Centerwell Home Health

“Discharge Planning CFR(s): 484.58 Condition of Participation: Discharge planning. This Condition is not met as evidenced by: Based on reviews of clinical records, policies, and procedures, interviews with agency staff including the Administrator, Director of Patient Services, clinicians, and physicians, it was determined that safe and adequate discharge planning was not provided to all patients of the agency. Based on a review of patients discharged from the agency, the agency failed to develop and implement an effective discharge planning process that: - prepared patients and caregivers to be active partners in their post-discharge care - effectively transitioned the patient to post-agency care - reduced the factors that prevent negative patient outcomes The cumulative effect of the systemic issues identified in G562 was identified through a lack of: - preparation of patients and caregivers for agency discharge - transition of patients to post-agency care - planning for how needs would be met without the home health agency services The lack of discharge planning for patients #13, 18, and 19, left the patients at risk for negative outcomes and the potential negative outcomes for the patient population.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on reviews of clinical records, policies and procedures, interviews with patients and agency staff including the Administrator, the Director of Patient Services, clinicians, it was determined care planning, coordination of services, and quality of care were not provided to all patients of the agency as evidenced by the failure to ensure: - services were provided according to the physician ordered plan of care (G572) - an individualized care plan that included all medications and treatment orders (G574) - promptly alerting the relevant physician(s) to any changes in patients’ condition (G590) - coordinating care delivery to meet the patients’ needs (G608) - ensuring patients, and caregivers where applicable, received ongoing education and training provided by the agency (G610) The cumulative effect of the systemic issues identified in the care planning, coordination, and quality of care resulted in a negative outcome for patient #13 and the potential for negative outcomes for the agency patient population.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on a review of patient records, observational home visits, agency policies and procedures, and interviews with the Administrator and Director of Patient Services, it was determined the agency failed to ensure all encoded OASIS (Outcome Assessment Information Set) assessments in 2 of 19 patients, (patients #3 and 17) accurately reflected the patient’s status at the time of assessment. Evidence as follows: 1. Patient #17 was admitted to the agency on 03/13/24 with diagnoses of coronary artery disease with acute myocardial infarction (heart attack), bilateral foot drop, Alzheimer’s dementia, adult failure to thrive, dysphagia (difficulty swallowing), and protein-calorie malnutrition. The patient was discharged on 05/10/24 and was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report, dated 09/01/23 through 08/31/24, for an increase in the number of pressure ulcers. There was no evidence in the record the patient had a pressure ulcer. On 03/13/24 the Registered Nurse (RN) saw the patient for an initial assessment and documented the patient had no stage 1, stage 2, or unstageable pressure ulcers/injuries. On 04/09/24 the physical therapist (PT) saw the patient for a reassessment and documented the caregiver reported the patient had a new abrasion to the right lower leg in which a small bandage was applied. On 04/16/24 the patient was seen by nurse for a PRN (as needed) wound care visit. The nurse assessed the wound and documented the wound as a skin tear. A wound care order was then obtained from the physician for treatment of the skin tear. On 05/10/24 the nurse saw the patient for a discharge visit and documented the following for the OASIS questions: - does the patient have at least one unhealed pressure ulcer/injury at stage 2 or higher or designated as unstageable: “yes” - the oldest stage 2 pressure ulcer that is present at discharge: “developed since the most recent SOC/ROC [start of care/resumption of care] assessment” - record date pressure ulcer first identified: “5/1/2024” - current number of unhealed pressure ulcers/injuries at stage 2: “1” - number of these stage 2 pressure ulcers that were present at the most recent SOC/ROC: “1” The nurse failed to correctly answer the OASIS questions by: - documenting the patient had a stage 2 pressure ulcer when in fact, based on assessment, the patient had a skin tear - the skin tear was identified on 04/16/24 On 12/04/24 at 2:00 p.m. the findings were reviewed with the Administrator and Director of Patient Services who provided no additional information. HV 1. Patient # 3 was admitted to the agency on 10/12/24 with a diagnosis of cutaneous abscess of abdominal wall, type 2 diabetes mellitus, autistic disorder, depression, and moderate intellectual disabilities. Patient #3 is a resident of a group home. Diabetes On 10/12/24, the Registered Nurse (RN) visited for the start of care assessment and documented within the endocrine system that the patient had diabetes mellitus but did not monitor blood glucose levels. The RN documented the following for the OASIS questions: - is the patient taking injectable medication: “yes” - can the patient prepare medication and self-inject: “yes” - indicate patient reported confidence in managing their diabetes: “neither” The referral information contained hospital discharge instructions dated 10/11/24 included the following medication orders: - Mounjaro 5mg/0.5mL injection. Inject 5mg every seven days. The RN documented “unable to take medication unless administered by another person” in the medication section of the record. On 11/27/24 at 3:30 p.m. the surveyor conducted an observational visit with the Licensed Practical Nurse (LPN). During the surveyor’s interview with the group home manager, they stated that they manage all aspects of the patient’s medication regime including administering Mounjaro. The RN failed correctly answer the OASIS questions by: - documenting that the patient could prepare and self-inject medication On 12/3/24 at 1:30 p.m., the record was reviewed with the Administrator and Director. No further information was provided.”

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on a review of 8 patient records of discharged patients (#2, 13, 14, 15, 16, 17, 18, and 19), review of agency policies and procedures, and interviews with the Administrator, Director of Patient Services, patient/patient caregivers, clinicians, and physicians, it was determined for 7 of 8 discharged patients (patients # 2, 13, 14, 15, 16, 18, and 19) the agency failed to develop and implement an adequate discharge plan, that involved the patient, patient caregiver, and physician, to ensure continuity of care. Evidence as follows: The agency’s “Discharge or Transfer and job aide” policy dated 09/2024 included: - the certifying physician responsible for the plan of care provides confirmation the patient’s outcomes and/or goals have been met and home health services are no longer required - the patient’s authorized representative has received instructions/education and agrees to assume all responsibilities in the plan of care - the patient/authorized representative must understand and participate in the discharge planning as well as receive prior notice of the discharge - the patient’s physician will be notified of the patient’s discharge and be sent a copy of the discharge/transfer summary within 5 business days Patient #14 was admitted to the agency on 09/26/23 with diagnoses that included congestive heart failure (2 recent exacerbations requiring hospitalization), insulin dependent type 2 diabetes, atherosclerotic heart disease (walls of the arteries that supply the heart thicken and narrow), and stage 3 chronic kidney disease. This patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 09/01/23 through 08/31/24 for emergent care for hypo or hyperglycemia. The Home Health Certification and Plans of Care (Plan of Care) dated 09/26/23-11/24/23 and 11/25/23 to 01/23/24included the following goals and discharge plans: - patient/caregiver verbalizes/demonstrates diabetes management as evidenced by blood glucose within parameters, and blood glucose outside parameters reported to primary care provider. On 12/21/23, the RN visited and discharged the patient from nursing services, reason for discharge, “goals met for nursing,” and evaluation of goals, “met.” The RN documented in the 12/21/23 narrative note: - Patient follows with the Joslin Center for diabetes management. There was no evidence the RN or any nurse reported the high values, issues with blood glucose testing or self-injecting insulin as ordered to the provider at the Joslin Center. - Patient sitting up eating breakfast, states {patient] forgot to check glucose before breakfast,” indicating the patient was unable to test blood glucose as directed. - “Patient states compliance with insulin midday and long-acting at night” when the 2 visits prior, the nurse documented on 11/27 and 12/07/23 the patient was not testing or administering insulin correctly and, obtained a “high” reading. - “Fairly confident” response to diabetes management, a decrease from the start of care response, “very confident.” The nurse also documented on the day of discharge, “Eating breakfast, states [patient] had forgotten to check blood sugar prior to eating.” On 01/10/24, the physical therapy assistant documented, ready for discharge next visit. NOMNOC (Notice of Medicare Non-Coverage form) given “in case of discharge.” On 01/18/24, the patient was transported for emergent care fore for chest pain. The Hospital note included the 423 blood glucose level obtained by emergency transport personnel. On 01/22/24, the physical therapist documented: - date of discharge, 01/19/24 - patient will be discharged from physical therapy services and home care agency at this time as all goals are met. On 12/21/23, the RN failed to ensure the patient was safe to be discharged when determining the patient was unable to manage the diabetic blood glucose testing and insulin administration as ordered. On 12/03/24 at 1:30 p.m., the findings were reviewed with the Administrator and Director of Nursing Services who acknowledged the findings and offered no additional information. Patient #15 was admitted to the agency on 12/05/23 with diagnoses that included Covid-19 pneumonia, chronic lower back pain, chronic hypoxic respiratory failure, asthma, hypertension, and chronic atrial fibrillation. This patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 09/01/23 through 08/31/24 for urinary tract infection. On 01/10/24, the RN visited for the first time since the start of care on 12/05/24, and documented, patient had a “UTI,” had 2 falls today and left flank pain continues 6/10. The nurse documented the patient had no injuries from the falls and the patient had a slight burn from the heating pad on the left flank without blister or discharge. Patient educated on the importance of keeping visits and to be available by phone. “Patient understood and is accepting of skilled nurses and physical therapists to call [caregiver] to set up appointments.” The patient had visited the hospital 01/03/24 and 01/08/24 for pyelonephritis. An initial antibiotic was changed to a second antibiotic. On 01/17/24, the RN documented “development of urinary tract infection, Pt on antibiotic for UTI, Pt refusing homecare services.” On 01/18/24, the RN documented a verbal order from the physician’s office nurse as follows: - discharge patient from [agency] services per patient request The verbal order was taken by the RN and co-signed by the Administrator on 01/18/24. The physician’s signature line contained “Do Not Send” indicating the physician did not receive this discharge order to sign. There was no evidence the physician was aware of the discharge. The verbal order was taken by the agency RN from the physician’s office nurse and co-signed by the Administrator on 01/18/24. The agency failed to follow-up with the patient to determine: - the reason the patient chose to discharge themselves from the agency - a discharge plan - to investigate the “patient’s request” for discharge and “refusal of homecare services” The agency failed to develop and implement effective discharge planning. On 12/03/24 at 1:30 p.m., the findings were reviewed with the Administrator and Director of Nursing Services who acknowledged the findings and offered no additional information. On 12/06/24 at 1:56 p.m., the surveyor interviewed the discharging RN via phone. When asked why the patient had discontinued services, the RN stated, “I don’t recall.” Patient #19 was admitted to the agency on 11/08/23 with diagnoses that included malignant tongue cancer with metastasis to the lung and bone, dysphagia, and failure to thrive. On 11/08/23, the registered nurse (RN), visited the patient for the start of care assessment and documented the plan to admit for nursing assessment and refer the patient to occupational therapy, speech therapy, and home health aide services. There was no evidence to support discharge planning was discussed. The 11/08/23-01/06/24 Plan of Care listed discharge plans as “discharge to caregiver under supervision of MD when goals are met.” On 11/17/23, the RN visited the patient for a routinely scheduled visit. The patient inquired about end-of life and hospice care. The patient expressed concern about qualifying for hospice as they did not have a 24-hour caregiver available. On 12/01/23, a licensed practical nurse (LPN) visited the patient for a routinely scheduled visit and documented that the hospice was going to bring the patient more information, however, patient again expressed the concern regarding not have a 24-hour caregiver. On 12/07/23, the RN visited the patient for an as needed visit scheduled due to increased pain. The nurse documented the patient reported 8/10 pain in their shoulder that extended down to the right side of the torso and into the hip with anxiety as a contributing factor in the patient’s pain. The nurse also documented the patient was not eligible for hospice care as the patient was receiving chemotherapy treatment until the end of the month. Upon completion of the chemotherapy, patient was planning to be re-evaluated by hospice. On 12/09/23, the triage nurse documented a on on-call coordination note reporting a call from the patient’s caregiver reporting the patient’s narcotic pain medication was missing. The caregiver was instructed to file a police report if they were unable to locate the medication. On 12/15/23, the Director of Patient Services documented a complaint report and under description wrote “see on call notes from 12/09/23” and under intervention wrote “transfer/discharge from agency.” No further information was documented on the discharge or discharge plan. On 12/18/23, the Director documented a complaint report and under follow-up comments documented a phone call with the caregiver on 12/11/23 after interviewing the occupational therapist and nurse who had visited the patient recently. The caregiver reported that the police report was filed, not due to criminal intent, but to allow the caregiver to refill the pain medication so the patient wouldn’t be in pain. The Director also documented “mutual decision between writer and [caregiver] to discharge services due to the nature of the complaint. [Caregiver] states they are likely to move [patient] to hospice later this month.” The agency failed to assess the caregiver’s ability to refill the pain medication, the patient’s pain status, or develop an appropriate discharge plan. Despite the caregiver’s verbalization of intent to initiate Hospice services later in the month, there was no documented plan as to how the patient’s needs would be met following agency discharge or that the potential barriers to hospice had been identified on previous visits, including the unavailability of a 24-hour caregiver, had been resolved. On 12/12/24 at 2 p. m., the findings were reviewed with the Administrator, the Director of Patient Services, and a representative from the governing authority. They acknowledged the findings and offered no additional information. Patient #18 was admitted to the agency on 01/03/24 with diagnoses that included cirrhosis of liver, liver cell carcinoma, and type 2 diabetes. The agency failed to coordinate a discharge plan that met all of patients needs, goals, and treatment preferences. On 01/03/24, the registered nurse (RN) visited the patient for the start of care assessment. The nurse documented the need for weekly RN assessments for sterile dressing changes and assessment of the patient’s multiple comorbidities with the goal of preventing exacerbations or rehospitalizations. On the 01/03/24-03/02/24 Plan of Care, the discharge plan field was documented as “need for ongoing care.” There was no documentation a discharge plan was developed with the patient or caregiver at the time of start of care or during the 7 weeks that followed. On 02/27/24, an RN visited the patient and requested the caregiver perform the dressing change to the peritoneal dialysis catheter with education and guidance, and the caregiver refused. The nurse changed the dressing using sterile technique. The nurse “discussed discharge from the agency and [caregiver] adamantly against patient being discharged as [they are] reliant on and appreciative of the nurse care that [patient] is receiving.” The caregiver refused to sign the Notice of Medicare Non-coverage. On 03/14/24, the RN manager documented a coordination note reporting patient and caregiver were encouraged to speak to palliative care or Hospice care in the near future, however, at this time, they are not prepared for Hospice.” The manager also “explained that home care services through [the agency] are for short-term and cannot continue to assess beyond the acute phase of an illness.” On 03/15/24 the Director of Patient Services documented that the discharge appeal determined Medicare would continue to pay for home care services On 03/21/24, the RN manager documented a coordination note reporting changes in the patient condition, including that the patient seemed slightly confused, was sleeping more than usual, not hungry, nauseated, and with darker skin tone possibly due to jaundice. On 03/22/24, the following 2 verbal order were taken by the RN manager: - “SN to assess patient today, 03/22/24, will speak to patient’s spouse about hospice care. Further plan of care based on assessment findings today.” - “SN assessment weekly for 3 weeks to identify change in condition requiring physician assessment and/or hospice referral. Planned discharge on the second week as caregiver is able to provide care related to abdominal drain and verbalize symptoms requiring physician assessment.” On 03/24/24, the RN manager visited the patient and drained an additional 500 milliliters of ascites fluid during the visit, in addition to the 1,000 milliliters the caregiver had already drained earlier that day. The RN then documented that patient will receive weekly visits for 2 more weeks and then will be discharged from home care agency. Patient and caregiver are not interested in Hospice services at this time. There was no evidence an alternative discharge plan was made if patient and caregiver continued to decline hospice services. On 03/29/24, the RN manager visited the patient and delivered the Notice of Medicare Non-coverage, which the patient refused to sign. The patient presented with increased edema to lower extremities, increased jaundice, and was “slowly declining.” On 03/30/24, the triage RN documented in a care coordination note that the patient filed for a second appeal. On 04/01/24, RN manager visited the patient for the discharge visit and documented “at this time the patient has no skilled nursing needs from home care, they do understand the patient’s condition is terminal and [patient] can be referred to hospice whenever they are ready.” On 04/05/24, the agency was notified the final determination of the appeal, which stated, “the physician reviewer disagrees with the termination of services.” On 04/11/24, the RN manager documented a telephone call to the physician office to report “that the patient needed a referral to a home care agency other than [agency name], this agency is no longer providing care. On 04/16/24, the RN manager documented another call to the physician office “to relay information that the patient needs to be referred to a different agency.” On 12/04/24 at 11:48 a. m., the surveyor spoke with the caregiver regarding the agency discharge. The caregiver reported that the patient had been receiving services from the home care agency for approximately one year (the start of care in January was due to a change in payor) and there had not been any discussion about discharge planning until the first notice of Medicare Non-coverage was delivered and that it “came out of nowhere”. The caregiver reported everyone from the patient’s physicians to the home care nurses that visited the patient thought the patient should remain open to the agency except one person. The caregiver reported by name that the Director of Patient Services seemed determined to see the patient discharged from the agency. Following agency discharge, the caregiver reported that patient died while trying to get patient “enrolled in another program.” On 12/10/24 at 10:42 a. m., the surveyor interviewed the office manager at the gastroenterologist office that gave the verbal orders relating to the discharge. When asked what the office’s involvement was in the discharge planning, the office manager replied that they did not believe they had any say in the home care agency discharge planning process. The office manager confirmed they received the verbal orders related to agency recert and discharge as well as multiple calls from patient’s caregiver attempting to enroll patient in several other home care agencies after the agency discharged the patient. On 12/05/24 at 3:08 p.m., the surveyor interviewed a nurse that was involved in the patient’s care. The nurse reported that they thought the patient had skilled need due to the changes in patient’s condition, medication diagnoses, and poor prognosis. The nurse reported that the Director ordered patient to be discharged from the agency. On 12/12/24 at 2 p. m., the findings were reviewed with the Administrator, the Director of Patient Services, and a representative from the governing authority. They acknowledged the findings and offered no additional information. Home visit Patient #2 was admitted to the agency on 08/01/24 with diagnoses that included spinal stenosis, hypertension, yeast dermatitis, and fecal incontinence with urgency. The patient was residing in an adult home. On 08/01/24, the physical therapist visited the patient for the start of care assessment. In the documentation field that asked if the “patient along with the patient’s caregiver and representative (if any and as appropriate), agrees with and participated in development/ update the plan of care, the therapist documented “yes” without indication who care was coordinated with. The list of caregivers included 2 family members that live locally as well as phone number for the adult home. The 08/01/24-09/29/24 Plan of Care in a field regarding discharge plan was answered, “discharge to caregiver under supervision of MD when goals are met.” The plan was not clear if the caregiver was a family member or the adult home staff. On 09/04/24, the RN manager documented a coordination note with a check box indicating patient was to be discharged as goals met. There was no evidence to support what discharge plan was in place. On 09/18/24 the Director of Patient Services documented a coordination note that stated patient will be recertified for further services because the “Notice of Medicare Non-coverage was not completed correctly, and discharge was overturned.” On 10/31/24, the physical therapist visited the patient for a reassessment visit and documented the patient continued to make progress using the following examples: - patient demonstrated “transfers from recliner to wheelchair as well as wheelchair to bed in all directions with supervision/independent level. Previous assessment patient required contact guard assist as well as increased verbal cueing to performing these bed mobility activities.” - Patient was “able to stand 2 times with up to 20-25 seconds with contact guard. Previously patient will be able to stand approximately 10 seconds with contact guard min assist.” The therapist also documented “the above functional testing shows sufficient improvement to justify continued physical therapy to work on balance and standing. Patient would benefit from continued home physical therapy to improve strength and stamina for potential advancement of balance activities.” On 11/13/24, the physical therapy assistant made the next scheduled visit and issued the patient the Notice of Medicare-Noncoverage. The assistant documented “patient had a good session working on transfer mechanics and standing weight bearing activities, would benefit from continued skilled therapy to improve those skills to aide in transfers.” On 11/27/24, the surveyor conducted an observational home visit with the physical therapist, which was a discharge visit. The patient’s caregiver, an adult child who resides locally, arrived near the end of the visit. The caregiver expressed dissatisfaction that the patient was being discharged from the agency as the patient had been making progress and had recently begun standing for short periods of time with the assistance of home care. The therapist told the caregiver that the patient had been receiving home care for 4 months, was at baseline, and gave the caregiver the name of another agency that might be able to provider further physical therapy services. After the visit concluded, the surveyor interviewed the patient and caregiver about their experiences with home care agency. The caregiver expressed frustration that they were not aware when the patient was being discharged from the agency. The caregiver reported that they appealed the discharge a couple of months prior and had appealed the current discharge but was not aware if a ruling had been determined for the current appeal. On 12/04/24 at 10:12 a. m., the surveyor interviewed the physical therapist who reported that if patient was “making gains” they would be kept on service, evaluate the goals, and may “shoot for higher level with new goal established.” On 12/04/24 at 1:35 p. m., the Administrator and Director of Patient Services were interviewed about the discharge planning process. The Director reported that discharge planning begins at the start of care visit and the patient and/or caregiver should have been aware of the discharge plan. A “Notice of Medicare Non-Coverage” is also issued at the visit prior to discharge or at least 48 hours prior to discharge. When asked if the start of care visit and the issuance of the “Notice of Medicare Non-Coverage” could be the only 2 timepoints during a patient’s episode that the discharge is discussed, the Director replied yes. On 12/04/24 at 1:35 p. m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and offered no additional information. 1. Patient #13 was admitted to the agency on 09/22/24 for wound care to a stage 3 pressure ulcer of the coccyx and stage 3 pressure ulcers of the bilateral inner knees. The patient’s medical history included osteoarthritis, osteoporosis, and dementia. The patient was previously admitted to the agency on 04/26/23, discharged on 08/16/24, and identified on the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report, dated 09/01/23 through 08/31/24, for an increase in the number of pressure ulcers and discharged to the community with an unhealed stage 2 pressure ulcer. Review of the discharge record revealed the patient received wound care for 2-3 wounds for approximately 16 months. The nurse saw the patient for wound care weekly and the caregiver provided wound care on the days the nurse did not. On 08/13/24, 3 days prior to discharge, the nurse case manager saw the patient for a recertification visit. The nurse documented: - risks for hospitalizations: decline in mental, emotional, or behavioral status in the past 3 months; currently reports exhaustion; reported/observed history of difficulty complying with medical instructions, recent urinary tract infection (UTI) requiring antibiotics, and pressure ulcer wounds related to contractures and lack of moving - primary focus of care: bilateral knee pressure ulcers, re-opened coccyx wound pressure ulcer; assist family in finding long term caregiver, and education for prevention of infections, falls, UTI’s, and pressure ulcers - patient with increased sleeping/lethargy and disorientation during conversations as well as “many changes in patient’s condition as [the patient] has dementia” There was no evidence of any discharge planning and/or discussions about a potential discharge occurring. On 08/16/24 the licensed practical nurse (LPN) visited the patient. There was no evidence of any discharge planning and/or discussions about a potential discharge occurring. On 08/16/24 the nurse case manager completed a visit note titled “RN [registered nurse] Discharge Data Collection Only-No Visit Made” which included only OASIS (tool used to gather patient assessment information for Medicare) information. The nurse also documented in a “Client Coordination Note Report”: - date of discipline discharge: 08/16/24 - reason for discharge: patient having new face to face with physician next week hopefully - evaluation of goals: not met, wounds remain On 12/03/24 at 1:30 p.m. the findings were reviewed with the Administrator and Director of Patient Services who provided no additional information. The nurse case manager who discharged the patient was no longer employed with the agency and therefore could not be interviewed. On 12/05/24 at 4:30 p.m. and 12/06/24 at 9:50 a.m. this surveyor interviewed the patient’s primary caregiver (adult child). They stated: - the agency did mention the possibility of discharge, however, there was no timeframe given for discharge - they were not in agreement with the patient’s discharge and neither was the physician, which was conveyed to the agency (the caregiver believed they spoke to a manager, however, could not remember the person’s name) - they were not home at the time of discharge; they received a call from the private aide in the home stating the patient had just been discharged - they were not set up with supplies or a vendor that could provide supplies which led to the patient running out of items needed to provide wound care; eventually they obtained supplies from a local pharmacy. On 12/09/24 this surveyor called the physician’s office to inquire about the patient’s discharge on 08/16/24. Per an interview with the RN at 1:30 p.m.: - there was no documentation of any calls from the agency regarding discharge of the patient; normally an agency would call to get a verbal order to discharge - there was no discharge summary attached to the patient’s chart, the only evidence of discharge was a new/re-referral entered on 08/19/24 after the patient’s physician visit - there was no request for a prescription or referral for the supplies needed to continue wound care Per an interview with the physician at 3:15 p.m., they were not aware the patient was being discharged from the agency and would have voiced concern because the patient had several wounds. On 12/04/24 the surveyor requested the agency’s discharge policy, which was then provided at 3:40 p.m. The “Discharge or Transfer Policy and Job Aide”, dated 09/2024, included that: - the certifying physician responsible for the plan of care provides confirmation the patient’s outcomes and/or goals have been met and home health services are no longer required - the patient’s authorized representative has received instructions/education and agrees to assume all responsibilities in the plan of care - the patient/authorized representative must understand and participate in the discharge planning as well as receive prior notice of the discharge - the patient’s physician will be notified of the patient’s discharge and be sent a copy of the discharge/transfer summary within 5 business days The agency failed to develop and implement a safe discharge plan that involved the patient, patient caregiver, and physician.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on a review of clinical records and interviews with the Administrator and Director of Patient Services, it was determined in 4 of 19 records, (patients #3, 6, 8, and 13), the agency failed to ensure each patient received care and services as written in the plan of care. Evidence as follows: 1. Patient #13 was admitted to the agency on 09/22/24 with diagnoses of a stage 3 pressure ulcer of the coccyx and stage 3 pressure ulcers of the bilateral inner knees. The patient’s medical history included osteoarthritis, osteoporosis, and dementia. The patient was also identified on the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report, dated 09/01/23 through 08/31/24, for an increase in the number of pressure ulcers and discharged to the community with an unhealed stage 2 pressure ulcer (patient was previously on service 4/26/23-8/16/24). The nurse failed to perform wound care as ordered in the Plan of Care which resulted wound deterioration from a stage 3 pressure ulcer to a stage 4 pressure ulcer. The 09/22/24-11/20/24 Plan of Care included: - skilled nursing 1/week X 9 weeks - “Skilled nurse to observe/assess integumentary system, identify changes, and intervene to minimize complication.” Nursing assessment to be performed by RN [registered nurse]: LPN [licensed practical nurse] to observe and report changes to the RN.” - “Skilled nurse to perform/teach pressure ulcer care to the bilateral inner knees and coccyx. Cleanse with wound cleanser, apply medihoney, cover with opticell, secure with mepiplex using clean technique. Change dressing every day and PRN [as needed] soiling/dislodgement.” - “Caregiver to perform on days skilled nurse is not in the home. Skilled nurse to perform 1 day a week when CG [caregiver] is unable to perform On 09/22/24 the RN visited the patient for an initial assessment and documented in the wound grid for all three pressure ulcers: - wound assessed: yes - total WAT (wound assessment tool) score: not applicable - documentation in Swift (program used to photograph and measure wounds): yes - wound care provided: cleansed with wound cleaner, applied medi-honey, covered with opticell, secured with mepilex, patient tolerated with no discomfort No wound descriptions or measurements were documented in the wound grid or narrative note on 09/22/24. A 10/01/24 supplemental order included: - “Skilled nurse to perform/teach pressure ulcer care to the bilateral inner knees and coccyx. Cleanse with wound cleanser, apply hydrofera blue, followed by ABD [abdominal] pads & secure with rolled gauze & tape using clean technique (may use optifoam mepilex for coccyx). Change dressing every day and PRN [as needed] soiling/dislodgement.” - “Caregiver to perform on days skilled nurse is not in the home. Skilled nurse to perform 1 day a week when caregiver is unable to perform.” On 10/01, 10/07, 10/14, 10/21, 10/28, 11/04, 11/12, and 11/19/24 the nurses visited the patient and documented they performed wound care to the bilateral inner knees. The following was documented regarding the pressure ulcer on the coccyx: - 10/1/24 RN visit: “refused care”; “patient refused care to coccyx along with caregiver (changed when patient is incontinent etc.) - 10/7/24 LPN visit: “caregiver completed care” - 10/14/24 RN visit: “caregiver completed care” - 10/21/24 LPN visit: “caregiver completed care” - 10/28/24 RN visit: “refused care”; “patient and dtr [daughter] refusing care att [at this time] as patient had completed this am” - 11/4/24 LPN visit: “caregiver completed care” - 11/12/24 RN visit: “refused care”; “pictures and care refused of sacrum”; “refusal of sacral wound as performed approx. 1-2 hrs ago via dtr [daughter]” - 11/19/24 RN Recertification Visit: “caregiver completed care” From 10/01/24 to 11/19/24 the skilled nurses failed to assess and provide wound care to the coccyx wound per the physician ordered plan of care. There was no evidence the nurse: - notified the physician the coccyx wound was not being assessed weekly - tried to coordinate with the patient’s caregiver for a different time and/or day to provide wound care to the coccyx, allowing for an assessment to be completed - escalated to the nurse case manager/supervisor On 11/29/24 the nurse case manager visited the patient and performed wound care to the coccyx and bilateral inner knees and documented: - the wound was “very concerning…..as it is 4 cm deep and bone is exposed” - patient caregiver reports “the wound just keeps getting worse and is growing in size” On 12/03/24 at 1:30 p.m. the findings were reviewed with the Administrator and Director of Patient Services (Director). The surveyor requested the wound documentation from Swift be provided. The RN was no longer employed with the agency and therefore could not be interviewed. On 12/04/24 the surveyor again requested any wound documentation from Swift. On 12/05/24 at 4:30 p.m. and 12/06/24 at 9:50 a.m. this surveyor interviewed the patient’s primary caregiver (adult child). When asked about the wound care to the coccyx, the caregiver stated they would let the nurse know wound care had been completed already, however, they were not asked: - how the wound appeared when wound care was provided - if there was a different time and/or day the nurse could come to provide wound care so the wound could be assessed - if they would be okay with the dressing being removed so the wound could be assessed The patient caregiver also stated the wound had been improving, however, within a 7-10 day time period, prior to the 11/29/24 visit, the wound went from looking “okay” to “crappy”. When the caregiver was asked to define “crappy”, they stated the wound was a “big hole” again and had brownish/yellowish drainage. On 12/06/24 at approximately 8:45 a.m. the Director provided a picture of the coccyx wound dated 09/22/24 and a second undated blurry picture of the coccyx. Per the Director, the undated picture was from the 11/29/24 nursing visit. Later that same day, at approximately 1:45 p.m., this surveyor showed the Director a printout from Swift of a different wound that contained a picture and measurements. The surveyor asked the Director if they could print the same type of document for the coccyx wound from the 09/22/24 and 11/29/24 nursing visit. Per the Director, they only had the pictures already provided. When asked where those pictures came from, the Director stated the nurse took them with their tablet, uploaded them, and then sent them to the agency. When asked if there were any measurements for the patient’s coccyx wound from either the 09/22/24 or 11/29/24 nursing visit, the Director stated there were not. Failure to assess the coccyx wound from 09/22/24 through 11/29/24 resulted in the wound deteriorating from a stage 3 pressure ulcer to a stage 4 pressure ulcer. Patient #11 was admitted to the agency on 11/03/24 with diagnoses that included dysphagia, respiratory failure, heart failure, and constipation. The 11/03/24-01/01/25 Plan of Care contained the following order for dressing change to the percutaneous cholecystostomy tube: “SN [skilled nurse] to change dressing every week, cleans area with alcohol, cover with stayfix, secure with Tegaderm (caregiver is unable to perform and patient is unable to perform due to location).” On 11/09/24 the RN documented a missed visit notification for nursing visit missed on 11/08/24. The reason for the missed visit was “the caregiver and patient declined the need for a nursing visit as the patient had an MD appointment the prior day and have no current concerns and feel comfortable with the next nursing visit Tuesday.” The note also stated that there was no potential negative clinical impact as the patient was tolerating tube feedings better and caregiver was able to independently care for PEG tube. There was no evidence of who would perform the dressing change to the percutaneous cholecystostomy tube per the physician ordered plan of care. On 12/02/24 at 1:30 p. m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and offered no additional information. Failure to develop individualized plans of care that are complete, accurate, and/or addressed the total needs of the patients has the potential for unmet patient needs. HV 1. Patient #3 was admitted to the agency on 10/12/24 with diagnoses of cutaneous abscess of abdominal wall, type 2 diabetes mellitus, autistic disorder, depression, and moderate intellectual disabilities. Patient #3 is a resident of a group home. The Plan of Care dated 10/12/24 – 12/10/24 included: - Three visits per week for eight weeks -“SN to perform/teach wound care to abdomen. Cleanse with wound cleanser, pack both sites with ½ inch or ¼ inch iodoform. Cover with folded 4x4 gauze, cover with folded ABD, secure with tape using clean technique. Change dressing every other day and prn for soiling/dislodgement. Once taught, patient/caregiver to perform on days skilled nurse not in home.” The RN failed to ensure that the Plan of Care matched the physician ordered plan for wound care. On 11/27/24 at 3:30 p.m. the surveyor conducted an observational visit with the licensed practical nurse (LPN) present. During the surveyor’s interview with the group home manager, they stated that they were unable to complete wound care. On 12/3/24 at 1:30 p.m., the record was reviewed with the Administrator and Director. No further information was provided.”

“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: The agency failed to track all adverse patient events to determine through subsequent analysis whether they were the result of errors that should have been preventable to reduce the likelihood of such events in the future. Evidence as follows: On 11/25/24 at 10:09 a. m., during the entrance conference, the surveyor requested the Quality Improvement/Professional Advisory Committee meeting minutes for the previous 12 months. The 05/15/24 Professional Advisory Committee minutes report: - 9 potentially avoidable events: 1 emergent care for improper medication administration, 2 development of urinary tract infections, 1 increase in the number of pressure ulcers, 1 discharged to community needing wound care, 1 discharge to community needing toileting assistance, 1 discharge to community with behavioral problems, 2 discharged to community with unhealed stage 2 pressure ulcers. - number of falls in the following categories without staff member present: 173 falls without injury, 104 falls with minor injury, 5 falls with major injury - number of falls with a staff member present :9 falls with minor injury There was no evidence of analysis to determine if any of the events could have been prevented to reduce the likelihood of preventing similar events in the future. On 12/06/24 at 12:30 p. m. the surveyor interviewed the Administrator and the Director of Patient Services regarding the tracking and analyzing adverse events. During the interview, the Administrator and Director reported: - potentially avoidable events are identified when report is run monthly - typically, every adverse event is reviewed, including urinary tract infection, pressure ulcers, falls - analysis for cause involved common themes, common trends, and “common clinicians” During the record reviews (12/03/24 at 1:30 p. m. and 12/04/24 at 1:35 p. m.) for the 5 patients selected from the “Potentially Avoidable Event Patient Listing Report” for 09/01/23-08/31/24, the surveyor requested a copy of the agency’s audit for these patients. On 12/06/24, during the interview regarding management of adverse events, they surveyor again requested a copy of the adverse event audits for those 5 patients. On 12/09/24, the Administrator provided copies of “potentially avoidable event notification” for 2 patients selected from the potentially avoidable event report (#15 and #17) that included: - patient #17 – “increase in number of pressure ulcers skin tear RLE (right lower extremity) patients daughter wants to care for.” It was unclear that a potentially avoidable event occurred, which would have been identified if the event was reviewed by the agency, as a skin tear is not a pressure ulcer. - patient #15 – “development of urinary tract infection patient on antibiotic of UTI [urinary tract infection] patient refusing home care service.” There was no evidence to support the agency was analyzing adverse patient events. Failure to analyze adverse patient events places the patient population at risk by failing to identify gaps in practice, near misses, and prevent future adverse events.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Following a review of the Professional Advisory Committee meeting minutes and interview with the Administrator and Director of Patient Services, the agency failed to maintain an ongoing program for quality improvement and implement actions that are evaluated for effectiveness. Evidence as follows: On 11/25/24 at 10:09 a. m., during the entrance conference, the surveyor requested the Quality Improvement/Professional Advisory Committee meeting minutes for the previous 12 months and this was provided by the Administrator and Director of Patient Services on the same day. The 05/15/24 (2nd quarter) Professional Advisory Committee minutes were the most recent meeting minutes and reported: - a focus on rehospitalization audits with 30 audits being completed in the quarter - content of the comprehensive assessment audit was no longer being done as of 4th quarter of 2022 as they “are in compliance” - plan of care focused audit was no longer being completed “as of Q4 2022 as we are in compliance” - promptly alert relevant physician of changes audit identified deficiency in 4th quarter but an audit indicated the “branch is in compliance with this tag for Q1.” The meeting minutes did not reflect that any comprehensive assessments were completed with most of the clinical auditing activity focused on rehospitalization. On 12/06/24 at 12:30 p. m., the surveyor interviewed the Administrator and Director of Patient Services regarding the agency’s quality improvement program. The Administrator and Director reported that the 30 rehospitalization audits were a focused audit, not a comprehensive review of the record. During the interview, the Director reported that they were not surprised by the surveyor’s findings that had been shared in record reviews as they were aware of problems in these areas. The director also reported that “we’ve been putting things into place.” The agency failed to implement a quality improvement program that would identify gaps in patient care and implement a timely and effective action plan. There was no documentation to support once an issue was deemed to be “in compliance” that any ongoing monitoring was completed.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on a review of patient records, observational home visits, and interviews with the Administrator, Director of Patient Services and agency staff, it was determined in 2 of 7 visits (patients #2 and 7), staff failed to adhere to accepted standards and practices to prevent the transmission of infection. Evidence as follows: Home Visit 1. Patient #7 was admitted to the agency on 09/28/24 with diagnoses of liver transplant infection, sepsis, abscess of liver and malignant neoplasm of bone and articulate cartilage. The 09/28/24 Plan of Care included weekly nurse visits for peripherally inserted central catheter (PICC) line management and labs. On 12/02/24 the surveyor conducted an observational home visit with the Registered Nurse (RN) and observed the following: The RN performed a PICC line dressing change to the right arm: -The RN completed hand hygiene and donned clean gloves to remove the PICC line dressing -The RN then removed the gloves, performed hand hygiene and donned sterile gloves to complete the PICC line dressing change utilizing sterile technique. -After the PICC dressing change was complete, wearing the same sterile gloves, the RN opened the end clave and normal saline flush packaging while still wearing the sterile gloves thus contaminating them. -While wearing the contaminated sterile gloves, the RN removed the PICC end claves and replaced with a new clave without cleansing the end hub with alcohol. The surveyor reviewed the agency policy and procedure for PICC dressing change (revised 08/19/24) which did not specify procedures for changing the end claves. *According to the Nursing Research and Practice, “colonization of needleless connectors is considered the cause of 50% of postinsertion catheter-related infections. Breaks in aseptic technique, from failure to disinfect, result in contamination and subsequent biofilm formation within needless connector and catheters increasing the potential for infection of central and peripheral catheters. Needleless catheters should be consistently and thoroughly disinfected using mechanical friction with 70% alcohol”. On 12/3/24 at 1:30 p.m., the record was reviewed with the Administrator and Director. No further information was provided. Failure to follow accepted standards of practice has the potential for unmet patient needs and possible negative patient outcomes. *Moureau NL, Flynn J. Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review. Nurs Res Pract. 2015;2015:796762. doi: 10.1155/2015/796762. Epub 2015 May 14. PMID: 26075093; PMCID: PMC4446481. Home visit Patient #2 was admitted to the agency on 08/01/24 with diagnoses that included spinal stenosis, hypertension, yeast dermatitis, and fecal incontinence with urgency. On 11/27/24, the surveyor conducted an observational home visit with the physical therapist who was conducting a discharge visit. Throughout the visit, the physical therapist was documenting on a tablet. On multiple occasions, the physical therapist placed the tablet inside the bag without cleansing the tablet and reached into the bag to retrieve the tablet without performing hand hygiene. On 12/04/24 at 1:35 p. m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and offered no additional information.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on a review of the agency’s Quality Assessment and Performance Improvement (QAPI) program and interviews with the Administrator and Director of Patient Services, the agency failed to maintain a coordinated, agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as an integral part of the agency’s quality assessment and performance improvement plan. Evidence as follows: On 11/25/24 at 10:09 a. m., during the entrance conference, the surveyor requested the Quality Improvement/Professional Advisory Committee meeting minutes for the previous 12 months. The 05/15/24 Professional Advisory Committee minutes, in the “Infection Reporting – Patient” section, there was a field for “report/discussion summarize findings and/or trends” stated the following: - 18 UTI [urinary tract infection] - 4 indwelling catheter - 14 UTI [urinary tract infection] - 2 wound - 1 surgical wound - 1 non-surgical wound - 4 respiratory - 3 URI [upper respiratory infection] - 0 COVID - 1 CDIFF [clostridium difficile] - 39 UTI [urinary tract infection] - 2 indwelling catheter - 1 suprapubic catheter - 36 UTI [urinary tract infection] non device related - 8 wound - 2 surgical wound - 6 non-surgical wound - 9 respiratory - 4 URI [upper respiratory infection] - 5 LRI [lower respiratory infection] - 1 GI [gastrointestinal] - 4 other There was no discussion or summary of the findings or explanation as to why there were multiple categories listed more than once. On 12/06/24 at 12:30 p. m., the surveyor interviewed the Administrator and Director of Patient Services regarding infection prevention. The surveyor reviewed the above Professional Advisory Committee infection reporting section of the minutes and inquired about analysis of the data collected. The Administrator and Director reported that the agency looks for common themes, common trends, and “common clinicians.” The example was given that if a patient had a urinary tract infection following a catheter change, the manager would perform a supervised visit to observe the employee perform a catheter change. There was no evidence provided to surveyors that the agency incorporated investigation of infection as part of the performance improvement plan.”

“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 a review of clinical records for 2 patients receiving home health aide (HHA) services, (patients #8 and 9) it was determined in 1 of 2 records, (patient #8) the skilled nurse failed to develop complete and accurate aide care plans. Evidence as follows: Patient #8 was admitted to the agency on 09/17/24 with diagnoses of congestive heart failure, type 2 diabetes mellitus, anemia, foot drop left foot, and spinal stenosis. The 09/17/24 plan of care included a personal care aide once weekly, the patient’s medication included Eliquis (a blood thinner). The 09/17/24 and 11/16/24 aide care plans failed include bleeding precautions. The nurse failed to include bleeding precautions in the 09/17 and 11/16/24 aide care plans. On 12/04/24 at 2.p. m., the findings were reviewed with the Administrator and Director of Patient Services. 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.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on a review of patient records, the agency’s complaint log, and interviews with the Administrator and Director of Patient Services, it was determined the agency failed to identify, investigate, and develop a plan to address voiced concerns. Evidence as follows: During the entrance conference on 11/25/24 at 10:10 a.m., the surveyor requested the complaint log for the previous 12 months and complaint information was given to the surveyor by the Director of Patient Services at 1:45 p.m. The complaint information provided consisted of 5 complaint documentation forms (from previous record keeping system) and a complaint report (log) that listed 18 complaints by patient name. The log did not include information regarding the nature of the complaint, investigation that was conducted, or the resolution. On 12/06/24 at 12:30 p.m., the surveyor interviewed the Administrator and the Director of Patient Services regarding how complaints are logged, and they reported: - the person taking the call fills out a complaint form - if a patient or caregiver sounds unhappy, this should be filed as a complaint - the managers review the on-call log each morning for calls received on their team Following the interview, the surveyor randomly selected 3 patients from the complaint report and requested all documentation pertaining to those complaints including details of the complaint investigation and resolution. This was provided to the surveyor by the Administrator at 2 p.m. Based on review of the information provided, it was determined for 3 patients the agency failed to sufficiently track and resolve complaints. Tracking complaints 1. Patient #18 On 02/28/24 the Director of Patient Services documented a phone call with the caregiver regarding plan to discharge patient from the agency. The caregiver reported there had been no plan in place for discharge and the Director informed the caregiver that patient had been receiving agency services for a year, there was no skilled need, and if they want a nurse to visit to “check on patient,” they should transition to hospice or hire privately. The caregiver reported they were “not happy with writer” and Director apologized then reinforced home care guidelines. Caregiver refused hospice services citing a previous bad experience. On 02/29/24, the Director of Patient Services documented receiving a call from the patient’s insurance company with caregiver on the line to discuss skilled need and caregiver was again informed patient is more appropriate for hospice care despite caregiver’s refusal of the service the previous day. On 12/04/24 at 11:48 a.m., the surveyor interviewed the caregiver who reported multiple calls with the Director of Patient Services in which they expressed dissatisfaction with the decision to discharge the patient from the agency. The complaint information the agency provided failed to include a complaint logged for this patient. On 12/06/24 at 12:30 p.m., the surveyor interviewed the Administrator and Director of Patient Services regarding this patient and Director reported that they did not think to file the encounter as a complaint. The Administrator and Director reported they did not track discharge appeals. 2. On 12/02/24, the surveyor requested the on-call log for 12/27/23-01/2024 and this was provided by the Administrator. On 01/06/24 at 12:11 p.m., the triage nurse documented receiving a call from a patient (#20) reporting they “were supposed to have a nurse visit this a. m. no one has showed up or called [them]. Friday the same thing happened, and the nurse didn’t show until 4 p.m. after they were notified that no one showed earlier that day. Stated this has been an ongoing issue for the past 2 weeks in general. Wound dressing needs to be changed.” The on-call nurse apologized for the scheduling errors and the patient was educated that the nurse will call the evening prior to the visit. There was no evidence the case manager, nurse manager, or scheduling was notified of the scheduling errors. There was no evidence this was documented or investigated as a complaint. 3. Resolution of the complaint On 01/26/24, a complaint was logged for a patient (#21) stating, “patient reports calling several times on Friday and today with no return call. [Patient] needs supplies, and was told that staff would call [patient] back, and no one has as of this call. Received a box with urostomy bags today and that is not what [they] use.” The following fields on the complaint report were blank: interventions, intervention/resolution comments, prevention, prevention comments, processed by, follow-up comments, date processed, last modified date, and last modified by. On 12/06/24 at 2:30 p.m., the surveyor interviewed the Administrator and the Director of Patient Services about the specific complaint. The Administrator said they ensured the patient received supplies and then “end-staged” the complaint without any investigation into the complaint. The agency failed to track all complaints received or the resolution. Failure to track, investigate, and resolve complaints has the potential for patients to have unmet needs and prevents the agency from identifying patient care issues.”

“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 a review of patient records, observational home visits, and interviews with agency staff, Administrator and Director of Patient Services, it was determined in 10 of 19 records, (patients #2, 7, 8, 10, 11, 12, 14, 15, 17, and 18) ) comprehensive assessments were incomplete and/or not of sufficient scope to identify all patient needs. Evidence as follows: Patient #17 was admitted to the agency on 03/13/24 with diagnoses of coronary artery disease with acute myocardial infarction (heart attack), bilateral foot drop, Alzheimer’s dementia, adult failure to thrive, dysphagia (difficulty swallowing), and protein-calorie malnutrition. The patient was discharged on 05/10/24 and was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report, dated 09/01/23 through 08/31/24, for an increase in the number of pressure ulcers. Swallowing The 03/13/24-05/11/24 Plan of Care included a diagnosis of dysphagia. On 03/13/24 the Registered Nurse (RN) visited the patient for an initial assessment. In the Eyes/Ears/Nose/Throat section of the assessment there was no evidence the nurse assessed the patient’s ability to swallow and/or assessed the patient’s potential need for a speech evaluation (see also tag G0590). Skin Tear On 04/09/24 the physical therapist (PT) visited the patient to perform a reassessment and documented the caregiver reported the patient had a new abrasion to the right lower leg, approximately 1 x 1.5 inches, to which a small bandage was applied, and that the abrasion was at the site of the orthotic strap. The PT also documented they communicated with the RN. On 04/16/24, 7 days later, the nurse saw the patient for a PRN (as needed) visit for wound care and documented the patient caregiver was called at work by the private aide in the home expressing concerns regarding the leg wound. Wound documentation included: - type: skin tear - measurements (length x width x depth): 7 cm x 2 cm x 0.2 cm - depth description: partial thickness - exudate: small bloody drainage The nurse failed to visit the patient in a timely manner in order to assess the patient’s wound, determine if a wound care order was needed, and update the plan of care. On 12/04/24 at 2:00 p.m. the findings were reviewed with the Administrator and Director of Patient Services who provided no additional information. 1.Patient #10 was admitted to the agency of 01/10/24 with diagnoses of type 2 diabetes mellitus with foot ulcer, heart failure, chronic kidney disease, chronic obstructive respiratory disease and retention of urine. On 07/06/24, the RN visited for a recertification of home care services for ongoing suprapubic catheter maintenance and documented a new wound to the right lower legs. The RN documented in the assessment that the “patient has an open blister to right lower legs, cleansed with soap and water, covered with a foam dressing, family is performing wound care.” The 07/11/24 order obtained for wound care to the new site stated, “cleanse open blister with normal saline, cover with foam border dressing”. The order did not contain wound care frequency or who was to complete. There was no evidence the RN assessed the caregiver’s ability and availability to perform wound care. There was no evidence that a caregiver was able to demonstrate or teach back wound care steps with proficiency. On 12/03/24 at 1:30 p. m., the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. HV 2. Patient #7 was admitted to the agency on 09/28/24 with diagnoses of liver transplant infection, sepsis, abscess of liver and malignant neoplasm of bone and articulate cartilage. IV antibiotics On 10/07/24, the RN visited for a resumption of care assessment following a hospitalization for bacteremia with intravenous antibiotics via peripherally inserted central catheter (PICC). The RN documented in the integument area of the assessment that the skilled nurse and caregiver were “responsible party for management of picc catheter”. The RN documented that the “patient is unable to take injectable medication unless administered by another person”. The RN failed to assess the caregiver’s ability to manage the administration of intravenous antibiotics. There was no documented evidence that a caregiver was able to demonstrate or teach back antibiotics administration steps with proficiency. On 12/03/24 at 1:30 p. m., the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. Patient #14 was admitted to the agency on 09/26/23 with diagnoses that included congestive heart failure, insulin dependent type 2 diabetes, atherosclerotic heart disease (walls of the arteries that supply the heart thicken and narrow), and stage 3 chronic kidney disease. The patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 09/01/23 through 08/31/24 for emergent care for hypo or hyperglycemia. On 09/26/23, the registered nurse (RN) visited for the start of care assessment and documented within the assessment tool endocrine system, the patient had diabetes, polyuria (high glucose levels cause the kidneys to remove excess sugar from the body by producing more urine) and monitored glucose with a meter and continuous glucose system (CGM). Recent low and high readings were 88 that morning, and 406 the “night of discharge,” (09/22/23). The patient’s hospital discharge instructions dated 09/22/23 included the following insulin regimen: - Basaglar Kwikpen U-100 100 u/ml solution, inject 12 units subcutaneously at bedtime - Insulin Aspart (U-100) 100 u/ml subcutaneous pen. Inject 2 units daily at lunchtime, hold if BG Patient #12 was admitted to the agency on 09/15/24 with diagnoses of type 2 diabetes mellitus with foot ulcer, acute osteomyelitis, chronic obstructive pulmonary disease, aortic aneurysm without rupture, malignant neoplasm of upper left lobe, and peripheral neuropathy. On 09/04/24 a referral was sent to the agency for this patient requesting skilled nursing for wound care to 3 chronic ulcers of left foot. The 09/15/24 Plan of Care orders included: - skilled nurse to perform and teach wound care to left planter foot diabetic ulcers, clean with normal saline, pack with iodoform, cover with dry sterile dressing, secure with ace wrap using clean technique. Change dressing every day and as needed for soiling or dislodgement. Teach patient/caregiver to perform on the days skilled nurse is not in the home. - provide teaching/reinforcement with infection control measures. - nursing visit frequency 3x a week for 2 weeks, 2x a week for 1 week and 1x a week for 4 weeks. On 09/15, 09/17, 09/20, 09/23, 09/25, 09/27, and 09/30/24 each visit the nurses documented in the clinical summary notes, a single wound location of left planter foot. On 10/02/24 the patient had a follow up visit in the physician’s office, the agency received an office report that included: - left medical ulcer 0.5 cm x 0.5 cm x 0.5 cm (length by width by depth) - left lateral ulcer 0.5 cm x 0.5 cm x 0.7 cm - left toe ulcer 0.5 cm x1 cm x 0.4 cm All left foot ulcers conservatively debrided. Wound care orders as follows: - “tightly pack all 3 ulcers with iodoform and cover with dry gauze and apply Kling wrap, dressing to be changed once daily.” On 10/11, 10/15, 10/18, and 10/30/24 the nurse visited the patient and included an assessment of a single wound located left plantar foot. The nurse failed to assess 2 of the 3 active wounds identified on the referral and the follow up physician visit on 10/02/24. On 12/03/24 at 1:30 p. m., the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. 2. Patient #8 was admitted to the agency on 09/17/24 with diagnoses of congestive heart failure, type 2 diabetes mellitus, anemia, foot drop left foot, and spinal stenosis. On 11/13/24 the physical therapist completed a recertification assessment. The assessment included the patient was having significant overall difficulty in the shower, could not care for their feet, was diabetic and felt like they were going to fall when attempting to clean feet, had not been able to clean both feet, and had significant risk for developing wounds. The clinician obtained an occupational therapy order for evaluation and teaching bathing strategies for diabetic foot care. On 11/18/24 a nurse visited and documented new wounds on the right foot 3rd, 4th, and 5th toes related to unknown trauma. On 11/21/24 a nurse documented they reported to the physician the patient keeps reinjuring right foot, wound care orders obtained to apply skin prep to blisters on toes may cover with dry sterile dressing and secure with tape as needed. On 11/22/24 the occupational therapist conducted an initial visit. The findings were “pt is independent with diabetic foot care, has basin they use to wash their feet and has scrubber brush for in between toes.” There was no evidence the occupational therapist assessed: - patient’s feet for wounds - whether right foot dressing was in place. - whether the patient was able to change the dressing independently - patient’s knowledge of diabetic foot care (or provided the patient with education regarding diabetic foot care) On 12/04/24 at 2.p. m. the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. 1. Patient #18 was admitted to the agency on 01/03/24 with diagnoses that included cirrhosis of liver, liver cell carcinoma, and type 2 diabetes. On 01/03/24 the registered nurse (RN) visited the patient and completed a start of care assessment and failed to fully assess the following: Ascites management The nurse documented the patient had ascites that required draining daily or every other day and a nurse was required for weekly sterile dressing change. The sterile dressing change was done at the start of care visit. There was no evidence the nurse assessed: - when the ascites was last drained, amount drained, color of fluid drained - what type of tube or catheter was present to drain ascites fluid - insertion site of the tube or catheter - details of the dressing change that was done including any cleansing of the insertion site and what dressing was applied Integumentary The nurse documented the presence of a rash in the integumentary section, however, there is no evidence the nurse assessed the rash, including location, size, treatment, and patient or caregiver ability to manage the rash. Diabetes The nurse documented the patient reported they were in the “yellow zone” using the diabetic self-management tool without assessment of what placed patient in the yellow zone. On 12/12/24 at 2 p.m., the findings were reviewed with the Administrator, the Director of Patient Services, and a representative from the governing authority. They acknowledged the findings and provided no additional information. 2. Patient #12 was admitted to the agency on 09/15/24 with diagnoses of type 2 diabetes mellitus with foot ulcer, acute osteomyelitis, chronic obstructive pulmonary disease, aortic aneurysm without rupture, malignant neoplasm of upper left lobe, and peripheral neuropathy. On 09/04/24 a referral was sent to the agency for this patient requesting skilled nursing for wound care to 3 chronic ulcers of left foot. The 09/15/24 Plan of Care orders included: - skilled nurse to perform and teach wound care to left plantar foot diabetic ulcers, clean with normal saline, pack with iodoform, cover with dry sterile dressing, secure with ace wrap using clean technique. Change dressing every day and as needed for soiling or dislodgement. Teach patient/caregiver to perform on the days skilled nurse is not in the home. - provide teaching/reinforcement with infection control measures. - nursing visit frequency 3x a week for 2 weeks, 2x a week for 1 week and 1x a week for 4 weeks. On 09/15, 09/17, 09/20, 09/23, 09/25, 09/27, and 09/30/24, the nurses documented in the clinical summary notes a single wound location of left plantar foot. On 10/02/24, the patient had a follow up visit in the physician’s office, the agency received an office report that included: - left medical ulcer 0.5 cm x 0.5 cm x 0.5 cm (length by width by depth) - left lateral ulcer 0.5 cm x 0.5 cm x 0.7 cm - left toe ulcer 0.5 cm x1 cm x 0.4 cm All left foot ulcers conservatively debrided. Wound care orders as follows: - “tightly pack all 3 ulcers with iodoform and cover with dry gauze and apply Kling wrap, dressing to be changed once daily.” On 10/11, 10/15, 10/18, and 10/30/24, the nurse visited the patient and included an assessment of a single wound located left plantar foot. The nurse failed to assess 2 of the 3 active wounds identified on the referral and the follow up physician visit on 10/02/24. On 12/03/24, at 1:30 p.m., the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. 3. Patient #8 was admitted to the agency on 09/17/24 with diagnoses of congestive heart failure, type 2 diabetes mellitus, anemia, foot drop left foot, and spinal stenosis. On 11/13/24, the physical therapist completed a recertification assessment. The assessment included the patient was having significant overall difficulty in the shower, could not care for their feet, was diabetic and felt like they were going to fall when attempting to clean feet, had not been able to clean both feet, and had significant risk for developing wounds. The clinician obtained an occupational therapy order for evaluation and teaching bathing strategies for diabetic foot care. On 11/18/24, a nurse visited and documented new wounds on the right foot 3rd, 4th, and 5th toes related to unknown trauma. On 11/21/24, a nurse documented they reported to the physician the patient keeps injuring right foot, wound care orders obtained to apply skin prep to blisters on toes may cover with dry sterile dressing and secure with tape as needed. On 11/22/24, the occupational therapist documented the patient was independent with diabetic foot care, had basin they use to wash their feet, and had scrubber brush for in between toes. There was no evidence the occupational therapist assessed: - patient’s feet for wounds - whether right foot dressing was in place. - whether the patient was able to change the dressing independently - patient’s knowledge of diabetic foot care On 12/03/24 at 2 p.m. the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. 4. Patient #14 was admitted to the agency on 09/26/23 with diagnoses that included congestive heart failure, insulin dependent type 2 diabetes, atherosclerotic heart disease (walls of the arteries that supply the heart thicken and narrow), and stage 3 chronic kidney disease. The patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 09/01/23 through 08/31/24 for emergent care for hypo or hyperglycemia. On 09/26/23, the registered nurse (RN) visited for the start of care assessment and documented within the assessment tool endocrine system, the patient had diabetes, polyuria (high glucose levels cause the kidneys to remove excess sugar from the body by producing more urine) and monitored glucose with a meter and continuous glucose system (CGM). Recent low and high readings were 88 that morning, and 406 the “night of discharge,” (09/22/23). The patient’s hospital discharge instructions dated 09/22/23 included the following insulin regimen: - Basaglar Kwikpen U-100 100 u/ml solution, inject 12 units subcutaneously at bedtime - Insulin Aspart (U-100) 100 u/ml subcutaneous pen. Inject 2 units daily at lunchtime, hold if BG < 70 The Plan of Care dated 09/26/23-11/24/23 included blood glucose monitoring 3 times daily before meals via CGM. The RN documented the patient used injectable therapy and could take the medication as prescribed, prepare and self-inject the insulin, and the patient was “very confident” in their ability to manage their diabetes. There was no evidence the RN assessed the patient’s ability to manage self-insulin injections through demonstration/re-demonstration or verbalization. Both assessment tool questions regarding management of oral and injectable medications were answered, “unable to take medication/injectable medication unless administered by another person,” which contradicted the nurse’s assessment the patient could take the medication as prescribed, prepare and self-inject the insulin and the patient was “very confident” in their ability to manage their diabetes. The RN also documented: - “no” in response to “was caregiver knowledge assessed?” - “not appropriate at this time” in response to “indicate reason for the caregiver knowledge not assessed” - the primary caregiver’s availability was “evenings and weekends.” The RN failed to assess: - The patient’s ability to self-inject insulin - The caregiver’s ability to manage the blood glucose testing and administration of insulin after realizing and documenting the patient could not complete these tasks without another person. - Who would be available to assist the patient with the noontime dose of insulin On 12/03/24 at 1:30 PM the record was reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no further information. 5. Patient #15 was admitted to the agency on 12/05/23 with diagnoses that included COVID-19 pneumonia, chronic lower back pain, chronic hypoxic respiratory failure, asthma, hypertension and chronic atrial fibrillation. This patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 09/01/23 through 08/31/24 for urinary tract infection. Genitourinary/Toileting Hygiene On 09/26/23, the registered nurse (RN) documented in the start of care assessment: - the genitourinary system was assessed (without specifying what was assessed or the details of the assessment) - the patient was incontinent of urine - “no” in response to the assessment tool question, “patient had a urinary tract infection (UTI) in the past 14 days?” - “someone must help the patient to maintain hygiene” in response to “able to maintain perineal hygiene safely?” - “substantial/maximal assistance-helper does more than half the effort” in response to “have the ability to maintain peritoneal hygiene, adjust clothes before and after voiding?” The RN failed to assess: - how the patient and caregivers were managing the incontinence - although no UTI in 14 days, UTI history was not assessed A review of the nursing visit notes dated 12/05/23 through discharge on 01/10/24 (4 visits) revealed no evidence the patient and caregiver’s knowledge of peritoneal care was assessed, or toileting hygiene education was provided. The RN failed to assess the patient and caregiver’s knowledge, frequency of, and comfort (3 male family members) assisting the patient with toilet hygiene. The nurses failed to teach the patient and caregivers urinary tract infection prevention at all visits. Respiratory On 12/05/23, the registered nurse (RN) visited the patient and performed the start of care assessment. The Plan of Care included oxygen, 2 liters via nasal cannula as needed for shortness of breath, wheezing. The oxygen saturation was documented at 98% with no supplemental oxygen. Further documentation of the respiratory system findings included: - oxygen use - shortness of breath - using 2 liters as needed - patient is dyspneic or noticeably short of breath with minimal exertion (for example, while eating, talking, or performing other activities) or with agitation. The RN failed to assess: - patient’s breath sounds - frequency the supplemental oxygen was being used On 12/03/24 at 1:30 p.m., the record was reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no further information. 6. Patient #10 was admitted to the agency of 01/10/24 with diagnoses of type 2 diabetes mellitus with foot ulcer, heart failure, chronic kidney disease, chronic obstructive respiratory disease and retention of urine. On 07/06/24, the registered nurse (RN) visited for a recertification of home care services for ongoing suprapubic catheter maintenance and documented a new wound to the right lower leg. The RN documented in the assessment that the “patient has an open blister to right lower leg, cleansed with soap and water, covered with a foam dressing, family is performing wound care.” The 07/11/24 order obtained for wound care to the new site stated, “cleanse open blister with normal saline, cover with foam border dressing”. The order did not contain wound care frequency or who was to complete. There was no evidence the RN assessed the caregiver’s ability and availability to perform wound care. There was no evidence that a caregiver was able to demonstrate or teach back wound care steps with proficiency. On 12/03/24 at 1:30 p.m., the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. Home Visit 7. Patient #7 was admitted to the agency on 09/28/24 with diagnoses of liver transplant infection, sepsis, abscess of liver and malignant neoplasm of bone and articulate cartilage. IV antibiotics On 10/07/24, the registered nurse (RN) visited for a resumption of care assessment following a hospitalization for bacteremia with intravenous antibiotics via peripherally inserted central catheter (PICC). The RN documented in the integument area of the assessment that the skilled nurse and caregiver were “responsible party for management of picc catheter”. The RN documented that the “patient is unable to take injectable medication unless administered by another person”. The RN failed to assess the caregiver’s ability to manage the administration of intravenous antibiotics. There was no documented evidence that a caregiver was able to demonstrate or teach back antibiotics administration steps with proficiency. On 12/03/24 at 1:30 p.m., the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. 8. Patient #17 was admitted to the agency on 03/13/24 with diagnoses of coronary artery disease with acute myocardial infarction (heart attack), bilateral foot drop, Alzheimer’s dementia, adult failure to thrive, dysphagia (difficulty swallowing), and protein-calorie malnutrition. The patient was discharged on 05/10/24 and was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report, dated 09/01/23 through 08/31/24, for an increase in the number of pressure ulcers. Swallowing The 03/13/24-05/11/24 Plan of Care included a diagnosis of dysphagia. On 03/13/24 the Registered Nurse (RN) visited the patient for an initial assessment. In the Eyes/Ears/Nose/Throat section of the assessment there was no evidence the nurse assessed the patient’s ability to swallow and/or assessed the patient’s potential need for a speech evaluation (see also tag G0590). Skin Tear On 04/09/24 the physical therapist (PT) visited the patient to perform a reassessment and documented the caregiver reported the patient had a new abrasion to the right lower leg, approximately 1 x 1.5 inches, to which a small bandage was applied, and that the abrasion was at the site of the orthotic strap. The PT also documented they communicated with the RN. On 04/16/24, 7 days later, the nurse saw the patient for a PRN (as needed) visit for wound care and documented the patient’s caregiver was called at work by the private aide in the home expressing concerns regarding the leg wound. Wound documentation included: - type: skin tear - measurements (length x width x depth): 7 cm x 2 cm x 0.2 cm - depth description: partial thickness - exudate: small bloody drainage The nurse failed to visit the patient in a timely manner in order to assess the patient’s wound, determine if a wound care order was needed, and update the plan of care. On 12/04/24 at 2 p.m. the findings were reviewed with the Administrator and Director of Patient Services who provided no additional information. Home visit 9. Patient #2 was admitted to the agency on 08/01/24 with diagnoses that included spinal stenosis, hypertension, yeast dermatitis, and fecal incontinence with urgency. The 07/25/24 physician office visit note included in the referral documented the presence of a recurrent rash under the breast, abdominal fold, and groin area. Patient was to start topical nystatin ointment for treatment of yeast rash x 7 days with start date on 07/25/24 and end date of 08/01/24. The 08/01/24-09/29/24 Plan of Care included an order for nystatin topical cream to be applied to affected areas 2 times a day for 7 days with discharge date of 08/01/24, which was congruent with the order in the referral. On 08/01/24, the physical therapist visited for the start of care assessment and documented “no problems identified” in the integumentary section and in the narrative note documented “has a rash under [their] breasts which they are managing independently.” There was no evidence the physical therapist assessed the rash or the patient’s ability to manage the rash. On 11/27/24, the surveyor conducted an observational home visit with the physical therapist. The patient reported that their skin is still itchy sometimes and they apply topical nystatin as needed. Toilet transfers On 08/01/24, the physical therapist visited the patient for the start of care assessment. The patient had diagnoses that included incontinence of feces and fecal urgency. The gastrointestinal documentation reported bowel incontinence more than once daily, was dependent upon another person to dress lower body (including undergarments), and dependent with toilet hygiene. The physical therapist failed to assess how incontinence and toileting hygiene were managed. Patient resided at an adult home, but it was unclear in the assessment and plan of care if the patient was receiving assistance with personal care. There was no evidence the physical therapist assessed and addressed the toileting hygiene deficits. On 11/27/24, the surveyor conducted an observational home visit with the physical therapist. During the visit, the physical therapist assessed the patient’s ability to complete the transfer from wheelchair to toilet and back to wheelchair with clothing in place. The physical therapist did not assess the patient’s ability to perform toilet hygiene. Near the end of the visit, the caregiver arrived and reported that management of toilet hygiene had been a significant issue for the patient for months now. The caregiver reported multiple interventions the family implemented over the last few months, including the instillation of a bidet (which was not a viable solution for the patient and had to be removed) and the instillation of a hose with nozzle the patient can use to assist the patient with performing peri care. Following the visit, the surveyor interviewed the patient and caregiver about their home care experience. The patient (who was alert and oriented but very forgetful/poor historian) and caregiver could not recall the physical therapist assessed or addressed toilet hygiene deficits. On 12/04/24, an interview was conducted with the physical therapist that conducted the home visit on 11/27/24 who reported that they did not complete the start of care comprehensive assessment and were unaware there were toileting issues until the discharge visit on 11/27/24. When asked about the rash assessment, the PT reported this would have been assessed at the start of care visit. However, the physical therapist confirmed they completed the recert visit and failed to assess the rash or toilet hygiene deficits at that time. On 12/03/24 at 1:30 p.m. the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and offered no additional information. 10. Patient #11 was admitted to the agency on 11/03/24 with diagnoses that included dysphagia, respiratory failure, heart failure, and constipation. On 11/03/24, the registered nurse (RN), visited the patient for the start of care assessment and documented: - gastrointestinal assessment included constipation - patient diagnoses included active diagnosis of constipation - last bowel movement was 10/31/24 (3 days prior) The nurse failed to assess the patient’s usual bowel pattern or how the constipation was being managed. On 12/03/24 at 1:30 p.m., the findings were reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and offered no additional information.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on a review of clinical records and interviews with the Administrator and Director of Patient Services, it was determined in 10 of 19 records, (patients # 2, 3, 5, 6, 7, 10, 11, 12, 17, and 18) ), the Plan of Care was incomplete and/or failed to reference all pertinent information. Evidence as follows: 1. Patient #17 was admitted to the agency on 03/13/24 with diagnoses of coronary artery disease with acute myocardial infarction (heart attack), bilateral foot drop, Alzheimer’s dementia, adult failure to thrive, dysphagia (difficulty swallowing), and protein-calorie malnutrition. The patient was discharged on 05/10/24 and was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report, dated 09/01/23 through 08/31/24, for an increase in the number of pressure ulcers. Orthotics The 03/11/24 skilled nursing facility discharge plan of care, included with the agency referral, documented the patient used bilateral AFO’s (ankle foot orthosis) while standing and ambulating. On 03/13/24 the Registered Nurse (RN) visited the patient for an initial assessment and documented the patient had a history of foot drop and had bilateral AFO’s. The 03/13/24-05/11/24 Plan of Care failed to include an order for the use of the bilateral AFO’s, including when they should be applied and removed. Weight The 03/13/24-05/11/24 Plan of Care included diagnoses of protein-calorie malnutrition and adult failure to thrive. The RN visited the patient and documented in the initial assessment the patient’s weight was 89 pounds and the patient was a high nutritional risk. The plan of care failed to include an order for weight monitoring and/or an alternate intervention to monitor for weight loss. On 12/04/24 at 2:00 p.m. the findings were reviewed with the Administrator and Director of Patient Services who offered no additional information. Home Visit 2. Patient #5 was admitted to the agency on 10/15/24 for wound care following a right foot 4th toe amputation. Additional diagnoses included type 2 diabetes, peripheral artery disease, osteoarthritis, and coronary artery disease. Diabetes The 10/15/24-12/13/24 Plan of Care included: - skilled nurse to teach regarding blood glucose out of parameters - patient to assess glucose levels four times daily - patient uses continuous glucose monitor - Novolog FlexPen 100 unit/mL: 3-7 units based on sliding scale (number of units to be administered based on blood glucose reading); no instructions for the sliding scale were present On 11/01/24 the nurse visited the patient and documented the patient was using their glucometer as they were waiting on more supplies for the continuous monitor to be delivered. On 11/27/24 at 9:00 a.m. the surveyor performed an observational home visit with the skilled nurse. After the visit the surveyor stayed and interviewed the patient and patient caregiver. While reviewing the patient’s medication list, the surveyor asked the patient/patient caregiver if they had the sliding scale for the insulin. The patient caregiver responded the sliding scale was in there somewhere (indicating the kitchen) and stated the patient usually takes 3-4 units for a small meal and 7 units for a larger meal because that was what the physician told them to do. The Plan of Care failed to include: - a back-up glucometer, including instructions for use if continuous monitor failed - blood glucose parameters for which to notify the physician - the insulin sliding scale Wound Care The 10/15/24-12/13/24 Plan of Care included orders for both the right 4th toe amputation site and right plantar foot blister to be cleansed with saline during wound care. On 11/5/24 a supplemental order was obtained for wound care to a left toe blister. The order included washing the area with soap and water. During the 11/27/24 observational home visit, this surveyor observed the nurse cleaning both the right and left foot wound area’s with Hibiclens skin cleanser prior to performing wound care. The nurse failed to update the plan of care to include the use of Hibiclens skin cleaner in addition to or instead of the saline and soap and water. Allergies The 10/09/24 physician’s visit, note included with the agency referral, documented the patient had allergies to Chantix, bee venom protein, lisinopril, sitagliptin, and telmisartan. The 10/15/24-12/13/24 Plan of Care only listed bees in the allergy section. The Plan of Care failed to include all allergies that patient had. Medical Equipment On 10/17/24 the Physical Therapist (PT) visited the patient to perform an initial evaluation. The PT documented the patient “currently only weightbearing in offloading boot at all times.” The plan of care failed to include an order for the use of the offloading boot, including instructions for when the boot should be worn and removed. Medication On 10/19/24 the nurse visited the patient and documented advising the patient to use Tylenol prior to wound care to help with pain control. On 11/04/24 the nurse visited the patient and documented “minimal pain to right foot for which Tylenol provides relief.” The nurse failed to update the plan of care to include the use of Tylenol for pain control, including dose and frequency. On 12/03/24 at 1:30 p.m. the findings were reviewed with the Administrator and Director of Patient Services (Director). On 12/04/24 at approximately 1:45 p.m. the Director stated the insulin sliding scale had been entered into a comments section within the medication profile, therefore it did not appear when printed out, including when printed for the patient. The Director further stated the sliding scale was moved to the correct location within the medication profile, however, this does not change the above findings. Patient #1 was admitted to the agency on 10/02/24 with diagnoses including stage 2 pressure ulcer of left buttock, stage 2 pressure ulcer of right buttock, blister (nonthermal) left lower leg, sick sinus syndrome, and chronic obstructive pulmonary disease. Plan of Care The 10/02/24-11/30/24 Plan of Care included type 2 diabetes mellitus without complications as one of the patient’s diagnoses. On 11/26/24 at 10:00 a.m. the surveyor completed an observational home visit. During the visit, the registered nurse (RN) spoke to the patient’s primary caregiver. The RN asked about the patient’s type 2 diabetes and how it was being controlled. The caregiver responded that the patient did not have diabetes and that the caregiver does. The Plan of Care incorrectly included type 2 diabetes. On 12/03/24 at 1:30 p.m., the record was reviewed with the Administrator and Director. No further information was provided. Medications The 10/02/24-11/30/24 Plan of Care included the medications: - furosemide 20 mg tablet, take 1 tablet by mouth daily for 4 days per week - spironolactone 25 mg tablet, take 1 tablet by mouth 3 times a week During the observational home visit with the skilled nurse (SN) on 11/26/24, the SN performed a medication reconciliation. During the medication reconciliation, the SN asked the patient what days they took the furosemide 20 mg and the spironolactone 25 mg. The patient’s caregiver reported the patient took the furosemide on Mondays, Wednesdays, Fridays, and Sundays and the spironolactone on Mondays, Wednesdays, and Fridays. The SN then added the specific days of the week that that the patient took the medication to the medication list and updated plan of care for those medications. Not including the specific days of the week on medication list and plan of care could lead to confusion for the patient and the caregiver. Bathing The 10/02/24-11/30/24 Plan of Care included an order for the skilled nurse to perform/teach wound care to left lower leg: cleanse with wound cleanser, apply xeroform, and cover with mepore using clean technique. Change dressing 2 times per week and as needed for soiling/dislodgement. Once taught, patient/caregiver to perform on days skilled nurse is not in the home. The plan of care failed to include instructions for bathing with consideration of the wound dressing (e.g. it did not specify if the patient was permitted to shower or required to bed bathe). On 12/03/24 at 1:30 p.m., the record was reviewed with the Administrator and Director. No further information was provided. Patient #16 was admitted to the agency on 10/22/23 with diagnoses of Systemic Lupus Erythematosus, non-pressure chronic ulcer skin sites with fat layer exposed, cellulitis, hypertension, and type 2 diabetes mellitus. This patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 09/01/23 through 08/31/24 for Urinary Tract Infection. The 10/22/23-12/10/23 Plan of Care included an order for the skilled nurse to perform/teach wound care to the back of the right upper leg: cleanse with wound cleanser/normal saline/soap and water, apply hydrofera blue, and cover with boarder gauze using clean technique. Change dressing every Monday and Wednesday; at wound clinic on Fridays. Once taught, patient/caregiver to perform on days skilled nurse is not in the home. The plan of care failed to include instructions for bathing with consideration of the wound dressing (e.g. it did not specify if the patient was permitted to shower or required to bed bathe). On 12/3/24 at 1:30 p.m., the record was reviewed with the Administrator and Director. No further information was provided. Home visit Patient #6 was admitted to the agency on 10/18/24 with diagnoses of heart failure, chronic kidney disease, anemia, and hyperlipidemia. On 10/28/24 the patient was admitted to the hospital with diagnoses of anemia, patient underwent a gastrointestinal work up without any evidence of a gastrointestinal bleed. Bilateral PleurX catheters (tubes inserted in the lining of the lung) were placed for significant bilateral pleural effusions. Inferior vena cava filter (a small device that prevents blood clots traveling to the lungs) was placed by vascular surgical team due to concerns of ongoing anemia and on Xarelto (blood thinner). On 11/09/24 the patient was discharged home from the hospital. The referral orders included the following: Medications Start taking the following: - Amoxicillin 4 capsules (2,000 mg a day) by mouth, one time if needed for dental work or procedures. - Aspirin 81 mg enteric coated once a day. Stop taking the following: -metoprolol succinate 25 mg (24 hours tablet) -potassium chloride 20 mEq extended release -rivaroxaban 20 mg tablet (Xarelto) -torsemide 20 mg (diuretic) -pravastatin 40mg On 11/12/24 the nurse performed a resumption of care comprehensive visit. The nursing assessment included: - no changes to frequency/duration, medications, or treatments. - no changes found on drug review. - patient is taking high risk medication – anticoagulant. - medication reconciliation was completed using the patients home list The nurse failed to update the plan of care to include: - amoxicillin 4 capsules (2,000 mg a day) by mouth, one time if needed for dental work or procedures. - aspirin 81 mg enteric coated once a day. The nurse failed to discontinue the following medications from the plan of care: - metoprolol succinate 25 mg (24 hours tablet) - potassium chloride 20 mEq extended release - rivaroxaban 20 mg tablet (Xarelto) Respiratory Hospital discharge instructions included: - “Keep PleurX sites clean dry and covered. Home care nurse to drain on Mondays/Wednesday/Friday, up to max 1-liter pleural fluid from each pleural catheter. “ On 11/12/24 the nurse performed a resumption of care comprehensive visit. The nursing assessment included: Integumentary -Surgical drains/tubes – PleurX -Indicate the amount of output – “1ML”. -Surgical site tubes surrounding skin – clean dry and intact. The 11/12/24 resumption of care orders included: - “SN [skilled nurse] to drain PleurX drain 3 times a weekly drain system of ML/L with max of 1,000 ML/L using sterile drainage procedure, change dressing 3 times weekly cleanse area with alcohol prep pad, cover with foam secure with gauze and Tegaderm, may change dressing as needed if soiled.” The nurse failed to update the plan of care to include: - Left and right PleurX drain, with maximum drain form each site. On 11/27/24 at 10 a.m., the surveyor conducted an observational home visit. The nurse drained the left and right PleurX drain and completed a sterile dressing to each site, monitored the patient’s weight, and measured bilateral lower leg edema. The nurse failed to accurately update the plan of care to include all treatments, and medications to reflect the patient’s needs. On 12/03/24 at 1:30 p. m., the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. Patient #12 was admitted to the agency on 09/15/24 with diagnoses of type 2 diabetes mellitus with foot ulcer, acute osteomyelitis, chronic obstructive pulmonary disease, aortic aneurysm without rupture, malignant neoplasm of upper left lobe, and peripheral neuropathy. On 09/04/24 a referral was sent to the agency for this patient and requesting skilled nursing for wound care, 3 chronic ulcers to left foot. The 09/15/24 plan of care orders included: -skilled nurse to perform and teach wound care to left planter foot diabetic ulcers, clean with normal saline, pack with iodoform, cover with dry sterile dressing, secure with ace wrap using clean technique. Change dressing every day and as needed for soiling or dislodgement. Teach patient/caregiver to perform on the days skilled nurse is not in the home. -provide teaching/reinforcement with infection control measures. -nursing visit frequency 3x a week for 2 weeks, 2x a week for 1 week and 1x a week for 4 weeks. On 09/15, 09/17, 09/20, 09/23, 09/25, 09/27, and 09/30/24 each visit the nurses documented in the clinical summary notes, a single wound location of left planter foot. On 10/02/24 the patient had a follow up visit in the physician’s office, the agency received an office report that included: -left medical ulcer 0.5 cm x 0.5 cm x 0.5 cm (length by width by depth) -left lateral ulcer 0.5 cm x 0.5 cm x 0.7 cm -eft toe ulcer 0.5 cm x1 cm x 0.4 cm All left foot ulcers conservatively debrided. Wound care orders as follows: -“tightly pack all 3 ulcers with iodoform and cover with dry gauze and apply Kling wrap, dressing to be changed once daily.” There was no evidence the above wound care orders were included in the plan of care. On 12/03/24 at 1:30 p. m., the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. 1. Patient #10 was admitted to the agency on 01/10/24 with diagnoses of type 2 diabetes mellitus with foot ulcer, heart failure, chronic kidney disease, chronic respiratory failure with hypoxia, and retention of urine requiring suprapubic catheter. Weight/Edema On 09/04/24, the Registered Nurse (RN) visited for a recertification of care assessment and documented “edema” within the cardiovascular portion of the record and in the narrative section, that “patient is non ambulatory and requires a hoyer lift for transfers”. The plans of care dated 09/06/24-11/04/24 and 11/05/24–01/03/25 included the following: -Notify physician for 3lb weight gain in 24 hours, patient is unable to obtain a weight in home due to body habitus. There were no recorded weights within the record. On 12/04/24 at 1:30 p.m., the surveyor requested the agency policy for heart failure. On 12/05/24 at 10:43 a.m. the surveyor was provided with a policy titled “Circumferential Edema Measurement- Patients who Cannot Perform Daily Weights” (revised 03/25/24). Per the agency policy, circumferential edema measurements are required for all patients who are unable to perform daily weights. The RN failed to develop a plan of care for weight and edema monitoring that followed the agency policy. Suprapubic Catheter and Bathing The plans of care dated 09/06/24-11/04/24 and 11/05/24–01/03/25 did not include orders for care to the suprapubic catheter insertion site. On 12/04/24 at 9:35 a.m., the surveyor requested the agency policy for suprapubic catheter management. On 12/05/24 at 10:43 a.m. the surveyor was provided with a policy titled “Suprapubic catheter care, home care” (revised 11/18/24). Per the policy, site care for an established catheter included cleansing, assessing the site, and notifying the practitioner of any signs of irritation, excoriation, redness, swelling, warmth and tenderness. The plan of care lacked orders for suprapubic catheter site care and bathing instructions. The RN failed to develop a plan of care for the suprapubic catheter insertion site that followed agency policy. On 12/3/24 at 1:30 p.m., the record was reviewed with the Administrator and Director. No further information was provided. HV 2. Patient #3 was admitted to the agency on 10/12/24 with diagnoses of cutaneous abscess of abdominal wall, type 2 diabetes mellitus, autistic disorder, depression, and moderate intellectual disabilities. Patient #3 is a resident of a group home. Bathing The hospital referral dated 10/11/24 stated “should keep wound site/dressing dry but can shower”. On 11/27/24 at 3:30 p.m. the surveyor conducted an observational visit with the licensed practical nurse (LPN) present. During the surveyor’s interview with the group home manager, they stated that the patient showers daily and that the staff of the group home changes the “outer dressing”, but they are unable to complete wound care. The plan of care dated 10/12/24 – 12/10/24 did not include bathing orders and did not specify if the patient was permitted to bathe. Medications The plan of care dated 10/12/24 to 12/10/24 included the medications: - Mounjaro 5mg/0.5mL injection. Inject 5mg every seven days - Ketoconazole 2% cream. 1 inch daily During the observational home visit with the Licensed Practical Nurse (LPN) on 11/27/24, the LPN asked if there were any medication changes since the last visit to which the house manager reported there were not. Following the survey, the surveyor interviewed the house manager who advised that the patient’s Mounjaro injection is completed every Friday morning, and the Ketoconazole cream is applied to forehead and nose. On 12/04/24, the surveyor requested the agency policy for medication reconciliation. On 12/06/24 at 2:30 p.m. the surveyor was provided with a policy titled “Medication Review and Documentation” (Reviewed 10/24). Per the agency policy, during each patient visit the agency will review all medications the patient is taking and “examine the medication bottles and current medication list”. Diabetes The plan of care for 10/12/24 - 12/10/24 included “fasting blood glucose daily by patient/caregiver and prn for signs and symptoms of hypo/hyperglycemia”. On 10/12/24, the RN visited for the start of care assessment and documented within the endocrine system that the patient had diabetes mellitus but did not monitor blood glucose levels. There was no evidence in the record that the physician was contacted regarding the patients’ blood glucose monitoring orders and the plan of care was not updated. On 12/3/24 at 1:30 p.m., the record was reviewed with the Administrator and Director. No further information was provided. HV 3. Patient #7 was admitted to the agency on 09/28/24 with diagnoses of liver transplant infection, sepsis, abscess of liver and malignant neoplasm of bone and articulate cartilage. Patient was receiving intravenous antibiotics via a peripherally inserted central catheter (PICC) and Jackson Pratt (JP) drain care. The hospital referral dated 09/27/24 stated that the patient could shower but would need to cover the PICC site with plastic wrap and to ensure that all lumens of the catheter were under the plastic wrap and to tape the edges. The plan of care dated 09/28/24 – 11/26/24 did not include bathing orders and did not specify if the patient was permitted to bathe. On 12/3/24 at 1:30 p.m., the record was reviewed with the Administrator and Director. No further information was provided. Patient #11 was admitted to the agency on 11/03/24 with diagnoses that included dysphagia, respiratory failure, heart failure, and constipation. Medications On 11/03/24, the registered nurse (RN) conducted the start of care visit and documented the patient: - had a percutaneous endoscopic gastrostomy (PEG) tube as they were unable to take food or medications orally, received bolus nutritional supplements and medications crushed through the tube - had a “clinically significant medication issue.” In the coordination notes under “briefly describe the medication issue and follow up: the nurse documented “lansoprazole and liquid multivitamin with iron was not picked up due to cost. No liquid Tylenol – planning to pick up.” - was instructed not to exceed 3 grams of Tylenol per day unless directed by a physician The nurse answered “yes” to the question “was medication follow-up competed by midnight the next calendar day, however, there was no documentation to support who the medications were reconciled with, and it was unclear if the medications were to remain active medications or were discontinued. None of these 3 medications were included on the 11/03/24-01/01/2025 Plan of Care. On 11/09/24 the triage RN documented the caregiver called to inquire if an over-the-counter vitamin with iron could be used instead of the prescribed multivitamin with iron that cost $400. The caregiver was instructed to follow-up with the physician. There was no documentation at subsequent nursing visits or coordination notes that the agency reconciled the use of multivitamin with iron. On 11/14/24, a licensed practical nurse (LPN) visited the patient and documented the caregiver inquired about administering Tylenol through the gastrostomy tube. The Tylenol in the home was gel-coated and the caregiver was instructed not to crush or attempt to administer gel-coated Tylenol through the tube as it could clog the tube. The caregiver was instructed to obtain a non-coated Tylenol. Report was given to RN case manager, however, there was no evidence that the provider was contacted to obtain a Tylenol order or follow-up to determine if Tylenol was obtained. On 11/22/24 a registered nurse visited at patient for a routinely scheduled visit and documented “patient reported neck pain due to sitting up for tube feedings” and the pain was managed with Tylenol. There was no evidence to support the nurse assessed if the caregiver obtained Tylenol compatible with use in the gastrostomy, the dose or frequency of the Tylenol administration. Flush order The 11/03/24-01/01/25 Plan of Care included an order the flushing of the gastrostomy (PEG) tube, including: - flush gastrostomy with 30 milliliters after feeds - 150 milliliters 2 hours after feeding The plan of care failed to identify the solution to be used for flushing the tube. Spirometer The 11/03/24-01/01/25 Plan of Care included incentive spirometer in the supplies section and failed to include an order for incentive spirometer use, including how often the patient should be using. On 11/03/24, the registered nurse (RN) visited the patient for the start of care assessment. The respiratory narrative does not mention the presence of a spirometer. On 11/12/24, the occupational therapist (OT) documented that the patient had a spirometer and use of the spirometer was encouraged. On 12/02/24 at 1:30 p. m., the findings were reviewed with the Administrator and Director of Patient Services, who acknowledged the findings and offered no further information. Patient #18 was admitted to the agency on 01/03/24 with diagnoses that included cirrhosis of liver, liver cell carcinoma, and type 2 diabetes. On 01/03/24 the registered nurse (RN) visited the patient for the admission assessment and documented that the patient requires weekly RN visit “to do sterile dressing change.” The 01/03/24-03/02/24 Plan of Care included the following order for peritoneal dialysis catheter care: “Skilled nurse to perform/teach PD cath management: LUQ [left upper quadrant] inspect drain/tube every week, cg [caregiver] to drain every day using clean techniques drainage procedure up to 1-liter daily check vs [vital signs] before and after change dressing every week cleanse area with alcohol x3 cover with foam dressing gauze and tedaderm x2. May change dressing prn [as needed] if soiled/dislodged.” The care plan failed to: - identify if the dressing change was to be done using clean technique or sterile technique On 2/29/24, the RN case manager documented in a coordination note that the patient was being recertified for further home care services because patient was “drained daily” and has sterile dressing change. The 03/03/24-05/01/24 Plan of care included the following order for peritoneal dialysis catheter care: “Skilled nurse to teach patient and spouse peritoneal drain dressing changes and to report significant changes in status to physician.” The care plan failed to: - include orders related to drainage of ascites fluid via the peritoneal dialysis catheter - specify what dressing was to be applied to the peritoneal dialysis catheter, how often it was to be changed, or if it was to be changed using clear versus sterile technique On 12/12/24 at 2 p. m., the findings were reviewed with the Administrator, the Director of Patient Services, and a representative from the governing authority. They acknowledged the findings and offered no additional information. Home visit Patient #2 was admitted to the agency on 08/01/24 with diagnoses that included spinal stenosis, hypertension, yeast dermatitis, and fecal incontinence with urgency. On 08/01/24, the physical therapist visited the patient for the start of care assessment and documented patient used a wheelchair, sliding board, and use of continuous positive airway pressure (CPAP). The 08/01/2024-09/29/24 Plan of Care included: - DME and supplies as “none” - does not include order for CPAP machine On 11/27/24, the surveyor made an observational home visit with the physical therapist who asked the patient if the they continued to use the CPAP machine and the patient reported yes. The plan of care was incomplete for CPAP instructions. On 12/04/24 the findings were reviewed with the Administrator and the Director of Patient Services. They acknowledged the findings and provided no additional information.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on a review of clinical records and interviews with the Administrator and Director of Patient Services, it was determined in 6 of 19 records, (patients #3, 5, 11, 14, 16, and 17), the skilled nurse failed to communicate with the physician when changes in the patient’s condition occurred. Evidence as follows: Patient #14 was admitted to the agency on 09/26/23 with diagnoses that included congestive heart failure, insulin dependent type 2 diabetes, atherosclerotic heart disease, and stage 3 chronic kidney disease. The patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 09/01/23 through 08/31/24 for emergent care for hypo or hyperglycemia. The Plan of Care dated 09/26/23-11/23/23 included: - Basaglar Kwikpen U-100 100 u/ml solution, inject 12 units subcutaneously at bedtime - Insulin Aspart (U-100) 100 u/ml subcutaneous pen, inject 2 units daily at lunchtime, hold if BG 450 On 10/13/23, the RN documented the patient reported not taking the noon dose of insulin On 10/29/23, the licensed practical nurse (LPN) documented, “patient reported hasn’t been taking insulin at lunch.” On 11/01/23, the LPN reported during the visit, the alarm of the continuous glucose monitor (CGM) was going off, indicating the patient “had not checked the a.m. glucose.” On 11/14/23, the RN visited for the recertification and documented range 116-484 and the patient reported not taking the noon insulin. The patient stated [caregiver] is often not present at noontime to ensure insulin is taken. On 11/29/23, the LPN documented, patient forgetful. Forgetting to take noontime insulin. On 12/07/23 at 12:46 p.m., the LPN visited and performed the patient’s blood glucose via the CGM and obtained a reading of “HI.” The LPN notified the primary care provider who “knows the patient is non-compliant with insulin use and managing blood glucoses.” The LPN documented the patient “was only agreeable to giving self-2 units,” however it was unclear if the LPN had obtained an order for a higher dose of short acting insulin for the “high” reading and the patient refused. The was no evidence the RN reported: - 11/14/23 high glucose - multiple dates (10/13, 10/29, 11/01, 11/14, and 11/29/23) of patient not self-injecting insulin correctly at noon On 12/21/23, the RN visited and discharged the patient from nursing services, reason for discharge, “goals met for nursing,” and evaluation of goals, “met.” On 12/03/24 at 1:30 p.m. during the record review, the surveyor inquired what the Administrator and Director of Patient Services (DPS) expectation of the patient’s physician notification of blood glucose range would be. They replied, the usual range in the Plan of Care would be less than 70 or greater than 350. On 12/03/24 at 1:30 p.m., the findings were reviewed with the Administrator and Director of Nursing Services who acknowledged the findings and offered no additional information. 1. Patient #17 was admitted to the agency on 03/13/24 with diagnoses of coronary artery disease with acute myocardial infarction (heart attack), bilateral foot drop, Alzheimer’s dementia, adult failure to thrive, dysphagia (difficulty swallowing), and protein-calorie malnutrition. The patient was discharged on 05/10/24 and was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report, dated 09/01/23 through 08/31/24, for an increase in the number of pressure ulcers. On 03/13/24 the Registered Nurse (RN) visited the patient for an initial assessment. In the Eyes/Ears/Nose/Throat section there was no documentation regarding dysphagia (also see tag G0528). On 04/26/24 the licensed practical nurse (LPN) visited the patient and documented in: - Ears, Nose, Throat assessment: dysphagia - communicated with other disciplines involved: not applicable On 04/29/24 a non-clinical staff member documented in a “Client Coordination Note Report” the patient’s caregiver called requesting a speech therapy evaluation be completed because the patient was having difficulty swallowing solid food. The note further documented the information was relayed to the patient’s clinical team. On 04/30/24 the licensed practical nurse (LPN) visited the patient and documented in: - Ears, Nose, Throat assessment: dysphagia - communicated with other disciplines involved: RN (registered nurse)/Supervisor There was no evidence the RN, LPN, and/or other patient team members communicated with the physician regarding the patient’s difficulty with swallowing to determine if the plan of care needed to be updated. The LPN was no longer employed with the agency therefore could not be interviewed regarding the documented dysphagia. On 12/04/24 at 2:00 p.m. the findings were reviewed with the Administrator and Director of Patient Services who provided no additional information. 2. Patient #5 was admitted to the agency on 10/15/24 for wound care following a right foot 4th toe amputation. Additional diagnoses included type 2 diabetes, peripheral artery disease, osteoarthritis, and coronary artery disease. On 11/08/24 the nurse visited the patient and documented wound measurements for the 4th toe amputation site as 3.2 cm x 2 cm x 1.8 cm (length x width x depth). On 11/11/24 the nurse visited the patient and documented the wound measure 3.4 cm x 1.5 cm x 2.7 cm. There was no evidence the nurse notified the physician of the increase in depth of the wound by 0.9 cm to determine if a change in the plan of care was needed. On 12/03/24 at 1:30 p.m. the findings were reviewed with the Administrator and Director of Patient Services who offered no additional information. Patient #3 was admitted to the agency on 10/12/24 with diagnoses of cutaneous abscess of abdominal wall, type two diabetes mellitus, autistic disorder, depression and moderate intellectual disabilities. Patient #3 is a resident of a group home. Wound Care The was receiving wound care to abdominal abscesses. The wound measurements for wound two was 0.8x0.5x3.7 on 10/28/24. During the visit on 11/06/24 the wound measured 1.7x0.7x4.5 on 11/06/24. There is no evidence that the RN reported the increase in depth and deterioration of wound to the patient’s physician to see if the plan of care needed to be updated or altered. Diabetes The plan of care for 10/12/24 - 12/10/24 included “fasting blood glucose daily by patient/caregiver and prn for signs and symptoms of hypo/hyperglycemia”. On 10/12/24, the RN visited for the start of care assessment and documented within the endocrine system that the patient had diabetes mellitus but did not monitor blood glucose levels. There was no evidence that the physician was contacted regarding the patients’ blood glucose monitoring orders and the plan of care was not updated. On 12/3/24 at 1:30 p.m., the record was reviewed with the Administrator and Director. No further information was provided. Patient #16 was admitted to the agency on 10/22/23 with diagnoses of Systemic Lupus Erythematosus, non-pressure chronic ulcer skin sites with fat layer exposed, cellulitis, hypertension, and type 2 diabetes mellitus. This patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 09/01/23 through 08/31/24 for Urinary Tract Infection. On 10/22/23 the Registered Nurse (RN) completed the initial assessment and documented the patient did not have any edema. On 10/31/23 the nurse documented the patient had trace edema to the bilateral lower extremities. On 11/06/23 the nurse documented the patient had +1 pitting edema to the bilateral lower extremities as well as several small blisters. On 11/08/23 the nurse documented the patient had +1 pitting edema to the bilateral lower extremities as well as a new wound on the posterior (back) of their left thigh. On 11/15, 11/22, 11/29, 12/1, 12/6, 12/9, 12/15, 12/20, and 12/22/23 the patient had edema ranging from trace to +1 in their bilateral lower extremities. There was no evidence the nurse reported the presence of bilateral lower extremity edema or new blisters to the patient’s physician to determine if the plan of care needed to be updated or altered. On 12/3/24 at 1:30 p.m., the record was reviewed with the Administrator and Director. No further information was provided. Patient #11 was admitted to the agency on 11/03/24 with diagnoses that included dysphagia, respiratory failure, heart failure, and constipation. Constipation The 11/03/24 – 01/01/25 Plan of Care included the following orders for the gastrostomy (PEG tube): - flush with 30 milliliters after bolus tube feedings - administer 150 milliliters 2 hours after tube feedings The plan of care failed to identify the solution that should be used for flushing the PEG tube. On 11/15/24, the RN visited the patient for a routine visit and documented the “patient has been experiencing mild bouts of constipation” and the “nurse encouraged more fluids via PEG tube to help aid in constipation.” There was no documentation the physician was notified of constipation episodes, or an order was obtained to increase the amount of free water (or other fluids) the patient was to consume via gastrostomy each day. Vital signs outside parameters The 11/03/24- 01/01/25 Plan of care included an order for licensed professional to report vital signs falling outside the following established parameters including: - heart rate less than 60 or greater than 100 - systolic blood pressure less than 90 or greater than 150 On 3 visits, clinicians documented vital signs outside of parameters: - 11/06/24 heart rate was 112 and systolic blood pressure was 87; note states “MD aware” of both vital signs outside of parameters, however, there was no documentation to support the physician was notified. - 11/13/24 heart rate was 118; coordination note states MD would be notified when office reopens after lunch.” The “Vital Signs Report” printed on 11/26/24 at 2:49 p. m. stated “follow-up comment entered by [RN Manager] on 11/13/24”, however, there was no evidence a follow-up contact was made. On 12/02/24 at 1:30 p. m. the surveyor requested documentation the provider was notified and no documentation was produced. - 11/14/24 heart rate was 114; licensed practical nurse that visited the patient documented MD aware and that patient reported this is their baseline. No documentation to support physician was notified. On 12/02/24 at 1:30 p. m., the findings were reviewed with the Administrator and Director of Patient Services, who acknowledged the findings and no further information was provided.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on review of patient records, observational home visits, and interviews with the Administrator and Director of Patient Services, it was determined in 3 of 19 patients (patients # 14, 15, and 17) the agency staff failed to provide coordinated care to meet the needs of the patients. Evidence as follows: 1. Patient #17 was admitted to the agency on 03/13/24 with diagnoses of coronary artery disease with acute myocardial infarction (heart attack), bilateral foot drop, Alzheimer’s dementia, adult failure to thrive, dysphagia (difficulty swallowing), and protein-calorie malnutrition. The patient was discharged on 05/10/24 and was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report, dated 09/01/23 through 08/31/24, for an increase in the number of pressure ulcers. On 03/13/24 the Registered Nurse (RN) visited the patient for an initial assessment and documented the “pt [patient] has 2 lg [large] purple bruises on both [their] legs from AFO [ankle foot orthosis]. Pt dtr [daughter] will schedule an orthotic appt for eval and proper fitting.” The nurse further documented they communicated with the following disciplines: supervisor, physical therapist (PT), occupational therapist (OT), registered nurse (RN), licensed practical nurse (LPN), and physician. On 03/22, 03/26, 04/03, 04/16, 04/23, 04/26, 04/30, 05/03, 05/07, and 05/10/24 the patient was seen by the RN/LPN. On 03/14, 03/19, 03/22, 03/27, 03/29, 04/03, 04/05, 04/09, 04/17, and 05/01/24 the patient was seen by the PT/PTA (physical therapy assistant). On 03/25/24 the patient was seen by OT. There was no evidence any of the skilled disciplines followed up and/or coordinated with the patient caregiver prior to discharge to ensure the patient was seen for proper AFO fitting.On 12/04/24 at 2:00 p.m. the findings were reviewed with the Administrator and Director of Patient Services who provided no additional information. Patient #14 was admitted to the agency on 09/26/23 with diagnoses that included congestive heart failure, insulin dependent type 2 diabetes, atherosclerotic heart disease and stage 3 chronic kidney disease. The patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 09/01/23 through 08/31/24 for emergent care for hypo or hyperglycemia. On 09/26/23, during the start of care, the registered nurse (RN) documented the patient’s blood glucose range was 88-406, adding the 406 was the night patient returned from hospital. (09/22/23) On 10/04/23, the licensed practical nurse (LPN) documented “patient reported decreased appetite,” and “leg weakness” On 10/13/23, the RN documented the patient reported not taking the noon dose of insulin and a blood glucose range of 141-330, 27% in target range. On 10/29/23, the LPN documented, “patient reported hasn’t been taking insulin at lunch.” On 11/01/23, the LPN reported during the visit, the alarm of the continuous glucose monitor (CGM) was going off; the patient “had not checked the a.m. glucose.” On 11/14/23, the RN visited for the recertification and documented blood glucose range 116-484 and the patient reported not taking the noon insulin. The patient stated [caregiver] was often not present at noontime to ensure insulin is taken, and patient stated, “does feel fatigued lately and has a poor appetite.” On 11/29/23, the LPN documented, patient forgetful. Forgetting to take noontime insulin. On 12/07/23 at 12:46 p.m., the LPN visited and performed the patient’s blood glucose via the CGM and obtained a reading of “HI.” The LPN notified the nurse practitioner who “knows the patient is non-compliant with insulin use and managing blood glucoses.” The LPN documented the patient “was only agreeable to giving self-2 units,” however there was no documentation the LPN had obtained an order for a higher dose of short acting insulin for the “high” reading, and “patient follows with the [diabetic treatment and research center] for diabetes management.” On 01/18/24, the patient was transported for emergent care fore for chest pain. The Hospital note included the blood glucose level was 423, obtained by emergency transport personnel. The agency’s “Visit Note Record” included a prompt for the nurse as follows: “Indicate if you communicated with other disciplines involved in this case.” The visit notes completed by the RN on 10/13, 11/14, 11/24, and 12/21/23 had the response “no.” All visits completed by the LPN included the response “yes” and further documented the coordination was with the RN at each visit, however, does not include what was communicated. The RN failed to coordinate care delivery to meet the patient’s needs, and involve the patient, caregiver, and clinical team as follows: - when it was identified the patient was unable to manage diabetes when alone at noontime, the RN failed ensure a new plan would be created, and the noon insulin was given (was a social work referral offered?) - the [diabetic treatment and research center] was not informed when diabetes management and monitoring were unstable - reports of decreased appetite, weakness and high blood glucose levels occurred, there was no evidence the case manager offered a referral for a dietician On 12/03/24 at 1:30 p.m., the findings were reviewed with the Administrator and Director of Nursing Services who acknowledged the findings and offered no additional information. Patient #15 was admitted to the agency on 12/05/23 with diagnoses that included COVID-19 pneumonia, chronic lower back pain, chronic hypoxic respiratory failure, asthma, hypertension, and chronic atrial fibrillation. The patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 09/01/23 through 08/31/24 for urinary tract infection. On 01/02/24, the patient called the agency and spoke with the on-call RN at 10:43 p.m. with complaints of pain on the left side getting worse, pain 9/10. Patient stated: - pain medication not helping - not sure if it is from the kidneys - pain is unbearable and can’t make it through the night The on-call nurse instructed the patient to go to the “ER.” On 01/03/24, the agency failed to follow-up the next day after the on-call RN documented the patient’s condition and nursing recommendation and to determine if the patient had gone to the “ER” or coordinate with the clinicians to determine if a PRN visit was warranted. The 01/04/24 hospital discharge paperwork included, on 01/03/24 at 10:24 p.m., the patient went for emergency care at the hospital for complaints of left sided lower abdominal discomfort with radiation into the left lower back for the past 4 days, and complaints of mild dysuria, indicating the patient had not gone to the hospital for almost 24 hours after the call to the agency and had not received agency follow-up. The patient was diagnosed with pyelonephritis (after urinalysis and CT scan of the abdomen and pelvis.) Discharged occurred 01/04/24 at 5:56 a.m. According to the National Institute of Health’s National Library of Medicine, “Pyelonephritis is generally a complication of an ascending urinary tract infection.” (www.ncbi.nlm.nih.gov) On 01/04/24, the physical therapist documented, “attempted to schedule physical therapy re-evaluation on 01/03 and again on 01/04 with no answer and no return call. The agency staff failed to follow-up and coordinate with the patient’s clinicians that the patient had been at the hospital throughout the night, discharged around 6 a.m. On 01/05/24, an agency staff documented “Emergency Department use without admission.” Patient in [hospital] 1/3 into 1/4/24 and missed visit. On 01/05/24, an as-needed (PRN) visit order was obtained. On 01/08/24, agency staff again documented “Emergency Department use without admission.” The agency was notified the patient was returning to [hospital name] Despite the agency obtaining an order for a PRN visit, there was no evidence of a nursing visit after the patient’s call to the agency on 01/02/24. On 01/10/24, the RN visited fand documented the patient had a “UTI,”(diagnosis was actually pyelonephritis, or kidney infection, caused by a urinary tract infection), had 2 falls today and left flank pain continues, 6/10. The nurse documented the patient had no injuries from the fall. Patient educated on the importance of keeping visits and to be available by phone. “Patient understood and is accepting of skilled nurses and physical therapists to call [caregiver] to set up appointments.” On 01/18/24, the RN documented a verbal order from the physician’s office nurse as follows: - discharge patient from [agency] services per patient request The agency failed to coordinate with the patient, caregivers, physical therapist, and physician to ensure all of the patient’s needs were met. On 12/03/24 at 1:30 p.m., the findings were reviewed with the Administrator and Director of Nursing Services who acknowledged the findings and offered no additional information.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on a review of patient records and interviews with the Administrator and Director of Patient Services, it was determined in 3 of 19 records, (patients #11, 12 and 17) the agency failed to educate patients and caregivers. Evidence as follows: 1. Patient #17 was admitted to the agency on 03/13/24 with diagnoses of coronary artery disease with acute myocardial infarction (heart attack), bilateral foot drop, Alzheimer’s dementia, adult failure to thrive, dysphagia (difficulty swallowing), and protein-calorie malnutrition. The patient was discharged on 05/10/24 and was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report, dated 09/01/23 through 08/31/24, for an increase in the number of pressure ulcers. On 04/16/24 the skilled nurse saw the patient for a PRN (as needed) visit for wound care. The skilled nurse documented the patient had a skin tear to the right lower leg which they cleaned with saline and covered with a protective dressing. On 04/17/24 the skilled nurse obtained the following wound care order: - cleanse area with normal saline/wound cleaner, pat dry, cover with xeroform, and foam dressing - change twice a week and as needed for compromised dressing - may teach caregiver to perform The patient was then seen by nursing for wound care on 04/23, 04/26, 04/30, 05/03, and 05/07/24. On 05/10/24 the patient was seen, wound care was provided, and the patient was discharged. There was no evidence the nurse educated the patient caregiver on wound care and then ensured the caregiver’s ability to perform the wound care through return demonstration. On 12/04/24 at 2:00 p.m. the findings were reviewed with the Administrator and Director of Patient Services who provided no additional information. Patient #12 was admitted to the agency on 09/15/24 with diagnoses of type 2 diabetes mellitus with foot ulcer, acute osteomyelitis, chronic obstructive pulmonary disease, aortic aneurysm without rupture, malignant neoplasm of upper left lobe, and peripheral neuropathy. On 09/04/24 a referral was sent to the agency requesting skilled nursing for wound care, 3 chronic ulcers to left foot. The 09/15/24 plan of care orders included: -skilled nurse to perform and teach wound care to left planter foot diabetic ulcers, clean with normal saline, pack with iodoform, cover with dry sterile dressing, secure with ace wrap using clean technique. Change dressing every day and as needed for soiling or dislodgement. Teach patient/caregiver to perform on the days skilled nurse is not in the home. -provide teaching/reinforcement with infection control measures. -nursing visit frequency 3x a week for 2 weeks, 2x a week for 1 week and 1x a week for 4 weeks. The 09/15/24 nursing initial comprehensive assessment included: -“skilled nurse performed wound care to left planter foot to surrey small diabetic ulcer areas per MD order”. -daughter and son in- law present at the opening visit. On 09/17/24 the registered nurse visited the patient and documented in the clinical summary note the patient does not have alternative caregiver, only once or two times/week and will notify the agency if dressing needs to be changed. There was no evidence the nurse: -identified a caregiver or patient to perform wound care on days nursing is not visiting, including the responsible person’s ability to perform wound care correctly. -educated the patient and caregiver to perform daily wound care. Skilled nurses continued to visit the patient with decreasing visit frequency throughout the episode of care and there was no evidence of: -who was providing wound care on the days nursing was not in the home -caregiver or patient education and training regarding wound care On 12/03/24 at 1:30 p. m., the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. 1. Patient #12 was admitted to the agency on 09/15/24 with diagnoses of type 2 diabetes mellitus with foot ulcer, acute osteomyelitis, chronic obstructive pulmonary disease, aortic aneurysm without rupture, malignant neoplasm of upper left lobe, and peripheral neuropathy. On 09/04/24 a referral was sent to the agency requesting skilled nursing for wound care, 3 chronic ulcers to left foot. The 09/15/24 plan of care orders included: - skilled nurse to perform and teach wound care to left planter foot diabetic ulcers, clean with normal saline, pack with iodoform, cover with dry sterile dressing, secure with ace wrap using clean technique. Change dressing every day and as needed for soiling or dislodgement. Teach patient/caregiver to perform on the days skilled nurse is not in the home. - provide teaching/reinforcement with infection control measures. - nursing visit frequency 3x a week for 2 weeks, 2x a week for 1 week and 1x a week for 4 weeks. The 09/15/24 nursing initial comprehensive assessment included: - “skilled nurse performed wound care to left planter foot to surrey small diabetic ulcer areas per MD order”. - daughter and son in- law present at the opening visit. On 09/17/24 the registered nurse visited the patient and documented in the clinical summary note the patient does not have alternative caregiver, only once or two times/week and will notify the agency if dressing needs to be changed. There was no evidence the nurse: - identified a caregiver or patient to perform wound care on days nursing is not visiting, including the responsible person’s ability to perform wound care correctly. - educated the patient and caregiver to perform daily wound care. Skilled nurses continued to visit the patient with decreasing visit frequency throughout the episode of care and there was no evidence of: - who was providing wound care on the days nursing was not in the home - caregiver or patient education and training regarding wound care On 12/03/24 at 1:30 p. m., the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. 2. Patient #17 was admitted to the agency on 03/13/24 with diagnoses of coronary artery disease with acute myocardial infarction (heart attack), bilateral foot drop, Alzheimer’s dementia, adult failure to thrive, dysphagia (difficulty swallowing), and protein-calorie malnutrition. The patient was discharged on 05/10/24 and was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report, dated 09/01/23 through 08/31/24, for an increase in the number of pressure ulcers. On 04/16/24 the skilled nurse saw the patient for a PRN (as needed) visit for wound care. The skilled nurse documented the patient had a skin tear to the right lower leg which they cleaned with saline and covered with a protective dressing. On 04/17/24 the skilled nurse obtained the following wound care order: - cleanse area with normal saline/wound cleaner, pat dry, cover with xeroform, and foam dressing - change twice a week and as needed for compromised dressing - may teach caregiver to perform The patient was then seen by nursing for wound care on 04/23, 04/26, 04/30, 05/03, and 05/07/24. On 05/10/24 the patient was seen, wound care was provided, and the patient was discharged. There was no evidence the nurse educated the patient caregiver on wound care and then ensured the caregiver’s ability to perform the wound care through return demonstration. On 12/04/24 at 2:00 p.m. the findings were reviewed with the Administrator and Director of Patient Services who provided no additional information. 3. Patient #11 was admitted to the agency on 11/03/24 with diagnoses that included dysphagia, respiratory failure, heart failure, and constipation. On 11/03/24, the registered nurse visited the patient and completed the start of care assessment. The nurse failed to instruct the patient and caregiver on heart failure monitoring and pressure ulcer prevention. Heart failure monitoring The 11/03/24-01/01/25 Plan of Care included an order to teach heart failure management including daily weight monitoring and to notify physician of weight gain of 2 – 3 pounds in 24 hours or 5 pounds in a week. If patient is unable to weigh, obtain lower extremity circumference each visit and notify physician of increase in 2 cm or greater. On 11/03/24, the RN conducted the start of care visit and documented cardiovascular findings including presence of heart failure and that patient was not performing daily weights. There is no evidence to support the patient was unable to perform daily weights, that patient/caregiver instructed on importance of obtaining daily weights or instructed on heart failure management. Pressure ulcer prevention The 11/03/24-1/1/25 Plan of Care included the an order due to high risk for pressure ulcer, “educate on weight shifting and pressure relieving devices , coccyx pressure ulcer prevention with mepilex every 5-7 days/as needed soiling or dislodgement days or barrier cream twice daily/as needed soiling.” At the start of care on 11/03/24, the RN documented that the patient was at high risk for pressure ulcers from “prolonged sitting due to weakness, mepilexes and barrier cream ordered for patient and caregiver will obtain pressure relief chair cushion, encouraged weight shifting. There is no evidence to support the patient or caregiver was instructed on how to use mepilex, where to apply, or use of barrier cream at the start of care or on subsequent visits. Failure to provide patient and caregiver education has the possibility for negative patient outcomes.”