Northern Lights Home Health Care

“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 clinical records and interviews with the Administrator and Clinical Manager, it was determined in 1 out of 13 records (patient #5) the agency failed to ensure the skilled professionals conducted a comprehensive assessment of the patient’s needs. Evidence as follows: Home visit 1. Patient #5 was admitted to the agency on 01/03/25 with diagnoses that included laceration, heart failure, and diabetes. The 01/03/25 and 03/04/25 Plans of Care included an order for nystatin-triamcinolone cream to be applied 3 times a day to groin for rash. On 01/03/25, the registered nurse (RN) visited the patient for the start of care assessment and documented a complete skin assessment was performed with “chronic rash noted to abdominal folds. Skin without other areas of redness on back/buttocks/heels/elbows/behind the ears.” On 02/27/25, the RN visited the patient for a recertification assessment and documented a complete skin assessment was performed, “skin is intact with chronic rash noted to abdominal folds. Skin without other areas of redness on back/buttocks/heels/elbows/behind the ears.” On 04/10/25, the physical therapist (PT) visited the patient for a reassessment visit and documented a complete skin assessment was performed, “skin is intact with chronic rash noted to abdominal folds. Skin without other areas of redness on back/buttocks/heels/elbows/behind the ears.” On 05/02/25, the PT visited the patient for a recertification visit and documented a complete skin assessment was performed, “skin is intact with chronic rash noted to abdominal folds. Skin without other areas of redness on back/buttocks/heels/elbows/behind the ears.” On 05/06/25, the surveyor conducted a home visit with the PT. Following the visit, the surveyor interviewed the patient about the rash. The patient reported that the rash was present under both breasts, in the groin, as well as under the abdominal fold and the cream was applied twice a day (ordered three times per day). On 05/07/25 at 10:20 a.m., the surveyor interviewed the PT who reported the rash is not considered an open wound and there wasn’t a wound care order, therefore, the rash would not be documented as a wound. The PT also reported the patient was educated to notify the agency if the rash gets worse and the patient did not do this. At every PT reassessment visit, the “patient would be asked those questions.” On 05/07/25 at 12:00 p.m., the findings were reviewed with the Administrator, Director of Patient Services (DPS), VP of Operations, Clinical Manager, and Team Leader. During the record review, the surveyor interviewed the clinical manager about the expectations of documenting the rash and was informed a rash would not be considered an open wound and therefore not documented in the electronic medical record’s “wound grid,” but a narrative assessment of the rash should be included in the integument narrative. The skilled professional failed to assess the characteristics of the rash (such as approximate size, color, presence or absence of drainage), the patient or caregiver’s ability to manage the rash, effectiveness of the treatment, or all the areas patient reported having the rash (including the groin where the medication was ordered to be applied). Failure to perform complete and accurate comprehensive assessments has the potential for unmet patient needs and possible negative patient outcomes.”

“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 review of clinical records, observational home visits, and interviews with the Administrator and Clinical Manager, it was determined in 3 out of 13 records (patients #3, 5, and 8) the Registered Nurse (RN) failed to perform complete and accurate medication assessments. Evidence as follows: Home Visit Patient #1 was admitted to the agency on 02/22/25 with diagnoses of pneumonia, chronic obstructive pulmonary disease, congestive heart failure, and atrial fibrillation. The patient was hospitalized from 03/17/25-03/20/25. The 03/20/25 discharge medication list included clonidine 0.1 mg, 1 tab by mouth at bedtime. On 03/23/25 the RN saw the patient for a resumption of care visit and documented a medication reconciliation was completed and the patient was not taking clonidine. On 04/22/25 the RN saw the patient for a recertification visit and documented a complete medication reconciliation was completed. On 05/07/25 at 10:00 a.m. the surveyor conducted an observational home visit with RN. After the visit the surveyor asked to review the patient’s medications with them. The patient handed the surveyor a printout of their medications and stated that was what they use to pre-pour their medications every week. The patient’s printed medication list was compared to the agency’s active medication profile. The surveyor noted the patient’s medication list included clonidine 0.1 mg, 1 tab by mouth at bedtime, however, the agency’s active medication list did not. The RN failed to perform and complete and accurate medication reconciliation and update the patient’s medication profile to include the clonidine. On 05/07/25 at 12:00 p.m. the record was reviewed with the VP of Operations, Administrator, DPS, Clinical Manager, Team Leader, and PCA Manager. The findings were acknowledged and no additional information was provided. Home visit 1. Patient #3 was admitted to the agency on 04/24/25 with diagnoses of chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, chronic kidney disease, chronic pain, and type 2 diabetes. On 04/24/25, the registered nurse (RN) saw the patient for the start of care (SOC) and documented the patient used a medication box/organizer, however, it was not pre-poured when they visualized it. The nurse also documented the patient declined having them fill the box. The 07/12/24-09/09/24 Plan of Care included the following order: “Patient pre-pours medications into pill organizer weekly on random days.” On 04/26/25, the RN saw the patient and documented that the patient reported no medication changes. There was no documented information related to the patient’s pill box/organizer being used or not. On 05/06/25 at 9 a.m., the surveyor supervised a home visit with the RN. The surveyor heard the RN ask the patient if there were any recent medication changes. The patient requested clarification about a new medication order following a physician office visit. The RN contacted the physician’s office to clarify the order and stated that they would arrange for the pharmacy to deliver the medication. The RN did not visualize the medications or the medication box. After the RN concluded the visit, the surveyor interviewed the patient and asked to look at their medications. The medication box was empty, and when asked, the patient stated that they hadn’t had an opportunity to fill the box. The patient had all medication bottles in a cardboard box which was located on the floor just out of reach from their recliner in the living room. There is no evidence the RN assessed the patient’s ability or compliance with pre-filling their pill box/organizer as ordered in the Plan of Care. 2. Patient #8 was admitted to the agency on 07/12/24 with diagnosis of cellulitis of left lower limb, type 2 diabetes, chronic kidney disease, congestive heart failure, and history of cancer of head and neck. On 07/12/24 at the start of care visit, the patient had a pain rating of 8/10. The registered nurse (RN) made the physician aware of the pain level and developed plan for patient to take hydromorphone when it arrived from the pharmacy. The hydromorphone was on backorder at the pharmacy and the physician was notified. On 07/17/24, the licensed practical nurse (LPN) saw the patient and documented that the patient had a new prescription in the home that was filled by the pharmacy. The LPN documented in an activity note that the new medication was morphine sulfate 15 mg. A review of the patient’s medication profile showed the LPN entered the order into the patient’s medication list as morphine extended release 15 mg tablet, take ½ tablet every 4 hours as needed for pain. The order was left as incomplete, and the RN was notified of the new order. On 05/07/25, the surveyor reviewed the agency’s policy “Drug Regimen Review” dated 01/29/25. The policy stated, “Ordered medications are transcribed into the EMR medication profile by the RN or medical assistant/LPN. Orders entered by the medical assistant/LPN will be entered as “incomplete” until reviewed by the RN who will verify the information is correct. If the order needed to be clarified or modified the RN is responsible to do so. Once verified as correct the RN will change the status of the order to “complete.”” On 05/07/25 at 2 p.m., the surveyor interviewed the Clinical Manager who confirmed the RN did not complete the order which is why the order remained as incomplete in the EMR. The Clinical Manager further stated that because the order was incomplete, it was not sent to the physician. The RN failed to verify and complete the new medication order which led to the medication error not being identified or corrected. Home Visit Patient #5 was admitted to the agency on 01/03/25 with diagnoses that included laceration, heart failure, and diabetes. On 01/31/25 and 02/21/25, the physical therapist documented that the patient had chronic left shoulder pain and occasionally the caregiver applies Biofreeze for pain relief. On 05/02/25 the clinical manager completed a medication reconciliation using video conferencing software with patient and physical therapist case manager. No medication discrepancies were identified. The medication reconciliation note did not mention the use of Biofreeze. On 05/06/25 the surveyor made a home visit with the physical therapist case manager. During the visit, the patient mentioned the use of muscle rub (clarified with the patient to be the topical medication Voltaren) and Biofreeze. Following the therapy visit, the nurse interviewed the patient and reviewed the medications they are currently taking, with the following discrepancies identified: - nystatin-triamcinolone topical cream ordered to be applied 3 times a day to groin for rash (patient reported this was used twice a day and applied to rash under breasts, abdominal fold, and groin) - ferrous gluconate 324 mg 1 tablet daily (patient reported this was causing constipation so they were taking with Miralax for some time but within the past week they stopped taking both due to the constipation) - Voltaren and Biofreeze are both applied topically as needed to left shoulder for pain relief On 05/07/25 at 10:20 a.m., the surveyor interviewed the case manager and asked about a medication reconciliation for Voltaren and Biofreeze since they are not active medications. The case manager replied, “they’re not active?” On 05/07/25 at 12 p.m., the findings were reviewed with the Administrator, Director of Patient Services (DPS), VP of Operations (VP), Clinical Manager, and Team Leader. No further information was provided. Home visit 1. Patient #8 was admitted to the agency on 07/12/24 with diagnoses of cellulitis of left lower limb, type 2 diabetes, chronic kidney disease, congestive heart failure, and history of cancer of head and neck. On 07/12/24 at the start of care visit, the patient had a pain rating of 8/10. The registered nurse (RN) made the physician aware of the pain level and developed plan for patient to take hydromorphone when it arrived from the pharmacy. The hydromorphone was on backorder at the pharmacy and the physician was notified. On 07/17/24, the licensed practical nurse (LPN) saw the patient and documented that the patient had a new prescription in the home that was filled by the pharmacy. The LPN documented in an activity note that the new medication was morphine sulfate 15 mg. A review of the patient’s medication profile showed the LPN entered the order into the patient’s medication list as morphine extended release 15 mg tablet, take ½ tablet every 4 hours as needed for pain. The order was left as incomplete, and the RN was notified of the new order. On 05/07/25, the surveyor reviewed the agency’s policy “Drug Regimen Review” dated 01/29/25. The policy stated, “Ordered medications are transcribed into the EMR medication profile by the RN or medical assistant/LPN. Orders entered by the medical assistant/LPN will be entered as “incomplete” until reviewed by the RN who will verify the information is correct. If the order needed to be clarified or modified the RN is responsible to do so. Once verified as correct the RN will change the status of the order to “complete.”” On 05/07/25 at 2:00 p.m., the surveyor interviewed the Clinical Manager who confirmed the RN did not complete the order which is why the order remained as incomplete in the EMR. The Clinical Manager further stated that because the order was incomplete, it was not sent to the physician. The RN failed to verify and complete the new medication order which led to the medication error not being identified or corrected. Home visit 2. Patient #3 was admitted to the agency on 04/24/25 with diagnoses of chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, chronic kidney disease, chronic pain, and type 2 diabetes. On 04/24/25, the registered nurse (RN) saw the patient for the start of care (SOC) and documented the patient used a medication box/organizer, however, it was not pre-poured when visualized. The nurse also documented the patient declined having them fill the box. The 07/12/24-09/09/24 Plan of Care included the following order: “Patient pre-pours medications into pill organizer weekly on random days.” On 04/26/25, the RN saw the patient and documented that the patient reported no medication changes. There was no documented information related to the patient’s pill box/organizer being used or not. On 05/06/25 at 9:00 a.m., the surveyor conducted an observational home visit with the RN. The RN asked the patient if there were any recent medication changes. The patient requested clarification about a new medication order following a physician office visit. The RN contacted the physician’s office to clarify the order and stated that they would arrange for the pharmacy to deliver the medication. The RN did not visualize the medications or the medication box. After the RN concluded the visit, the surveyor interviewed the patient and asked to look at their medications. The medication box was empty, and when asked, the patient stated that they hadn’t had an opportunity to fill the box. The patient had all medication bottles in a cardboard box which was located on the floor just out of reach from their recliner in the living room. There is no evidence in the record the RN assessed the patient’s ability or compliance with pre-filling their pill box/organizer as ordered in the plan of care. Home Visit 3. Patient #1 was admitted to the agency on 02/22/25 with diagnoses of pneumonia, chronic obstructive pulmonary disease, congestive heart failure, and atrial fibrillation. The patient was hospitalized from 03/17/25-03/20/25. The 03/20/25 discharge medication list included clonidine 0.1 mg, 1 tab by mouth at bedtime. On 03/23/25 the RN saw the patient for a resumption of care visit and documented a medication reconciliation was completed and the patient was not taking clonidine. On 04/22/25 the RN saw the patient for a recertification visit and documented a complete medication reconciliation was completed. On 05/07/25 at 10:00 a.m. the surveyor conducted an observational home visit with RN. After the visit the surveyor asked to review the patient’s medications with them. The patient handed the surveyor a printout of their medications and stated that was what they use to pre-pour their medications every week. The patient’s printed medication list was compared to the agency’s active medication profile. The surveyor noted the patient’s medication list included clonidine 0.1 mg, 1 tab by mouth at bedtime, however, the agency’s active medication list did not. The RN failed to perform and complete and accurate medication reconciliation and update the patient’s medication profile to include the clonidine. Home Visit 4. Patient #5 was admitted to the agency on 01/03/25 with diagnoses that included laceration, heart failure, and diabetes. On 01/31/25 and 02/21/25, the physical therapist documented that the patient had chronic left shoulder pain and occasionally the caregiver applies Biofreeze for pain relief. On 05/02/25 the clinical manager completed a medication reconciliation using video conferencing software with patient and physical therapist case manager. No medication discrepancies were identified. The medication reconciliation note did not mention the use of Biofreeze. On 05/06/25 the surveyor made a home visit with the physical therapist case manager. During the visit, the patient mentioned the use of muscle rub (clarified with the patient to be the topical medication Voltaren) and Biofreeze. Following the therapy visit, the nurse interviewed the patient and reviewed the medications they are currently taking, with the following discrepancies identified: - nystatin-triamcinolone topical cream ordered to be applied 3 times a day to groin for rash (patient reported this was used twice a day and applied to rash under breasts, abdominal fold, and groin) - ferrous gluconate 324 mg, 1 tablet daily (patient reported this was causing constipation so they were taking with Miralax for some time but within the past week they stopped taking both due to the constipation) - Voltaren and Biofreeze are both applied topically as needed to left shoulder for pain relief On 05/07/25 at 10:20 a.m., the surveyor interviewed the case manager and asked about a medication reconciliation for Voltaren and Biofreeze since they are not active medications. The case manager replied, “they’re not active?” On 05/07/25 at 12:00 p.m. the records were reviewed with the VP of Operations, Administrator, DPS, Clinical Manager, Team Leader, and PCA Manager. The findings were acknowledged and no additional information was provided. Failure to perform complete and accurate medication reviews has the potential for patients taking medications inconsistent with the physician’s intentions, and possible negative patient outcomes.”

“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 review of clinical records, observational home visits, and interviews with the Administrator and Clinical Manager, it was determined in 3 out of 13 records (patients #5, 6, and 10) the agency failed to develop plans of care that were complete, accurate, and addressed the total needs of the patient. Evidence as follows: Patient #9 was admitted to the agency on 02/17/25 with diagnoses of type 2 diabetes mellitus with diabetic peripheral angiopathy, diabetic neuropathy, right foot ulcer and chronic kidney disease, stage 3. The 02/17/25 – 04/17/25 plan of care included patient to self-catheterize using a 14 French speedicath. Patient to use 8 -10 times a day and as needed. The 02/17/25 initial nursing visit included: -patient has chronic urinary retention, they straight cath 6-7 times a day independently -catheter present, knowledge/skill deficit: patient The 02/17/25 plan of care failed to include: Patient return demonstration with self-catheterizing treatment to determine if infection control practices had been followed. The vendor for the equipment if there was a supply issue. On 05/07/25 at 12:00 p.m., the record was reviewed with the VP of Operations, Administrator, DPS, Clinical Manager, Team Leader, and PCA Manager. On 05/08/25 at 1p.m., the agency’s team leader provided the surveyor with an audit tool dated 02/21/25 that included the need for corrections in the record. The audit tool indicated the need for additional documentation needed for a return demonstration with self-catheterizing. The surveyor asked to identify where the correction is located in the record, they stated the nurse that completed the initial assessment was no longer employed by the agency. The surveyor asked if the current case manager or supervisor completed an addendum in the record to clarify the patient was proficient with the treatment. The surveyor did not receive an answer, and no other documentation was provided, therefore the additional information provided did not change the findings. The agency failed to provide the most recent 485 orders due on 04/18/25. Patient #6 was admitted to the agency on 03/31/25 with a diagnosis of right knee prosthetic joint infection following a total knee replacement. The 03/31/25-05/29/25 Plan of Care included the following medications: - oxycodone 5 mg, 1-2 tabs every 4 hours as needed for pain - prochlorperazine 5 mg, 1-2 tabs every 6 hours as needed for nausea The Plan of Care failed to include any qualifiers for when the patient should take 1 tab versus 2 tabs of the oxycodone and the prochlorperazine (i.e. mild-moderate pain/nausea take 1 tab, moderate-severe pain/nausea take 2 tabs). On 05/07/25 at 12:00 p.m. the record was reviewed with the VP of Operations, Administrator, DPS, Clinical Manager, Team Leader, and PCA Manager. The findings were acknowledged and no additional information was provided. 1. Patient #10 was admitted to the agency on 03/14/24 with diagnoses that included diabetes with foot ulcer, chronic ulcer to left foot, chronic kidney disease, and heart failure. Patient was selected from the “Potentially Avoidable Event Patient Listing Report” for period 01/02/2024 – 01/31/25 that was run on 04/29/25 for event type “emergent care for hypo/hyperglycemia”. The 05/13/24 Plan of Care included the following diabetic orders: - lispro insulin (short-acting) 5 units at breakfast and lunch, 13 units at dinner subcutaneously - Basaglar insulin (long-acting) 20 units subcutaneously daily - supplies included Dexcom (a continuous glucose meter) - patient/caregiver to test blood sugar fasting twice a day and call MD 300 - instruct patient/caregiver in diabetes management including maintenance of log of blood sugar readings, signs/symptoms or hypo/hyperglycemia, diabetic meal planning, sick day management, and foot care On 05/13/24, a registered nurse (RN) visited for a routine revisit and documented “the has not received sensor yet, [RN] called pharmacy, and it is on backorder.” The RN also documented they educated the patient on the use of glucometer at home and that the “patient was going to find it.” A 05/15/24 Supervisor Case Review note documented the “patient does not currently have a sensor for continuous blood glucose monitoring as it expired, and the pharmacy is waiting for them to come in. Patient does not have a backup glucometer.” The Plan of Care failed to include orders for continuous blood glucose monitoring, how often the sensors should be changed, who should be notified of issues with continuous blood glucose monitoring, and instructions for back-up glucometer use. On 05/07/25 at 12 p.m., the findings were reviewed with the Administrator, Director of Patient Services (DPS), VP of Operations, Clinical Manager, and Team Leader. On 05/08/25 at 2 p.m., the clinical manager provided the surveyor with documentation to support the potentially avoidable event was reviewed and determined the patient did not have a hypo/hyperglycemic event and sought emergent care for other issues. Since the potentially avoidable event was triggered by incorrect OASIS response, a potentially avoidable event audit was not conducted. The Clinical Manager also provided a copy of the case review note that confirmed the patient had a continuous blood glucose monitor. The additional documentation did not change the findings.+ The agency failed to develop a complete plan of care that included how the diabetic patient would monitor their blood glucose. 2. Patient #5 was admitted to the agency on 01/03/25 with diagnoses that included laceration, heart failure, and diabetes. On 02/20/25, a case conference note reported the wound [hip laceration] was healed. On 02/27/25, the registered nurse (RN) visited the patient for the recertification assessment and documented: - patient no longer utilizes oxygen and not in home - chronic rash to abdominal folds was present The 03/04/25 Plan of Care: - listed the primary diagnosis as laceration on the right hip - included dependence on supplemental oxygen as an active diagnosis - failed to include the rash as a diagnosis On 05/06/25, the surveyor requested the plan of care for the certification period that began on 05/03/25 and the Clinical Manager reported this Plan of Care was not available as it was pending the review of the OASIS, coding of the diagnoses, and review of the care plan. At this time, the primary diagnosis in the electronic medical record was listed as laceration despite no evidence to support the patient had a laceration. On 05/07/25 at 10:20 a.m., the surveyor interviewed the case manager regarding the OASIS and plan of care review process, including the diagnosis selection. The case manager reported that they do not look at the diagnoses or ICD-10 codes when completing the recertification OASIS. They reported that the diagnoses were determined through the review process, and they were unsure of who determines which diagnoses are included or removed as the patient’s condition changes. The case manager reported that the corrections have been completed for this patient. On 05/07/25 at 12 p.m., the findings were reviewed with the Administrator, Director of Patient Services (DPS), CP of Operations, Clinical Manager, and Team Leader. On 05/09/25 at 9 a.m., the electronic medical record still did not have the plan of care for the certification period that began 05/03/25, however, the primary diagnosis on the home page banner and in the recertification note had been changed to heart failure. The rash was not included in the list of current diagnosis and dependence on supplemental oxygen was still included as a current diagnosis. On 05/09/25 at 11:35 a.m., the surveyor interviewed the clinical manager about the OASIS/Plan of care review process, including how the diagnoses are selected and again requested a copy of the plan of care. The surveyor asked who determined heart failure was the primary diagnosis. The Clinical Manager reported that the coding company selects the primary diagnosis based on the documentation and does not consult with the clinician. If a change is made, the coding company does not document within or outside the electronic medical record about why a change was made. The Clinical Manager also reported that the primary diagnosis should have been questioned at the recertification following the wound healing. The 01/29/25 OASIS Compliance policy stated: - the OASIS assessment will be completed by the clinician in the appropriate timeframe - the OASIS coordinator/designee with review the assessment/OASIS data elements for accuracy and completeness using the OASIS-E audit tool - a coder will assign the proper ICD-10 code to the OASIS document in accordance with the guidelines of CMS which excludes provider services from coverage and payment that are not reasonable and necessary. The OASIS document will then be returned to the OASIS coordinator/designee for review. - if the original clinician does not make the correction, documentation is made in the medical record which describes the turn of events and communication that took place among the involved staff. Date and initial correction is indicated. - once coded, accurate, and completed the Plan of Care/Physician orders are created/printed and sent to the physician for signature. The policy failed to address who will be selecting the diagnoses or how inconsistencies between the coding and the documentation will be reconciled. The agency failed to include an accurate list of pertinent diagnoses. 1. Patient #10 was admitted to the agency on 03/14/24 with diagnoses that included diabetes with foot ulcer, chronic ulcer to left foot, chronic kidney disease, and heart failure. Patient was selected from the “Potentially Avoidable Event Patient Listing Report” for period 01/02/2024 – 01/31/25 that was run on 04/29/25 for event type “emergent care for hypo/hyperglycemia”. The 05/13/24 Plan of Care included the following diabetic orders: - lispro insulin (short-acting) 5 units at breakfast and lunch, 13 units at dinner subcutaneously - Basaglar insulin (long-acting) 20 units subcutaneously daily - supplies included Dexcom (a continuous glucose meter) - patient/caregiver to test blood sugar fasting twice a day and call MD 300 - instruct patient/caregiver in diabetes management including maintenance of log of blood sugar readings, signs/symptoms or hypo/hyperglycemia, diabetic meal planning, sick day management, and foot care On 05/13/24, a registered nurse (RN) visited for a routine revisit and documented “the patient has not received sensor yet, [RN] called pharmacy, and it is on backorder.” The RN also documented they educated the patient on the use of glucometer at home and that the “patient was going to find it.” A 05/15/24 Supervisory Case Review note documented the “patient does not currently have a sensor for continuous blood glucose monitoring as it expired, and the pharmacy is waiting for them to come in. Patient does not have a backup glucometer.” The Plan of Care failed to include orders for continuous blood glucose monitoring, how often the sensors should be changed, who should be notified of issues with continuous blood glucose monitoring, and instructions for back-up glucometer use. On 05/07/25 at 12:00 p.m., the findings were reviewed with the Administrator, Director of Patient Services (DPS), VP of Operations, Clinical Manager, and Team Leader. On 05/08/25 at 2:00 p.m., the clinical manager provided the surveyor with documentation to support the potentially avoidable event was reviewed and determined the patient did not have a hypo/hyperglycemic event and sought emergent care for other issues. Since the potentially avoidable event was triggered by incorrect OASIS response, a potentially avoidable event audit was not conducted. The Clinical Manager also provided a copy of the case review note that confirmed the patient had a continuous blood glucose monitor. The additional documentation did not change the findings. The agency failed to develop a complete plan of care that included how the diabetic patient would monitor their blood glucose. 2. Patient #9 was admitted to the agency on 02/17/25 with diagnoses of type 2 diabetes mellitus with diabetic peripheral angiopathy, diabetic neuropathy, right foot ulcer and chronic kidney disease, stage 3. The 02/17/25 – 04/17/25 plan of care included patient to self-catheterize using a 14 French speedicath. Patient to use 8 -10 times a day and as needed. The 02/17/25 initial nursing visit included: -patient has chronic urinary retention, they straight cath 6-7 times a day independently -catheter present, knowledge/skill deficit: patient The 02/17/25 plan of care failed to include: Patient return demonstration with self-catheterizing treatment to determine if infection control practices had been followed. The vendor for the equipment if there was a supply issue. On 05/07/25 at 12:00 p.m., the record was reviewed with the VP of Operations, Administrator, DPS, Clinical Manager, Team Leader, and PCA Manager. On 05/08/25 at 1p.m., the agency’s team leader provided the surveyor with an audit tool dated 02/21/25 that included the need for corrections in the record. The audit tool indicated the need for additional documentation needed for a return demonstration with self-catheterizing. The surveyor asked to identify where the correction is located in the record, they stated the nurse that completed the initial assessment was no longer employed by the agency. The surveyor asked if the current case manager or supervisor completed an addendum in the record to clarify the patient was proficient with the treatment. The surveyor did not receive an answer, and no other documentation was provided, therefore the additional information provided did not change the findings. The agency failed to provide the most recent 485 orders due on 04/18/25. Home visit 3. Patient #5 was admitted to the agency on 01/03/25 with diagnoses that included laceration, heart failure, and diabetes. On 02/20/25, a case conference note reported the wound [hip laceration] was healed. On 02/27/25, the registered nurse (RN) visited the patient for the recertification assessment and documented: - patient no longer utilizes oxygen and not in home - chronic rash to abdominal folds was present The 03/04/25 Plan of Care: - listed the primary diagnosis as laceration on the right hip - included dependence on supplemental oxygen as an active diagnosis - failed to include the rash as a diagnosis On 05/06/25, the surveyor requested the Plan of Care for the certification period that began on 05/03/25 and the Clinical Manager reported this Plan of Care was not available as it was pending the review of the OASIS, coding of the diagnoses, and review of the care plan. At that time, the primary diagnosis in the electronic medical record was listed as laceration despite no evidence to support the patient had a laceration. On 05/07/25 at 10:20 a.m., the surveyor interviewed the case manager regarding the OASIS and plan of care review process, including the diagnosis selection. The case manager reported that they do not look at the diagnoses or ICD-10 codes when completing the recertification OASIS. They reported that the diagnoses were determined through the review process, and they were unsure of who determines which diagnoses are included or removed as the patient’s condition changes. The case manager reported that the corrections have been completed for this patient. On 05/09/25 at 9:00 a.m., the electronic medical record still did not have the plan of care for the certification period that began 05/03/25, however, the primary diagnosis on the home page banner and in the recertification note had been changed to heart failure. The rash was not included in the list of current diagnoses and dependence on supplemental oxygen was still included as a current diagnosis. On 05/09/25 at 11:35 a.m., the surveyor interviewed the clinical manager about the OASIS/Plan of Care review process, including how the diagnoses are selected and again requested a copy of the Plan of Care. The surveyor asked who determined heart failure was the primary diagnosis. The Clinical Manager reported that the coding company selects the primary diagnosis based on the documentation and does not consult with the clinician. If a change is made, the coding company does not document within or outside the electronic medical record about why a change was made. The Clinical Manager also reported that the primary diagnosis should have been questioned at the recertification following the wound healing. The 01/29/25 OASIS Compliance policy stated: - the OASIS assessment will be completed by the clinician in the appropriate timeframe - the OASIS coordinator/designee with review the assessment/OASIS data elements for accuracy and completeness using the OASIS-E audit tool - a coder will assign the proper ICD-10 code to the OASIS document in accordance with the guidelines of CMS which excludes provider services from coverage and payment that are not reasonable and necessary. The OASIS document will then be returned to the OASIS coordinator/designee for review. - if the original clinician does not make the correction, documentation is made in the medical record which describes the turn of events and communication that took place among the involved staff. Date and initial correction is indicated. - once coded, accurate, and completed the Plan of Care/Physician orders are created/printed and sent to the physician for signature. The policy failed to address who will be selecting the diagnoses or how inconsistencies between the coding and the documentation will be reconciled. The agency failed to include an accurate list of pertinent diagnoses. 4. Patient #6 was admitted to the agency on 03/31/25 with a diagnosis of right knee prosthetic joint infection following a total knee replacement. The 03/31/25-05/29/25 Plan of Care included the following medications: - oxycodone 5 mg, 1-2 tabs every 4 hours as needed for pain - prochlorperazine 5 mg, 1-2 tabs every 6 hours as needed for nausea The Plan of Care failed to include any qualifiers for when the patient should take 1 tab versus 2 tabs of the oxycodone and the prochlorperazine (i.e. mild-moderate pain/nausea take 1 tab, moderate-severe pain/nausea take 2 tabs). On 05/07/25 at 12:00 p.m., the records were reviewed with the VP of Operations, Administrator, DPS, Clinical Manager, Team Leader, and PCA Manager. The findings were acknowledged and no additional information was provided. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on clinical record review and interviews with the Administrator and Clinical Manager, the agency failed to ensure a revised Plan of Care reflect current information from the patient’s updated comprehensive assessment. This was evident for 1 of 15 clinical records (patient #6). Evidence as follows: 1. Patient #6 was admitted to the agency on 03/31/25 with a diagnosis of right knee prosthetic joint infection following a total knee replacement. On 3/31/25 the patient was discharged home from the hospital with a double lumen PICC (peripherally inserted central catheter) line which would be used to administer IV antibiotics at home. The 03/31/25-05/29/25 Plan of Care included the following orders: - cefepime (antibiotic) 2 grams in 20 mL sterile water; infuse 20 mL via IV push over 5-10 minutes every 12 hours - sodium chloride (normal saline) 10 mL flush; flush line with 10 mL pre/post antibiotic administration and post lab draws - heparin 10 units/5mL; flush line with 5 mL post antibiotic administration (after saline flush) and flush unused lumen daily - nurse to obtain labs weekly; cleanse port with alcohol wipe, flush with 10 mL normal saline, draw/discard 10 mL blood, obtain blood for specimens, flush with 10 mL normal saline post blood draw On 04/03/24 the RN saw the patient and documented both PICC lumens flushed easily and had blood return, however, not enough blood could be obtained for lab specimens. The RN notified the physician and subsequently obtained a supplemental order stating labs could be obtained via venipuncture if the nurse could not obtain blood from the PICC. On 04/10/25 the RN saw the patient and documented they flushed both lumens with normal saline and heparin and that the lumens flushed easily but had no blood return. The RN further documented “MD is aware of issues with blood return…” There was no evidence the RN: - notified the physician on 04/10/25 to report there was no longer any blood return from either PICC lumen - obtained an order and updated the Plan of Care allowing for the continuation of the IV antibiotics with no blood return as long as the PICC continued to flush easily On 05/07/25 at 12:00 p.m., the record was reviewed with the VP of Operations, Administrator, DPS, Clinical Manager, Team Leader, and PCA Manager. The findings were acknowledged. On 5/8/25 the Team Leader was asked if they were able to find any communication or orders from the physician allowing for the administration of the antibiotic through the PICC line even though there was no blood return. The Team Leader stated they could not find anything. Failure to ensure revised plan of care reflect current information from the patient’s updated comprehensive assessment, has the potential risk for negative patient outcomes.”

“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 review of clinical records and interview with the Administrator and Clinical Manager, for 2 of 15 patients (patients #7 and 9) the agency failed to ensure the registered nurse provided the patient with appropriate education regarding the care and services identified in the plan of care. Evidence as follows: 1. Patient #7 was admitted to the agency on 02/19/25 with diagnoses of atherosclerosis of native arteries of the extremities with gangrene of left leg, type 2 diabetes mellitus, osteomyelitis, and acute kidney failure. On 03/17/25 the wound clinic faxed the following orders to the agency: - wound vac (negative pressure wound therapy) to left heel, nurse to clean area with normal saline, cover surrounding skin with drape, apply black foam to wound bed, cover with drape and suction tubing, wound vac to run at 125mmhg/hr - nurse to instruct patient to change canister weekly and as needed - nurse to instruct patient or caregiver to troubleshoot alarms on wound vac and to call agency if unable to restart. Nurse to instruct patient or caregiver on back up dressing of hydrofera blue and cover with an abdominal pad, and secure with tape. On 05/08/25 at 10:30 a.m., the surveyor conducted a phone interview with the patient, the surveyor asked about the back up dressing and hydrofera blue agent to be used if the wound vac malfunctions. The patient stated they had no idea what hydrofera blue was and if there were a problem they would call the agency, they are available 24/7. On 05/08/25 at 1:00 p.m., the surveyor asked agency’s team leader for any additional teaching in the clinical record after the wound vac had been applied. There was no additional information provided. The agency failed to educate the patient/caregiver on: - changing the wound vac canister - removing the wound vac if malfunctioned -instructing on the backup wound care if the wound vac had malfunctioned 2. Patient #9 was admitted to the agency on 02/17/25 with diagnoses of type 2 diabetes mellitus with diabetic peripheral angiopathy, diabetic neuropathy, right foot ulcer and chronic kidney disease, stage 3. The 02/17/25–04/17/25 Plan of Care included patient to self-catheterize using a 14 French speedicath. Patient to use 8 -10 times a day and as needed. The 02/17/25 initial nursing visit included: -patient has chronic urinary retention, they straight cath 6-7 times a day independently -catheter present, knowledge/skill deficit: patient The 02/17/25 Plan of Care failed to include: Patient return demonstration with self-catheterizing treatment to determine if infection control practices had been followed. On 05/07/25 at 12:00 p.m., the record was reviewed with the VP of Operations, Administrator, DPS, Clinical Manager, Team Leader, and PCA Manager. On 05/08/25 at 1:00 p.m., the agency’s Team Leader provided the surveyor with an audit tool dated 02/21/25 that included the need for corrections in the record. The audit tool indicated the need for additional documentation needed for a return demonstration with self-catheterizing. The surveyor asked for documentation the patient’s ability was assessed. The surveyor did not receive any other documentation. Failure to provide appropriate education has the potential to result in the patient receiving inadequate care and could result in potential negative patient outcomes.”