Royal Home Health Services

“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 observation, interview, and record review, the agency failed to ensure the review of the medications included the patient’s current medications to identify any potential adverse effects and drug reaction for one of three sampled patients (Patient 1). This failure had the potential risk for not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for this patient. Findings: Review of the agency’s P&P titled Administration of Medications Policy effective 1/1/18, showed during the initial evaluation visit, the Case Manager will ask the patient to identify all the medications the patient is taking, both prescribed and over the counter medications. The nurse will verify the medications in the home with the medication orders given by the patient’s physician. The nurse will ensure that all medications are dispensed from the original correctly labeled containers. The Case Managers will review each medication a patient may be taking, prescribed or over the counter, to identify potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. All verified medications will be documented on the Medication Profile. The Medication Profile will be updated whenever a new medication is prescribed, changed or discontinued. This includes over-the-counter, herbal, or sample medications. Review of Patient 1’s clinical record was initiated on 7/16/26. The clinical record showed the SOC was 5/23/26. The patient was certified for home health services during the certification period from 5/23/26 to 7/21/26. The Home Health Certification and Plan of Care for Certification Period from 5/23/26 to 7/21/26, showed the patient’s medications included the following: -trazodone (antidepressant) 50 mg one tablet once daily -acetaminophen (analgesic) 325 mg one tablet every four hours as needed for pain. A joint visit with LVN 2 was conducted on 7/17/26 at 1545 hours, to the board and care facility where Patient 1 resided. Review of the patient’s medication with LVN 2 showed the following: -trazodone 100 mg one tablet at bedtime -acetaminophen 325 mg two tablets every four hours as needed for pain. Furthermore, the following medications were also administered by the caregiver to the patient: -Norco (opioid analgesic) 5/325 mg one tablet every four hours as needed -buspirone (antianxiety) 5 mg by mouth in the morning, two tablets in the afternoon, and one tablet at bedtime -quetiapine (antipsychotic) 50 mg one half tablet at noon for behavior -lactobacillus (supplement to restore healthy gut) two tablets by mouth daily -vitamin C (supplement) one tablet daily -multivitamins (supplement) one tablet daily However, the above medications were not listed in the medication section of The Home Health Certification and Plan of Care for Certification Period from 5/23/26 to 7/21/26. LVN 2 confirmed the medications were not updated and reconciled. On 7/21/26 at 0947 hours, an interview and concurrent clinical record review were conducted with the CEO and DPCS/Administrator. The DPCS/Administrator stated the SN should review and reconcile the patient’s medication every visit. The DPCS/Administrator acknowledged the findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the POC included the required components for two of three sampled patients (Patients 1 and 2). This failure had the potential risk of not addressing the care needs for these patients. Findings: Review of the agency’s P&P titled Plan of Care Policy effective date 1/1/18, showed it shall be the policy of the agency to implement an individualized plan of care established by the patient’s physician for each patient. The plan of care will include among others: -All pertinent diagnoses -Mental status -Types of services and equipment required -Frequency of services -Prognosis -Medications/treatments/procedures including who is to administer the medication and/or who is to perform the treatment or procedure, a description of the procedure/treatment to be done, including when appropriate, the type, frequency, and duration, when staff is observing and assessing the effectiveness of medications, a description of the medications, including the name, dosage, frequency, route of each medication, and an indication if medication is new or changed and a description of equipment and supplies, if any, necessary in the provision of treatment -Instructions to patient/family -Statement of treatment goals Review of Patient 1’s clinical record was initiated on 7/16/26. The clinical record showed the SOC was 5/23/26. The patient was certified for home health services during the certification period from 5/23/26 to 7/21/26. Review of the POC, for the certification period 5/23/26 to 7/21/26, showed SN for evaluation and treatments. The POC included assessment of patient with fracture of “unsp” part of neck of femur * However, there was no documented evidence on information regarding the SN’s frequency and duration of visits to be made. On 7/21/26 at 0947 hours, an interview and concurrent clinical record review were conducted with the CEO and DPCS/Administrator. The DPCS/Administrator acknowledged and confirmed the findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the patient received care and services as ordered by the physician for two of three sampled patients (Patients 1 and 3). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 1’s clinical record was initiated on 7/16/26. The clinical record showed the SOC was 5/23/26. The patient was certified for home health services during the certification period from 5/23/26 to 7/21/26. Review of the POC, for the certification period 5/23/26 to 7/21/26, showed SN for evaluation and treatments. Review of the SN visits dated 5/29, 6/5, 6/12, and 6/19/26, showed Patient 1 had a surgical wound on the right hip measuring 4 cm with 14 staples. Also, the SN’s narrative showed wound care was performed as follows: cleansed with normal saline, patted, dry and covered with clean dry dressing. However, the POC did not show wound care treatment for the patient’s surgical wound. On 7/21/26 at 0947 hours, an interview and concurrent clinical record review were conducted with the CEO and DPCS/Administrator. The DPCS/Administrator acknowledged and confirmed the findings. 2. Review of Patient 3’s closed clinical record was initiated on 7/17/26. The clinical record showed the SOC was 3/27/26. The patient was certified for home health services during the certification periods 3/27/26 to 5/25/26 and 5/26/26 to 7/24/26. The patient was discharged on 6/24/26. Review of the POC, for certification period 3/27/26 to 5/25/26, showed SN visits daily for 15 days, 3W2 (three times a week for two weeks), and 2W3. Review of the LVN Visit Notes showed no documented visit for 3/30/26. Furthermore, there was no documented evidence for the reason of the missed visit, neither was the visit rescheduled and the physician was notified. On 7/21/26 at 1039 hours, an interview and concurrent clinical record review were conducted with the CEO and DPCS/Administrator. The DPCS/Administrator acknowledged and confirmed the findings.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the verbal orders were authenticated timely for two of three sampled patients (Patients 1 and 3). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: Review of the agency’s P&P titled Plan of Care Policy effective 1/1/18, showed a copy of the initial Plan of Care is placed in the patient’s clinical record and the original is sent to the physician for review, approval, signature and date. Once the original has been returned, it is filed in the patient’s clinical record. The Plan of Care must be approved and signed by the physician, dentist, podiatrist or other licensed and legally authorized practitioner within his or her scope of practice within 30 days of the Start of Care date or recertification date. Review of the agency’s P&P titled Communication with a Patient’s Physician Policy effective 1/1/20, showed all physician orders are to be signed and dated by the physician and return to the office within 30 working days of the date of order. 1, Review of Patient 1’s clinical record was initiated on 7/16/26. The clinical record showed the SOC was 5/23/26. The patient was certified for home health services during the certification period from 5/23/26 to 7/21/26. The Home Health Certification and Plan of Care for Certification Period from 5/23/26 to 7/21/26, showed the DPCS/Administrator had electronically signed and dated the POC on 5/23/26. The POC also included the physician’s name and address. However, the physician failed to electronically sign and date the SOC orders within 30 days of the start of care date as per the agency’s P&P. On 7/21/26 at 0947 hours, an interview and concurrent clinical record review were conducted with the CEO and DPCS/Administrator. The DPCS/Administrator acknowledged and confirmed the findings. 2. Review of Patient 3’s closed clinical record was initiated on 7/17/26. The clinical record showed the SOC was 3/27/26. The patient was certified for home health services during the certification periods 3/27/26 to 5/25/26 and 5/26/26 to 7/24/26. The patient was discharged on 6/24/26. The recertification reassessment dated 5/21/26, showed the reassessment was completed. The Home Health Certification and Plan of Care for Certification Period from 5/26/26 to 7/24/26, showed the DPCS/Administrator had electronically signed and dated the POC on 5/26/26. Documentation showed the “Date of Verbal SOC” was 5/26/26. The POC also included the physician’s name and address. However, the physician failed to electronically sign and date the orders within 30 days of the recertification date as per the agency’s P&P. In addition, the PT’s initial visit dated 3/28/26, showed the physician was notified of the plan of care, goals, frequency, duration and direction. The PT had electronically signed and dated the visit; however, the physician failed to electronically signed and date the verbal order for the start of PT. On 7/21/26 at 1039 hours, an interview and concurrent clinical record review were conducted with the CEO and DPCS/Administrator. The DPCS/Administrator acknowledged and confirmed the findings.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure effective communication with the patient’s physician for two of three sampled patients (Patients 1 and 3). This failure had the potential of not providing necessary care and services to these patients. Findings: 1. Review of Patient 1’s clinical record was initiated on 7/16/26. The clinical record showed the SOC was 5/23/26. The patient was certified for home health services during the certification period from 5/23/26 to 7/21/26. The PT start of care assessment dated 5/23/26, showed the patient had recent hospitalization for S/P fracture neck of right femur ORIF on 5/20/26. Documentation showed the patient had surgical wound but not observable due to non-removable dressing. Review of LVN 1’s visit dated 6/5/26, showed the agency was notified the patient went to the post operation appointment and the “Ortho” did not remove the staples. Patient 1 was noted to have the 4 cm right hip surgical wound with 14 staples. Review of LVN 1’s visit dated 6/19/26, showed the 14 staples on the right hip surgical wound was still in place. Documentation showed the agency was aware of the staples still in place. Review of LVN 1’s visit dated 6/26/26, showed the patient was noted to have the 4 cm right hip surgical wound with 14 staples. Documentation showed the surgical wound appears healed. Documentation showed the family member, the caregiver, and the home health supervisor were asked about the next “Ortho” visit as the staples are not removed by the physician on the post op visit and the wound is fully healed and ready for staples removal. Documentation showed waiting for the order. The physician’s order dated 6/26/26, showed to remove the staples from the right leg surgical incision, and cover the wound with “steristrips.” Review of LVN 1’s visit dated 6/27/26, showed an order was received for the removal of surgical staple. Documentation showed on-call visit to remove the surgical staples as ordered. * However, further review of the clinical record failed to show documented evidence the SN had communicated or clarified with the physician when to remove the staples from the right hip surgical incision not until 6/26/26, more than two weeks when the LVN identified the “Ortho” did not remove the staples on the LVN visit dated 6/5/26. Review of the PT’s 30-day summary dated 6/21/26, showed a recommendation for the continuation of skilled HHPT to improve functional mobility, strength endurance, and to further improve ability in the patient’s functional activities ambulation. * However, the clinical record failed to show documented evidence the HHPT had communicated to the physician regarding the continuation of the skilled HHPT. The 30-day summary was not sent to the physician either by fax, mail or delivery. On 7/21/26 at 0947 hours, an interview and concurrent clinical record review were conducted with the CEO and DPCS/Administrator. The DPCS/Administrator acknowledged and confirmed the findings. 2. Review of Patient 3’s closed clinical record was initiated on 7/17/26. The clinical record showed the SOC was 3/27/26. The patient was certified for home health services during the certification periods from 3/27/26 to 5/25/26 and 5/26/26 to 7/24/26. The patient was discharged on 6/24/26. a. Review of LVN 4’s visit dated 3/29 and 3/31/26, showed the patient refused wound care treatment to the bilateral lower extremities. Documentation showed per patient, the physician instructed not to open the wound dressing. LVN 4 coordinated with the Clinical Manager. * However, further review of the clinical record failed to show documented evidence LVN 4 nor the Clinical Manager had communicated or clarified with the physician regarding instruction not to open the wound dressing. Review of LVN 4’s visit dated 4/7/26, showed the patient was seen by the wound doctor for the wound on the bilateral lower extremities. Review of the physician’s order dated 4/30/26, showed an order for SN services on hold for two weeks per the patient’s request, and the SN to resume the week of 5/10/26, for once a week as the patient was getting treatment at the wound care clinic. * However, further review of the clinical record failed to show documented evidence the SN had communicated with the wound doctor or wound care clinic regarding the patient’s wound care treatment. b. Review of the POC, for certification period 3/27/26 to 5/25/26, showed SN visits daily for 15 days, 3W2, and 2W3. Review of the communication notes dated 3/28, 4/1, 4/3, 4/5, and 4/6/26, showed the SN called the agency. The SN was unable to contact the patient, left several messages but no answer to reschedule the visit. An agency staff also tried contacting the patient. However, there was no documented evidence the physician was notified of the missed visits. On 7/21/26 at 1039 hours, an interview and concurrent clinical record review were conducted with the CEO and DPCS/Administrator. The DPCS/Administrator acknowledged and confirmed the findings.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the OT services were integrated in the POC for one of three sampled patients (Patient 3). This failure created the risk of not providing quality of care and services to this patient. Findings: Review of Patient 3’s closed clinical record was initiated on 7/17/26. The clinical record showed the SOC was 3/27/26. The patient was certified for home health services during the certification periods from 3/27/26 to 5/25/26 and 5/26/26 to 7/24/26. The patient was discharged on 6/24/26. Review of the SNF’s note with an order dated 3/26/26, showed an Order Summary for “RESIDENT LED DISCHARGE” to home on 3/26/26, home health services for PT/OT/Nursing/Wound Tech/Daily Wound Care. Review of the POC, for certification period 3/27/26 to 5/25/26, showed SN visits daily for 15 days, 3W2, and 2W3; and PT evaluation and treatment. * However, there was no documented evidence the OT services were provided and the reason why the patient was not referred to OT as per the SNF’s discharge order summary. On 7/21/26 at 1039 hours, an interview and concurrent clinical record review were conducted with the CEO and DPCS/Administrator. The DPCS/Administrator acknowledged and confirmed the findings.”

“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 observation, interview, and record review, the agency failed to provide the written instructions outlining the disciplines’ visit schedules for one of three sampled patients (Patient 1). This failure had the potential for not providing the necessary information to this patient. Findings: Review of Patient 1’s clinical record was initiated on 7/16/26. The clinical record showed the SOC was 5/23/26. The patient was certified for home health services during the certification period from 5/23/26 to 7/21/26. Review of the POC, for certification period from 5/23/25 to 7/21/26 showed PT visits 1W1, 2W3, and 1W5; and SN evaluation and treatments. On 7/17/26 at 1545 hours, a joint home visit was conducted with LVN 2 to Patient 1’s home. The patient’s caregiver was asked for the written instructions outlining the PT and SN visit schedule. The caregiver provided the patient’s admission packet folder. The folder contained a calendar; however, the calendar was blank. The patient’s caregiver stated there was no calendar of visits. The patient’s caregiver stated the SN and PT would just say when the next visit would be. On 7/17/26 at 1630 hours, an interview and concurrent clinical record review were conducted with LVN 2. LVN 2 acknowledged and confirmed the findings. On 7/21/26 at 0947 hours, an interview and concurrent clinical record review were conducted with the CEO and DPCS/Administrator. The DPCS/Administrator acknowledged and confirmed the findings.”