Elmwood Home Care, Inc.

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven Quality Assessment Performance Improvement program (QAPI). Findings are as follows: Review on 3/21/2024 at approximately 1:30 PM, of the agencies Quality assessment and performance improvement (QAPI) documentation provided by the agency failed to contain a QAPI plan, which includes program objectives, organizations involved, oversight responsibilities, with a written plan that includes ongoing monitoring of quality performance and improvement. During surveyor interview on 3/21/2024 at approximately 1:30 PM the Administrator and Director of Nursing, could not provide evidence of a current, comprehensive QAPI program.”

“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 record review, staff and client interview it has been determined that the agency failed to ensure that the clients receive services that are written in an individualized plan of care, including physician orders for treatments, services and goals relative to assessments for 2 of 8 clients who received a home visit, Client ID #’s1 and 5. Findings are as follows: Review of the record for Client ID # 1, who has a start of care (SOC) date of 3/16/2024. Review of the physician orders on the certification dated 3/16/2024 through 5/14/2024, stated “skilled nurse to assess Port-a-Cath surgical incision site for healing/complications; teach patient/caregiver care of incision to prevent infection, s/s (signs & symptoms) to report immediately and who to contact. Additionally, physician orders state to care for the incision is as follows: keep incision clean and dry, may shower after 24 hours.” During a surveyor home visit with the nurse, Staff A, on 3/18/2024, the nurse was observed reviewing the client’s medication and assessing and flushing the G tube according to the physician’s orders. She also reviewed the teaching of flushing the G tube with the client and caregiver who was present in the home. At the conclusion of visit the nurse asked the patient to sign for the visit and stated she would call prior to the next visit. At this time the surveyor questioned the nurse about the port a Cath assessment that was ordered. Staff A asked the client if s/he had the port a Cath placed, at which time s/he lifted their clothing and exposed the chest area where the port a Cath incision was observed. Staff A told the surveyor that she was unaware that the port a Cath had been placed and was only aware that the G-tube had been placed. During surveyor interview with the Director of Nurses (DON) on 3/20/2024, at approximately 1:00 PM, she acknowledged that the nurse should have been aware that the port a Cath had been placed and assessed the incision as ordered by the physician. 2. Review of record for Client ID # 5, who has a certification dated 3/13/2024 through 5/11/2024, that was completed by the nurse and signed on 3/13/2024. During record review with the DON on 3/20/2024, the certification lacked completion of the “Rehabilitation Potential and Discharge Plan”. The DON acknowledged that the information was not completed as required.”

“Physician CFR(s): 484.115(j) Standard: Physician. A person who meets the qualifications and conditions specified in section 1861(r) of the Act and implemented at §410.20(b) of this chapter. This Standard is not met as evidenced by: Based on record review and staff interview it has been determined that the Agency failed to have a Medical Director who meets the qualifications and conditions relative to licensure in Rhode Island. Findings are as follows: Review of Title 23 Health and Safety Chapter 17 Licensing of Healthcare Facilities RI General Laws 23-17-10.5 revealed in part, “…Each nursing facility licensed under this chapter shall designate a physician to serve as medical director. The medical director shall be responsible for implementation of resident care policies and for the coordination of medical care in the facility. Such responsibilities shall include, but not be limited to: the implementation of facility policies and procedures related to the medical care delivered in the facility; physician and advanced practice practitioner credentialing; practitioner performance reviews; employee health including infection control measures; evaluation of health care delivery, including oversight of medical records and participation in quality improvement; provision of staff education on medical issues; participation in state survey process, including the resolution of deficiencies as needed; and such other duties and responsibilities as may be stipulated in regulations promulgated by the department of health…” Review of Title 216 Department of Health Chapter 40 Professional Licensing and Facility Regulation Subchapter 10 Facilities Regulation Part 17 Licensing Home Nursing Care Providers and Home Care Providers revealed the following under definitions: “… ‘Health Care Provider’ means any person licensed by the state of Rhode Island to provide or otherwise lawfully providing health care services, including, but not limited to, a physician, hospital, intermediate care facility or other health care facility, dentist, nurse, APRN, Certified Clinical Nurse Specialist, physician assistant, optometrist, podiatrist, physical therapist…and any officer, employee or agent of that provider acting in the course and scope of his or her employment or agency related to or supportive of health services. Review of the agency’s documentation revealed the Medical Director is licensed in the State of New York. Review of the Rhode Island Department of Health, verify a physician’s license portal failed to have record of a Rhode Island License for the Medical Director. During a surveyor interview on 3/21/2024 at approximately 2:30 PM with the Administrator and the Director of Nursing Services, they were unable to provide evidence that the Medical Director was licensed in Rhode Island.”

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on record review and staff interview, it has been determined that the agency failed to ensure that all alleged violations involving abuse are reported to the State Survey Agency and other officials in accordance with state law for 1 of 1 client with a report of sexual abuse, Client ID #18. Findings are as follows: Review of Rhode Island General Law 23-17.8.2 “Duty to report” revealed in part, “…Any physician, physician assistant, medical intern, registered nurse, licensed practical nurse, nurse’s aide, orderly, certified nursing assistant, medical examiner, dentist, optometrist, optician, chiropractor, podiatrist, coroner, police officer, probation officer, emergency medical technician, firefighter, speech pathologist, audiologist, social worker, pharmacist, physical or occupational therapist, or health officer, or any person, within the scope of their employment at a facility or in their professional capacity, who has knowledge of or reasonable cause to believe that a patient or resident in a facility has been abused, mistreated, or neglected, either while in the facility or prior to being admitted, shall make, within twenty-four (24) hours or by the end of the next business day, a telephone report to the director of the department of health, or his or her designee, for those incidents involving healthcare facilities, and in addition to the office of the state long-term care ombudsperson for those incidents involving nursing facilities, assisted living residences, home-care and home nursing-care providers, veterans’ homes and long-term care units in Eleanor Slater hospital, or to the director of the department of behavioral healthcare, developmental disabilities and hospitals, or his or her designee, for those incidents involving community residences for people with developmental disabilities or the director of the office of healthy aging for individuals aged sixty (60) years or older…” Record review of the agency’s policy titled, “Abuse and Neglect Policy” revealed in part, “…The Director of Nursing will communicate assessment findings to the physician and the appropriate agency according to state regulations/laws. All findings and communications will be documented in the patient’s medical record. The Agency will report allegations, observations and suspected cases of exploitation, abuse and/or neglect to appropriate authorities…” Record review for Client ID #18 revealed a start of care dated 3/26/2020, and has diagnoses including, but not limited to, Type 2 diabetes mellitus, hypertension and acquired absence of right leg below the knee. The client was receiving services by a Home Health Aide, Staff O. Review of the Home Care Agency’s log of complaints revealed a communication note dated 2/7/2024 which states in part, “…a call from [family]. [S/he] stated that the aide takes [Client ID #18’s] EBT card and household spending card and spends it on herself. [S/he] also stated that the management people from the building [Client ID #18] resides in told [him/her] that the aide has a sexual relationship with [Client ID # 18] …” The family member further revealed that s/he would like to have the agency assign a new aide. Record review failed to reveal evidence that the Agency reported this allegation of sexual abuse as indicated in the facility policy and in accordance with State law. During a surveyor interview on 3/21/2024 at 1:00 PM with the Home Health Care Agency’s Non- Skilled Manager, Staff P, she acknowledged that the incident failed to be reported to the State Survey Agency in accordance with State Law.”

“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 record review and staff interview it has been determined the agency failed to ensure the patient’s clinical record identified all medications that the patient is taking (both prescription and non-prescription) as well as the time of medication administration and route for 5 of 8 clients who received a surveyor home visit, Client ID #s 2, 4, 5, 6, and 7. Findings are as follows: Review of an agency provided policy titled, “Medication Reconciliation Policy” revealed in part, “To define the medication reconciliation process in order to accurately and completely reconcile every patient’s medication upon Start of Care [SOC]…and on an on-going weekly basis…Medication Reconciliation is the process of identifying the most complete and accurate list of medications ordered for each patient receiving service from…Home Care. This process includes communication of the patient’s medication information across the care continuum. At Start-of Care (Admission): This included obtaining medication orders from the discharging facility (if applicable) or the referring and/or certifying physician. Any discrepancies to such are noted and communicated to the…physician…At each subsequent Home-Health Visit: This reviewing the medication profile in the patient’s chart which was completed at SOC. This medication profile should be updated and re-signed weekly upon on-going medication reconciliation. Any discrepancies to such are noted and communicated to the certifying…physician…” 1) Review of the medications during a home visit with Speech Therapist, Staff B, on 3/18/2024 revealed that Client ID #2 had a start of care date of 2/17/2024, while reviewing the client’s medications it was noted that the client had an additional prescription dated 2/19/2024 for Seroquel 50mg take 1 to 2 tablets at bedtime if needed in addition to the Seroquel 400mg that is ordered. The client stated that s/he received the additional Seroquel at his/her last doctor’s visit in February. During a surveyor interview on 3/20/2024, with the DON, she was unable to produce evidence the medication reconciliation had identified the above discrepancies. 2) Review of the medications during a home visit with Licensed Practical Nurse, Staff E, on 3/20/2024 revealed that Client ID #4 had a start of care date of 2/14/2024, the client stated that s/he also takes Novolog insulin U 100/ml via pump, which is not on the client’s medication list. Review of the medication list failed to reveal any orders for insulin. During a surveyor interview on 3/21/2024 with the DON, she was unable to provide evidence of any orders for insulin. 3) Review of the medications during a home visit with the Home Health Aide, Staff C, on 3/19/2024, the surveyor reviewed the client’s medication with the client’s caregiver which revealed that Client ID #5 was taking Vyvanse (to treat ADHD) 70mg once daily and Bactrim DS 400-80mg tablets once a day. These medications were not listed on the Client’s medication list. The surveyor interviewed the client’s spouse who stated the client was taking these medications and provided the surveyor with the bottles of medication that were dated 3/11/2024. During a surveyor interview on 3/20/2024, with the DON, she was unable to produce evidence the medication reconciliation had identified the above discrepancies. 4) Review of the medications during a home visit with Registered Nurse, Staff J, on 3/18/2024 at approximately 2:00 PM, revealed that Client ID #6 had a start of care date of 9/10/2022. Review of the client’s record revealed the following list of medications that the client is currently taking, including but not limited to the following: Praluent pen (used to treat high cholesterol) 150 milligrams/milliliter (mg/ml) inject once weekly on Mondays. During observation of the medication with Staff J and Client ID #6, the client stated that s/he had been off the Praluent pen since s/he started on Repatha sure click 140mg/ml. The Repatha (used for the treatment of hyperlipidemia) in the home had a fill date of 1/30/2024. The client also had a Breztri inhaler (used to treat chronic obstructive pulmonary disease) 160 micrograms (mcg)/4.8mcg inhaler that s/he takes 3 times daily as needed. The client revealed that s/he has been taking the Breztri for “a while.” Review of the facility provided current list of medications and the list in the client’s home failed to reveal Repatha or the Breztri inhaler orders. During a surveyor interview on 3/18/2024 at approximately 3:00 PM, Registered Nurse, Staff J acknowledged that the medications were not present on the client’s medication lists. During a surveyor interview on 3/20/2024, with the DON, she was unable to produce evidence the medication reconciliation had identified the above discrepancies. 5) Review of the medications during a home visit with Physical Therapy Assistant, Staff I, on 3/18/2024 at approximately 4:00 PM, revealed that client ID #7’s record had the following list of medications that the client is currently taking, including but not limited to the following: Donepezil (used to treat confusion)10mg once daily. Memantine (used to treat confusion)10mg one tablet twice daily. During observation of the medication with Staff I and Client ID #7. The client’s family stated that s/he had been off the Donepezil and Memantine for “a couple of months.” During a surveyor interview on 3/18/2024 at approximately 5:00 PM with Staff I, she acknowledged the discrepancies between the client’s medication list and the medications the client was taking currently.”

“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 record review and staff interview it has been determined that the agency failed to administer drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner for 6 of 8 Clients observed during home visits, Client’s ID # 1, 2, 4, 5, 6 and 10. Findings are as follows: 1. Review of record for Client ID # 1, who has a start of care (SOC) dated 3/16/2024. The record revealed orders on the certification form dated 3/16/2024 through 5/14/2024, that states “Skilled nurse to assess new G-tube site for healing/complications; teach patient/caregiver care of incision to prevent infection, s/s (signs & symptoms) to report immediately and who to contact. Per the physician orders, care of incision is as follows: keep incision clean and dry, may shower after 24 hours.” During a surveyor home visit with the nurse, Staff A, on 3/18/2024, the nurse inquired of the client and caregiver as to why there was not a dressing around the G-tube. The caregiver stated that the client did not have a dressing on when s/he returned home from the hospital, nor did the nurse who visited on 3/16/2024 apply a dressing. The surveyor observed, Staff A, cleaning the area around the G-Tube and flushing the tube. She then obtained dressing supplies from her car and covered the G-Tube site with a dressing. During surveyor review of the client’s record with the Director of Nurses (DON) on 3/20/2024, at approximately 1:00 PM, there was no evidence of a physician’s order for a dressing to cover the G-Tube. The DNS acknowledged that the nurse should have contacted the physician to check if he wanted a dressing applied over the G-Tube. 2. Review of the record for Client ID # 2, who has a SOC date 2/17/2024, and a current certification dated 2/17/2024 through 4/16/2024. During a surveyor home visit on 3/18/2024, with the Speech Therapist, Staff B, while reviewing the client’s medications it was noted that the client had an additional prescription dated 2/19/2024 for Seroquel 50mg, take 1 to 2 tablets at bedtime if needed in addition to the Seroquel 400mg that is ordered. The client stated that she received the additional Seroquel at her last doctor’s visit in February. During a surveyor interview with the DON on 3/20/2024, she was unable to produce evidence of a physician’s order for the Seroquel 50mg that the client is taking. 3. Review of the record for Client ID # 4, who has a SOC date 2/14/2024, and a certification dated 2/14/2024 through 4/13/2024 that was signed by the nurse and the physician on 2/14/2024. The client has a primary diagnosis of a pressure ulcer on the right ankle, (unstageable) and other diagnoses including type 1 diabetes with hyperglycemia. The client was admitted to the agency on 2/14/2024 after being hospitalized for evaluation of nausea, vomiting, and found to have diabetic keto acidosis which was treated. The hospital record states, “ type 1 diabetes on insulin pump (malfunctioning over the last 1 week),” and had an initial blood sugar of 639. During a home visit with the nurse, Staff E on 3/20/2024, the surveyor reviewed the client’s medications with the nurse and the client and the medication list that was provided to the surveyor by the agency. The client stated that s/he also takes Novolog insulin U-100/ml via pump, which is not on the client’s medication list nor on certification noted above. Review of the medication list failed to include orders for insulin. During surveyor interview with the DON on 3/21/2024, she was unable to explain why the client’s medication list did not contain orders for insulin. 4. Review of the record for Client ID # 5, with a SOC date 3/13/2024, and a certification dated 3/13/2024 through 5/11/2024, that was signed by the nurse on 3/13/2024. During a surveyor home visit with the Home Health Aide, Staff C, on 3/19/2024, the surveyor reviewed the client’s medications with the client’s caregiver. Review of the medications revealed the client was taking Vyvanse [for ADHD] 70 mg once a day, and Bactrim DS 400-80mg tablets once a day in addition to the medications listed on the physician’s orders and medication list. The surveyor interviewed the client’s spouse/caregiver who stated that the client is taking these medications and provided the surveyor with the bottles of medication that were dated 3/11/2024. On 3/20/2024 the surveyor interviewed the DON at approximately 12:40 PM, who was unable to produce evidence of a physician’s order for the above medications. 5) Review of the record for Client ID #6, who has a SOC date of 9/10/2022 and a current certification 3/3/2024 through 5/1/2024. During a surveyor home visit on 3/18/2024 at approximately 2:00 PM with Registered Nurse, Staff J, while reviewing the medication in the resident’s home noted that the client was taking the following medications: Repatha sure click 140mg/ml (used for the treatment of hyperlipidemia) in the home had a fill date of 1/30/2024. This medication was not present on the patient’s medication list. Breztri inhaler (used to treat chronic obstructive pulmonary disease) 160 micrograms (mcg)/4.8mcg inhaler that s/he takes 3 times daily as needed. The client revealed that s/he has been taking the Breztri for “a while.” This medication was not present on the patient’s medication list. During a surveyor interview with the DON on 3/20/2024, she was unable to produce evidence of a physician’s order for the Repatha or the Breztri inhaler. 6. Review of the record for Client ID # 10, has a SOC date of 7/26/2023, and a current certification dated 2/5/2023 through 4/4/2024. The record reveals the client was admitted to the agency from a skilled nursing facility, with a jejunostomy tube (J-tube) (is a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine. The tube delivers food and medicine) and orders for Nepro via feeding pump at 75cc an hour for 12 hours a day. Review of the notes with the DON, revealed that the client continues the tube feedings and continues with visits from Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy and the Home Health Aide. The DON was unable to produce evidence of a physician’s order for the Nepro tube feedings.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on surveyor observation, record review and staff interview it has been determined that the agency failed to ensure that care is coordinated for 1 of 1 client who resides in an Assisted Living Facility, Client ID #4 to meet the patient’s needs, and involve the patient, representative and caregiver(s), as appropriate, in the coordination of care activities. Findings are as follows: Review of the Agency provided policy titled, “ Coordination of Patient Care Policy” revealed in part, “...Home Care staff will regularly communicate with patients, families and caregivers, interdisciplinary care team members, Agency leadership, physicians and other community partners to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care...Care will be coordinated with other involved external organizations, such as home medical equipment providers, infusion therapy/pharmacy companies and all other involved community agencies. Staff will...Communicate with other individuals or organizations involved in the patient’s care when significant changes occur in the patient’s overall care...Share relevant information to facilitate appropriate continuity and care coordination. During a surveyor home visit, with Nurse, Staff E, on 3/20/2024 at approximately 2:15 PM, to Client ID # 4, they were met in the hallway on the third floor by a staff member from the Assisted Living Facility (ALF). The staff member inquired as to who the nurse was seeing. Staff E informed her that she was seeing Client ID # 4, for wound care. The ALF staff member stated that the facility was unaware that a home care agency was seeing the client, and that the nurse needs to fill out a communication form in the Wellness Office each time she visits the client. Additionally, she stated that the facility needs to be aware of any wound care that is being provided to any of their resident. During surveyor interview with the Nurse Staff E, at the time of the visit, she stated that she was unaware that she needed to coordinate care with the ALF, and keep the ALF informed of the status of the client’s wound/condition.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to ensure that a written visit schedule is provided to the clients that is consistent with the client’s most current plan of care, for 4 of 8 Clients who received home visits, ID #’s 1, 2, 4 and 5. Findings are as follows: Review of record for Client ID #1, who has a start of care (SOC) date of 3/16/2024. The record revealed orders for skilled nursing visits, 1 time a week times 1 week, 2 times a week times 2 weeks, then 1 time a week times 6 weeks. Review of Client # 1’s home record during a surveyor home visit with the Nurse, Staff A, on 3/18/2024 failed to reveal a schedule of visits for the skilled nursing visits ordered on the plan of care. During surveyor interview with the Nurse, Staff A, she stated that the staff call the clients the night before the visit and was unable to produce evidence of a visit schedule. 2. Review of the record for Client ID # 2, who has a SOC date of 2/17/2024, revealed orders for skilled nursing visits, 1 time a week times 6, speech therapy 1 time a week times 8 weeks, and physical therapy 2 times a week times 4 weeks, then 1 time a week times 2 weeks. Review of the home record during a surveyor home visit with the Speech Therapist on 3/18/2024 failed to reveal a schedule of visits for the above services as ordered on the plan of care. During surveyor interview with the Speech Therapist, Staff B, during the home visit, she stated that she calls the client the night before she visits and was unable to produce evidence of the client having a visit schedule. 3. Review of the record for Client ID # 4, who has a start of care date of 2/14/2024, revealed orders for skilled nursing visits, 1 time a week times 9 weeks, and physical therapy 1 time a week times 9 weeks. Review of the home record during a surveyor home visit with the Nurse, Staff E, on 3/18/2024 failed to reveal a schedule of visits for the skilled nursing visits ordered on the plan of care. During surveyor interview with the nurse Staff E, during the home visit, she stated that she calls the client the night before she visits and was unable to produce evidence of the client having a visit schedule. During surveyor interview with the client on 3/18/2024, she stated that she does not have a written schedule, and that sometimes the Physical Therapist and the Nurse end up visiting at the same time. 4. Review of the record for Client ID # 5, who has a start of care date of 3/13/2024, revealed orders for skilled nursing visits,1 time a week times 6 weeks, a physical therapy evaluation and Occupational therapy 1 time a week times1 week, then 2 times a week times 8 weeks, and home health aide visit 1 time a week times 6 weeks. Review of the client’s home record during a surveyor home visit with the home health aide, Staff D, 3/19/2024 failed to reveal a schedule of visits for the above services ordered on the plan of care. During surveyor interview with the client and spouse, who stated that they do not have a schedule, of when the nurse and therapist are coming to the home. The client stated that s/he needs a schedule and that it would be very helpful as there are a lot of people and it would be better if they were spaced out. S/he stated that the Occupational Therapist was scheduled to arrive soon and that she gets short of breath and tires easily (as the health aide just completed the clients shower) that with more than one service coming on the same day and very close in time it is difficult. During surveyor interview with the Director of Nurses, Staff G, on 3/20/2024, she stated that there is a calendar in the information packet that is given to the clients and that the staff should be filling it out and leaving it with the client. She stated that they are asked to call the clients’ the night prior to visits to remind them of the visit the following day.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review, staff and client interviews it has been determined that the agency failed to provide the patient and his/her caregiver with a medication schedule with instructions that include the medication name, dosage and frequency, in plain language for 1 of 1 client, (Client ID # 5) who was on a Prednisone taper. Findings are as follows: During a surveyor home visit to Client ID #5, on 3/19/2024 with the home health Aide, Staff C, the surveyor was reviewing the client’s medications with the client’s spouse. Review of the medication list and the plan of care provided to the surveyor, revealed an order for Prednisone 10mg tablets take 5 tablets for 7 days, then take 4 tablets for 7 days, then 3 and half tablets for 4 days, then 2 and a half tablets for 4 days then 2 tablets for 4 days, the 1 and a half tablets for 4 days, then 1 tablet for 4 days, then a half tablet for 4 days. The records stated to start taking the Prednisone on 3/11/2024. The client’s record revealed that s/he was in an acute care hospital from 2/21/2024 through 3/11/2024 when s/he was discharged to home. The client has a Start of Care (SOC) date of 3/13/2024, at which times s/he had an RN Skilled nursing visit and assessment. The visit notes that a medication reconciliation was completed on 3/13/2024. While reviewing the medications with the client’s spouse, s/he stated that the client was taking 3 and a half tablets of the prednisone. The surveyor reviewed with the spouse, that the Prednisone should have been 5 tablets from 3/11/2024 through 3/17/2024, then 4 tablets from 3/18/2024 though 3/24/2024. The husband stated that she has been on the 3 and a half tablets for a couple of days. Review of the prednisone on the medication list did not include the dates that the client should be taking the medication, as noted above. During a surveyor interview with the Director of Nurses on 3/20/2024 at approximately 1:30 PM, when informed by the surveyor of the error in the administration of the prednisone, she stated that the nurse should have written the dates for each of the days of the taper to avoid any confusion leading to errors in the administration of the prednisone taper.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to ensure that all services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice relative measurements of wounds for 1 of 3 clients with pressure wounds Client ID #4. Findings are as follows: Review of the Agency’s policy titled, “Wound Assessment and Reassessment Policy” revealed in part, “...Purpose To define processes wound assessment and reassessment...Procedure Wound measurements will be taken on a weekly basis by the first clinician of the week to perform wound assessment...E.g.: A Monday, Wednesday, Friday patient should have wound measurements reported on Monday each week...When conducting initial and ongoing wound assessments the following considerations should be taken into account to allow for appropriate management in conjunction with the treating team...type of wound- acute or chronic...Etiology- surgical, laceration, ulcer, burn, abrasion, traumatic, pressure injury, neoplastic...Location and surrounding skin...Tissue loss...Clinical appearance of the wound bed and stage of healing...Measurement and dimensions...wound edge...exudate...presence of infection...pain...previous wound management...” Record review for Client ID# 4 revealed s/he has a start of care date of 2/14/2024 and has diagnoses including but not limited to, pressure ulcer of the right ankle unstageable (wound that is covered by slough or eschar making it impossible to determine the true depth of the ulcer.) A physician’s order for the certification period 2/14/2024 through 4/13/2024 revealed an order for the skilled nurse (SN) “for wound care management based on physician orders due to the inherent complexity of the wound…SN to instruct patient/caregiver on wound care performance and Assess wound progression or decline…” Review of the wound documentation in the patients record revealed missing documentation of weekly wound measurements during the initial visit on 2/14/2024. Record review revealed that the wound failed to be measured until 2/21/2024. During an interview with the Director of Nursing Services, Staff G, on 3/21/2024 at approximately 11:00 AM, she was unable to provide evidence that weekly measurements were obtained per policy.”