Parker Jewish Inst for Health Care & Rehab Chha

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on clinical record review and staff interview, the Governing Authority failed to provide infection control education to patients and caregivers. This was evident in one (1) of seven (7) clinical records reviewed. (Patient #4.) Failure to provide infection control education to patients and caregivers has the potential to result in negative patient outcomes. Findings are: 1) Patient #4 has a start of care date of 8/3/2024 with diagnoses of pressure ulcer of other sites, pressure-induced tissue damage to left heel, acute/chronic respiratory failure with hypoxia, end stage renal disease, dependence on renal dialysis as documented on the “Home Health Certification and Plan of Care certification period 08/03/2024 to 10/01/2024.” The “Home Health Certification and Plan of Care certification period of 08/03/2024 to 10/01/2024 documented orders for skilled nursing 1/week x 6 weeks to assess instruct patient and care giver on disease management and complications The “Resident Face Sheet” documented “Encounter for surgical aftercare following surgery on the circulatory system and persistent post procedural fistula.” The physician note dated 5/23/2024 documented patient is medically complex, on hemodialysis three times a week, with open wounds, pressure ulcer/injury, respiratory infections and with a right sided permcath and right fistula. The agency Start of Care Oasis dated 8/3/2024 general system review documented patient did not have any access/infusion sites. The Skilled Nurse/Registered Nurse “Start of Care” assessment and clinical note dated 08/03/2024, the team care plan dated 08/06/2024, skilled nursing clinical notes dates of 08/17/2024, 08/30/2024 and 09/06/2024, lacked documented evidence of patient/family instructions on care of permcath access, infection prevention to right chest wall access, and fistula, and safe infection prevention practices in the home setting. The survey findings and interview were conducted with the agency’s Director of Patient Services, and the Vice President of Operations on 09/18/2024 at 01:17.PM.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure that Consent for all services is provided by the agency. This was evident in six(6) of seven (7) clinical records reviewed (Patients #2, #3, #4, #5, #6, #7). Failure to ensure that consent for services include the type of services has the potential for negative patient outcomes. The findings are: 3) Patient #4 has a start of care date of 8/3/2024 with diagnoses of pressure ulcer of other sites, pressure-induced tissue damage to left heel, acute/chronic respiratory failure with hypoxia, end stage renal disease, dependence on renal dialysis as documented on the “Home Health Certification and Plan of Care certification period 08/03/2024 to 10/01/2024. The “Home Health Certification and Plan of Care certification period of 08/03/2024 to 10/01/2024 documented orders for skilled nursing 1/week x 6 weeks , physical therapy 1x week x1week, 2x week x 3weeks, 2x week x3 weeks. Aide 3-5xweek x5 weeks The “Assignment/referral sheet” dated 7/31/2024 documented services of skilled nursing , physical therapy services, and assessment of home health aide needs. The “Admission Consent” dated 8/3/2024 did not include services, the frequency of such services for the Physical Therapist and Home Health Aide. The agency did not obtain signed consents for the services of Physical Therapy and Home Health Aide as outlined in the Plan of Care. The survey findings and interview were conducted with the agency’s Director of Patient Services, and the Vice President of Operations on 09/18/2024 at 01:00.PM. 4) Patient # 2 has a start of care date of 08/16/2024 with diagnoses of “Displaced Transverse Fracture of Left Femur, Encounter for closed fracture with routine healing” as documented on the “Home Health Certification and Plan of Care” for certification period 08/16/2024 to 10/14/2024. The “Referral/Assignment sheet and Resident Face sheet” dated 08/13/2024 documents a request for “Skilled Nurse and Physical Therapy services”. The “Admission Consent” dated 08/16/2024 lacks documentation of the Skilled Nurse and Physical Therapy services. The “Home Health Certification and Plan of Care” for certification period 08/16/2024 to 10/14/2024 documents orders for services “Skilled Nurse 1x week x 4 weeks (one visit a week for four weeks)” and “Physical Therapy 1 day x 1 day, 3x week x 2 weeks (one visit for one day, three visits a week for two weeks)”. The Agency did not obtain signed consent for Skilled Nurse and Physical Therapy services to be provided, as ordered in the Plan of Care. The survey findings and interview were conducted on 09/18/2024 at 12:17 PM with the Director of Patient Services and at 02:37 PM with the Agency’s staff. No explanation was provided. 5) Patient #3 has a start of care date of 08/22/2024 with diagnoses of “Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side” as documented on the “Home Health Certification and Plan of Care” for certification period 08/22/2024 to 10/20/2024. The “Referral/Assignment sheet and Resident Face sheet” dated 08/15/2024 documents a request for “Skilled Nurse and Physical Therapy services”. The “Home Health Certification and Plan of Care” (Plan of Care) for certification period 08/22/2024 to 10/20/2024 documents diagnose of “Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side”. Skilled Nurse 1x week x 3 weeks (one visits a week for three weeks). Physical Therapy services 2x week x 4 weeks (two visits a week for four weeks), Aide 5x week, 5 weeks (five days a week for five weeks)”. The “Admission Consent” dated 08/22/2024 lacks documentation of the Physical Therapy and Home Health Aide services. The Agency did not obtain signed consent for Skilled Nurse and Physical Therapy services to be provided, as ordered in the Plan of Care. The survey findings and interview were conducted on 09/18/2024 at 12:17 PM with the Director of Patient Services and at 02:37 PM with the Agency’s staff. No explanation was provided. 6) Patient #7 has a start of care date of 01/02/2024 with diagnoses of Hemiplegia and Hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side and Pressure Ulcer of Sacral Region. The “Home Health Certification and Plan of Care” for certification period 01/02/2024 to 03/01/2024 documents orders for services “Skilled Nurse 1 - 2x week x 3 weeks, 1 - 2x week x 1 week, 1x week x 2 weeks, (one to two visits a week for four weeks and one visit a week for two weeks) and “Physical Therapy 2x week x 4 weeks (two visits a week for four weeks)”. The “Admission Consent” dated 01/30/2024 lacks documentation of Physical Therapy services. The Agency did not obtain signed consent for Physical Therapy services to be provided, as ordered in the Plan of Care. The survey findings and interview were conducted on 09/18/2024 at 03:05 PM with the Director of Patient Services and the Agency’s staff. No explanation was provided. 1) Patient # 5 has a start of care date of 08/09/2024 with diagnoses of “Chronic Atrial Fibrillation Atrioventricular Block, Alzheimer’s Disease, Dementia, Type 2 Diabetes, Hypertension, Hyperlipemia and Transient Ischemic Attack” as documented on the “Home Health Certification and Plan of Care” for certification period 08/09/2024 to 10/07/2024. The “Home Health Certification and Plan of Care” for certification period 08/16/2024 to 10/14/2024 documents orders for services “Skilled Nurse 1x week x 5 weeks (one visit a week for five weeks)”, “Physical Therapy 1 week x 1 week, 2x week x 4 weeks, 2 x week x 2 weeks (one visit a week for one week, two visits a week for four weeks and two visits a week for two weeks)” and “ Aide 3x week x6 weeks ( three times a week for six weeks)”. The “Referral/Assignment sheet and Resident Face sheet” dated 08/06/2024 documents a request for “Skilled Nurse, Physical Therapy and Home Health Aide services”. The “Admission Consent” dated 08/06/2024 lack documentation of the Physical Therapy and Home Health Aide services. The Agency did not obtain signed consent for Physical Therapy and Home Health Aide services to be provided as ordered in the Plan of Care. 2) Patient # 6 has a start of care date of 04/18/2023 and discharge date of 04/30/2024 with diagnoses of “Pressure Ulcer left Buttock Stage 2, Cellulitis of Buttock, Local Infection of the skin and Subcutaneous tissue, Urinary Tract Infection, Atrial Fibrillation, Hypertension and Hyperlipemia” as documented on the “Home Health Certification and Plan of Care” for certification period 04/12/2024 to 06/10/2024. The “Home Health Certification and Plan of Care” for certification period 04/12/2024 to 06/10/2024 documents orders for services “Skilled Nurse 1-2x week x1 weeks, 1-3x week x 8 weeks (one to two visit a week for one week, one to three times a week for eight week)” and “Aide 1-2 x week x1 week, 1-5 x week x 7 weeks( one to two times a week for one week, one to five times for seven weeks”. The “Referral/Assignment sheet and Resident Face sheet” dated 04/10/2024 documents a request for “Skilled Nurse, Physical Therapy and Occupational Therapy services”. The “Home Health Certification and Plan of Care” for certification period 04/18/2023 to 06/16/2023 documents orders for services “Skilled Nurse 1-2x week x 9 weeks (one to two visit a week for nine weeks)”, “Physical Therapy 1 week x 1 week,1- 2x week x 1 weeks, 1 x week x 4weeks (one visit a week for one week, one to two visits a week for one week and one visit a week for four weeks)”, “ Occupational therapy 1 x week x 4 week ( one times a week for four weeks) and “ Aide 1-2 x week x 1 week, 3-5 x week x 3 week, 3-5 x week x 5 weeks (one to two times a week for one week, three to five times a week for three weeks, three to five times a week for five weeks”. The “Admission Consent” dated 04/18/2024 lack documentation of the Physical Therapy, Occupational therapy, and Home Health Aide services. The Agency did not obtain signed consent for Physical Therapy, Occupational therapy and Home Health Aide services to be provided, as ordered in the Plan of Care. The survey findings and interview were conducted on 09/18/2024 at 3:00 PM with the Director of Patient Services and the Agency’s staff. No explanation was provided.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) 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: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on review of clinical records and staff interview, the Governing Authority failed to ensure comprehensive assessment is consistent and accurately reflects the patient’s health status and needs. Failure to ensure comprehensive assessments accurately reflect the patient status and needs has the potential for unmet patient needs and the potential for negative patient outcomes. This is evident in five (5) of seven (7) records reviewed. (Patient #2, #3, # 4, #6 and #7) Findings are: 2) Patient # 4 has a start of care date of 08/03/2024 with diagnoses of pressure ulcer of other sites unstageable, pressure induced tissue damage of left heel, acute and chronic respiratory failure with hypoxia, end stage renal disease with dependence on renal dialysis as documented on the “Home Health Certification and Plan of Care” for certification period 08/03/2024 to 10/01/2024. The “Home Health Certification and Plan of Care” for certification period 08/03/2024 to 10/01/2024 documents an order for Skilled Nurse 1x week x 6 weeks to assess, instruct patient/caregiver in disease management and complications. Medications listed on home Health Plan of Care includes Sevelamer Hydrochloride 800mgs by mouth, a phosphate binder for renal osteodystrophy, and Sodium Bicarbonate tablet 650mgs, one tablet three times daily for renal osteodystrophy. The Skilled Nurse/Registered Nurse “Start of Care” assessment and clinical note dated 08/03/2024, the team care plan dated 08/06/2024, skilled nursing clinical notes dates of 08/17/2024, 08/30/2024 and 09/06/2024, lacked documented evidence of patient instruction regarding the use of these medications, when patient is to take these medications, the dietary implications, potential side effects and the importance of adhering to the medications regimen. The Agency “Start of Care Oasis” did not include a comprehensive nutrition assessment needs of patient with diagnosis of end stage renal disease on hemodialysis. The Start of Care Oasis “Care Management/Medications” did not include instructions , precautions and possible side effects associated with Sevelamer Hydrochloride and Sodium Bicarbonate tablets. The survey findings and interview were conducted on 09/18/2024 at 1:17 PM with the Director of Patient Services and Agency’s staff. No explanation was provided. 3)Patient # 2 has a start of care date of 08/16/2024 with diagnoses of “Displaced Transverse Fracture of Left Femur, Encounter for closed fracture with routine healing” as documented on the “Home Health Certification and Plan of Care” for certification period 08/16/2024 to 10/14/2024. The “Home Health Certification and Plan of Care” for certification period 08/16/2024 to 10/14/2024 documents an order for Skilled Nurse 1x week x 4 weeks (one visit a week for four weeks) to “assess and instruct hypertension every visit”. Medications include “Triamterene- HCTZ (Hydrochlorothiazide) by mouth capsule 37.5/25 milligram one capsule daily po (by mouth)” for hypertension. The Skilled Nurse/Registered Nurse “Start of Care” assessment dated 08/16/2024 lacks documentation of an assessment of the patient’s vital signs including Blood Pressure reading. The Agency comprehensive assessment does not include the patient’s current health status of vital signs and blood pressure assessment for a patient with diagnosis of Essential Primary Hypertension and prescribed therapeutic anti-hypertensive medications. The survey findings and interview were conducted on 09/18/2024 at 12:17 PM with the Director of Patient Services and at 02:37 PM with the Agency’s staff. No explanation was provided. 4) Patient #3 has a start of care date of 08/22/2024 with diagnoses of “Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side” as documented on the “Home Health Certification and Plan of Care” for certification period 08/22/2024 to 10/20/2024. The “Home Health Certification and Plan of Care” for certification period 08/22/2024 to 10/20/2024 documents diagnose of “Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side”. Skilled Nurse 1x week x 3 weeks (one visits a week for three weeks)”. Oxygen at 2 liter as needed daily per nostril”. The Skilled Nurse/Registered Nurse “Start of Care” assessment dated 08/16/2024 lacks documentation of an assessment of the patient’s Oxygen at 2 liter as needed daily. The “Respiratory system” assessment documents” Patient does not use oxygen”. There is no documented evidence of instruction of oxygen usage and precautions. The survey findings and interview were conducted on 09/18/2024 at 03:45 PM with the Director of Patient Services and the Agency’s Staff. No explanation was provided. 5) Patient #7 has a start of care date of 01/02/2024 with diagnoses of Hemiplegia and Hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side and Pressure Ulcer of Sacral Region, and Essential Primary Hypertension. The “Home Health Certification and Plan of Care” for certification period 01/02/2024 to 03/01/2024 documents orders for services “Skilled Nurse 1 - 2x week x 3 weeks, 1 - 2x week x 1 week, 1x week x 2 weeks, (one to two visits a week for four weeks and one visit a week for two weeks) to “assess/instruct signs and symptoms of Hypertension and assess/instruct signs and symptoms of Hypotension”. Skilled Nurse to “notify Physician if blood pressure is outside the range of systolic blood pressure less than 90 or greater than 160”. The Skilled Nurse/Registered Nurse “Start of Care” assessment dated 01/02/2024 lacks documentation of an assessment of the patient’s vital signs including Blood Pressure reading. The Cardiovascular system assessment lacks documentation of the patient’s Hypertension. The Agency comprehensive assessment does not include the patient’s current health status of vital signs and blood pressure assessment for a patient with diagnosis of Essential Primary Hypertension. The survey findings and interview were conducted on 09/18/2024 at 03:05 PM with the Director of Patient Services and the Agency’s staff. No explanation was provided. 1) Patient # 6 has a start of care date of 04/18/2023 and discharge date of 04/30/2024 with diagnoses of “Pressure Ulcer left Buttock Stage 2, Cellulitis of Buttock, Local Infection of the skin and Subcutaneous tissue, Urinary Tract Infection, Atrial Fibrillation, Hypertension and Hyperlipemia” as documented on the “Home Health Certification and Plan of Care” for certification period 04/12/2024 to 06/10/2024. The “Home Health Certification and Plan of Care” for certification period 04/12/2024 to 06/10/2024 documents orders for services “Skilled Nurse 1-2x week x1 weeks, 1-3x week x 8 weeks(one to two visit a week for one week, one to three times a week for eight week) skill nurse to perform care 2-3 times weekly “ “ and “ Aide 1-2 x week x1 week, 1-5 x week x 7 weeks( one to two times a week for one week, one to five times for seven weeks”. The Agency comprehensive assessments lacks documented assessments of current vital signs measurements (blood pressure, pulse, temperature and respiration) which is pertinent information in patient health status as it relates to monitoring infection and other changes due to patient diagnoses of Pressure Ulcer left Buttock Stage 2, Cellulitis of Buttock, Local Infection of the skin and Subcutaneous tissue, Urinary Tract Infection, Atrial Fibrillation and Hypertension. The “ Start of Care” comprehensive assessment dated 04/18/2023 lacks documentation of the patient’s vital signs: Blood Pressure, Pulse, Temperature, Respirations readings. The “ Resumption of Care” comprehensive assessment dated 08/02/2023 lacks documentation of the patient’s vital signs: Blood Pressure, Pulse, Temperature, Respirations readings. The “Recertification of Care” comprehensive assessment dated 08/11/2023 lacks documentation of the patient’s vital signs: Blood Pressure, Pulse, Temperature, Respirations readings. The “Recertification of Care” comprehensive assessment dated 04/10/2024 lacks documentation of the patient’s vital signs: Blood Pressure, Pulse, Temperature, Respirations readings. The survey findings and interview were conducted on 09/18/2024 at 3:00 PM with the Director of Patient Services and the Agency’s staff. No explanation was provided.”

“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 clinical record review, interview with agency staff and home visits, one (1) of three home visits conducted (Patient #3) lack documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns. Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for negative patient outcomes. The findings are: 1) Patient #3 has a start of care date of 08/22/2024 with diagnoses of “Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side” as documented on the “Home Health Certification and Plan of Care” for certification period 08/22/2024 to 10/20/2024. The “Home Health Certification and Plan of Care” for certification period 08/22/2024 to 10/20/2024 documents diagnose of “Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side”. Skilled Nurse 1x week x 3 weeks (one visit a week for three weeks) to “compare current and newly ordered medications every visit; provide a reconciled medication list to patient/caregiver every visit; call Medical Doctor to verify medication changes/clarify discrepancies every visit”. Medication includes “Atorvastatin Calcium by mouth tablet 40 milligram one tablet daily per oral, Metropolol Succinate extended release by mouth tablet 25 milligram one tablet daily oral, Synthroid by mouth tablet 50 microgram one tablet daily per oral, Omeprazole by mouth capsule delayed release 40 milligram one capsule daily per oral, Senna by mouth 8.6 milligram two tablet daily per oral, Magnesium by mouth tablet 400 milligram one tablet daily per oral, Melatonin by mouth tablet 3 milligram one tablet daily per oral”. Skilled Nurse/Registered Nurse visits are dated 08/22/2024, 09/03/2024, and 09/10/2024. The Skilled Nurse routine visit note dated 09/03/2024, the Registered Nurse documents: “Medication education- Celebrex”. There is no documentation of the medication dosage, route, frequency, duration, and start date. There is no documented evidence of a Physician’s Order for Celebrex. A Home Visit was conducted on 09/17/2024 with the Skilled Nurse/Registered Nurse. During the visit, the Registered Nurse reviewed the patient’s medications. Medication discrepancies were identified for: Lovastatin by mouth tablet 10 milligram one tablet daily (prescription bottle is dated 07/08/2024). “Patient states taking medication since home” on 08/22/2024. Atorvastatin Calcium by mouth tablet 40 milligram prescription bottle was not observed the home. Metropolol Succinate by mouth tablet 25 milligram two tablet daily per oral (presciption bottle is dated 04/19/2024. “patient states taking two tablets daily since home” on 08/22/2024). Synthroid by mouth tablet 75 microgram one tablet daily per oral (prescription bottle is dated 07/08/2024). “patient states taking medication since home” on 08/22/2024). Sucrafate/Carafate by mouth tablet 1 gram one tablet twice daily per oral (prescription bottle is dated 04/22/2024, “patient states taking medication four days prior”). Omeprazole by mouth capsule delayed release 40 milligram one capsule daily per oral (prescription bottle is dated 07/08/2024). “Patient states taking medication for fifteen years”) Colace by mouth tablet 100 milligram one tablet twice daily per oral (no prescription label noted - over the counter medication, “patient states taking since home” on 08/22/2024). Senna by mouth 8.6 milligram two tablet (not available in-home during survey home visit on 09/17/24) Magnesium by mouth tablet 500 milligram one tablet daily per oral (no prescription label noted - over the counter medication. “Patient states taking medication for fifteen years”). Magnesium 400 milligram not observed in the home. Melatonin by mouth tablet 3 milligram one tablet daily per oral (medication not observed in the home during survey home visit on 09/17/24) AREDS-2 by mouth capsule one capsule twice a day per oral (no prescription label noted - over the counter medication, “patient states taking since home” on 08/22/2024) The clinical records lack documented evidence that the Registered Nurse compared current and newly ordered medications every visit, as ordered in the Plan of Care. The Agency did not ensure a comprehensive review of all medications that the patient is taking including prescription and over-the-counter medications. The survey findings and interview were conducted on 09/17/2024 at 3:41 PM with the Director of Patient Services and on 09/18/2024 at 3:45 PM with the Agency’s Staff. No explanation was provided.”

“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 clinical record review, observational home visits, and staff interviews, the Governing Authority failed to establish a complete individualized Plan of Care that identifies all pertinent diagnosis, medications, and treatments, specific tasks and responsibilities of the Registered Nurse and Paraprofessional care and services to be performed, and all required treatments based on the patient’s needed home care services. This was evident in five (5) of the seven (7) clinical records reviewed (Patient #2, #3, #4, #6 and #7). Failure to ensure a complete individualized Plan of Care is developed for each patient has the potential for negative patient outcomes. The findings are: 2) Patient # 2 has a start of care date of 08/16/2024 with diagnoses of “Displaced Transverse Fracture of Left Femur, Encounter for closed fracture with routine healing” as documented on the “Home Health Certification and Plan of Care” for certification period 08/16/2024 to 10/14/2024. The “Referral/Resident Face sheet” dated 08/13/2024 other diagnoses of “Unspecified Fall, Hypothyroidism, mixed Hyperlipidemia, Atherosclerotic Heart Disease of Coronary Artery without Angina Pectoris, and Essential Primary Hypertension”. The “Home Health Certification and Plan of Care” for certification period 08/16/2024 to 10/14/2024 documents diagnoses of “Displaced Transverse Fracture of Left Femur, Encounter for closed fracture with routine healing, and Long-term current use of Aspirin”. Services include Skilled Nurse 1x week x 4 weeks (One visit a week for four weeks)” and “Physical Therapy 1 day x 1 day, 3x week x 2 weeks (one visit for one day, three visits a week for two weeks)”. The “Start of Care” assessment dated 08/16/2024, the Skilled Nurse/Registered Nurse documents the patient’s other diagnoses of “Unspecified Fall, Hypothyroidism, mixed Hyperlipidemia, Atherosclerotic heart disease of coronary artery without angina pectoris, Essential Primary Hypertension”. The Home Health Certification and Plan of Care lacks an order for the Physical Therapy treatments, and the patient’s other pertinent diagnoses of “Unspecified Fall, Hypothyroidism, mixed Hyperlipidemia, Atherosclerotic heart disease of coronary artery without angina pectoris, Essential Primary Hypertension. There is no order for assessment of the patient’s risk for Emergency Department visits, and risk for hospital readmission. The survey findings and interview were conducted on 09/18/2024 at 12:17 PM with the Director of Patient Services and at 02:37 PM with the Agency’s staff. No explanation was provided. 3) Patient #3 has a start of care date of 08/22/2024 with diagnoses of “Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side” as documented on the “Home Health Certification and Plan of Care” for certification period 08/22/2024 to 10/20/2024. The “Home Health Certification and Plan of Care” for certification period 08/22/2024 to 10/20/2024 documents diagnose of “Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side”. Skilled Nurse 1x week x 3 weeks (one visit a week for three weeks) to “compare current and newly ordered medications every visit; provide a reconciled medication list to patient/caregiver every visit; call Medical Doctor to verify medication changes/clarify discrepancies every visit”. Physical Therapy services 2x week x 4 weeks (two visits a week for four weeks), Aide 5x week, 5 weeks (five days a week for five weeks)”. Medication includes “Atorvastatin Calcium by mouth tablet 40 milligram one tablet daily per oral, Metropolol Succinate extended release by mouth tablet 25 milligram one tablet daily oral, Synthroid by mouth tablet 50 microgram one tablet daily per oral, Omeprazole by mouth capsule delayed release 40 milligram one capsule daily per oral, Senna by mouth 8.6 milligram two tablet daily per oral, Magnesium by mouth tablet 400 milligram one tablet daily per oral, Melatonin by mouth tablet 3 milligram one tablet daily per oral”. The “Start of Care” assessment dated 08/22/2024, the Skilled Nurse/Registered Nurse documents the patient’s other diagnoses of “Asthma, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Hyperlipidemias, Hypertension, Pulmonary Fibrosis, Aortic Stenosis, Atrial Fibrillation”. Blood pressure 117/81 and pulse oxygen saturation rate of 97%. A Home Visit was conducted on 09/17/2024 with Skilled Nurse/Registered Nurse. During the visit, the Registered Nurse reviewed the patient’s medications. Medication discrepancies were identified for several medications in the home that the patient reports taking since home on start of care 08/22/2024. Lovastatin by mouth tablet 10 milligram one tablet daily (prescription bottle is dated 07/08/2024). “Patient states taking medication since home” on 08/22/2024. Atorvastatin Calcium by mouth tablet 40 milligram prescription bottle was not observed the home. Metoprolol Succinate by mouth tablet 25 milligram two tablet daily oral (prescription bottle is dated 04/19/2024. “Patient states taking two tablets daily since home” on 08/22/2024). Synthroid by mouth tablet 75 microgram one tablet daily per oral (prescription bottle is dated 07/08/2024). “Patient states taking medication since home” on 08/22/2024). Omeprazole by mouth capsule delayed release 40 milligram one capsule daily per oral (prescription bottle is dated 07/08/2024). “Patient states taking medication for fifteen years”) Colace by mouth tablet 100 milligram one tablet twice daily per oral (no prescription label noted - over the counter medication, “patient states taking since home” on 08/22/2024). Magnesium by mouth tablet 500 milligram one tablet daily per oral (no prescription label noted - over the counter medication. “Patient states taking medication for fifteen years”). Magnesium 400 milligram not observed in the home. AREDS-2 by mouth capsule one capsule twice a day per oral (no prescription label noted - over the counter medication, “patient states taking since home” on 08/22/2024) The medications listed on the Home Health Certification and Plan of Care dated 08/22/2024 does not reflect an accurate list of the patient’s medication regimen. The Home Health Certification and Plan of Care lacks an order for the current medications from start of care 08/22/2024. The Plan of Care lacks the Physical Therapy treatments, Blood Pressure parameters, Oxygen saturation rate, and pertinent diagnoses of “Asthma, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Hyperlipidemias, Hypertension, Pulmonary Fibrosis, Aortic Stenosis, Atrial Fibrillation”. The Agency did not establish an individualized Plan of Care to include all medications, diagnoses, and treatments. The survey findings and interview were conducted on 09/18/2024 at 03:45 PM with the Director of Patient Services and the Agency’s Staff. No explanation was provided. 4) Patient #7 has a start of care date of 01/02/2024 with diagnoses of Hemiplegia and Hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side and Pressure Ulcer of Sacral Region. The “Home Health Certification and Plan of Care” for certification period 01/02/2024 to 03/01/2024 documents orders for services “Skilled Nurse 1 - 2x week x 3 weeks, 1 - 2x week x 1 week, 1x week x 2 weeks, (one to two visits a week for four weeks and one visit a week for two weeks) and “Physical Therapy 2x week x 4 weeks (two visits a week for four weeks)”. Physical Therapy services and treatments were provided on 01/12/24, 01/16/24, 01/18/24, 01/23/24, 01/25/24, 01/30/24, 02/01/24, 02/06/24, 02/08/24, and 02/21/24. The Home Health Certification and Plan of Care lacks an order for Physical Therapy treatments. The survey findings and interview were conducted on 09/18/2024 at 03:05 PM with the Director of Patient Services and the Agency’s staff. No explanation was provided. 5) Patient # 4 has a start of care date of 08/01/2024 with diagnoses of pressure ulcer of other sites unstageable, pressure induced tissue damage of left heel, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and end stage renal disease with dependence on renal dialysis as documented on the “Home Health Certification and Plan of Care” for certification period 08/03/2024 to 10/01/2024. The Home Health Certification and Plan of Care documents patient’s need of CPAP (continuous positive airway pressure), oxygen, oxygen concentrator, and suction as durable medical equipment. The “Home Health Certification and Plan of Care” certification period of 08/03/2024 to 10/01/2024 documented orders for skilled nursing 1/week x 6 weeks , physical therapy 1x week x1week, 2x week x 3weeks, 2x week x3 weeks. Aide 3-5xweek x5 weeks. Skilled nurse order and treatment plan on the Home Health Certification and Plan of Care did not include teaching and instructions on patient’s dependence on CPAP (continuous positive airway pressure). The “Start of Care Oasis skilled nursing assessment dated 08/03/2024 documents the patient has no sleep disturbance. The general respiratory systems review documentation did not include patient experiencing difficulty breathing during sleep and the use of CPAP. The Home Health Certification and Plan of Care is not individualized and lacked comprehensive assessment accurately reflecting patient’s inability to maintain spontaneous airway oxygenation during sleep and the potential for recurrent emergency room visits or re-hospitalization. The survey findings and interview were conducted on 09/18/2024 at 1:17 PM with the Director of Patient Services and Vice President of Operations. 1) Patient # 6 has a start of care date of 04/18/2023 and discharge date of 04/30/2024 with diagnoses of “Pressure Ulcer left Buttock Stage 2, Cellulitis of Buttock, Local Infection of the skin and Subcutaneous tissue, Urinary Tract Infection, Atrial Fibrillation, Hypertension and Hyperlipemia” as documented on the “Home Health Certification and Plan of Care” for certification period 04/12/2024 to 06/10/2024. The “Home Health Certification and Plan of Care” for certification period 04/12/2024 to 06/10/2024 documents orders for services “Skilled Nurse 1-2x week x1 weeks, 1-3x week x 8 weeks(one to two visit a week for one week, one to three times a week for eight week) skill nurse to perform wound care to let buttock 2-3 times weekly” and “Aide 1-2 x week x1 week, 1-5 x week x 7 weeks (one to two times a week for one week, one to five times for seven weeks)”. The plan of care lacked duration of Aide services, specific tasks to perform for the patient and instruction and responsibilities to monitor and report to skilled nurse. The Plan of Care lacked documented evidence to include the specific task of skilled nursing services of the Registered Nurse to include ongoing nursing assessments of patient health status/management, to assess/instruct patient and caregiver in precipitating factors leading to skin impairments, instruct patient/caregiver in methods to prevent pressure ulcers, adequate nutrition for prevention of skin breakdown, infection control, frequent turn and position, assess pain and non-pharmacological methods, review of medication regimen, education and effects of medication. Signs and symptoms to report to physician and skilled nurse, supervision of the aide services and review of the plan of care. The survey findings and interview were conducted on 09/18/2024 at 3:00 PM with the Director of Patient Services and the Agency’s staff. No explanation was provided.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on Home Visit observation and clinical record review, the Agency failed to ensure medications and treatments are administered as ordered by the Physician. This was evident in two (2) of seven (7) records reviewed. (Patients #3 and #7). Failure to ensure medications and treatments are administered only as ordered by the Physician, has the potential for negative patient outcome. The findings include: 1) Patient #3 has a start of care date of 08/22/2024 with diagnoses of “Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side” as documented on the “Home Health Certification and Plan of Care” for certification period 08/22/2024 to 10/20/2024. The “Home Health Certification and Plan of Care” for certification period 08/22/2024 to 10/20/2024 documents diagnose of “Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side”. Skilled Nurse 1x week x 3 weeks (one visit a week for three weeks) to “compare current and newly ordered medications every visit; provide a reconciled medication list to patient/caregiver every visit; call Medical Doctor to verify medication changes/clarify discrepancies every visit”. Medication includes” Atorvastatin Calcium by mouth tablet 40 milligram one tablet daily per oral, Metropolol Succinate extended release by mouth tablet 25 milligram one tablet daily oral, Synthroid by mouth tablet 50 microgram one tablet daily per oral, Omeprazole by mouth capsule delayed release 40 milligram one capsule daily per oral, Senna by mouth 8.6 milligram two tablet daily per oral, Magnesium by mouth tablet 400 milligram one tablet daily per oral, Melatonin by mouth tablet 3 milligram one tablet daily per oral”. The Skilled Nurse routine visit note dated 09/03/2024, the Registered Nurse documents: “Medication education- Celebrex”. There is no documentation of the medication dosage, route frequency, duration and start date. There is no documented evidence of a Physician’s Order for Celebrex. A Home Visit was conducted on 09/17/2024 withe Skilled Nurse/Registered Nurse. During the visit, the Registered Nurse reviewed the patient’s medications. Medication discrepancies were identified for several medications in the home that the patient reports taking since home on start of care 08/22/2024. Lovastatin by mouth tablet 10 milligram one tablet daily (prescription bottle is dated 07/08/2024). “Patient states taking medication since home” on 08/22/2024. Atorvastatin Calcium by mouth tablet 40 milligram prescription bottle was not observed the home. Metoprolol Succinate by mouth tablet 25 milligram two tablet daily oral (prescription bottle is dated 04/19/2024. “Patient states taking two tablets daily since home” on 08/22/2024). Synthroid by mouth tablet 75 microgram one tablet daily per oral (prescription bottle is dated 07/08/2024). “Patient states taking medication since home” on 08/22/2024). Omeprazole by mouth capsule delayed release 40 milligram one capsule daily per oral (prescription bottle is dated 07/08/2024). “Patient states taking medication for fifteen years”) Colace by mouth tablet 100 milligram one tablet twice daily per oral (no prescription label noted - over the counter medication, “patient states taking since home” on 08/22/2024). Magnesium by mouth tablet 500 milligram one tablet daily per oral (no prescription label noted - over the counter medication. “Patient states taking medication for fifteen years”). Magnesium 400 milligram not observed in the home. AREDS-2 by mouth capsule one capsule twice a day per oral (no prescription label noted - over the counter medication, “patient states taking since home” on 08/22/2024) The Skilled Nurse routine visit notes dated 09/03/24 and 09/10/24 lack documented evidence that the Registered Nurse compared the patient’s current and newly ordered medications every visit; provide a reconciled medication list to patient/caregiver every visit; call Medical Doctor to verify medication changes/clarify discrepancies every visit. The survey findings and interview were conducted on 09/18/2024 at 03:45 PM with the Director of Patient Services and the Agency’s Staff. No explanation was provided. 2) Patient #7 has a start of care date of 01/02/2024 with diagnoses of Hemiplegia and Hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side and Pressure Ulcer of Sacral Region, and Essential Primary Hypertension. The “Home Health Certification and Plan of Care” for certification period 01/02/2024 to 03/01/2024 documents orders for services “Skilled Nurse 1 - 2x week x 3 weeks, 1 - 2x week x 1 week, 1x week x 2 weeks, (one to two visits a week for four weeks and one visit a week for two weeks) to “assess/instruct on patient/caregiver in proper wound care, assess wound location, size, stage, drainage, wound bed and periwound”. The “Start of Care” assessment visit dated 01/02/2024, the Skilled Nurse/Registered Nurse documents the patient has: Sacrum Pressure Ulcer- stage 2 with a measurement of “1.1 centimeter Lenght X 1.3 centimeter width”. Left Lower Sacrum Pressure Ulcer -satge 2 with a measurment of “1.0 centimeter Lenght X 0.9 centimeter width”. The “Skilled Nurse routine visit” notes dated 01/08/24, 01/18/24, 01/30/24, 02/08/24, 02/14/24, 02/21/24, and 02/26/24 lack documentation of the Sacrum and Left Lower Sacrum Pressure Ulcers wound measurement and wound size. The survey findings and interview were conducted on 09/18/2024 at 03:05 PM with the Director of Patient Services and the Agency’s staff. No explanation was provided.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on a review of clinical records, and staff interviews, the Governing Authority failed to ensure the patient current comprehensive assessments includes all assessments and clinical notes. Failure to ensure all content of the comprehensive assessment is in the clinical record have the potential for negative patient outcome. This is evident in two (2) of seven (7) clinical records reviewed. (Patient #2 and #6). Findings are: 2) Patient # 2 has a start of care date of 08/16/2024 with diagnose of “Displaced Transverse Fracture of Left Femur, Encounter for closed fracture with routine healing” as documented on the “Home Health Certification and Plan of Care” for certification period 08/16/2024 to 10/14/2024. The “Home Health Certification and Plan of Care” for certification period 08/16/2024 to 10/14/2024 documents diagnose of “Displaced Transverse Fracture of Left Femur, Encounter for closed fracture with routine healing, and Long-term current use of Aspirin”. Services include Skilled Nurse 1x week x 4 weeks (One visit a week for four weeks) to “assess and instruct hypertension every visit”. Medications include “Triamterene- HCTZ (Hydrochlorothiazide) by mouth capsule 37.5/25 milligram one capsule daily po (by mouth)” for hypertension. The “ Start of Care” comprehensive assessment dated 08/16/2024 lacks documentation of the patient’s vital signs and Blood Pressure reading. The Agency’s comprehensive assessment does not include the patient’s current vital signs and blood pressure reading for a patient with diagnosis of Essential Primary Hypertension and prescribed anti-hypertensive medications. The survey findings and interview were conducted on 09/18/2024 at 12:17 PM with the Director of Patient Services and at 02:37 PM with the Agency’s staff. No explanation was provided. 3) Patient #7 has a start of care date of 01/02/2024 with diagnoses of Hemiplegia and Hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side and Pressure Ulcer of Sacral Region. The “Home Health Certification and Plan of Care” for certification period 01/02/2024 to 03/01/2024 documents orders for services “Skilled Nurse 1 - 2x week x 3 weeks, 1 - 2x week x 1 week, 1x week x 2 weeks, (one to two visits a week for four weeks and one visit a week for two weeks) and “Physical Therapy 2x week x 4 weeks (two visits a week for four weeks)”. The Physical Therapy visit notes dated 01/16/24, 01/18/24, 01/23/24 01/25/24, 01/30/24, 02/01/24, 02/06/24, and 02/08/24 lack documented evidence of the patients vital signs and blood pressure readings. The “Skilled Nurse routine visit” notes dated 01/08/24, 01/18/24, 01/30/24, 02/08/24, 02/14/24, 02/21/24, and 02/26/24 lack documentation of the patient vital signs and blood pressure readings. The survey findings and interview were conducted on 09/18/2024 at 03:05 PM with the Director of Patient Services and the Agency’s staff. No explanation was provided. 1) Patient # 6 has a start of care date of 04/18/2023 and discharge date of 04/30/2024 with diagnoses of “Pressure Ulcer left Buttock Stage 2, Cellulitis of Buttock, Local Infection of the skin and Subcutaneous tissue, Urinary Tract Infection, Atrial Fibrillation, Hypertension and Hyperlipemia” as documented on the “Home Health Certification and Plan of Care” for certification period 04/12/2024 to 06/10/2024. The “Home Health Certification and Plan of Care” for certification period 04/12/2024 to 06/10/2024 documents orders for services “Skilled Nurse 1-2x week x1 weeks, 1-3x week x 8 weeks(one to two visit a week for one week, one to three times a week for eight week) skill nurse to perform wound care to let buttock 2-3 times weekly “ “ and “ Aide 1-2 x week x1 week, 1-5 x week x 7 weeks( one to two times a week for one week, one to five times for seven weeks”. The “ Start of Care” comprehensive assessment dated 04/18/2023 lacks documentation of the patient’s vital signs: Blood Pressure, Pulse, Temperature, Respirations readings. The “ Resumption of Care” comprehensive assessment dated 08/02/2023 lacks documentation of the patient’s vital signs: Blood Pressure, Pulse, Temperature, Respirations readings. The “Recertification of Care” comprehensive assessment dated 08/11/2023 lacks documentation of the patient’s vital signs: Blood Pressure, Pulse, Temperature, Respirations readings. The “Recertification of Care” comprehensive assessment dated 04/10/2024 lacks documentation of the patient’s vital signs: Blood Pressure, Pulse, Temperature, Respirations readings. The Agency comprehensive assessments lack documented monitoring of vital signs measurements (blood pressure, pulse, temperature and respiration) which is pertinent information in patient health status as it relates to monitoring infection and other changes due to patient diagnoses of Pressure Ulcer left Buttock Stage 2, Cellulitis of Buttock, Local Infection of the skin and Subcutaneous tissue, Urinary Tract Infection, Atrial Fibrillation and Hypertension. The survey findings and interview were conducted on 09/18/2024 at 3:00 PM with the Director of Patient Services and the Agency’s staff. No explanation was provided.”