminated or a significant amount of cleaning solution has touched gloves; remove and discard gloves in appropriate container.” The skilled nurse failed to follow agency policy and change gloves after they had a large amount of cleaning solution on them, and were used to clean a wound with a significant amount of drainage, thus contaminating the gloves. On 08/02/24 at 11:00 a.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. Peripherally Inserted Central Catheter - Removal On 07/31/24 at 9 a.m., the surveyor conducted an observational home visit with the skilled nurse. The physician’s orders included: - discontinue the patient’s peripherally inserted central catheter after antibiotic therapy had been completed. The nurse removed the catheter, then covered the site with a small adhesive bandage, (band-aid style). On 07/31/24 the agency provided the surveyor a policy titled “Peripherally inserted central catheter (PICC) removal,” dated 12/2008. The policy included: - Cover site with sterile gauze dressing then cover with transparent film dressing. - Instruct the patient to assess site after 24 hours until the site is epithelialized (formation of a covering of skin cells over a wound). - Instruct patient to observe site for, bleeding, or drainage, pain, signs of infection, chest pain or discomfort. - Instruct patient to leave the dressing in place for 24 hours. If no bleeding occurs, site may be left open to air. The nurse failed to: - Cover site with sterile gauze dressing then cover with transparent film dressing, and educate the patient as per the policy The nurse failed to follow infection control standards when a small adhesive bandage was applied. This is not consistent with the agency policy, or the Centers for Disease Guidance which states as use of an occlusive dressing after peripherally inserted central catheters are removed aids in the prevention of complications such as infection and air embolism. Failure to follow agency policies and procedures regarding standard precautions for the prevention and transmission of infectious agents has the potential for cross-contamination and negative outcomes for the patient.”

“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 a review of clinical records, and interviews with the Administrator/Director of Patient Services and Clinical Managers it was determined in 1 out of 17 records (patient #13), the agency failed to conduct the initial assessment visit to determine immediate care needs within 48 hours of referral or return home. Evidence as follows: Patient #13 was chosen from an Internet Quality Improvement & Evaluation System (iQIES) Potentially Avoidable Event Report for Emergent Care for Hypo/Hyperglycemia. The patient was admitted to the agency 11/12/23 for surgical aftercare of an aortic coronary bypass, additional diagnoses included type one diabetes, hypertension, atrial fibrillation, and dependence on oxygen. The skilled nurse documented in a communication note the patient went to the hospital with elevated blood glucose on 11/12/23, was admitted to the hospital, and on 11/14/23 the patient was discharged from the agency. Present in the record was a hospital discharge summary, completed 11/20/23 that included home care services were to be provided by the agency. On 11/21/23 a skilled nurse documented they telephoned the patient to coordinate a nurse visit for assessment and admission on 11/22/23. On 11/24/23 the same nurse documented they called the physician to advise “planning to resume home care by 11/27.” There was no reason documented for the delay. On 11/27/23 the patient was readmitted to the agency. The agency failed to ensure a registered nurse conducted an initial assessment visit within 48 hours of the patient’s return home from the hospital. On 08/01/24 at 3:00 p.m. the findings were reviewed with the Administrator/Director of Patient Services and Clinical Managers. On 08/02/24 at approximately 11 a.m. the Administrator provided the surveyor a printout with an entry dated 11/22/23 that stated “Appointment, Home Health, Canceled (Provider. Hospitalized).” The surveyor interviewed the Administrator who stated the patient went to a cardiology appointment on 11/22/24 and was sent from there to the Emergency Department, the patient was released from the Emergency Department about 4 hours later. The additional information does not change the above findings. Failure to conduct an initial assessment of the patients’ needs within 48 hours of referral has the potential for unmet patient needs and negative outcomes for the agency patient population.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on a review of clinical records, policies and procedures, observational home visits, and interviews with the Administrator/Director of Patient Services, Clinical Managers, staff, and patients, it was determined in 4 of 17 records (patients #6, 8, 12, and 13) the agency failed to ensure comprehensive assessments were of sufficient scope to identify all patient needs. Evidence as follows: Patient # 13 was chosen from an Internet Quality Improvement & Evaluation System (iQIES) Potentially Avoidable Event Report for Emergent Care for Hypo/Hyperglycemia. The patient was admitted to the agency 11/12/23 for surgical aftercare of an aortic coronary bypass, additional diagnoses included type one diabetes, hypertension, atrial fibrillation, and dependence on oxygen. The SN documented in a communication note the patient went to the hospital with elevated blood glucose on 11/12/23, was admitted to the hospital, and on 11/14/23 the patient was discharged from the agency. On 11/27/23 the patient was readmitted to the agency. The hospital discharge summary, completed 11/20/23, included the patient presented to the emergency department with visual hallucinations and was monitored and treated for alcohol withdrawal. The 11/27/23 Home Health Plan of Care included a diagnosis of alcohol abuse with withdrawal delirium. On 11/27/23 the skilled nurse completed the initial comprehensive assessment and documented in the safety section of the assessment “Patient drinks more than two alcoholic drinks a day: no”. There was no evidence the nurse assessed the patient for ongoing alcohol use/potential for withdrawal, and/or the patient’s knowledge regarding same. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. Patient #8 was admitted to the agency on 05/22/24 with diagnoses that included diabetes with foot ulcer, chronic obstructive pulmonary disease, heart failure, and urinary retention with catheter. The agency failed to assess the patient and caregiver’s ability to manage diabetes and urinary catheter care. Diabetes management On 05/22/24 the registered nurse visited the patient to complete the start of care comprehensive assessment. The visit documentation included that the clinician was unable to reconcile the injectable medications or assess caregiver’s ability to manage injectable medications, including sliding scale insulin. Additionally, the patient reported they had not been checking their blood sugar levels as they were unable to find the glucometer. The 05/22/24 plan of care included the task of patient or caregiver demonstrating proficiency of insulin administration with notation this will be done on 05/24/24. On 05/24/24 a different registered nurse visited the patient and documented that a complete medication reconciliation was completed without any changes. The visit documentation does not include documentation on diabetes management including demonstration of insulin administration, ability to use the sliding scale, glucometer, or blood glucose readings. Urinary catheter management The 05/22/24 start of care assessment documentation included that the patient had a urinary catheter and the caregiver demonstrated emptying the bag. There is no documentation to support the admitting clinician assessed the patient or caregiver’s ability to manage other tasks related to catheter management. On 05/27/24 a registered nurse visited the patient following a report of small blood clots in the catheter tubing. The nurse documented that catheter care education was given but did not specify what was taught. Documentation also included that reinforcement of catheter teaching was needed but does not indicate what teaching needed to be reinforced. On 06/07/24 a home health aide case communication note reported that the patient’s spouse reported that they were not notified when discharged from the hospital that catheter bags would need to be washed with a vinegar solution or that they would need to clean the catheter connections with alcohol when changing bags. The case communication note supports the case manager was notified of this. There was no evidence in subsequent nursing visit notes to support patient or caregiver demonstrated catheter care. On 08/02/24 at 11:00 am the above findings were reviewed with the Administrator/Director of Patient Services and clinical managers who acknowledged the findings and provided no additional information. Failure to of the agency staff to perform a comprehensive assessment of the patients may result in unmet patient needs and negative outcomes. Patient #6 was admitted to the agency on 06/27/24 with diagnoses of right above the knee amputation, type 2 diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Home visit Infusion therapy The 06/27/24 plan of care included: - IV antibiotic ertapenem 1 gram into venous catheter one time each day at the same time of day. The 06/28/24 nurse visit included “Husband able to demo proficiency with hooking up IV infusion today.” However, it was unclear what the husband/caregiver was taught and proficient with when the plan of care failed include the following: - the antibiotic duration of administration - equipment necessary for the infusion - type, amount, and frequency of flushes The nurse failed to provide evidence of a comprehensive assessment and ability to participate with infusion therapy services. Peripherally inserted central catheter - removal On 07/31/24 the agency provided the surveyor a policy titled “Peripherally inserted central catheter (PICC) removal “dated 12/2008. The aftercare PICC removal policy included: - Cover site with sterile gauze dressing then cover with transparent film dressing. - Instructed the patient to assess site after 24 hours until the site is epithelialized. - Instruct patient to observe site for, bleeding, or drainage, pain, signs of infection, chest pain or discomfort. - Instruct patient to leave the dressing in place for 24 hours. If no bleeding occurs, site maybe left open to air. On 07/31/24 at 9 a.m. the surveyor conducted an observational home visit with the nurse present. The nurse had an order to discontinue the patient’s peripherally Inserted central catheter (PICC) after antibiotic therapy had been completed. The nurse had removed the PICC per order, then covered the site with a band- aide. The nurse failed to: - Cover site with sterile gauze dressing then cover with transparent film dressing. - Instructed the patient to assess site after 24 hours until the site is epithelialized. - Instruct patient to observe site for, bleeding, or drainage, pain, signs of infection, chest pain or discomfort. - Instruct patient to leave the dressing in place for 24 hours. If no bleeding occurs, site maybe left open to air. On 08/01/24 @ 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers. They acknowledged the findings and provided no additional information at that time. On 08/06/24, the Administrator/Director of Patient Services electronically provided the pharmacy order which included drip rate 30 minutes via dial flow 200ml/hour duration of antibiotic, flushes, type amount and frequency. Along with teaching patient on medication administration. However, the orders were not included in the agency plan of care therefore, it did not change the above findings. Patient #12 was admitted to the agency on 07/06/24 with diagnoses of osteomyelitis of the right foot, type 2 diabetes mellitus, chronic diastolic heart failure, and hypertension. On 07/31/24 the agency provided the surveyor with a policy titled “Infusion Therapy – Peripherally Inserted Central Catheter (PICC) Maintenance and Management of Potential Complications” dated 05/2019. Page 2 #8 The patient/caregiver is to be taught to check site for: a - Excessive drainage or bleeding from catheter exit site. b - Redness or swelling around the catheter exit site. c - Pain, soreness, swelling or tenderness in the arm where the catheter is inserted. d - Pain or discomfort during the infusion of IV solution. e - Chest pain or discomfort while catheter is in place. The 07/06/24 plan of care included IV antibiotics of ceftriaxone (Rocephin) 1 gram by intravenous push route daily. The initial assessment included a note stating “Patient was able to demo his infusion up to the point of infusing. He is proficient with this.” However, it is unclear what was instructed by the nurse in the initial assessment, the infusion section of the assessment was not completed by the nurse. The plan of care did not include normal saline flushes, heparin flushes or the duration of the IV antibiotic therapy. The nurse failed to: - provide evidence of a comprehensive assessment and ability to participate with infusion therapy services. - Provide instruction with flushes, type, amount and frequency. - Provide instruction with complications to the PICC line. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers. They acknowledged the findings and provided no additional information.”

“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, Clinical Managers, and patients, it was determined in 3 of 17 records (patients #4, 5, and 8) the skilled nurse failed to perform comprehensive medication reviews. Evidence as follows: Patient #8 was admitted to the agency on 05/22/24 with diagnoses that included diabetes with foot ulcer, chronic obstructive pulmonary disease, heart failure, and urinary retention with catheter. The 05/22/24 Home Health Plan of Care was incomplete as follows: - Humalog insulin “inject per scale before meals subcutaneous” without including the sliding scale. - Diclofenac (Voltaren) 1% topical gel “place on the skin 4 times a day. Apply 2 GM to hand joints twice daily” without clarifying where to apply 4 times a day or how often to apply to the hand joints each day. The plan of care failed to include complete insulin sliding scale order and clear instructions for the use of diclofenac topical gel. On 08/02/24 at 11:00 am the above findings were reviewed with the Administrator/Director of Patient Services and clinical managers. Home Visit Patient #5 was admitted to the agency on 06/13/24 with diagnoses of chronic venous hypertension with ulcer of bilateral lower extremity, stage 2 pressure ulcer of left buttock, hypertensive heart disease with heart failure, and type 2 diabetes. On 07/30/24, the surveyor obtained and reviewed the patient’s medication profile. On 7/31/24, the surveyor completed an observational home visit with the skilled nurse. The patient lived in an assisted living facility and their medications were managed by the facility staff. After the visit, the surveyor obtained the patient’s medication list from the assisted living facility. The following medications were not on the patient’s medication list provided by the assisted living facility: - fexofenadine 180 mg by mouth daily - Vitamin A&D ointment 1 application topically twice a day - lisinopril 10 mg by mouth daily The following medication were not on the patient’s agency medication profile: - miconazole 2% powder 1 application topically twice a day The following medications had doses that were inconsistent between the agency medication profile and the medication list provided by the assisted living facility: - The agency medication profile included furosemide 10 mg daily. The assisted living facility list included furosemide 20 mg daily. - The agency medication profile included guaifenesin oral syrup 100 mg (5 mL) 4 times per day if needed for cough. The assisted living facility list included guaifenesin oral syrup 200 mg (10 mL) every 4 hours as needed for cough. - The agency medication profile included Tresiba FlexTouch U-100 (insulin) inject 30 units under the skin every night. The assisted living facility list included Tresiba FlexTouch U-100 (insulin) inject 18 units subcutaneously one time per day. On 08/01/24, the surveyor reviewed the Medication – Comprehensive Medication Review policy dated 07/2022 which included: - a comprehensive medication review includes all medications the patient is taking - must match the medications a physician has ordered - must match the agency medication profile - at each visit nursing must ask about medications - a comprehensive medication review is required weekly The skilled nurse failed to perform comprehensive medication assessment to ensure a complete and accurate medication profile was maintained. On 08/02/24 at 11:00 a.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. Home Visit Patient #4 was admitted to the agency on 07/24/24 with diagnoses of sacrococcygeal disorders, pain in right knee, presence of right artificial knee joint, and other chronic pain. On 07/12/24, the patient was referred for physical therapy only. At the start of care visit on 07/24/24, the physical therapist documented they did a complete drug regime review. On 07/26/24, the skilled nurse telephoned the patient and conducted a complete medication review, as well as teaching on all the medications. The skilled nurse documented there were no issues. The patient was taking acetaminophen 325 mg every 4 hours as needed for mild to moderate pain and oxycodone 5 mg – acetaminophen 325 mg, one to two tablets every 4 hours for moderate to severe pain with a maximum daily dose of 8 tablets. The skilled nurse failed to contact the physician to clarify the maximum amount of acetaminophen the patient could take in 24 hours. The patient’s medication profile included lidocaine 5% patch, apply 1 patch topically daily to painful area 12 hours per day, remove for 12 hours per day. Under “medication notes”, on 07/24/24 the physical therapist documented the lidocaine patch was used for “LBP” (low back pain) with good success and “no recent use”. On 07/26/24, the collaborating registered nurse documented the last dose was “last week” to the back with results. The patient was no longer using the lidocaine 5% patch as ordered. The collaborating registered nurse failed to contact the physician to notify them the patient was no longer using this medication. On 08/01/24, the surveyor completed an observational home visit with the physical therapist. During the visit, the patient told the physical therapist they were no longer taking the sennoside-docusate sodium stool softener that was listed on their medication profile. There is no evidence in the documentation the physical therapist reported this to the collaborating registered nurse. After the visit, the surveyor went over the medication profile with the patient. On the medication profile, apixaban 2.5 mg, take one tablet twice a day for 21 days was listed. When the surveyor asked the patient about the apixaban, the patient reported they were only taking the medication once a day. They reported this was how they had been taking the medication since they were prescribed it after their surgery. Neither the physical therapist nor the collaborating registered nurse identified the patient was not taking the apixaban as ordered. On 08/01/24 the surveyor reviewed the agency’s policy “Medications – Drug Regime Review Therapy Only Patients”, revised 01/2007 which included: - “therapy only patient medication review will be completed by the therapist in collaboration with an RN [registered nurse]. - ”The therapist’s role is to “collect information on all the medications used by the patient” and “enter medications to the Medication Profile.” - The role of the collaborating registered nurse is to “review the therapist’s medication findings” and “contact the physician as soon as possible on the day of start of care with needed clarification”. - The collaborating registered nurse’s role is to “contact the patient and/or individual managing the medications, via phone within 48 hours (72 hours for weekends/holidays)” to “relay any clarifications, reinforce high risk medication teaching, and provide medication education.” - “the therapist is to ask about medication regime compliance and about any medication changes at each visit” and communicate all medication issues to the collaborating registered nurse, including new/changed medications. - ”The collaborating registered nurse is to “contact the physician as soon as possible with needed clarification and notification and follow-up with the physician daily until all medication issues are resolved. “ On 08/02/24 at 11:00 a.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who 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. Home Visit 2. Patient #2 was admitted to the agency on 06/27/24 with diagnoses of multiple sclerosis, cerebrovascular accident (stroke), expressive aphasia, and hypertension. The 06/27/24-08-25/24 Home Health Plan of Care included pantoprazole 40 mg to be taken daily. On 08/01/24 at 11:00 a.m. the surveyor completed an observational home visit with the speech language pathologist. After the speech language pathologist left, the surveyor conducted an interview with the patient and patient caregivers (significant other and home health aide). When reviewing the patient’s medication list with the significant other it was found that the patient no longer takes the pantoprazole. When asked how long ago the patient stopped taking it, the significant other stated approximately 1 ½-2 months ago. On 08/01/24 the surveyor requested the medication review policy. The 07/2022 “Comprehensive Medication Review” policy states, for all disciplines, “a comprehensive medication review is required weekly.” There is no evidence any skilled discipline: - performed of a full medication reconciliation at the 07/03/24, 07/04/24, 07/09/24, 07/10/24, 07/11/24, 07/12/24, 07/16/24, 07/17/24, 07/18/24, 07/30/24, 07/31/24, or 08/01/24 On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. Patient #3 was admitted to the agency on 06/10/24 with diagnoses that included stage 4 pressure ulcer of the sacral region, stage 4 pressure ulcer of the right buttock, cervical spine fusion, paralytic syndrome/tetraplegia, dysfunction of the bladder, coronary artery disease, acute and subacute endocarditis and rheumatic tricuspid valve disease. Home Visit On 07/31/24, the surveyor conducted an observational home visit with the skilled nurse. During the visit, the nurse reviewed the patient’s medications with the caregiver. The skilled nurse added the following medications to the patient’s current medication profile that had not been identified at the start of care: - cranberry d-mannose (supplement) 1 tablet at bedtime - melatonin 10mg at bedtime - zinc 50mg daily - Juven nutritional powder, 1 packet twice daily - Metamucil fiber, 3 capsules daily. After the visit, the caregiver stated the medications had been taken “for awhile.” The following medication orders were incomplete: - nystatin-triamcinolone cream, apply topically 2 times daily for 8 doses; did not include the location to apply. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information at that time. 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.”

“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, and interviews with the Administrator/Director of Patient Services and Clinical Managers, it was determined in 7 of 17 records (patients #1, 2, 6, 7, 8, 12, and 13) 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 #8 was admitted to the agency on 05/22/24 with diagnoses that included diabetes with foot ulcer, chronic obstructive pulmonary disease, heart failure, and urinary retention with catheter. The plans of care failed to include wound care orders for all wounds, Hoyer (mechanical) lift order, and order for dietary supplement. Wound care orders The 06/04/24 nursing visit note documented the presence of an “unopened pressure area to right heel” with recommendation to apply moisture barrier to area. There was no evidence to support order was obtained to apply moisture barrier or other treatment for this wound. The 06/27/24 nursing visit note documented the use of booties to bilateral heels. The plan of care was not updated to include wound care use of booties to bilateral heels. Hoyer lift The 05/22/24 comprehensive assessment stated that the patient had not ambulated in several weeks but has a Hoyer (mechanical) lift to assist with transfers out of bed. (explain after 1st Hoyer above) The 05/23/24 physical therapy evaluation also confirmed that the patient was bedbound but had a Hoyer lift for transfers. The 05/22/24 plan of care did not include an order for Hoyer transfers. Dietary supplement The 05/22/24 plan of care includes order for diabetic and 2-gram sodium diet with 2 liters fluid restriction per day. Plan of care does not include order for protein supplement. The 06/07/24 nursing visit note documented that the patient is consuming 1 protein drink daily. The 06/14/24 nursing visit note documented that the patient is consuming protein drink 1 or 2 times daily. There is no evidence to support an order was obtained for protein supplement. On 08/02/24 at 11:00 am the above findings were reviewed with the Administrator/Director of Patient Services and clinical managers. Home Visit 1. Patient #1 was admitted to the agency with diagnoses of malnutrition, peritoneal cancer, mucinous adenocarcinoma (cancer) within the digestive system, and partial small bowel obstruction. TPN The 06/26/24 hospital discharge instructions included “continue TPN” (total parental nutrition). The 06/26/24-08/25/24 “Home Health Plan of Care” included caregiver to administer total parental nutrition via central catheter and flush per medication profile. On 07/30/24, in the patient record, the surveyor located a scanned pharmacy order dated 06/26/24 which included: - total parental nutrition: infuse 1100 mL over 14 hours every day, 7 days/week - vascular access: DL PICC (double lumen peripherally inserted central catheter) - flush: flush before and after infusion/labs with 10 mL of normal saline and 5 mL of heparin post infusion/labs after normal saline On 08/01/24 the surveyor requested the total parental nutrition policy. The 01/2007 “Infusion Therapy-Total Parental Nutrition Administration” policy states, initial orders for TPN should include formula of solution and total daily volume as well as flushing protocol. The skilled nurse failed to develop a plan of care which included orders for the total parental nutrition and flushes including: - amount, duration, and frequency of the total parental nutrition infusion - type, amount, and frequency of flushes On 07/17/24 the skilled nurse visited the patient for a routine visit and documented the patient stated “TPN being infused nightly for 10 hrs”. There was no evidence the skilled nurse verified the change and updated the plan of care. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers. They acknowledged the findings and provided no additional information at that time. On 08/06/24, the Administrator/Director of Patient Services electronically provided the same scanned pharmacy, however it did not change the above findings. Medications On 07/15/24 the patient’s medication list was updated to include magic mouthwash, swish and spit 5 mL as needed for mouth sores. On 07/31/24 at 10:00 a.m. the surveyor completed an observational home visit with the skilled nurse. After the skilled nurse left, the surveyor conducted an interview with the patient. During the visit the skilled nurse asked the patient about the use of the magic mouthwash and its effect. The patient responded that the mouthwash worked “good” and added the “cream works good on my lip.” When reviewing the patient’s medication list with them, after the skilled nurse left, the following was noted: - the patient was using triamcinolone acetonide 0.1% on her lips as needed for sores - the instructions for use for the magic mouthwash was to swish and spit 5 ml 4 times per day as needed for mouth sores The skilled nurse failed to update the plan of care to include: - triamcinolone acetonide 0.1% to the lips as needed for sores and the frequency of use - the frequency of use for the magic mouthwash Gastrointestinal The 06/26/24 hospital discharge included the patient was found to have an extrinsic (from outside) bowel compression with partial small bowel obstruction. The 06/26/24 plan of care failed to include orders for monitoring bowel movements, including what to do if the patient does not have a bowel movement and when to notify the physician. Nutritional Supplements On 07/01/24 the Registered Dietician visited the patient for nutritional education and documented the patient drinks 2-3 Ensure Plus cartons a day. The plan of care failed to include the use of nutritional supplements. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. 2. Patient #2 was admitted to the agency on 06/27/24 with diagnoses of multiple sclerosis, cerebrovascular accident (stroke), expressive aphasia, and hypertension. The 06/26/24 referral sent to the agency included the patient’s last physician’s visit note, dated 06/24/24. The visit note included: - blood pressure is checked 3 times per week - blood pressure is low normal range - decrease propranolol (blood pressure medication) and follow blood pressure readings for further assessment On 06/27/24 the skilled nurse visited the patient for an initial assessment and documented the home health aide demonstrated use of the home blood pressure machine and the significant other was educated on the new dose of blood medication and they will keep a blood pressure log. The 06/27/24-08/25/24 “Home Health Plan of Care” failed to include the patient caregiver to check the patient’s blood pressure 3 times per week and when to notify the physician. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers. They acknowledged the findings and provided no additional information. 3. Patient #15 was chosen from an Internet Quality Improvement & Evaluation System (iQIES) Potentially Avoidable Event Report for Emergent Care for being hospitalized related to improper medication administration side effects. The patient was admitted to the agency on 11/04/23 with diagnoses of non-small cell lung cancer with left supraclavicular (neck area) metastasis, alcohol abuse, hepatitis C, and hypertension. The patient was discharged from the agency on 12/18/24. The 06/27/24-08/25/24 “Home Health Plan of Care” included the patient had: - muscle weakness and arthralgias (joint stiffness) - limited endurance, increased fatigue, and shortness of breath with/after ambulation - an assistive device (cane) to use as needed - a history of alcohol abuse The 11/04/23-01/02/24 plan of care failed to include fall precautions. On 08/02/24 at 11:00 a.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. Patient #6 was admitted to the agency on 06/27/24 with diagnoses of right above the knee amputation, type 2 diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Home visit The 06/27/24 plan of care included IV antibiotic ertapenem 1 gram into venous catheter one time each day at the same time of day. On 07/31/24 at 9 a.m. the surveyor conducted an observational visit with the nurse present to perform a skilled nursing visit. The patient had a peripherally Inserted Central Catheter (PICC) in place. The patient’s caregiver participates in care and the surveyor observed the care giver administering a saline flush followed by a heparin flush via the PICC after the patient’s antibiotic had been completed. The plan of care failed to include: - the antibiotic duration of administration - -equipment necessary for the infusion - type, amount, and frequency of flushes - who can administer flushes and medication On 08/01/24 @ 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers. They acknowledged the findings and provided no additional information at that time. On 08/06/24, the Administrator/Director of Patient Services electronically provided the pharmacy order which included drip rate 30 minutes via dial flow 200ml/hour duration of antibiotic, flushes, type amount and frequency. Along with teaching patient on medication administration. However, the orders were not included in the agency plan of care therefore, it did not change the above findings. Patient #12 was admitted to the agency on 07/06/24 with diagnoses of osteomyelitis of the right foot, type 2 diabetes mellitus, chronic diastolic heart failure, and hypertension. The 07/06/24 plan of care included: - IV antibiotics of ceftriaxone (Rocephin) 1 gram by intravenous push route daily. - intravenous therapy section dated 07/07/24 included, intervention skilled nurse, and patient to administer intravenous medication via single lumen peripherally inserted central catheter (PICC) flush per medication profile. The medication profile/plan of care failed to include: - type, amount, frequency, and route of flushes - the duration of administration with IV medication On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information at that time. Home Visit Patient #7 was admitted to the agency 06/01/24 with diagnosis including multiple sclerosis, pressure ulcer of the sacrum, suprapubic catheter, and frequent urinary tract infections. On 07/31/24 at 9:30 a.m. the surveyor completed an observational home visit with the nurse to change a wound VAC dressing (vacuum-assisted closure of a wound is a type of therapy to help wounds heal). During the visit, the surveyor observed a sit-to-stand lift (medical device designed to assist individuals with limited mobility in transitioning from a seated to a standing position) and that the patient was wearing TED stockings on both legs (compression stockings to help prevent blood clots and swelling in the legs). Following the nurse’s visit the surveyor interviewed the patient and caregiver. They both stated the sit-to stand lift is used whenever the patient gets out of bed. The patient stated wears TED stockings 24/7 aside from when washing legs or the stockings. The 06/01/24 Home Health Plan of Care failed to include instructions for use of us sit-to-stand lift or TED stockings. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. Patient # 13 was chosen from an Internet Quality Improvement & Evaluation System (iQIES) Potentially Avoidable Event Report for Emergent Care for Hypo/Hyperglycemia. The patient was admitted to the agency 11/12/23 for surgical aftercare of an aortic coronary bypass, additional diagnoses included type one diabetes, hypertension, atrial fibrillation, and dependence on oxygen. The SN documented in a communication note the patient went to the hospital with elevated blood glucose on 11/12/23, was admitted to the hospital, and on 11/14/23 the patient was discharged from the agency. On 11/27/23 the patient was readmitted to the agency. The 11/27/23 Home Health Plan of Care included insulin aspart, B3, pump cartridge (a system that automatically tests blood glucose and administers insulin based on blood glucose reading). The 11/27/23 Home Health Plan of Care failed to include instructions for blood glucose testing and insulin administration in the event of insulin pump failure. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. 1. Patient #6 was admitted to the agency on 06/27/24 with diagnoses of right above the knee amputation, type 2 diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Home visit The 06/27/24 plan of care included IV antibiotic ertapenem 1 gram into venous catheter one time each day at the same time of day. On 07/31/24 at 9 a.m. the surveyor conducted an observational visit with the skilled nurse. The patient had a peripherally Inserted Central Catheter (PICC) in place. The patient’s caregiver participated in care and the surveyor observed the caregiver administer a saline flush followed by a heparin flush via the PICC after the patient’s antibiotic had been completed. The Home Health Plan of Care failed to include: - the antibiotic duration of administration - -equipment necessary for the infusion - type, amount, and frequency of flushes - who can administer flushes and medication On 08/01/24 at 3:00 p.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers. They acknowledged the findings and provided no additional information at that time. On 08/06/24, the Administrator/Director of Patient Services electronically provided the pharmacy order which included drip rate 30 minutes via dial flow 200ml/hour duration of antibiotic, flushes, type amount and frequency, and teaching patient medication administration. However, the orders were not included in the agency plan of care therefore, it did not change the above findings. 2. Patient #12 was admitted to the agency on 07/06/24 with diagnoses of osteomyelitis of the right foot, type 2 diabetes mellitus, chronic diastolic heart failure, and hypertension. The 07/06/24 plan of care included: - IV antibiotics of ceftriaxone 1 gram by intravenous push route daily. - patient to administer intravenous medication via single lumen peripherally inserted central catheter, flush per medication profile. The medication profile/plan of care failed to include: - type, amount, frequency, and route of flushes - the duration of administration with IV medication On 08/01/24 at 3:00 p.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information at that time. Home Visit 3. Patient #1 was admitted to the agency with diagnoses of malnutrition, peritoneal cancer, mucinous adenocarcinoma (cancer) within the digestive system, and partial small bowel obstruction. Total Parenteral Nutrition The 06/26/24 hospital discharge instructions included “continue TPN” (total intravenous nutrition). The 06/26/24-08/25/24 Home Health Plan of Care included caregiver to administer total parental nutrition via central catheter and flush per medication profile. On 07/30/24, in the patient record, the surveyor reviewed a scanned pharmacy order in the patient’s record dated 06/26/24 which included: - total parental nutrition: infuse 1100 mL over 14 hours every day, 7 days/week - vascular access: DL PICC (double lumen peripherally inserted central catheter) - flush before and after infusion/labs with 10 mL of normal saline and 5 mL of heparin post infusion/labs after normal saline The skilled nurse failed to include the total parental nutrition orders in the plan of care which included orders for the total parental nutrition and flushes including: - amount, duration, and frequency of the total parental nutrition infusion - type, amount, and frequency of flushes On 07/17/24 the nurse visited the patient for a routine visit and documented the patient stated “TPN being infused nightly for 10 hrs”. This was inconsistent with the pharmacy order, and there was no evidence the skilled nurse contacted the physician to verify the pharmacy order. On 08/01/24 at 9:00 a.m., the surveyor requested the total parental nutrition policy. The 01/2007 “Infusion Therapy-Total Parental Nutrition Administration” policy states, initial orders for TPN should include formula of solution and total daily volume as well as flushing protocol. Nutritional Supplements On 07/01/24 the registered dietician visited the patient for nutritional education and documented the patient drinks 2-3 Ensure Plus cartons a day. The plan of care failed to include the use of nutritional supplements. Medications On 07/31/24 at 10:00 a.m., the surveyor completed an observational home visit with the skilled nurse. During the visit, the patient told the nurse, “the cream works good on my lips.” After the visit, the surveyor reviewed the patient’s current medication list from the medical record, and noted there were no creams or ointments. The patient was using triamcinolone acetonide 0.1% on the lips as needed for sores The nurse failed to update the plan of care to include: - triamcinolone acetonide 0.1% to the lips as needed for sores and the frequency of use On 08/01/24 at 3:00 p.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information at that time. On 08/06/24, the Administrator/Director of Patient Services electronically provided the scanned pharmacy order the surveyor had reviewed on 07/31/24, however it did not change the above findings. 4. Patient #2 was admitted to the agency on 06/27/24 with diagnoses of multiple sclerosis, cerebrovascular accident (stroke), expressive aphasia, and hypertension. The 06/26/24 referral sent to the agency included the patient’s last physician’s visit note, dated 06/24/24. The visit note included: - blood pressure is checked 3 times per week - blood pressure is low normal range - decrease propranolol (blood pressure medication) and follow blood pressure readings for further assessment On 06/27/24 the skilled nurse visited the patient for an initial assessment and documented the home health aide demonstrated use of the home blood pressure machine and the significant other was educated on the new dose of blood medication and to keep a blood pressure log. The 06/27/24-08/25/24 Home Health Plan of Care failed to include blood pressure monitoring 3 times per week, who would complete, and parameters to determine when readings were outside an acceptable range to notify the physician. On 08/01/24 at 3:00 p.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. Home Visit 5. Patient #7 was admitted to the agency 06/01/24 with diagnosis including multiple sclerosis, pressure ulcer of the sacrum, suprapubic catheter, and frequent urinary tract infections. On 07/31/24 at 9:30 a.m., the surveyor completed an observational home visit with the nurse to change a wound VAC dressing (vacuum-assisted closure of a wound is a type of therapy to help wounds heal). During the visit, the surveyor observed a sit-to-stand lift (medical device designed to assist individuals with limited mobility in transitioning from a seated to a standing position) and that the patient was wearing TED stockings on both legs (compression stockings to help prevent blood clots and swelling in the legs). Following the nurse’s visit the surveyor interviewed the patient and caregiver. They both stated the sit-to stand lift was used whenever the patient gets out of bed, and that they obtained the lift from an organization that loans medical equipment. The patient stated they wear TED stockings 24/7 aside from when washing legs or the stockings. The 06/01/24 Home Health Plan of Care failed to include instructions for use of s sit-to-stand lift or TED stockings. On 08/01/24 at 3:00 p.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. 6. Patient # 13 was chosen from an Internet Quality Improvement & Evaluation System (iQIES) Potentially Avoidable Event Report for Emergent Care for Hypo/Hyperglycemia. The patient was admitted to the agency 11/12/23 for surgical aftercare of an aortic coronary bypass, additional diagnoses included type one diabetes, hypertension, atrial fibrillation, and dependence on oxygen. The skilled nurse documented in a communication note the patient went to the hospital with elevated blood glucose on 11/12/23, was admitted to the hospital, and on 11/14/23 the patient was discharged from the agency. On 11/27/23 the patient was readmitted to the agency. The 11/27/23 Home Health Plan of Care included insulin aspart, B3, pump cartridge (a system that automatically tests blood glucose and administers insulin based on blood glucose reading). The 11/27/23 Home Health Plan of Care failed to include instructions for blood glucose testing and insulin administration in the event of insulin pump failure. On 08/01/24 at 3:00 p.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. 7. Patient #8 was admitted to the agency on 05/22/24 with diagnoses that included diabetes with foot ulcer, chronic obstructive pulmonary disease, heart failure, and urinary retention with catheter. The plans of care failed to include wound care orders for all wounds, Hoyer (mechanical) lift order, and order for dietary supplement. Hoyer Lift On 05/22/24, the skilled nurse documented in the initial comprehensive assessment that the patient had not ambulated in several weeks but had a Hoyer (mechanical) lift to assist with transfers out of bed. The 05/23/24 physical therapy evaluation also confirmed that the patient was bedbound but had a Hoyer lift for transfers. The 05/22/24 plan of care failed to include an order for Hoyer transfers. Dietary Supplement The 05/22/24 plan of care included an order for diabetic and 2-gram sodium diet with a 2-liter fluid restriction per day. The 06/07/24 nursing visit note documented that the patient was consuming 1 protein drink daily. The 06/14/24 nursing visit note documented that the patient was consuming protein drink 1 or 2 times daily. The plan of care failed to include an order for a protein supplement. Wound Care Orders The 06/04/24 nursing visit note documented the presence of an “unopened pressure area to right heel” with recommendation to apply moisture barrier to area. The 06/27/24 nursing visit note documented the use of booties to bilateral heels. The plan of care was not updated to include the wound care, or the use of booties to bilateral heels. On 08/02/24 at 11:00 a.m., the above findings were reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and offered no additional information. 8. Patient #10 was admitted to the agency 07/19/24 with diagnoses that included hypokalemia (low potassium), history of coronary artery bypass surgery, peripheral arterial disease, and hypothyroidism. The Home Health Plan of Care dated 07/19/24-09/16/24 included: - All Home Health skilled disciplines assess patient’s understanding of prescribed diet. - Instruct patient on prescribed diet - BRAT (mild diet consisting of bananas, rice, apple juice, and toast) On 07/23/24, the skilled nurse visited the patient and documented the patient was eating a soft, bland diet, including soups, protein drinks and watermelon. On 07/26/24, the registered dietician visited the patient and documented: - the patient was on a BRAT diet for a week in the hospital - has been eating and gained 2 pounds since home - eating ice cream, milkshakes, and protein drinks The skilled nurse and registered dietician failed to contact the physician and update the plan of care with the current, advanced diet order. On 08/01/24 at 3:00 p.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. Failure to ensure the development of complete and accurate plans of care to meet the needs of the patients has the potential for negative outcomes for the agency’s patient population.”

“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 and Clinical Managers it was determined in 2 of 17 patients (patients #1 and 8) the agency staff failed to provide coordinated care to meet the needs of the patients. Evidence as follows: Patient #8 was admitted to the agency on 05/22/24 with diagnoses that included diabetes with foot ulcer, chronic obstructive pulmonary disease, heart failure, and urinary retention with catheter. The agency failed to coordinate care related to the pain medication administration error, new wounds, and unfilled medications. Pain medication administration error The 06/04/24 home health aide encounter note reported patient’s pain level 8 out of 10, patient took “pain medications” 3 hours apart instead of 8 hours apart, a low blood pressure reading, very dark uring, and a small pea sized opened area on coccyx. A registered nurse visited that day to follow-up on the home health aide report. The nursing note documented, “address any med changes/issues significant to care – no changes.” The pain section of the note reported “the client received 2 doses of hydrocodone within 4 hours this am” without any documentation of the cause of the medication error, education to patient or family, or assessment of how many doses the patient has had the previous 24 hours. The 05/22/24 plan of care includes order for Lorcet (hydrocodone-acetaminophen) 10-325mg 1 tablet over 6 hours if needed for severe pain with maximum daily dose of 4 tablets. No evidence was found that case manager or physician was notified of the pain medication administration error. New wounds On the 06/04/24 nursing visit, the nurse also documented the presence of “another unopened pressure area to right heel.” The nurse recommended the use of moisture barrier. The nurse failed to document a complete wound assessment, including description of the wound and wound measurements. No evidence was found that the case manager or physician was notified of the presence of this wound. Subsequent nursing visits failed to include assessment of the unopened pressure ulcer on the right heel. On 06/14/24 a registered nurse visited the patient and documented “an area of concern to the left collar bone area.” Documentation stated that the wife will request the patient’s physician assess the location at an appointment scheduled several days later. No evidence was found to support physician or case manager was notified of this new wound or that wound care orders were obtained. Subsequent nursing visits failed to include assessment of the left collar bone area. Unfilled medications On 06/25/24, the occupational therapist documented that wife reported several medications were called into the pharmacy but 5 of them were not filled, including pain medication, which resulted in an increase of pain to the left heel at location of the wound. The documentation does not list what the other medications waiting at the pharmacy were, indicate if the medications were new for this patient, if the patient is out of previously ordered medication, or if the caregiver had a plan to obtain the medication. There is no documentation to support the case manager, nurse manager, or physician were notified. On 06/27/24 the occupational therapist visited the patient and documentation stated that the patient has significant pain to left knee and ankle due to caregiver had not had a chance to obtain patient’s pain medication from the pharmacy. The documentation does not mention the status of the other medications called into the pharmacy. There is no documentation to support the case manager, nurse manager, or physician were notified. On 08/02/24 at 11:00 am the above findings were reviewed with the Administrator/Director of Patient Services and clinical managers. 1. Patient #1 was admitted to the agency with diagnoses of malnutrition, peritoneal cancer, mucinous adenocarcinoma (cancer) within the digestive system, and partial small bowel obstruction. On 07/01/24 the Registered Dietician visited the patient for nutritional education and documented the patient “would like to trial appetite stimulant as [the patient] is very aware of her lack of appetite and its effect with this diagnosis” and “RD [Registered Dietician] to follow via Epic and phone calls as needed.” On the same day, the dietician forwarded their note to the nurse case manager and the physician’s office. There is no evidence the nurse case manager or dietician followed up with either the physician’s office or patient regarding the use of an appetite stimulant. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers. They acknowledged the findings and provided no additional information. 2. Patient #2 was admitted to the agency on 06/27/24 with diagnoses of multiple sclerosis, cerebrovascular accident (stroke), expressive aphasia, and hypertension. The 06/27/24-08/25/24 “Home Health Plan of Care” included: - skilled nursing: 1 visit per week x 5 weeks and 3 as needed visits - physical therapy: 1 visit x 1 week, 2 visits per week x 2 weeks - occupational therapy: 1 visit x 1 week, 2 visits per week x 4 weeks - social work: 1 visit x 1 week (for evaluation) - speech language: 1 visit x 1 week (for evaluation) On 06/27/24 the skilled nurse saw the patient for an initial visit and documented the patient “has slow speech and word find issues”, the patient is “forgetful”, and their BIMS (brief interview for metal status) score was 10 (moderately impaired). The social worker visited the patient for an initial evaluation on 07/12/24 (10 business days after admission) and the speech language therapist visited the patient for an initial evaluation on 07/16/24 (12 business days after admission). On 08/01/24 the surveyor requested the policies for professional staff. The “Medical Social Services” and “Speech Language Pathology Services” policies, both dated 05/2023, states, services are “generally provided within 7 business days of the physician’s orders.” The agency failed to ensure the patient was evaluated timely by social week and speech language pathology. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers. They acknowledged the findings and provided no additional information. Patient #14 was admitted to the agency on 02/13/24 with diagnoses including hypertensive heart disease, chronic kidney disease with heart failure, type 2 diabetes, and acute and chronic respiratory failure with hypoxia. On 02/13/24 the skilled nurse performed an initial admission assessment and obtained an order for home health aides once a week for nine weeks. On 02/14/24 at 10:26 a.m., the agency staffing coordinator called the patient/caregiver to set up home health aide visits. The staffing coordinator documented they left a voicemail and would try again later. There is no evidence that any more calls were placed to the patient/caregiver to schedule home health aide visits. On 02/19/24, the electronic medical record shows a home health aide visit was canceled with a note there was a scheduling error. In an interview with the Clinical Manager on 08/02/2024, a home health aide visit was scheduled for 02/19/24 but it was unclear why it was cancelled or who canceled it. There is no evidence any attempt was made to reschedule this missed visit. The patient was admitted to the hospital on 02/21/24 and discharged on 02/23/24. There were no home health aide visits during the time the patient was admitted to the agency. On 08/01/24 the surveyor reviewed the agency policy titled “Home Health Aide Services”, revised 06/2024, which included, “Aide service is generally provided within five days of the initial request.” The agency failed to provide home health aide services in accordance with their policy and the patient’s plan of care. On 08/01/24 at 3:00 p.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. 1. Patient #1 was admitted to the agency with diagnoses of malnutrition, peritoneal cancer, mucinous adenocarcinoma (cancer) within the digestive system, and partial small bowel obstruction. On 07/01/24 the Registered Dietician visited the patient for nutritional education and documented the patient “would like to trial appetite stimulant as [the patient] is very aware of her lack of appetite and its effect with this diagnosis” and “RD [Registered Dietician] to follow via Epic and phone calls as needed.” On the same day, the dietician forwarded their note to the nurse case manager and the physician’s office. There is no evidence the nurse case manager or dietician followed up with either the physician’s office or patient regarding the use of an appetite stimulant. On 08/01/24 at 3:00 p.m. the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers. They acknowledged the findings and provided no additional information. 2. 4. Patient #14 was admitted to the agency on 02/13/24 with diagnoses including hypertensive heart disease, chronic kidney disease with heart failure, type 2 diabetes, and acute and chronic respiratory failure with hypoxia. On 02/13/24 the skilled nurse performed an initial admission assessment and obtained an order for home health aides once a week for nine weeks. On 02/14/24 at 10:26 a.m., the agency staffing coordinator called the patient/caregiver to set up home health aide visits. The staffing coordinator documented they left a voicemail and would try again later. There is no evidence that any more calls were placed to the patient/caregiver to schedule home health aide visits. On 02/19/24, the electronic medical record shows a home health aide visit was canceled with a note there was a scheduling error. In an interview with the Clinical Manager on 08/02/2024, a home health aide visit was scheduled for 02/19/24 but it was unclear why it was cancelled or who canceled it. There is no evidence any attempt was made to reschedule this missed visit. The patient was admitted to the hospital on 02/21/24 and discharged on 02/23/24. There were no home health aide visits during the time the patient was admitted to the agency. On 08/01/24 the surveyor reviewed the agency policy titled “Home Health Aide Services”, revised 06/2024, which included, “Aide service is generally provided within five days of the initial request.” The agency failed to provide home health aide services in accordance with their policy and the patient’s plan of care. On 08/01/24 at 3:00 p.m., the record was reviewed with the Administrator/Director of Patient Services and Clinical Managers who acknowledged the findings and provided no additional information. 5. Patient #8 was admitted to the agency on 05/22/24 with diagnoses that included diabetes with foot ulcer, chronic obstructive pulmonary disease, heart failure, and urinary retention with catheter. The agency failed to coordinate care related to the pain medication administration error, new wounds, and unfilled medications. Pain medication administration error The 06/04/24 home health aide encounter note reported patient’s pain level 8 out of 10, patient took “pain medications” 3 hours apart instead of 8 hours apart, a low blood pressure reading, very dark uring, and a small pea sized opened area on coccyx. A registered nurse visited that day to follow-up on the home health aide report. The nursing note documented, “address any med changes/issues significant to care – no changes.” The pain section of the note reported “the client received 2 doses of hydrocodone within 4 hours this am” without any documentation of the cause of the medication error, education to patient or family, or assessment of how many doses the patient has had the previous 24 hours. The 05/22/24 plan of care includes order for Lorcet (hydrocodone-acetaminophen) 10-325mg 1 tablet over 6 hours if needed for severe pain with maximum daily dose of 4 tablets. No evidence was found that case manager or physician was notified of the pain medication administration error. New wounds On the 06/04/24 nursing visit, the nurse also documented the presence of “another unopened pressure area to right heel.” The nurse recommended the use of moisture barrier. The nurse failed to document a complete wound assessment, including description of the wound and wound measurements. No evidence was found that the case manager or physician was notified of the presence of this wound. Subsequent nursing visits failed to include assessment of the unopened pressure ulcer on the right heel. On 06/14/24 a registered nurse visited the patient and documented “an area of concern to the left collar bone area.” Documentation stated that the wife will request the patient’s physician assess the location at an appointment scheduled several days later. No evidence was found to support physician or case manager was notified of this new wound or that wound care orders were obtained. Subsequent nursing visits failed to include assessment of the left collar bone area. Unfilled medications On 06/25/24, the occupational therapist documented that wife reported several medications were called into the pharmacy but 5 of them were not filled, including pain medication, which resulted in an increase of pain to the left heel at location of the wound. The documentation does not list what the other medications waiting at the pharmacy were, indicate if the medications were new for this patient, if the patient is out of previously ordered medication, or if the caregiver had a plan to obtain the medication. There is no documentation to support the case manager, nurse manager, or physician were notified. On 06/27/24 the occupational therapist visited the patient and documentation stated that the patient has significant pain to left knee and ankle due to caregiver had not had a chance to obtain patient’s pain medication from the pharmacy. The documentation does not mention the status of the other medications called into the pharmacy. There is no documentation to support the case manager, nurse manager, or physician were notified. On 08/02/24 at 11:00 am the above findings were reviewed with the Administrator/Director of Patient Services and clinical managers 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.”