Samaritan Home Health, Inc.

“Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: This Standard is not met as evidenced by: Based on clinical record review, observational home visits and interviews with the Administrator/Director of Patient Services (DPS) and Clinical Manager, it was determined in 7 of 17 records (patients #2, 7, 10, 12, 14, 16, and 17) comprehensive assessments were incomplete and not of sufficient scope to identify all patient needs. Evidence was as follows: Patient #5 was admitted to the agency on 11/08/23 with diagnoses of post-operative prosthetic joint infection (right shoulder), hypertension, high cholesterol, gastro-esophageal reflux disease, anxiety/depression, arthritis, and thyroid disease. The skilled nurse failed to perform a complete and/or accurate comprehensive assessment of the patient’s needs. On 11/08/23 the skilled nurse visited the patient and documented a blood pressure of 160/90 using an alternate site (instead of a bilateral upper extremity) because the patient had a recent surgical incision to the right upper arm and a central line in the left upper arm. The 11/08/23 Plan of Care included orders for the skilled nurse to assess vital signs and to notify the physician if systolic blood pressure was >160 and 90 and On the 11/10/23, 11/13/23, and 11/20/23 the skilled nurse documented that blood pressures were not checked because the patient’s bilateral upper extremities could not be used. The skilled nurse failed to use another part of the arm to check the blood pressure as done in multiple other assessments. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #16 was admitted to the agency on 06/20/23 with diagnoses of irradiation cystitis with hematuria (blood in urine), urine retention, prostate cancer, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, congestive heart failure, and anemia. The skilled nurse failed to perform a complete and/or accurate comprehensive assessment of the patient’s needs. On 06/20/23 the skilled nurse documented the patient had no pressure ulcers/injuries and the patient’s integumentary (skin) system was intact. On 06/27/23 and 07/06/23 the skilled nurse documented the patient’s current integumentary system was intact. On 07/11/2023 the skilled nurse visited the patient and documented the patient reported they had a pressure ulcer on the right heel since hospitalization and was told to leave it open to air. The skilled nurse assessed the pressure ulcer and documented it as an unstageable/deep tissue injury sized as 6 CM wide, 6 CM long, 0 CM depth. On 02/21/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #12 was admitted to the agency on 01/12/24 with diagnoses of surgical site infection following a procedure, hypertension and type 2 diabetes. The 01/09/24 discharge referral included Admelog Solostar (fast-acting) insulin per sliding scale three times daily before meals. The sliding scale was 0 units if blood glucose was less than 120, 2 units if blood glucose was 121-200 units, and 4 units if 201-251. The referral also included insulin glargine (long-acting) 50 units every morning and 30 units every evening. On 01/12/24 the skilled nurse visited the patient for the initial assessment and failed to perform a complete assessment of diabetes management. The nurse documented the patient was competent with use of the glucometer. They did not document how this was ascertained. They documented that the patient did not check their blood glucose frequently and had not checked it in the past three days. There was no evidence the skilled nurse observed the presence of the glucometer in the home, the patient use of the glucometer and the patient competence with administering injections. The skilled nurse documented that the patient was competent in in administration of all current medications and required no further medication education. The skilled nurse documented the patient was on albuterol sulfate HFA 90mcg/actuation aerosol inhaler 2 puffs every 4 hours as needed for shortness of breath/wheezing. The skilled nurse failed to assess the last time the patient needed to use the inhaler or if the patient could demonstrate proper use of the inhaler. On 02/22/24 at 10 a.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #2 was admitted to the agency on 02/01/24 with diagnoses aftercare following surgery on the circulatory system, atrial fibrillation and chronic obstructive pulmonary disease. On 02/01/24 the skilled nurse performed an initial assessment and found that the patient’s hands were having a blue-ish discoloration that started the night before and continued that morning. The medical doctor was called and informed by message. A nurse from the medical provider’s office called the skilled nurse back while in the home and stated that it was important for the patient to monitor their capillary refill. According to the 02/01/24 visit narrative, the patient/caregiver were instructed to monitor the patient’s capillary refill when the extremities change color. If the capillary refill was greater than 3 seconds, they were to notify the medical doctor. The patient and caregiver verbalized understanding. The skilled nurse never included monitoring of capillary refill on the patient’s plan of care or to notify the medical doctor or the agency if the capillary refill was greater than 3 seconds. No capillary refill was documented for visits on 02/08/24 or 02/15/24 by the skilled nurse. On 02/20/24 at 1 p.m. the surveyor reviewed the findings with the Administrator/Director of Patient Service and the Clinical Manager. They acknowledged the findings and no additional information was provided. Home Visit Patient #7 was admitted to the agency on 07/01/23 with diagnoses of circulatory system surgery, right lower leg ulcer, peripheral vascular disease, type 2 diabetes and history of deep vein thrombosis. The 06/27/23 hospital discharge instructions included Basaglar (long-acting) insulin 30 units injected once daily, Novolog (short-acting) insulin 8 units injected three times a day before meals, Trulicity (anti-diabetic weekly medication) 3 mg injected once weekly and Metformin (oral anti-diabetic medication). On 07/01/23 the skilled nurse visited the patient for the initial assessment and failed to perform a complete assessment of diabetes management. The nurse documented the patient had a glucose of 101 and the patient had a “glucometer-brand not available”. There was no evidence the skilled nurse observed the presence of the glucometer in the home, the patient use of the glucometer and the patient competence with administering injections. The skilled nurse documented the patient stated competency with injections. On 02/16/24 the surveyor conducted an observational home visit with the skilled nurse. Following the visit, the surveyor interviewed the patient who stated when admitted the nurse did not observe the patient using the glucometer or administering injections. The patient stated “I have been doing it for a long time”. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #10 was admitted to the agency on 02/02/24 with diagnoses of recent COVID-19 pneumonia, epilepsy, dysphagia (difficulty swallowing) and atrial fibrillation. The 02/02/24-04/01/24 Plan of Care included Home Health Aide services to assist with personal care. The skilled nurse failed to perform a complete assessment of the patient/caregiver understanding of interventions to prevent aspiration. The 01/24/24 hospital discharge instructions and progress note revealed the speech therapist had recommended a modified diet and aspiration precautions to minimize aspiration risk. On 02/02/24 the skilled nurse visited the patient and documented the patient had shortness of breath with minimal exertion and had a meter dose inhaler, incentive spirometer and was following a pureed diet with nectar thick liquids. There was no evidence the skilled nurse assessed patient/caregiver understanding of signs and symptoms of swallowing difficulties and aspiration and positioning or other interventions to minimize risk. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #17 was admitted to the agency on 02/06/24 with diagnoses of chronic atrial fibrillation on an anticoagulant, recent fall with a large hematoma to the left chest and acute blood loss anemia requiring a blood transfusion, congestive heart failure, hypertension and chronic wounds to lower legs. The skilled nurse failed to perform a complete assessment of the patient’s needs. Anticoagulant The 02/02/24 hospital discharge instructions directed the patient to hold Eliquis 2.5mg twice daily for 5 days and then resume. On 02/06 /24 the skilled nurse visited the patient for the initial assessment and failed to assess whether the patient had stopped the medication and when it was to be resumed. Pain management The hospital discharge instructions included the following interventions for pain: -Tylenol 650 mg every 8 hours as needed -Oxycodone10 mg four times daily -Tramadol 50 mg three times daily as needed for severe breakthrough pain The skilled nurse documented the patient had a pain level of 7 on a scale of 1 to 10 to back and leg, alleviating factors included body position, rest and medications. The skilled nurse failed to assess how often the patient was using the as needed medications. On 02/21/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Failure to ensure comprehensive assessments are complete and accurately reflect the patient’s status has the potential for negative outcomes for the agency patient population. Patient #14 was admitted to the agency on 01/31/23 with diagnoses of inflammatory disorders of the scrotum, diabetes, and heart failure. The patient was selected to review from the 11/2022 to 10/2023 Centers for Medicare and Medicaid Services (CMS) potentially avoidable event listing for emergency care for hypo/hyperglycemia with a discharge date of 03/17/23. The skilled nurse (SN), failed to perform a complete comprehensive assessment of the patient’s needs. Diabetes management The 01/27/2023 hospital discharge summary included Lantus (long-acting) insulin 35 units daily at bedtime, Trulicity (injectable diabetes medication) 1.5 milligrams weekly, Januvia (oral diabetes medication) 25 milligrams daily. There were no orders addressing if patient should or should not test blood sugars at home. On 01/31/23 the skilled nurse visited the patient for the initial comprehensive assessment and documented the patient demonstrated “competency with inhaled and subcutaneous injections via verbal step by step competency as no subcutaneous medication is due at this time.” The comprehensive assessment failed to address blood sugar monitoring or diabetes management. The 01/31/23-03/31/23 Plan of Care included Lantus insulin, Trulicity, and Januvia as listed on the discharge summary and the following orders: “patent does not check fingerstick blood sugar (FSBS) in home. A1C monitored routinely by primary care physician” and “monitor glucometer readings for variations and compliance; notify MD if FSBS >450 or The skilled nurse failed to visit to observe the caregiver performing wound care and scheduled the next visit for one week later. On 02/21/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on a review of the agency’s Quality Assessment Performance Improvement (QAPI) Program, interviews with the Administrator/Director of Patient Services (DPS), and Clinical Manager, it was determined that the agency failed to adequately review records of patients with adverse events, analyze their causes and implement preventive actions. Evidence was as follows: Professional Advisory Committee (PAC) meeting minutes for the past year and Quality Assessment Performance Improvement (QAPI) minutes for the last 9 months were provided by the Administrator/Director of Patient Services. The PAC and QAPI minutes do not reflect reporting on potentially avoidable events. During an interview with the Administrator/Director of Patient services (DPS) and the Clinical Manager on 02/22/24, it was reported that the agency has not completed any record reviews for 2023 Potentially avoidable events stating that they only run the Centers for Medicare and Medicaid Services (CMS) Potentially Avoidable Event (PAE) report annually and have not yet run a report in 2024 to identify 2023 potentially avoidable events. According to DPS and Manager, there is currently no process to identify potentially avoidable events. Additionally, in reviewing infections or transfers, it is possible a potentially avoidable event is identified but there is no formal tracking or ongoing auditing of these events. Once the CMS Potentially Avoidable Event report is run annually, a few of the records are randomly selected for review. Failure to adequately review and analyze adverse events risks negative outcomes for the agency patient population.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on review of clinical records for 2 patients receiving home health aide (HHA) service (patients #8 and 10), and interviews with the Administrator/Director of Patient Services (DPS) and Clinical Manager, for 1 of 2 records (patient #10) the skilled nurse failed to develop complete and accurate aide written instructions. This was evidenced by: Patient #10 was admitted to the agency on 02/02/24 with diagnoses of recent COVID-19 pneumonia, epilepsy, dysphagia (difficulty swallowing) and atrial fibrillation. The 02/02/24-04/01/24 Plan of Care included Home Health Aide services 2 times a week for 2 weeks and once a week for 2 weeks to assist with personal care. The agency failed to ensure the home health aide care plan included all necessary instructions to maintain patient safety. The 01/24/24 hospital discharge instructions and progress note revealed the speech therapist had recommended a modified diet and aspiration precautions to minimize aspiration risk. The 02/04/24 case coordination notes revealed the patient lived alone in an apartment and was waiting to transfer to assisted living once it could be arranged, and a Home Health Aide was requested until the patient regained strength, The patient’s diet was pureed, nectar thickened liquids for difficulty swallowing which had been a chronic problem. The family was coming in multiple times per day to feed the patient and give medications. The 02/07/24 Non-Skilled Care Plan included the modified diet, however, failed to include aspiration precautions. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Failure to ensure that home health aide care plans are complete has the potential for unmet patient needs.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on a review of clinical records, observational home visits and interviews with the Administrator/Director of Patient Services (DPS), and Clinical Manager, it was determined for 2 of 17 patients (Patients #2 and 11), the skilled nurse (SN) failed to perform complete and accurate medication reviews. Home Visit Patient #2 was admitted to the agency on 02/01/24 with diagnoses aftercare following surgery on the circulatory system, atrial fibrillation and chronic obstructive pulmonary disease. On 02/15/24 at 10:30 a.m. the surveyor performed a supervisory home visit with the skilled nurse. The skilled nurse went over the patient’s medications and made changes due to medications being discontinued and new medications being prescribed at the patient’s last doctor visit. The skilled nurse asked about the last time they had taken any “as needed” medications, including their Miralax 17 gm oral powder packet daily as needed for constipation. The patient stated they did not take they Miralax, they used a “stool softener”. After the skilled nurse had finished the visit and left, the surveyor asked the patient about the medications they were taking and compared it to the medication list on the plan of care. The surveyor asked what stool softener the patient was taking and they provided a bottle of docusate sodium 50mg-sennoside 8.6mg with instructions on the bottle to take 1 capsule as needed daily for constipation. The patient reported using that medication in the last week. The patient also provided a bottle of acetaminophen 325 mg and stated that they took 1 capsule as needed for pain and had taken it once since they had been discharged from the hospital. The skilled nurse failed to identify these medications in their medication review and include them on the patient’s plan of care. On 02/20/24 at 1 p.m. the surveyor reviewed the findings with the Administrator/Director of Patient Service and the Clinical Manager. They acknowledged the findings and no additional information was provided. Failure to perform complete and accurate medication reviews has the potential for patients taking medications inconsistent with the physician’s intentions, and possible negative patient outcomes. Patient #11 was admitted to the agency on 01/22/24 with diagnoses of surgical repair of left fractured femur, hypotension, atrial fibrillation, hypertension, and depression. The skilled nurse failed to ensure the medications were clarified and updated on the Plan of Care. The 01/18/24 hospital discharge instructions did not include orders for pain medication. On 01/22/24 the skilled nurse visited the patient for the initial comprehensive assessment and documented the patient was taking acetaminophen 1000mg twice a day and this did not control the post-surgical pain, the physician was notified, and visit documentation states physician sent prescription for Percocet to patient’s pharmacy. There is no documentation to support dose or frequency of Percocet clarified and medication was not added to the medication profile. The skilled nurse failed to reconcile all medications and update the plan of care to include the new Percocet orders. Multiple medications including prednisone, vitamin C, esomeprazole magnesium, and l-methylfolate were included on the medication profile with “awaiting review” status, some of which were duplicate medication entries. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. The director of patient services reported that some clinicians prefer to observe medication bottle in the home prior to entering, however, stated a verbal order obtained from the physician should have been entered. The Director of Patient Services also stated medications in “awaiting review” status are still present when all medications are reviewed. Patient #14 was admitted to the agency on 01/31/23 with diagnoses of inflammatory disorders of the scrotum, diabetes, and heart failure. On 01/31/23 the skilled nurse visited the patient and documented the “patient is taking vitamins in home that were not listed on discharge summary. Informed nurse at MD office.” Multiple medications including warfarin, magnesium oxide, and torsemide were on the medication profile with “awaiting review” status, some of which were duplicate medication entries. The skilled nurse failed to clarify and update the medications to include vitamins not listed on the discharge summary and reconcile all medications including those “awaiting review”. On 02/21/24 at 1 p.m. the surveyor reviewed the findings with the Administrator/Director of Patient Service and the Clinical Manager. They acknowledged the findings and no additional information 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 a review of clinical records, observational home visits and interviews with the Administrator/Director of Patient Services (DPS), and Clinical Manager, it was determined in 4 of 17 records (patients #1, 4, 5, and 14) the agency failed to develop individualized plans of care that were complete, accurate, and addressed the total needs of the patients. This was evidenced by: Patient #4 was admitted to the agency on 01/15/24 with diagnoses of right humerus (arm) fracture, nasal (nose) fracture, chronic back pain, anxiety/depression, migraines, gastro-esophageal reflux disease, and lichen planus (skin rash). The plan of care was incomplete and/or not updated to reflect the needs of the patient. Pain: The 01/15/24 Plan of Care instructions for pain mitigation included taking pain medication, frequent rest periods, changing position, and relaxation techniques. On 01/17/24 the physical therapist visited the patient for the initial evaluation and documented instructing the patient on using ice to help with pain management. There was no evidence the physical therapist updated the plan of care to include the use of ice including location, frequency, and duration of application. On 01/22/24 and 01/29/24 the skilled nurse visited the patient and documented instructing the patient in pain reduction methods including “heat/cold usage as instructed by the surgeon”. The skilled nurse failed to recognize these interventions were not included in the plan of care. On 01/26/24 the occupational therapy assistant visited the patient and documented the application and use of kinesiology tape (therapeutic tape) for pain as well as family instruction on taping. The 01/15/24 Plan of Care failed to include orders for using heat/ice or Kinesiotape and there is no evidence that the skilled nurse or physical therapist obtained subsequent orders. There was no evidence the physical therapist updated the plan of care to include the use of kinetic tape including location, frequency, and duration of application. Wound/Incision: The 01/15/24 Plan of Care orders for wound care stated the right arm surgical dressing is to remain on until ortho (physician) follow-up. On 01/15/24 the skilled nurse visited the patient and documented the patient had a non-removable dressing in place on the right upper arm. On 01/22/24 the skilled nurse visited and documented the patient no longer had a non-removable dressing and now had steri-strips to the surgical incision on the right arm. There was no evidence the skilled nurse obtained updated orders for wound care following the removal of the dressing. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #5 was admitted to the agency on 11/08/23 with diagnoses of post-operative prosthetic joint infection (right shoulder), hypertension, high cholesterol, gastro-esophageal reflux disease, anxiety/depression, arthritis, and thyroid disease. The plan of care was incomplete and/or not updated to reflect the needs of the patient. The 11/07/2023 hospital After Visit Summary listed allergies to aspirin, Demerol, fenofibrate, paroxetine, sulfa antibiotics, and tadalafil as well as instructions for activity restrictions of the operative shoulder/arm including no shoulder motion, no lifting, remain non-weight bearing, and no movement/exercises of shoulder. The 11/08/23 Plan of Care failed to include: -allergies to aspirin and Demerol -activity restrictions On 11/10/23 the skilled nurse visited the patient and documented the patient was using ice for pain relief and swelling. There was no evidence the skilled nurse updated the plan of care to include the use of ice including location, frequency, and duration of application. The 11/08/2023 Plan of Care included orders for the skilled nurse to assess vital signs and to notify the physician if systolic blood pressure was >160 and 90 and On 11/10/23, 11/13/23, and 11/20/23 the skilled nurse visited the patient and documented that blood pressures were not checked because the patient’s bilateral upper extremities could not be used due to the recent surgery and the central line. There was no evidence the skilled nurse updated the plan of care to include orders holding blood pressure monitoring until an upper extremity could be used. The 11/08/23 Plan of Care included the following wound care orders: -skilled nurse to remove old saturated dressing to right shoulder -cleanse site with normal saline and gauze -gently pat the site dry -apply a folded abdominal pad over surgical site vertically -cover with an adhesive telfa dressing -secure dressing in place with tegaderm tape The Plan of Care failed to include how often the dressing could/needed to be changed. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #12 was admitted to the agency on 01/12/24 with diagnoses of surgical site infection following a procedure, hypertension and type 2 diabetes. The skilled nurse failed to ensure the medications were clarified and updated on the Plan of Care. The 01/09/24 discharge referral included Admelog Solostar (fast-acting) insulin per sliding scale three times daily before meals. The sliding scale was 0 units if blood glucose was less than 120, 2 units if blood glucose was 121-200 units, and 4 units if 201-251. The 01/12/24 plan of care included Admelog Solostar insulin three times a day per sliding scale. The sliding scale for how much insulin to administer was not included in the plan of care. On 01/12/24 an order was obtained from the medical doctor to change the Admelog Solostar insulin to 10 – 30 units daily at night. It failed to include specific orders on how many units of insulin the patient should take and what the parameters were for taking a specific dose of the Ademlog Solostar. On 01/18/24 an order was obtained for acetaminophen 160mg/5mL oral elixir, 15-30 mL every 4 hours as need for pain, with a maximum daily dose of 3000mg. The order does not specify how much of the medication to take depending on how much pain the patient is in. On 01/26/24 an order was obtained for ibuprofen 200mg tablet, 1 to 4 tablets every 8 hours as needed for pain, with a maximum daily dose of 12 tablets. The order does not specify how much of the medication to take depending on how much pain the patient is in. On 02/22/24 at 10 a.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #14 was admitted to the agency on 01/31/23 with diagnoses of inflammatory disorders of the scrotum, diabetes, and heart failure. The patient was selected to review from the 11/2022 to 10/2023 Centers for Medicare and Medicaid Services (CMS) potentially avoidable event listing for emergency care for hypo/hyperglycemia with a discharge date of 03/17/23. The plan of care was incomplete and/or inaccurate. Blood Glucose Monitoring The 01/27/2023 discharge summary directed the patient to take Lantus (long-acting) insulin 35 units daily at bedtime and other medications for diabetes including Trulicity 1.5mg injection weekly, and Januvia 25mg tab daily. There were no orders addressing if patient should or should not tests blood sugars at home. On 01/31/23 the skilled nurse visited the patient and documented the patient demonstrated “competency with inhaled and subcutaneous injections via verbal step by step competency as no subcutaneous medication is due at this time.” The comprehensive assessment did not address blood sugar monitoring or diabetes management. The 01/31/23 Plan of Care was inconsistent, including the following orders: “Patient does not check fingerstick blood sugar (FSBS) in home. A1C monitored routinely by primary care physician” and “monitor glucometer readings for variations and compliance; notify MD if FSBS >450 or Ice/heat treatments On 01/31/23 the skilled nurse documented the patient had 5/10 pain to back at time of visit and denied use of pain medication; there was no mention of use of heat or ice for pain relief. The 01/31/23 Plan of Care included the following order: instruct patient/caregiver “Patient may use heat/ice as a method of pain relief. Instruct patient to apply heat/ice to affected area for 20 minutes using barrier between skin and heat/ice with removal for a least 20 minutes between application.” The Plan of Care was incomplete and failed to address which area(s) heat/ice should be applied and when to use these treatments. On 02/21/24 at 1 p.m. the surveyor reviewed the findings with the Administrator/Director of Patient Service and the Clinical Manager. They acknowledged the findings and no additional information was provided. Home Visit Patient #1 was admitted to the agency on 02/06/24 with diagnoses of chronic osteomyelitis, staphylococcal arthritis, methicillin resistant staphylococcus aureus infection, long-term use of antibiotics, and vascular access device. Pain management On 02/06/24 the skilled nurse visited the patient and documented the patient reported pain to left shoulder at a level of 9 on a 0-10 scale. The skilled nurse documented the patient reported the physician was aware of the high level of pain and the patient was scheduled for appointment with a pain management specialist. The 02/06/23 Plan of Care included an order for oxycodone-acetaminophen 5mg/325mg 1-2 tablets every 6 hours as needed for moderate pain and tizanidine 4mg tablet every 6 hours as needed for moderate pain, muscle spasms. The order failed to specify when the patient should take one tablet versus two tablets of oxycodone-acetaminophen. The Plan of Care failed to identify parameters to notify the physician regarding level of reported pain. On 02/15/24 the surveyor conducted an observational home visit with the skilled nurse. During the visit the patient reported icing the shoulder. The 02/06/24 Plan of Care did not include an order for ice to the shoulder and there was no subsequent order obtained to include the frequency and duration the treatment should be applied. Vascular access device On 02/06/24 the skilled nurse documented the patient had a single lumen peripherally inserted central catheter (PICC) to the right upper arm without noting catheter size or length. The 02/06/24 Plan of Care included orders for dressing change to peripherally inserted central catheter (PICC) and blood draws weekly for CMP, ESR, CBC with auto diff, and CRP. During the 02/15/24 observational home visit the patient reported discomfort to site where PICC suture site and requested gauze be placed to pad the area. The 02/06/24 Plan of Care failed to include the day of the week to change the PICC dressing and draw blood and the dressing orders did not include the application of gauze to the suture site. The skilled nurse failed to update the Plan of Care to include this intervention. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and no additional information was provided. Failure to ensure that a comprehensive, individualized plan of care is developed has the potential for unmet patient needs.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on review of clinical records, and interview with the Administrator/Director of Patient Services (DPS) and Clinical Manager, it was determined for 1 of 17 patients (patient #16) the agency failed to ensure there was communication with all involved physicians in the patient’s plan of care. Evidence was as follows: Patient #16 was admitted to the agency on 06/20/23 with diagnoses of irradiation cystitis with hematuria (blood in urine), urine retention, prostate cancer, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, congestive heart failure, and anemia. The agency failed to coordinate patient care to ensure the specialist was consulted regarding management of the urinary catheter. The 06/20/23 hospital Patient Visit Report at discharge included a scheduled follow-up appointment with the urology physician on 07/03/23. The 06/20/23 Plan of Care included a plan for the catheter to be managed by the urologist and problems could be reported to the urology group. On 06/20/23 the skilled nurse visited the patient and documented the patient had an 18 french catheter with a 10 mL balloon last changed on 06/15/23 and the catheter would be managed by the urologist. The patient had a follow up visit scheduled for 07/02/23. On 06/27/23 the skilled nurse visited the patient and documented the patient stated they did not have an appointment scheduled with urology yet. There was no evidence that the skilled nurse reminded the patient that an appointment was already scheduled. On 07/06/23 the skilled nurse visited the patient and documented the patient’s catheter “would be due for a monthly change next week”. The skilled nurse called and left a message about the foley catheter with the primary care physician. There was no evidence that the skilled nurse asked the patient about their scheduled visit with urology or consulted with the urologist regarding the plan for changing the catheter. On 07/11/23 and 07/18/23 the skilled nurse visited the patient and documented the primary care physician was called and messages were left regarding the foley catheter. The skilled nurse failed to recognize the urologist was managing the catheter and consult with the specialist regarding the catheter. On 07/25/23 and 08/02/23 the skilled nurse visited the patient and documented the patient was unsure when the next foley catheter change was and was waiting for the primary care physician to approve the skilled nurse to change it at home and it would be discussed when they see the physician at the 08/07/23 appointment. On 08/02/23 the skilled nurse documented calling the urology group for clarification on who was managing the patient’s catheter since the patient reports never having a follow-up with the urologist and despite the order stating the urologist was managing the foley care. On 08/07/23 the skilled nurse visited the patient and documented the patient stated they still did not know when they would be able to have the catheter changed and they did not want to see the urologist. The skilled nurse documented the patient was informed the skilled nurse would not be able to change the foley catheter in the home, the patient could see a different physician in the urology group, or the patient could go to the emergency room to have the foley catheter changed. There was no evidence the skilled nurse consulted with the urologist to facilitate the catheter change. On 08/16/23 the patient was discharged from home health services. There was no evidence the catheter issue was resolved. On 02/21/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Failure to ensure there is communication with all responsible physicians places patients at risk for negative outcomes and potential for hospital admission.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on review of patient records, observational home visits, and interviews with the Administrator/Director of Patient Services (DPS) and Clinical Manager it was determined in 4 of 17 patients (patients #1, 6, 14 and 16) the agency failed to coordinate care to meet the needs of the patients. Evidence was as follows: Patient #16 was admitted to the agency on 06/20/23 with diagnoses of irradiation cystitis with hematuria (blood in urine), urine retention, prostate cancer, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, congestive heart failure, and anemia. The agency failed to coordinate patient care to ensure social work services were provided for all the identified needs. The 06/20/23 Plan of Care included an order for a Medical Social Worker evaluation. On 06/25/23 the social worker documented in the patient activity log they had a phone conversation with the patient regarding filling out an application for Volunteer Transportation, referring to home delivered meals, and setting up an in person visit to complete an application for Medicaid. On 06/27/23 the social worker visited with the patient and documented the patient did not qualify for Veteran’s Administration benefits or for the “EISEP” program (Expanded In-Home Services for the Elderly). On 07/26/23 the patient was discharged from social services. There was no evidence the patient was assisted in completing the Medicaid application, Volunteer Transportation arranged for the patient, needs had been met and/or the patient had no further needs. On 02/21/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and provided no additional information. Home Visit Patient #6 was admitted to the agency on 06/21/23 with diagnoses of stage 2 pressure ulcer of the right buttock and type 2 diabetes. Follow-up Coordination On 11/17/23 the skilled nurse showed up to the adult home for a visit with the patient. They were informed by adult home staff that the patient had been transferred to the emergency department and would probably be back the following day. No reason was documented why the patient went to the emergency room. The skilled nurse notified the Director of Patient Services. No follow-up was conducted the following day, 11/18/23, to see if the patient had returned from the emergency room and needed a visit from the agency to follow-up. The next visit was on 11/20/23. The skilled nurse documented the patient did not have a dressing on their stage 2 pressure injury and reported that the dressing came off after being seen in the emergency department. The patient went multiple days with no dressing to their pressure ulcers. The agency failed to coordinate with the adult home to ensure that the patient’s needs were being met. Dressing removal At a skilled nurse visit on 09/01/23, the skilled nurse instructed the patient not to wear the dressing in the shower because it was saturated with water and the skilled nurse could not distinguish between the water and the wound drainage. During the supervisory home visit on 02/15/24 at 9:00 a.m., the patient already had the dressing off prior to the skilled nurses arrival. The skilled nurse questioned why the dressing was off and the patient responded that he took the dressing off to shower everyday and then he would put it back on after if the nurse was not coming that day. The skilled nurse acknowledged that the patient did shower daily and usually had the dressing off prior to their arrival. In the narrative section of the 02/15/23 visit summary, the skilled nurse documented they encouraged the patient to leave the dressing in place while showering and if the dressing became compromised to call the agency so another dressing could be placed. There is no evidence that the skilled nurse contacted the medical doctor to discuss that the patient was taking the dressing off to shower and if another dressing would be more appropriate. After the visit, the skilled nurse notified the nursing manager of the adult home that the patient had been re-certified and care would be continuing twice a week. The skilled nurse did not discuss that the patient had been taking off their dressing prior to showering and that should be avoided. The surveyor interviewed the adult home nurse manager and asked if they were aware of any issues with the patient taking off their dressing and re-applying it. They stated that they were not aware that it was happening. They stated that if they had been told this was a problem, they could have helped to encourage the patient to wash up a different way or help protect the dressing so that it did not become saturated. The skilled nurse failed to communicate to the adult home and to the medical doctor that the patient was removing and re-applying their dressing in-between visits. Patient #14 was admitted to the agency on 01/31/23 with diagnoses of inflammatory disorders of the scrotum, diabetes, and heart failure. The patient was selected to review from the 11/2022 to 10/2023 Centers for Medicare and Medicaid Services (CMS) potentially avoidable event listing for emergency care for hypo/hyperglycemia with a discharge date of 03/17/23. The plan of care was incomplete and/or inaccurate. Blood Glucose Monitoring The 01/27/2023 discharge summary directed the patient to take Lantus (long-acting) insulin 35 units daily at bedtime and other medications for diabetes including Trulicity 1.5mg injection weekly, and Januvia 25mg tab daily. There were no orders addressing if patient should or should not tests blood sugars at home. On 01/31/23 the skilled nurse visited the patient and documented the patient demonstrated “competency with inhaled and subcutaneous injections via verbal step by step competency as no subcutaneous medication is due at this time.” The comprehensive assessment did not address blood sugar monitoring or diabetes management. The 01/31/23 Plan of Care was inconsistent including both the “Patient does not check fingerstick blood sugar (FSBS) in home. A1C monitored routinely by primary care physician”; and “monitor glucometer readings for variations and compliance; notify MD if FSBS >450 or Ice/heat treatments On 01/31/23 the skilled nurse documented the patient had 5/10 pain to back at time of visit and denied use of pain medication; there was no mention of use of heat or ice for pain relief. The 01/31/23 Plan of Care included the following order: instruct patient/caregiver “Patient may use heat/ice as a method of pain relief. Instruct patient to apply heat/ice to affected area for 20 minutes using barrier between skin and heat/ice with removal for a least 20 minutes between application.” The Plan of Care was incomplete and failed to address which area(s) heat/ice should be applied and when to use these treatments. On 02/21/24 at 1 p.m. the surveyor reviewed the findings with the Administrator/Director of Patient Service and the Clinical Manager. They acknowledged the findings and no additional information was provided. Home Visit Patient #1 was admitted to the agency on 02/06/24 with diagnoses of chronic osteomyelitis, staphylococcal arthritis, methicillin resistant staphylococcus aureus infection, long-term use of antibiotics, and vascular access device. Pain management On 02/06/24 the skilled nurse visited the patient and documented the patient reported pain to left shoulder at a level of 9 on a 0-10 scale. The skilled nurse documented the patient reported the physician was aware of the high level of pain and the patient was scheduled for appointment with a pain management specialist. The 02/06/23 Plan of Care included an order for oxycodone-acetaminophen 5mg/325mg 1-2 tablets every 6 hours as needed for moderate pain and tizanidine 4mg tablet every 6 hours as needed for moderate pain, muscle spasms. The order failed to specify when the patient should take one tablet versus two tablets of oxycodone-acetaminophen. The Plan of Care failed to identify parameters to notify the physician regarding level of reported pain. On 02/15/24 the surveyor conducted an observational home visit with the skilled nurse. During the visit the patient reported icing the shoulder. The 02/06/24 Plan of Care did not include an order for ice to the shoulder and there was no subsequent order obtained to include the frequency and duration the treatment should be applied. Vascular access device On 02/06/24 the skilled nurse documented the patient had a single lumen peripherally inserted central catheter (PICC) to the right upper arm without noting catheter size or length. The 02/06/24 Plan of Care included orders for dressing change to peripherally inserted central catheter (PICC) and blood draws weekly for CMP, ESR, CBC with auto diff, and CRP. During the 02/15/24 observational home visit the patient reported discomfort to site where PICC suture site and requested gauze be placed to pad the area. The 02/06/24 Plan of Care failed to include the day of the week to change the PICC dressing and draw blood and the dressing orders did not include the application of gauze to the suture site. The skilled nurse failed to update the Plan of Care to include this intervention. On 02/20/24 at 1 p.m. the surveyor reviewed the record with the Administrator/Director of Patient Services and Clinical Manager. They acknowledged the findings and no additional information was provided. Failure to coordinate patient care has the potential for unmet patient needs, and possible negative patient outcomes.”