Riverspring Chha / Elderserve Chha

“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 clinical records review and staff interview the agency failed to ensure that all patients receive services as documented in their individualized plan of care. This was evident for two (2) of three (3) patient care records reviewed (Patient’s #1 and #2). Failure to ensure that all patients receive services as documented in their individualized plan of care has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 07/19/2024 with the following diagnoses “Type 2 Diabetes Mellitus, Unilateral Post-Traumatic Osteoarthritis Left Knee, Aftercare following Joint Replacement Surgery” documented in the Home Health Certification and Plan of Care for the certification period 07/19/2024 to 09/16/2024. The Home Health Certification and Plan of Care for the certification period 07/19/2024 to 09/16/2024 documents: “hha (home health aide) effective 07/21/2024 2WK1, 3WK1 (twice for one week, three times for one week).” The clinical record lacks documented evidence of home health aide services being provided as ordered in the Plan of Care. On 08/13/2024 at 03:55pm, the Administrator/Director of Patient Services and the Director of Rehabilitation were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 07/12/2024 with the following diagnoses “Acute on Chronic Diastolic (Congestive) Heart Failure, Unspecified Osteoarthritis” documented in the Home Health Certification and Plan of Care for the certification period 07/12/2024 to 09/09/2024. The Home Health Certification and Plan of Care for the certification period 07/12/2024 to 09/09/2024 documents: “SN (skilled nurse) 1WK1, 3WK8, 1WK1 (once a week for one week, three times a week for eight weeks, once a week for one week).” The clinical record lacks documented evidence of the patient receiving a Skilled Nurse visit for the week of 07/14/24 to 07/19/2024, missed one visit, as written in the plan of care. On 08/13/2024 at 03:55pm, the Administrator/Director of Patient Services and the Director of Rehabilitation were interviewed and did not provide an explanation for the findings.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure the right of each patient to receive all services as outlined in each patient’s plan of care. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure the right of each patient to receive all services as outlined in their plan of care has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 07/19/2024 with the following diagnoses “Type 2 Diabetes Mellitus, Unilateral Post-Traumatic Osteoarthritis Left Knee, Aftercare following Joint Replacement Surgery” documented in the Home Health Certification and Plan of Care for the certification period 07/19/2024 to 09/16/2024. The Home Health Certification and Plan of Care for the certification period 07/19/2024 to 09/16/2024 documents: “hha (home health aide) effective 07/21/2024 2WK1, 3WK1 (twice for one week, three times for one week).” The clinical record lacks documented evidence of home health aide services being provided as outlined in the Plan of Care. There is no documented evidence of the patient’s right to have hha (home health aide) services being fulfilled. On 08/13/2024 at 03:55pm, the Administrator/Director of Patient Services and the Director of Rehabilitation were interviewed and did not provide an explanation for the findings.”

“Plan of care revisions must be communicated CFR(s): 484.60(c)(3) Revisions to the plan of care must be communicated as follows: This Element is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure any revision to the plan of care must be communicated to the patient or representative. This was evident for two (2) of three (3) patient care records reviewed (Patient’s #1 and #3). Failure to ensure any revision to the plan of care must be communicated to the patient or representative has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 07/19/2024 with the following diagnoses “Type 2 Diabetes Mellitus, Unilateral Post-Traumatic Osteoarthritis Left Knee, Aftercare following Joint Replacement Surgery” documented in the Home Health Certification and Plan of Care for the certification period 07/19/2024 to 09/16/2024. The Home Health Certification and Plan of Care for the certification period 07/19/2024 to 09/16/2024 documents: “hha (home health aide) effective 07/21/2024 2WK1, 3WK1 (twice for one week, three times for one week).” The Coordination Notes dated 07/19/2024 documents: “Hha (home health aide) – 3DX4HX2W (three days times 4 hours for two weeks) - assist with ADLS/IADLS (activities of daily living / instrumental activities of daily living). The clinical record lacks documented evidence of the communication to the patient or family regarding aide services not being provided. The Coordination Notes documents: 07/23/2024 “Refused PT (physical therapy) services.” “Notified by RN (registered nurse) that patient does not want physical therapy, she will be going to outpatient PT (physical therapy) per MD (medical doctor) recommendation according to patient. MD (medical doctor) office notified.” 08/05/2024 “Patient called to state that she was commencing outpatient therapy. When she was informed that all homecare services will be discontinued based on the fact that she is no longer homebound. T/C (telephone call) to PMD (primary medical doctor name), via secretary (name), and informed him of discharge.” “Notice not given due to unexpected discharge. Patient referred for outpatient therapy.” The Client Calendar Report documents skilled nurse visits on 07/19/2024, 07/23/2024, and 07/26/2024. The clinical record lacks documented evidence of the communication about patient’s discharge, nurse was notified on 07/23/2024 of outpatient physical therapy and discharge was not mentioned. On 08/13/2024 at 03:55pm, the Administrator/Director of Patient Services and the Director of Rehabilitation were interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care date of 06/13/2024 with the following diagnoses “Constipation, Other Low Back Pain” documented in the Home Health Certification and Plan of Care for the certification period 06/13/2024 to 08/11/2024. The Client Calendar Report documents skilled nurse visits on 06/13/2024 and physical therapy visit 06/18/2024. The Physician Order dated 08/09/2024 documents: “Discharge from agency, no skilled need.” The clinical record lacks documented evidence of the communication about patient’s discharge, nurse did not mention of no follow up needed for skilled nurse services from 06/13/2024 to 08/09/2024 and no services provided since 06/19/2024 and discharged on 08/09/2024. On 08/13/2024 at 03:55pm, the Administrator/Director of Patient Services and the Director of Rehabilitation were interviewed and did not provide an explanation for the findings.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure a completed discharge summary. This was evident for two (2) of three (3) patient care records reviewed (Patient’s #1 and #3). Failure to ensure a completed discharge summary has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 07/19/2024 with the following diagnoses “Type 2 Diabetes Mellitus, Unilateral Post-Traumatic Osteoarthritis Left Knee, Aftercare following Joint Replacement Surgery” documented in the Home Health Certification and Plan of Care for the certification period 07/19/2024 to 09/16/2024. The Client Calendar Report documents skilled nurse visits on 07/19/2024, 07/23/2024, and 07/26/2024. The Coordination Notes dated 08/05/2024 documents: “Patient called to state that she was commencing outpatient therapy. When she was informed that all homecare services will be discontinued based on the fact that she is no longer homebound. T/C (telephone call) to PMD (primary medical doctor name), via secretary (name), and informed him of discharge.” “Notice not given due to unexpected discharge. Patient referred for outpatient therapy.” The clinical record lacks documented evidence of a discharge summary. On 08/13/2024 at 03:55pm, the Administrator/Director of Patient Services and the Director of Rehabilitation were interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care date of 06/13/2024 with the following diagnoses “Constipation, Other Low Back Pain” documented in the Home Health Certification and Plan of Care for the certification period 06/13/2024 to 08/11/2024. The Client Calendar Report documents skilled nurse visits on 06/13/2024 and physical therapy visit 06/18/2024. The Physician Order dated 08/09/2024 documents: “Discharge from agency, no skilled need.” The clinical record lacks documented evidence of a discharge summary. On 08/13/2024 at 03:55pm, the Administrator/Director of Patient Services and the Director of Rehabilitation were interviewed and did not provide an explanation for the findings.”

“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 clinical record reviews, and staff interviews, the agency failed to ensure the encoded OASIS (The Outcome and Assessment Information Set) assessments accurately reflect each patient’s status at the time of the assessment. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #4). Failure to ensure the encoded OASIS (The Outcome and Assessment Information Set) accurately reflect the patient’s status at the time of the assessment, has the potential for negative patient outcomes. The Finding Are: 1. Patient #4 (Potentially Avoidable Event) has a Start of Care date of 06/23/2023, discharge date of 07/24/2023 with diagnoses Pressure Ulcer of Left Upper Back Stage 4, Pressure Ulcer of Sacral Region Stage 2, Unspecified Open Wound of Left Elbow Subsequent Encounter documented in the Home Health Certification and Plan of Care dated 06/23/2023 to 08/21/2023. The Registered Nurse OASIS Admission/Start of Care note dated 06/23/2023 documents the patient’s integumentary status as follows: - Does the patient have at least one unhealed pressure ulcer/injury at stage 2 or higher or designated as unstageable? Yes, - Current number of unhealed pressure ulcers/injuries at stage 2: partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough, may also present as an intact or opened/ruptured blisters: 0 (zero), - Current number of unhealed pressure ulcers/injuries at stage 4: full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often includes undermining and tunneling: 1 (one), and - Current number of stage 1 pressure injuries: intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching: in dark skin tones only, it may appear with persistent blue or purple hues: 1 (one). The Registered Nurse OASIS Admission/Start of Care note dated 06/23/2023 documents the patient has one unhealed pressure ulcer stage 4 with loss of tissue (open wound/skin), and one pressure ulcer/injury stage 1 with intact skin (no open wound). The Registered Nurse Start of Care does documents stage 2 pressure ulcer is not present at the start of care. The Registered Nurse Discharge OASIS - Data Collection Only note dated 07/26/2023 documents the patient’s integumentary status as follows: - The oldest stage 2 pressure ulcer that is present at discharge (excludes healed stage 2 pressure ulcers): 1 - was present at the most recent SOC (Start of Care)/ROC (Resumption of Care), - Current number of unhealed pressure ulcers/injuries at stage 2: partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough, may also present as an intact or opened/ruptured blisters: 1 (one), - Number of these stage 2 pressure ulcers that were present at most recent SOC/ROC? Enter how many were noted at the time of most recent SOC/ROC: 1 (one), -Number of these stage 4 pressure ulcers that were present at most recent SOC/ROC: 1 (one), The Registered Nurse Discharge (OASIS)- Data Collection Only note dated 07/26/2023 documents the patient has two unhealed pressure ulcers since the start of care: stage 2 and stage 4. The last Registered Nurse Visit note dated 07/24/2023 documents the following wound assessment: one unhealed pressure ulcer stage 4 and one pressure ulcer stage 1 (skin intact/no open wound). The RN wound assessment does not document the patient has a stage 2 pressure ulcer present at the time of discharge. The agency failed to ensure the Registered Nurse Discharge OASIS Data Collection accurately reflects the patient’s status at the time of the discharge assessment. On 01/11/2024 at 2:00pm, the Administrators and the Director of Patient Services were interviewed. The Administrator stated that there was no stage 2 pressure ulcer present.”

“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 clinical record reviews, and staff interviews, the agency failed to ensure all patients receive services as documented in their individualized plan of care. This was evident for eight (8) of seventeen (17) clinical records reviewed (Patient: #1, #4, #5, #12, #13, #14, #15, and #16). Failure to ensure that all patients receive services as documented in their individualized plan of care has the potential for negative patient outcomes. The Findings Are: *Patient #12 has a Start of Care date of 11/09/2022 with the following diagnoses “Essential Hypertension, Syncope and Collapse, Unspecified Abnormalities of Gait and Mobility” documented in the Home Health Certification and Plan of Care dated 11/09/2022 to 01/07/2023. The Home Health Certification and Plan of Care dated 11/09/2022 to 01/07/2023 documents: PT (Physical Therapy) 1WK1 (once a week for one week), (missed one visit). The Physician Order dated 11/16/2022 documents: SN effective 11/20/2022 3WK7 (three times a week for seven weeks). The clinical record documents SN visit on 11/30/2022 for the week 11/27/2022 to 12/03/2022, missed 2 visits. There is no documented evidence of skilled nurse and physical therapy visits being conducted as ordered in the plan of care. On 01/12/2024 at 3:45pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. *Patient #13 has a Start of Care date of 12/02/2023 with the following diagnoses “Pressure Ulcer of Sacral Region Unstageable, Chronic Systolic Congestive Heart Failure, Type 2 Diabetes Mellitus” documented in the Home Health Certification and Plan of Care dated 12/02/2023 to 01/30/2024. The Home Health Certification and Plan of Care dated 12/02/2023 to 01/30/2024 documents: SN (Skilled Nurse) 1WK1, 2WK1, 3WK1. The clinical record documents skilled nurse visits on 12/02/2023, 12/05/2023, 12/08/2023, 12/12/2023, and 12/15/2023, (missed one visit between 12/10/2023 to 12/16/2023). There is no documented evidence of skilled nurse visits being conducted as ordered in the plan of care. On 01/11/2024 at 2:05pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. Patient #1 has a Start of Care date of 12/21/2023 with diagnoses Diffuse Large B-Cell Lymphoma, Adult Failure to Thrive, Chronic Obstructive Pulmonary Disease documented in the Home Health Certification and Plan of Care dated 12/21/2023 to 02/18/2024. The Home Health Certification and Plan of Care dated 12/21/2023 to 02/18/2024 documents orders for Skilled Nurse visits, two days a week for one week. The clinical record documents one skilled nurse visit dated 12/21/2023 for the week (one missed visit). There is no documented evidence of skilled nurse visits being conducted as ordered in the plan of care. There is no documented evidence of an explanation and notification to the physician for the one missed visit. On 01/11/2024 at 2:00pm, the Administrators and the Director of Patient Services were interviewed and did not provide an explanation for the findings. Patient #4 (PAE) has a Start of Care date of 06/23/2023, discharge date of 07/24/2023 with diagnoses Pressure Ulcer of Left Upper Back Stage 4, Pressure Ulcer of Sacral Region Stage 2, Unspecified Open Wound of Left Elbow Subsequent Encounter documented in the Home Health Certification and Plan of Care dated 06/23/2023 to 08/21/2023. The Home Health Certification and Plan of Care dated 06/23/2023 to 08/21/2023 documents orders for Skilled Nurse visits, five days a week for one week and then three days a week for seven weeks. The clinical record documents three skilled nurse visit dated 06/26/2023, 06/28/2023, and 06/30/2023 during the week of 06/25/2023 (two missed visits). There is no documented evidence of an explanation and notification to the physician for the two missed visits. The clinical record documents three skilled nurse visit dated 06/26/2023, 06/28/2023, and 06/30/2023 during the week beginning 6/25/2023 (two missed visits). On 01/11/2024 at 2:00pm, the Administrators and the Director of Patient Services were interviewed and did not provide an explanation for the findings. Patient #5 has a Start of Care date of 11/29/2023 with diagnoses Encounter for Other Orthopedic Aftercare, Complete Rotator Cuff Tear or Rupture of Right Shoulder Not Specified as Traumatic, Polyosteoarthritis Unspecified documented in the Home Health Certification and Plan of Care dated 11/29/2023 to 01/27/2024. The Home Health Certification and Plan of Care dated 11/29/2023 to 01/27/2024 documents orders for Skilled Nurse visits, three days a week for one week. The clinical record documents one skilled nurse visit dated 11/29/2023 for the week (two missed visits). There is no documented evidence of skilled nurse visits being conducted as ordered in the plan of care. There is no documented evidence of an explanation and notification to the physician for the two missed visits. The supplemental order dated 12/07/2023 documents orders for Occupational Therapy visits, one day week for four weeks. The clinical record documents one Occupational Therapy visit dated 12/7/2023 for the initial evaluation. There is no documented evidence of Occupational Therapy visits being conducted after 12/07/2023 as ordered by the physician. There is no documented evidence of an explanation and notification to the physician for the Occupational Therapy missed visits after 12/07/2023. On 01/12/2024 at 2:00pm, the Administrators, he Director of Patient Services, Clinical Manager, and Director of Rehab were interviewed. The Administrator stated that here is a glitch in the electronic medical record; the order for skilled nurse should have been entered as one visit a week for one week and two as need visits. 1. Patient #1 has a Start of Care date of 12/21/2023 with diagnoses Diffuse Large B-Cell Lymphoma, Adult Failure to Thrive, Chronic Obstructive Pulmonary Disease documented in the Home Health Certification and Plan of Care dated 12/21/2023 to 02/18/2024. The Home Health Certification and Plan of Care dated 12/21/2023 to 02/18/2024 documents orders for Skilled Nurse visits, two days a week for one week. The clinical record documents one skilled nurse visit dated 12/21/2023 for the week (one missed visit). There is no documented evidence of the skilled nurse visits being conducted as ordered in the plan of care. There is no documented evidence of an explanation and notification to the physician for the one missed visit. On 01/11/2024 at 2:00pm, the Administrators and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #4 (Potentially Avoidable Event) has a Start of Care date of 06/23/2023, discharge date of 07/24/2023 with diagnoses Pressure Ulcer of Left Upper Back Stage 4, Pressure Ulcer of Sacral Region Stage 2, Unspecified Open Wound of Left Elbow Subsequent Encounter documented in the Home Health Certification and Plan of Care dated 06/23/2023 to 08/21/2023. The Home Health Certification and Plan of Care dated 06/23/2023 to 08/21/2023 documents orders for Skilled Nurse visits, five days a week for one week and then three days a week for seven weeks. The clinical record documents three skilled nurse visit dated 06/26/2023, 06/28/2023, and 06/30/2023 during the week of 06/25/2023 (two missed visits). There is no documented evidence of an explanation and notification to the physician for the two missed visits. On 01/11/2024 at 2:00pm, the Administrators and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #5 has a Start of Care date of 11/29/2023 with diagnoses Encounter for Other Orthopedic Aftercare, Complete Rotator Cuff Tear or Rupture of Right Shoulder Not Specified as Traumatic, Polyosteoarthritis Unspecified documented in the Home Health Certification and Plan of Care dated 11/29/2023 to 01/27/2024. The Home Health Certification and Plan of Care dated 11/29/2023 to 01/27/2024 documents orders for Skilled Nurse visits, three days a week for one week. The clinical record documents one skilled nurse visit dated 11/29/2023 for the week (two missed visits). There is no documented evidence of skilled nurse visits being conducted as ordered in the plan of care. There is no documented evidence of an explanation and notification to the physician for the two missed visits. The supplemental order dated 12/07/2023 documents orders for Occupational Therapy visits, one day week for four weeks. The clinical record documents one Occupational Therapy visit dated 12/7/2023 for the initial evaluation. There is no documented evidence of Occupational Therapy visits being conducted after 12/07/2023 as ordered by the physician. There is no documented evidence of an explanation and notification to the physician for the Occupational Therapy missed visits after 12/07/2023. On 01/12/2024 at 2:00pm, the Administrators, he Director of Patient Services, Clinical Manager, and Director of Rehab were interviewed. The Administrator stated that “there is a glitch in the electronic medical record; the order for skilled nurse should have been entered as one visit a week for one week and two as need visits”. 4. Patient #12 has a Start of Care date of 11/09/2022 with the following diagnoses “Essential Hypertension, Syncope and Collapse, Unspecified Abnormalities of Gait and Mobility” documented in the Home Health Certification and Plan of Care dated 11/09/2022 to 01/07/2023. The Home Health Certification and Plan of Care dated 11/09/2022 to 01/07/2023 documents: PT (Physical Therapy) 1WK1 (once a week for one week), (missed one visit). The Physician Order dated 11/16/2022 documents: SN effective 11/20/2022 3WK7 (three times a week for seven weeks). The clinical record documents SN visit on 11/30/2022 for the week 11/27/2022 to 12/03/2022, missed 2 visits. There is no documented evidence of skilled nurse and physical therapy visits being conducted as ordered in the plan of care. On 01/12/2024 at 3:45pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 5. Patient #13 has a Start of Care date of 12/02/2023 with the following diagnoses “Pressure Ulcer of Sacral Region Unstageable, Chronic Systolic Congestive Heart Failure, Type 2 Diabetes Mellitus” documented in the Home Health Certification and Plan of Care dated 12/02/2023 to 01/30/2024. The Home Health Certification and Plan of Care dated 12/02/2023 to 01/30/2024 documents: SN (Skilled Nurse) 1WK1, 2WK1, 3WK1. The clinical record documents skilled nurse visits on 12/02/2023, 12/05/2023, 12/08/2023, 12/12/2023, and 12/15/2023, (missed one visit between 12/10/2023 to 12/16/2023). There is no documented evidence of skilled nurse visits being conducted as ordered in the plan of care. On 01/11/2024 at 2:05pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 6. Patient #14 has a Start of Care date of 03/06/2023 with the diagnoses “ Bilateral Primary Osteoarthritis of Knee, Essential (Primary) Hypertension, Hyperlipidemia” documented on the Home Health Certification and Plan of Care for the Certification Period 03/06/2023 to 05/04/2023. The Home Health Certification and Plan of Care dated 03/06/2023 to 05/04/2023 documents: “PT (Physical Therapy) 2WK6 (two times a week for six weeks)” The clinical record lacks documented evidence of Physical Therapy providing services as indicated in the plan of care for the week of 03/05/2023 to 03/11/2023 - one missed visit, and week of 04/02/2023 to 04/08/2023- one missed visit. The Physician order dated 04/10/2023 documents: “PT (Physical Therapy) Effective 04/09/2023 2WK3 (two times a week for three weeks)” The clinical record lacks documented evidence of Physical Therapy providing services as indicated in the plan of care for the week of: 04/09/2023 to 04/15/2023 - one missed visit. On 01/12/2024 at 3:45pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 7. Patient #15 has a Start of Care date of 08/24/2023 with the diagnoses “Type 2 Diabetes Mellitus with Hyperglycemia, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Other Obstructive and Reflux Uropathy” documented on the Home Health Certification and Plan of Care for the Certification Period 08/24/2023 to 10/22/2023. The Home Health Certification and Plan of Care dated 08/24/2023 to 10/22/2023 documents: “SN (Skilled Nurse) 3WK1 (three times a week for one week), 2WK3(two times a week for three weeks), 1WK1(one time a week for one week)” The clinical record lacks documented evidence of Skilled Nurse providing services as indicated in the plan of care for the week of 08/20/2023 to 08/26/2023 - two missed visit, for the week of 08/27/2023 to 09/02/2023 - one missed visit. On 01/12/2024 at 3:45pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 8. Patient#16 has a Start of Care date of 12/01/2023 with the following diagnoses “Aftercare Following Joint Replacement Surgery” documented on the Home Health Certification and Plan of Care dated 12/01/2023 to 01/29/2024. The Home Health Certification and Plan of Care for the Certification Period 12/01/2023 to 01/29/2024 documents: “OT (Occupational Therapist) effective 12/03/2023 1WK1 (one visit for one week)” There is no documented evidence of the OT (Occupational Therapist) conducting a visit and no documented evidence of a reason for the visit not being conducted. There is no documented evidence of an OT evaluation the week of 12/03/2023 and no documented evidence of the patient receiving OT services as ordered on the Plan of Care. On 01/12/2024 at 3:45pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings.”

“Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This Standard is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to coordinate care delivery to meet the patient’s needs. This was evident for three (3) of seventeen (17) clinical records reviewed (Patient: #6, #7, and #12). Failure to coordinate care delivery to meet the patient’s needs, has the potential for negative patient outcomes. The Findings Are: *Patient #8 has a Start of Care date of 05/01/2023 with the following diagnoses “Left Knee Effusion, Muscle Weakness, Unspecified Dementia” documented in the Home Health Certification and Plan of Care dated 05/01/2023 to 06/29/2023. The Visit Note Report – RN OASIS Admission dated 05/01/2023 documents: (M1800) Grooming: 3 – patient depends entirely upon someone else for grooming needs. (M1830) Bathing: 3 – Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision. (M1840) Toilet Transferring: 1 – when reminded, assisted or supervised by another person, able to get to and from the toilet and transfer. (M1845) Toileting Hygiene: 2 – someone must help the patient to maintain toileting hygiene and/or adjust clothing. (M1850) Transferring: 2 – able to bear weight and pivot during the transfer process but unable to transfer self. (M1860) Ambulation/Locomotion: 5 – Chairfast, unable to ambulate and is unable to wheel self. The Visit Note Report dated 05/04/2023 by the Occupational Therapist (OT) documents: Bathing: Dependent; Grooming: needs help with personal care; Toilet Use: dependent; Transfer: major help (one or two people, physical) can sit. The Visit Note Report dated 05/04/2023 by the Physical Therapist (PT) documents: Bathing: Dependent; Grooming: needs help with personal care; Toilet Use: needs some help, but can do something alone; Transfers: major help (one or two people, physical), can sit; Mobility: wheelchair independent. There is no documented evidence of the coordination with nursing, occupational therapy, and physical therapy for the functional status of the patient. The Visit Note Report documents: 05/09/2023 by OT “Patient’s son reports patient bit him in the upper arm, bruise noted on left upper arm, during deb mobility and transfer.” “with max encouragement due to patient perseverating on previous fall and fear of falling.” 05/15/2023 by OT “Patient has severe fear of falling and anticipation of pain reporting ‘You’re hurting me’ upon attempts to assist with mobility despite note being touched yet but does not show signs of pain during movement.” 05/16/2023 by OT “severe fear of falling and anticipation of pain.” “Verbally and physically aggressive”. 05/17/2023 by PTA (physical therapy assistant) “seen on/off combative and agitated”. 05/22/2023 by PTA “refuses to participate in any task.” “Patient’s son reports standard wc (wheelchair) is not a good device as it does not fit in every room including bathroom, therefore, they keep pt (patient) in transport wc to facilitate transportation and locomotion of pt.” 05/24/2023 dc (discharge) of PT services; transfer goals not met; 05/25/2023 by OT “reaching max potential due to not cooperating with therapy and overall care secondary to fear of falling and anticipating pain.” 05/26/2023 by OT “patient discharged secondary to non-compliance.” There is no documented evidence of the coordination with the physician regarding: behaviors, non-compliance, use of wheelchair, and goals not met by physical therapy. There is no documented evidence of the coordination of patient’s care. On 01/12/2024 at 3:45pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. *Patient #12 has a Start of Care date of 11/09/2022 with the following diagnoses “Essential Hypertension, Syncope and Collapse, Unspecified Abnormalities of Gait and Mobility” documented in the Home Health Certification and Plan of Care dated 11/09/2022 to 01/07/2023. The Home Health Certification and Plan of Care dated 11/09/2022 to 01/07/2023 documents: PT 1WK1 (once a week for one week); hha (home health aide) effective 11/13/2022 5WK3 (five time a week for three weeks). The Notification of Financial Liability and Service Plan of Care Consent Form signed and dated by client on 11/09/2022 documents: Services provided nursing, PT eval, hha 5DX4X2 (five days times 4 hours times two weeks) then W3W3 (three times a week for three weeks). The Physician Order dated 11/16/2022 documents: SN effective 11/20/2022 3WK7 (three times a week for seven weeks). The clinical record documents SN visit on 11/30/2022 for the week 11/27/2022 to 12/03/2022. On 01/12/2024 at 11:24am, the Administrator was interviewed and stated, “There is no note or communication of when the aide service is going to start. There is no documented evidence of the agency communicating with the patient/family of: start of aide and PT services; missed one PT visit between 11//09/2022 to 11/12/2022; and missed two SN visit between 11/27/2022 to 12/03/2022. The Client Coordination Note Report documents: 01/03/2023 “Spouse endorses need for ongoing agency services for BP (blood pressure) monitoring.” “Spouse verbalizes concerns regarding planned agency DC (discharge) this week” “Discharge coordination today with PCP (primary care physician) office (name of doctor) spoke with office confirmed PT DC (physical therapy discharge) 1/5. The Client Coordination Notes Report dated 01/04/2023 documents: “As per spouse patient has MD appointment.” There is no documented evidence of the coordination with the family in rescheduling of the missed visit on 1/4/2022. There is no documented evidence of a nursing visit prior to discharge to address family concerns. The clinical record lacks documented evidence of the coordination of care with patient/family. On 01/12/2024 at 3:45pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 1. Patient #6 has a Start of Care date of 11/25/2023 with diagnoses Type 2 Diabetes Mellitus with Hyperglycemia, Chronic Kidney Disease the Home Health Certification and Plan of Care dated 11/25/2023 to 01/23/2024. The Home Health Certification and Plan of Care dated 11/25/2023 to 01/23/2024 documents the orders for Insulin Humalog (fast acting insulin) Kwikpen (U-100) Insulin 100 Unit/ML subcutaneous, “40-unit(s), 2 times daily;” and “Skilled Nurse for instruction/reinforcement of preventing and managing symptoms of high and low blood sugar. Skilled Nurse to instruct patient/caregiver to call MD (Medical Doctor) or SN (Skilled Nurse) for blood glucose levels > (greater than) 250mg/dl and to report symptoms of hyperglycemia.” The Clinical Calendar Report dated 01/10/2024 documents “RN (Registered Nurse) Contract” nurses are assigned to provide the patient’s skilled nursing services. The contract Registered Nurse visit notes document the patient’s blood glucose levels are greater than 250 mg/dl, ranging from 255 to 416, on the following dates: 11/25/2023 to12/7/2023. 12/09/2023 to 12/14/2023, 12/18/2023, 12/20/2023 to 12/22/2023, 12/24/2023, 12/25/2023 12/28/2023, 12/29/2023, 01/02/2024, 01/04/2024, 01/05/2024, and 01/08/2024. The contract Registered Nurse visit note dated 11/28/2023 PM documents: patient’s blood glucose is 568; “patient was sent to ER (emergency room) for reevaluation oral medication and insulin. Patient doesn’t have s/s (signs/symptoms) of hypo/hyperglycemia.” The subsequent contract Registered Nurse visit note dated 11/29/2023 AM documents: blood glucose is 255 mg/dl; and “SN (Skilled Nurse) (instructed) patient to keep diabetic diet, to avoid concentrated sweets, cookies, (and) candies.” The clinical record lacks documented evidence of coordination of care between the agency, contract Registered Nurses, and the physician regarding the patient’s emergency room visit and elevated blood glucose levels. The clinical record lacks documented evidence of communication/coordination and oversight of the contract registered nurses to ensure the patient needs are being addressed and met in accordance with the plan of care. On 01/12/2024 at 1:50pm, the Administrators, the Director of Patient Services, Clinical Manager were interviewed about the findings. On 01/12/2024 at 4:pm, the Administrator stated that the patient’s reportable elevated blood glucose parameter was changed from greater than 250 to 450. but the plan of care was not revised. The Administrator confirmed the plan of care was not revised and unaware when the patient’s blood glucose parameter changed. The Administrator confirmed that the there was no documentation of coordination of care with the contract registered nurses in the patient’s electronic medical record.”

“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 clinical record reviews, and staff interviews, the agency failed to ensure all paraprofessionals receive a complete home health aide plan of care when providing patient care. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #12). Failure to ensure all paraprofessionals receive a complete home health aide plan of care, has potential for negative patient outcomes. The Findings Are: 1. Patient #12 has a Start of Care date of 02/02/2023 with the following diagnoses “Encounter for Surgical Aftercare Following Surgery on the Sense Organs, Retinal Hemorrhage Right Eye” documented in the Home Health Certification and Plan of Care dated 02/02/2023 to 04/02/2023. The Home Health Certification and Plan of Care dated 02/02/2023 to 04/02/2023 documents: hha (home health aide) effective 02/05/2023 5WK8 (five times a week for eight weeks). The Physician Order dated 02/21/2023 documents: hha effective 02/19/2023 3WK6 (three times a week for six weeks). The Aide Care Plan Report dated 02/03/2023 documents the following services (task) to be provided: Turn and position in bed and change linens. The Duty Sheet documents the following task being provided, but not documented on the aide’s plan of care: Prepare – breakfast/lunch/dinner on 02/09/2023, 02/10/2023, 02/24/2023, 03/03/2023; Transferring on 02/06/2023, 02/20/2023, 02/22/2023, 02/24/2023; Bath – shower/bed/tub on 02/06/2023 to 02/09/2023, 02/13/2023 to 02/17/2023, 02/20/2023, 02/22/2023, 03/03/2023; Dressing on 02/06/2023, 02/08/2023, 02/09/2023, 02/10/2023, 02/17/2023, 02/20/2023, 02/22/2023, 02/24/2023, 03/03/2023; Laundry on 02/06/2023, 02/08/2023, 02/20/2023, 02/22/2023; Mouth care on 02/07/2023, 02/08/2023, 02/14/2023, 02/20/2023, 02/22/2023; Hair care -comb/ shampoo on 02/07/2023, 02/09/2023, 02/10/2023, 02/13/2023, 02/15/2023, 02/17/2023, 02/22/2023; Grooming – shave/ nails on 06/10/2023, 02/13/2023 to 02/15/2023, 02/22/2023; Remind to take medication on 02/09/2023, 02/10/2023, 02/24/2023, 03/03/2023; and Foot care on 02/14/2023, 02/24/2023. The aide’s duty sheet lacks documented evidence of the following task being provided: Turn and position in bed from 02/06/2023 to 03/03/2023; and change linens from 02/06/2023 to 02/22/2023. There is no documented evidence of a complete and comprehensive aide’s plan of care. On 01/12/2024 at 3:45pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that the assessment of the patient’s current health status is accurate. This was evident for two (2) of seventeen (17) clinical records reviewed (Patient: #7, and #10). Failure to ensure that the assessment of the patient’s current health status is accurate, has the potential for negative patient outcomes. The Findings Are: 1. Patient #7 has a Start of Care date of 05/01/2023 with the following diagnoses “Left Knee Effusion, Muscle Weakness, Unspecified Dementia” documented in the Home Health Certification and Plan of Care dated 05/01/2023 to 06/29/2023. The Visit Note Report – RN OASIS Admission dated 05/01/2023 documents: Grooming - depends entirely upon someone else. Bathing - Able to participate in bathing self, but requires presence of another person. Toilet Transferring – when reminded, assisted or supervised by another person, able to get to and from the toilet and transfer. Toileting Hygiene – someone must help the patient to maintain toileting hygiene and/or adjust clothing. Transferring – able to bear weight and pivot during the transfer process but unable to transfer self. Ambulation/Locomotion – Chairfast, unable to ambulate and is unable to wheel self. The Visit Note Report dated 05/04/2023 by the Occupational Therapist documents: Bathing: Dependent; Grooming: needs help with personal care; Toilet Use: dependent; Transfer: major help (one or two people, physical) can sit. The Visit Note Report dated 05/04/2023 by the Physical Therapist documents: Bathing: Dependent; Grooming: needs help with personal care; Toilet Use: needs some help, but can do something alone; Transfers: major help (one or two people, physical), can sit; Mobility: wheelchair independent. There is no documented evidence of the accurate functional status of the patient – nursing, occupational therapy, and physical therapy with different status for grooming, bathing, toileting, transfer, and ambulation/locomotion/mobility. The comprehensive assessment lacks documented evidence of the coordination for the patient’s functional status. On 01/12/2024 at 3:45pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 2. Patient #10 has a Start of Care date of 12/16/2023 with the following diagnoses “Non-Pressure Chronic Ulcer of Left Ankle, Other Acute Osteomyelitis Left Ankle and Foot, Alzheimer’s Disease” documented in the Home Health Certification and Plan of Care dated 12/16/2023 to 02/13/2024. The Outcome and Assessment Information Set OASIS-E Manual Effective January 1, 2023 documents: Stage 1 Pressure Ulcer Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The Visit Note Report - RN (Registered Nurse) OASIS Admission dated 12/16/2023 documents: Wound Assessment: #3 Ant (anterior) – Ear, RT (right), PU (pressure ulcer) Stage II; Granulation Tissue: 75-100%; Epithelialization: 75-100%. #2 Ant (anterior)- med (medial) Malleolus, RT (right), PU (pressure ulcer) Stage 1; Epithelialization: 100%. There is no documented evidence of an accurate staging of the pressure ulcer – stage 1 open with epithelialization (should be a stage 2) and stage 2 with granulation tissue (should be a stage 3 or 4). There is no documented evidence of the patient’s accurate health status. On 01/11/2024 at 2:05pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that all medications were reviewed and accurately documented in each patient’s plan of care. This was evident for four (4) of seventeen (17) clinical records reviewed (Patient: #6, #10, #11, and #14). Failure to ensure that all medications are reviewed and accurately documented in each patient’s plan of care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #6 has a Start of Care date of 11/25/2023 with diagnoses Type 2 Diabetes Mellitus with Hyperglycemia, Chronic Kidney Disease the Home Health Certification and Plan of Care dated 11/25/2023 to 01/23/2024. The Registered Nurse OASIS Admission/comprehensive assessment note dated 11/25/2023 documents: Patient “live(s) in assisted living facility;” patient’s goal is to have better control of blood glucose (levels) and to better able to manage medication; and “All medications reviewed and adequate available. Humalog (fast acting insulin) use, safety, and side effects provided;” “Did a complete drug regimen review identify potential significant medication issues: No issues found during review.” The Client Medication Report/medication profile printed 01/10/2024 documents: Start Date 8/25/2023, Humalog Kwikpen (U-100) Insulin 100 Unit/ML subcutaneous, “40 unit(s), 2 times daily.” The Home Health Certification and Plan of Care dated 11/25/2023 to 01/23/2024 documents the orders for Insulin Humalog Kwikpen (U-100) Insulin 100 Unit/ML subcutaneous, “40 unit(s), 2 times daily.” The UAS (Uniform Assessment System) “Member Service Plan” dated 11/26/2023 documents: Novolog Mix 70-30 Insulin 30 Units BID (2 times daily) subcutaneous (Combination fast-acting and intermediate-acting insulin). The contract Registered Nurse/Skilled Nurse visit notes dated 11/25/2023 AM and 11/25/2023 PM document the nurse administered “Novolog 70-30 insulin 30 Units.” The contract Registered Nurse visit notes dated 11/26/2023 AM and 11/26/2023 PM document the nurse administered “Novolog 70-30 insulin 40 Units.” The Registered Nurse Start of Care comprehensive assessment lacks documented evidence of the Registered Nurse accurately reviewing and reconciling the injectable insulin the patient is currently using at the time of the assessment. On 01/12/2024 at 2:00pm, the Administrators, the Director of Patient Services, and Clinical Manager were interviewed. The Administrator stated that the correct insulin ordered is Novolog 70-30 40 Units two times daily. 2. Patient #10 has a Start of Care date of 12/16/2023 with the following diagnoses “Non-Pressure Chronic Ulcer of Left Ankle, Other Acute Osteomyelitis Left Ankle and Foot, Alzheimer’s Disease” documented in the Home Health Certification and Plan of Care dated 12/16/2023 to 02/13/2024. The Discharge Summary from the hospital dated 12/11/2023 does not document Atrovent, Nuedexta and Sertraline in the current medications. The Home Health Certification and Plan of Care dated 12/16/2023 to 02/13/2024 documents: Atrovent HFA 17 mcg/actuation Aerosol Inhaler 2 puffs 2 times daily; Nuedexta 20 mg-10mg capsule 1 capsule 2 times daily; Sertraline 50 mg tablet 1 tablet bedtime. On 01/09/2023 at 12:35pm during the home visit, Patient’s son stated, “Patient is not using Atrovent, Nuedexta and Sertraline for how many years now. There is no documented evidence of the review of all medication patient is currently using. There is no documented evidence of medication reconciliation. On 01/11/2024 at 2:05pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 3. Patient #11 has a Start of Care date of 12/26/2023 with the following diagnoses “Hypertension Heart and Chronic Kidney Disease with Heart Failure and with stage 5 Chronic Kidney, Chromic Diastolic Congestive Heart Failure, Type 2 Diabetes Mellitus” documented in the Home Health Certification and Plan of Care dated 12/26/2023 to 02/23/2024. The Home Health Certification and Plan of Care dated 12/26/2023 to 02/23/2024 documents: Bacitracin 500 Unit/Gram topical ointment to right ear excoriation daily; Humalog Kwikpen Insulin 4 times daily per sliding scale; Multivitamin Tablet daily (wife states patient does not need); Vitamin B-12 500 mcg (microgram) Tablet daily. The Visit Note Report documents: 12/26/2023 How Frequent are blood sugars checked? Twice a day. 01/02/2024 Call placed call to MD (Medical Doctor) during home visit and MD instructed spouse to administered Torsemide 80mg in one single dose as spouse currently administers Torsemide in 2 doses am/pm. The Physician Order dated 01/02/2024 documents: Torsemide 20mg tablet - dose 80mg daily. On 01/09/2023 at 12:35pm during the home visit, Patient’s list of medication dated 01/01/2024 (current list per wife) documents: Torsemide 20mg (milligram) 2 tablets am – log: 2 (tablet) in am and 2 (tablet) in evening; Vitamin B12 500 mg tablet 1 tablet at night – log: see calendar (calendar documents every other day). Patient’s wife stated, “I never put any ointment in the right ear from the time he came home (start of care 12/26/2023). “I’m doing the fingerstick three times a day and give the insulin if needed as per the result.” There is no documented evidence of the review of all medication patient is currently using or the review of list of medication at home. There is no documented evidence of medication reconciliation. On 01/11/2024 at 2:05pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 4. Patient #14 has a Start of Care date of 03/06/2023 with the diagnoses “Bilateral Primary Osteoarthritis of Knee, Essential (Primary) Hypertension, Hyperlipidemia” documented on the Home Health Certification and Plan of Care for the Certification Period 03/06/2023 to 05/04/2023. The Home Health Certification and Plan of Care dated 03/06/2023 to 05/04/2023 documents: “PT (Physical Therapy) 2WK6 (two times a week for six weeks)” The Physician order dated 04/10/2023 documents: “PT (Physical Therapy) Effective 04/09/2023 2WK3 (two times a week for three weeks)” The Client Coordination Note Report dated 04/10/2023 documents: “ Patient has new diagnosis of UTI (Urinary Tract Infection) with oral antibiotics prescribed by MD (Medical Doctor) till 04/13/2023.” The clinical record lacks documented evidence of supplemental order for antibiotics. There is no documented evidence of medication reconciliation. On 01/11/2024 at 2:05pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure each patient’s individualized plan of care include all the required information. This was evident for two (2) of seventeen (17) clinical records reviewed (Patients: #10, and #13). Failure to ensure individualized plan of care includes all the required information, has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #10 has a Start of Care date of 12/16/2023 with the following diagnoses “Non-Pressure Chronic Ulcer of Left Ankle, Other Acute Osteomyelitis Left Ankle and Foot, Alzheimer’s Disease” documented in the Home Health Certification and Plan of Care dated 12/16/2023 to 02/13/2024. The Visit Note Report - RN (Registered Nurse) OASIS Admission dated 12/16/2023 documents: Wound Assessment: #3 Ant (anterior) – Ear, RT (right), PU (pressure ulcer) Stage II; Granulation Tissue: 75-100%; Epithelialization: 75-100%. #2 Ant (anterior)- med (medial) Malleolus, RT (right), PU (pressure ulcer) Stage 1; Epithelialization: 100%. The plan of care lacks documented evidence of the treatment for wound #2 and #3. On 01/11/2024 at 2:05pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 2. Patient #13 has a Start of Care date of 12/02/2023 with the following diagnoses “Pressure Ulcer of Sacral Region Unstageable, Chronic Systolic Congestive Heart Failure, Type 2 Diabetes Mellitus” documented in the Home Health Certification and Plan of Care dated 12/02/2023 to 01/30/2024. The Home Health Certification and Plan of Care dated 12/02/2023 to 01/30/2024 documents: Admelog U-100 Insulin Lispro 100unit/ml (milliliter) 1-5 unit 3 times daily; Basaglar Kwikpen U-100 Insulin 100 unit/ml 6 units bedtime. The Visit Note Report dated 12/02/2023 documents: How frequent are blood sugars checked? BID (twice a day). The plan of care lacks documented evidence of the blood glucose parameters and frequency, and the goals for diabetes. On 01/11/2024 at 2:05pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that drugs are administered in accordance with physician orders. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #6). Failure to ensure that drugs are administered in accordance with physician orders. has the potential for negative patient outcomes. The Findings Are: 1. Patient #6 has a Start of Care date of 11/25/2023 with diagnoses Type 2 Diabetes Mellitus with Hyperglycemia, Chronic Kidney Disease the Home Health Certification and Plan of Care dated 11/25/2023 to 01/23/2024. The Client Medication Report/medication profile printed on 01/10/2024 documents: Start Date 8/25/2023, Humalog Kwikpen (U-100) Insulin 100 Unit/ML subcutaneous, “40 unit(s), 2 times daily.” The Home Health Certification and Plan of Care dated 11/25/2023 to 01/23/2024 documents the orders for Insulin Humalog (fast acting insulin) Kwikpen (U-100) Insulin 100 Unit/ML subcutaneous, “40-unit(s), 2 times daily;” and “Skilled Nurse for administration of insulin via SQ (subcutaneous) injection;” “Skilled Nurse to review medication profile and reconcile medications as needed.” The Client Medication Report/medication profile dated 01/10/2024 documents: Start Date 8/25/2023, Humalog Kwikpen (U-100) Insulin 100 Unit/ML subcutaneous, “40 unit(s), 2 times daily.” The Clinical Calendar Report dated 01/10/2024 documents, “RN (Registered Nurse) Contract” nurses are assigned to provide the skilled nursing services. The contract Registered Nurse/Skilled Nurse visit notes dated 11/25/2023 AM and 11/25/2023 PM documents the nurse administered the insulin Novolog 70/30 (combination fast-acting and intermediate-acting insulin).30 Units. The Home Health Certification and Plan of Care for certification period 11/25/2023 to 01/23/2024 lacks documentation of an order for Novolog 70/30 30 Units. The contract Registered Nurse/Skilled Nurse visit notes documents the nurse administering the insulin Lantus (long-acting insulin) 35 units in morning (AM) and Lantus 30 Units in evening (PM) on the following dates: 12/05/2023, 12/07/2023, 12/08/2023, 12/19/2023, 12/21/2023, 12/22/2023, 12/26/2023, 12/28/23, 12/29/2023, and 01/02/2024. The Home Health Certification and Plan of Care for certification period 11/25/2023 to 01/23/2024 lacks documentation of an order for Lantus. The contract Registered Nurse/Skilled Nurse visit notes document the nurse administered Novolog 70/30 insulin (combination fast-acting and intermediate-acting insulin).40 Units in morning (AM) and Novolog 70/30 40 Units in evening (PM) on the following dates: 11/25/2023, 11/27/2023 to 12/04/2023, 12/06/2023, 12/09/023 to 12/18/2023, 12/20/2023, 12/23/2023 to 12/25/2023, 12/27/2023, 12/30/2023 to 01/01/2024, 01/03/2024 to 01/08/2024. The Home Health Certification and Plan of Care for certification period 11/25/2023 to 01/23/2024 lacks documentation of an order for Novolog 70/30 40 Units. The contract Registered Nurse visit notes dated from 11/25/2023 to 01/08/2023 (45 days) documents the skilled nurses administering insulin not as ordered in the Home Health Certification and Plan of Care. The clinical record lacks documented evidence of the registered nurse reviewing and reconciling the insulin medication for the correct insulin to administer and revising the plan of care as needed to reflect the correct medication. On 01/12/2024 at 2:00pm, the Administrators. the Director of Patient Services, and Clinical Manager were interviewed. The Administrator stated that the “nurses are administering correct insulin Novolog 70/30 40 Units two times daily, in the assisted living facility,” where the patient resides. The Administrator stated, the nurses “documented the incorrect insulin” in the visit notes.”

“Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient’s care and treatments that the HHA will provide, specific to the patient’s care needs. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to provide pertinent instruction related to the patient’s care. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #12). Failure to provide pertinent instruction related to the patient’s care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #12 has a Start of Care date of 02/02/2023 with the following diagnoses “Encounter for Surgical Aftercare Following Surgery on the Sense Organs, Retinal Hemorrhage Right Eye” documented in the Home Health Certification and Plan of Care dated 02/02/2023 to 04/02/2023. The patients clinical record lacks documented evidence of the Home Exercise Program (HEP). On 01/12/2024 at 11:24am, the Administrator was interviewed and stated, “we could not find a copy of HEP (home exercise program).” “Part of our procedure is to provide HEP to all patients.” On 01/12/2024 at 03:45 am, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide further explanation for the findings.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure there is ongoing interdisciplinary assessments with accurate patient’s health status. This was evident for four(4) out of seventeen (17) clinical records reviewed (Patient #7, #10, #11, and #13). Failure to ensure the ongoing interdisciplinary assessments with accurate patient’s health status, has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #7 has a Start of Care date of 05/01/2023 with the following diagnoses “Left Knee Effusion, Muscle Weakness, Unspecified Dementia” documented in the Home Health Certification and Plan of Care dated 05/01/2023 to 06/29/2023. The Visit Note Report - (Registered Nurse) dated 05/16/2023 documents: #1 Left Posterior Heel, Unstageable DTI (deep tissue injury); Epithelialization: 100%; Necrotic Tissue Type: None; Necrotic Tissue Amount: None. There is no documented evidence of the registered nurse assessment accurately documenting the patient’s left posterior heel (no slough or eschar but not staged). On 01/11/2024 at 2:05pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 2. Patient #10 has a Start of Care date of 12/16/2023 with the following diagnoses “Non-Pressure Chronic Ulcer of Left Ankle, Other Acute Osteomyelitis Left Ankle and Foot, Alzheimer’s Disease” documented in the Home Health Certification and Plan of Care dated 12/16/2023 to 02/13/2024. The Visit Note Report (Registered Nurse) OASIS Admission dated 12/16/2023 documents: Current number of Unhealed pressure ulcer at unstageable: slough and /or eschar known but not stageable due to coverage of wound bed by slough and/or eschar: 1; Left Medial Foot #1 Lateral Medial Malleolus, Left Unstageable; Depth Description: Necrotic; Epithelization: 25%; Epithelialization: 50-<75%; Necrotic Tissue Type: None; Necrotic Tissue Amount: None. There is no documented evidence of the registered nurse’s assessment accurately documenting the patient’s left medial foot #1 lateral medial malleolus (no slough or eschar but not staged). On 01/11/2024 at 2:05pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 3. Patient #11 has a Start of Care date of 12/26/2023 with the following diagnoses “Hypertension Heart and Chronic Kidney Disease with Heart Failure and with stage 5 Chronic Kidney, Chromic Diastolic Congestive Heart Failure, Type 2 Diabetes Mellitus” documented in the Home Health Certification and Plan of Care dated 12/26/2023 to 02/23/2024. The Visit Note Report Registered Nurse dated 01/05/2024 documents: #3 Left great Toe, Unstageable DTI (deep tissue injury); Epithelialization: 100%; Necrotic Tissue Type: None; Necrotic Tissue Amount: None. There is no documented evidence of the registered nurse assessment accurately documenting the patient’s left great toe (no slough or eschar but not staged). On 01/11/2024 at 2:05pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 4. Patient #13 has a Start of Care date of 12/02/2023 with the following diagnoses “Pressure Ulcer of Sacral Region Unstageable, Chronic Systolic Congestive Heart Failure, Type 2 Diabetes Mellitus” documented in the Home Health Certification and Plan of Care dated 12/02/2023 to 01/30/2024. The Visit Note Report (Registered Nurse) dated 12/02/2023 documents: Does the patient have at least one unhealed pressure ulcer/injury at stage 2 or higher or designated as unstageable? YES; Current number of unhealed pressure ulcers/injuries at unstageable: slough and/or eschar: 1. The Visit Note Report for the following dates 12/05/2023, 12/08/2023, 12/12/2023, 12/15/2023, 12/21/2023, 12/27/2023, and 01/04/2023 documents: Indicate Integumentary Assessment: No problems identified. The Visit Note Report dated 01/04/2024 documents: #1 Posterior Sacral, Unstageable; Epithelialization: 25-50%; Necrotic Tissue Type: None; Necrotic Tissue Amount: None. There is no documented evidence of the registered nurse assessment accurately documenting the patient’s posterior sacral (no slough or eschar but not staged and no problems identified for skin assessment but with unstageable pressure ulcer). On 01/11/2024 at 2:05pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure all home health aide receive onsite supervision every 14 days. This was evident for two (2) of seventeen (17) clinical records reviewed (Patient: #1, and #12). Failure to ensure all home health aide receive onsite supervision every 14 days, has the potential for negative patient outcomes. The Findings Are: *Patient #12 has a Start of Care date of 11/09/2022 with the following diagnoses “Essential Hypertension, Syncope and Collapse, Unspecified Abnormalities of Gait and Mobility” documented in the Home Health Certification and Plan of Care dated 11/09/2022 to 01/07/2023. The Home Health Certification and Plan of Care dated 11/09/2022 to 01/07/2023 documents: hha (home health aide) effective 11/13/2022 5WK3 (five time a week for three weeks). The Physician Order dated 12/14/2022 documents: Extend hha (home health aide) hrs (hours) 3D X 4H X 1 (three days times four hours a day for one) week (12/5, 12/7 and 12/9), following weeks, 3D X 3H (three days for three hours a day) until 01/04/2023. The Duty Sheet documents aide providing services on: 11/14/2022 to 11/18/2022, 11/21/2022 to 11/25/2022, 11/28/2022 to 12/02/2022, 12/5/2022, 12/07/2022, 12/09/2022, 12/12/2022, and 12/14/2022. There is documented evidence of an aide supervision. There is no documented evidence of the aide being supervised every 14 days. On 01/12/2024 at 3:45pm, the Administrators, the Director of Rehabilitation, and the Clinical Managers were interviewed and did not provide an explanation for the findings. Patient #1 has a Start of Care date of 12/21/2023 with diagnoses Diffuse Large B-Cell Lymphoma, Adult Failure to Thrive, Chronic Obstructive Pulmonary Disease documented in the Home Health Certification and Plan of Care dated 12/21/2023 to 02/18/2024. The supplemental order dated 12/21/2023 documents orders for Home Health Aide service effective 12/21/2023 for two days a week for one week and three days a week for three weeks. The aide Duty Sheets document the aide provided services on the following dates:12/21/2023, 12/22/2023, 12/26/2023, 12/27/2023, 12/29/2023, 01/03/2023 and 01/05/2023. The clinical record documents Skilled Nurse visits dated 12/21/2023, 12/27/2023, and 01/02/2024. The clinical record lacks documented evidence of aide supervision being conducted during the skilled nurse visits and at least every 14 days since the start of aide services, from 12/21/2023 to 01/05/2023. On 01/11/2024 at 2:00pm, the Administrators and the Director of Patient Services were interviewed, and the Adminstrator confirmed the aide supervision “is late.””