Baptist Health Home Health-Lr

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on clinical record review and personnel interview, it was determined the agency failed to ensure there was a timely comprehensive assessment completed for a change of condition, including a hospital transfer for 1 (#7) of 17 (#1 -#17) clinical records reviewed. This failed practice had the potential to affect all patients on census in that there was a possibility of a lack of continuity of care. Findings follow: A. Clinical Record #7 with a start of care date of 01/22/26 revealed a patient with a diagnosis of Contusion of left hip, Acute Pain, and Pressure Ulcers. B. The clinical record revealed a change of condition for this patient on 01/23/26 and was transferred to an acute care hospital. The transfer OASIS (Outcome and Assessment Information Set) was not completed for another 10 days, on 02/02/26. C. On 03/18/26 at 2:00 p.m., Personnel #2 and the Agency Director were interviewed and asked to provide any further information. They confirmed the findings and had no further documentation.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s 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). This Element is not met as evidenced by: Based on clinical record review and personnel interview, it was determined the agency failed to ensure there was evidence of communication with the Hospice agency in order to transition to Hospice services for 1 (#1) and discharge education for a patient and family was provided for 1 (#5) of 5 (#1 - #5) closed records reviewed. This failed practice had the potential to affect all patients on census in that there could be a patient discharged without the appropriate teaching, and referrals for care and services needed for a safe and proper discharge. Findings follow: A. Clinical Record #1 with a start of care date of 01/13/26 revealed a patient with a diagnosis of Diabetes, Cerebrovascular Disease (Stroke) with left hemiplegia. A Speech and Language Pathologist (SLP) visit note dated (Monday) 02/09/26 documented the patient had a change of condition over the weekend. The SLP gave the agency’s nurse information on the patient’s condition and the request for Hospice referral.There was no evidence the agency coordinated the transfer to the family’s chosen hospice services, which included medical records sent to the hospice agency. B. Clinical Record #5 with a start of care date of 06/23/25 revealed a patient with a diagnosis of Hemiplegia and Hemiparesis. A Discharge skilled nurse visit documented a discharge on 07/22/25.On 03/18/26 at 2:00p.m., Personnel #2 was interviewed and stated the Discharge visit on 07/22/25 was a skilled nurse visit and later changed to a discharge visit. There was no communication to the patient and/or family which included teaching and potential referrals which would demonstrate a continuity of care. C. On 03/19/26 at 8:35 a.m., the Agency Director was interviewed, confirmed the findings and did not have any further documentation.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on clinical record review and personnel interview it was determined the agency failed to ensure there was a discharge from agency order from the physician for 1 (#1) of 5 (#1 - #5) clinical records reviewed. This failed practice had the potential to affect all patients on census in that there could be a lack of coordination of care and services without the physician’s discharge approval. Findings follow: A. Clinical Record #1 with a start of care date of 01/13/26 revealed a patient with a diagnosis of Cerebrovascular Accident (CVA) (stroke), Left hemiplegia, and aphasia. B. The Patient was discharged to Hospice Services on 02/10/26. C. There was no evidence of a physician’s order to demonstrate awareness of this patient’s sudden change of condition and family’s plan to discharge to hospice services. D. On 03/18/26 at 2:00 p.m., Personnel #2 was interviewed about this patient’s change of condition, transition to hospice services, and the discharge records. She confirmed there was no communication between the agency and the patient’s physician, as well as with the hospice agency chosen by the family.”

“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 clinical record review and personnel interview, it was determined the agency failed to ensure there was an accurate medication list for 1 of 1 (#1) clinical record reviewed which involved a patient with medications through a Percutaneous Gastrostomy tube (stomach tube). This failed practice had the potential to affect all clients on census that have a Percutaneous Gastrostomy (PEG) tube. Findings follow: A. Clinical Record #1 with a start of care date of 01/13/26 revealed a patient with a diagnosis of Diabetes, Cerebrovascular Accident (CVA) (stroke), Left Hemiplegia, and aphasia. B. The Home Health Plan of Care dated 01/13/26 documented the patient was NPO (nothing by mouth) and to receive medications through the PEG tube. C. The agency’s medication list documented 3 medications which had the instruction to administer “by mouth”. D. On 03/17/26 at 1:00 p.m., Personnel #2 was asked to provide any further information regarding the discrepancy on the medication list. On 03/18/26 at 8:45 a.m., the agency Director stated the nurse who entered 2 of the orders validated she entered the order incorrectly. The Agency Director stated the 3rd medication was entered by the Doctor’s office but confirmed the agency is responsible for the accuracy of the agency’s current medication list.”

“Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This Element is not met as evidenced by: Based on clinical record review and personnel interview, it was determined the agency failed to ensure there was a complete plan of care for 1 (#13) of 17 (#1 - #17) clinical records reviewed. This failed practice had the potential to affect all patients on census who had an acute injury and/ or evidence of pain. Findings follow: A. Clinical Record #13 with a start of care date of 02/19/26 revealed a patient with hemothorax, multiple rib fractures, and lung contusion. B. The Home Health Plan of Care dated 02/19/26 documented physical and occupational therapy. The medical record revealed the patient had signs of pain. It was documented on 02/25/26, a 5 out of 10 on the pain scale, which indicates moderate pain. C. The Home Health Plan of Care dated 02/19/26 did not include pain management. D. On 03/18/26 at 2:00p.m., the Agency Director was interviewed and asked to provide any further information. On 3/19/26 at 8:40 a.m., she confirmed the findings and was unable to provide further documentation.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on Clinical Record reviews and staff interviews, it was determined the Agency staff did not provide care in accordance with the written Plan of Care (POC) in 1 (#2) of 17 (#1 - #17) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census for a risk of adverse outcomes, potential to affect the attainment of the patient’s individual goals and risk of hospitalizations. A. Review of the Clinical Record with a Start of Care date of 01/02/2026 contained Physician orders for skilled nurse visits 3 times a week for 10 weeks. Review of documentation by the skilled nurse showed 1 skilled nurse visit was made for week 1 (01/02/26 through 01/03/26) and no other skilled nurse visits were made as ordered. B. During an interview on 3/18/26 at 09:15 AM, Agency Representatives were provided with an opportunity to present additional documentation. With no additional documentation presented, Personnel #2 confirmed the Agency staff failed to provide care in accordance with the written Plan of Care and visits should have been scheduled with a different frequency.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on clinical record review, agency policy and procedures, and personnel interview it was determined the agency failed to ensure the physician was notified of a blood pressure out of parameters for 1 (#14) of 17 (#1 - #17) clinical records reviewed. This failed practice had the potential to affect all clients on census in that the physician would not be given all information so that changes in the plan of care could be revised. Findings follow: A. Clinical Record #14 with a start of care date of 02/20/26 revealed a patient with a diagnosis of Peripheral Vascular Disease and Hypertension. B. On 02/27/26 the patient had a blood pressure of 177/99 and on 03/10/26 the patient had a blood pressure of 164/91. C. A Policy and Procedure titled “Parameters for Reporting” documented, “...Evidence based parameters guide home care clinician decision making. Measurements that fall outside of established parameters are reported to physicians...Systolic BP [blood pressure] ... greater than or equal to 160... Diastolic BP greater than or equal to 90...for 30 minutes or more...” D. There was no evidence that the physician was notified of the elevated blood pressures. E. On 03/18/26 at 9:30 a.m., Personnel #2 was asked about the process for notifying the physician of elevated blood pressures. She stated the current computer system does not alert the skilled nurse of a requirement for notification when the BP is entered so the nurse has to be aware of the agency protocol (Policy and Procedure) and complete that notification. She confirmed the findings and had no further documentation to provide.”

“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 record review and personnel interview, it was determined the agency failed to ensure there was a discharge summary completed and available to the physician within 5 business days from discharge for 1 (#5) and a transfer summary completed within 2 business days for 1 (#7) of 5 (#1 - #5) closed records reviewed. This failed practice had the potential to affect all clients on census in that there was a possibility for lack of continuity of care at discharge. Findings follow: A. Clinical Record #5 with a start of care date of 06/23/25 revealed a patient with a diagnosis of Hemiplegia and Hemiparesis. A Discharge skilled nurse visit documented a discharge on 07/22/25.On 03/18/26 at 1:20 p.m., Personnel #2 was interviewed and stated the Discharge visit on 07/22/25 was a skilled nurse visit and later changed to a discharge visit. The Discharge Summary was dated 08/13/25.B. Clinical Record #7 with a start of care date of 01/22/26 revealed a patient with a diagnosis of Contusion of left hip, Acute Pain, and Pressure Ulcers. The clinical record revealed a change of condition for this patient on 01/23/26 and was transferred to an acute care hospital. The transfer OASIS (Outcome and Assessment Information Set) was not completed for another 10 days, on 02/02/26. The late transfer OASIS resulted in a late transfer summary. C. On 03/18/26 at 1:45 p.m., Personnel #2 and the Agency Director were interviewed and asked to provide any further information. They confirmed the findings and had no further documentation.”