Better Health Home Care

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on interviews and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services in a patient’s residence) failed to ensure that the transfer and discharge policy was included in the admission packet (a collection of legal, financial, and clinical documents used to onboard a new patient and start home healthcare services) for one of seven sampled patients (Patient 1). This failure had the potential to expose Patient 1 to an unsafe or inappropriate discharge, which could lead to serious medical harm, lack of patient preparedness, and violation of patient rights. During a review of Patient 1’s “Home Health Certification and Plan of Care” (POC) for the certification period of 8/16/2026 to 10/14/2026, the POC indicated that the HHA admitted Patient 1 on 6/17/2026 with a principal diagnosis of hypertensive heart disease (a group of heart conditions caused by long term, unmanaged high blood pressure). During a home visit at the residence of Patient 1 on 8/20/2026 at 9 AM, the Patient 1’s admission packet was reviewed and found to contain a written notice of patient rights, a privacy notice, the facility’s contact information, and an Acknowledgment Receipt dated 6/17/2026 with the patient’s signature acknowledging receipt of the following: Patient Admission Agreement Patient’s Rights / Privacy Act / Advance Directive Use and Disclosure of PHI Notice of Privacy Practices Emergency Phone Numbers and Instructions Basic Home Safety Inspection Infection Instructions Sheet Patient Medication Profile Statement of Confidentiality Schedule of Charges Notice of Non Discrimination The admission packet did not contain the HHA’s transfer and discharge policy, nor did it have any indication that this policy was provided to or discussed with the patient. During a concurrent interview and record review on 8/20/2026 at 10 a.m. with Licensed Vocational Nurse (LVN 2), Patient 1’s admission packet was reviewed. LVN 2 stated that the transfer and discharge policy was not included in the admission packet. During a concurrent interview and record review on 8/20/2026 at 11:20 AM with the Administrator (ADM), the agency’s admission packet was reviewed. The ADM stated that the HHA had never included the transfer and discharge policy in the admission packet because he was not aware that it was required. The ADM further stated that it is crucial to include the transfer and discharge policy in the patient’s admission packet and ensure that the patient receives and understands the policy, because state and federal regulations require patients to be fully informed of their rights, including the conditions under which they may be transferred or discharged. During a concurrent interview and record review on 8/24/2026 at 10:24 AM, with the ADM Designee (ADM D), the agency’s admission packet and medical records of Patient 1 was reviewed. The ADM D stated that the HHA did not include the transfer and discharge policy in the patient’s admission packet. The ADM D stated that there was no documentation in the patient’s medical record showing that the transfer and discharge policy was provided to and discussed with the patient during the initial evaluation visit before hands-on care was initiated. The ADM D stated that it is crucial for the HHA to include the transfer and discharge policy in the patient’s admission packet to ensure that the patient understands her rights while under the care of the agency. The ADM D stated that the agency’s failure to include the transfer and discharge policy in the admission packet could result in patient rights violations and expose the patient to unsafe and uncoordinated care. During a review of the HHA’s undated policy and procedure (P&P) titled, “Client Transfer,” the P&P indicated that a client may be transferred as determined by the Director of Patient Care Services or a designated Registered Nurse/Therapist in response to the client’s request and/or an identified need that cannot be met by Better Health Home Health Care. During a review of the HHA’s undated P&P titled, “Discharge Summary,” the P&P indicated that a discharge summary must be completed within 7–14 days of the discharge date for clients discharged from the agency.”

“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 Home Health Agency (HHA, an organization that provides skilled nursing care, therapy services, and medical social services to patients in their homes) failed to perform medication reconciliation at the patient’s home during a joint home visit with a Skilled Nurse (SN- a professional medical services delivered by licensed healthcare professionals, including registered nurses and licensed practical nurses) for one of seven sampled patients (Patient 3). As a result, Patient 3’s medication record did not reflect an accurate, complete medication list including a narcotic (a powerful drug that relieves severe pain, numbs the senses, and often makes a person sleepy or relaxed) prescription. This failure had the potential to put Patient 3 at risk of medication errors and the serious adverse events (any harmful medical occurrence can be life-threatening, or requires hospitalization). During a review of Patient 3’s Home Health Certification and Plan of Care (POC), dated 7/18/2026, the POC indicated that Patient 3 had the primary diagnosis of pressure ulcer (pressure sore or bedsore, that happens when constant pressure cuts off blood flow to a specific area of the body) of right buttock (bottom), stage 4 (a deep, severe open wound where prolonged pressure has cut off blood flow, destroying all layers of the skin and exposing underlying muscle, tendons, joints, or bone). During a record review of Patient 3’s “Patient Medication Profile (PMP),” for episode period from 7/20/2026 to 9/19/2026, the “PMP” indicated for Hydrocodone 10 mg–Acetaminophen 325 mg, ordered as one tablet by mouth every 12 hours as needed for moderate to severe pain (pain score 4–10). During a concurrent observation and interview on 8/20/2026 at 2:25 p.m., during a joint home visit with Licensed Vocational Nurse (LVN- entry-level health care provider who is responsible for rendering basic nursing care) 1, Patient 3’s medication reconciliation was observed. The bottle label for Hydrocodone 10 mg–Acetaminophen 325 mg indicated “to be taken as one tablet by mouth every 12 hours.” The LVN 1 stated that the prescription listed on Patient 3’s medication profile for Hydrocodone 10 mg–Acetaminophen 325 mg did not match the medication bottle present in the home. LVN 1 stated the medication bottle was labeled Hydrocodone 10 mg–Acetaminophen 325 mg, to be taken as one tablet by mouth every 12 hours, without an “as needed” instruction. During an interview on 8/20/2026 at 2:45 p.m. with Patient 3, Patient 3 stated that does not take Hydrocodone 10 mg–Acetaminophen 325 mg routinely every twelve hours as indicated on the medication bottle. Patient 3 reported that does take the medication only as needed and not on a daily basis, stating does not want to be addicted to the medication. During an interview on 8/20/2026 at 3:00 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 confirmed that the medication order listed on Patient 3’s medication profile did not match the medication bottle present in the patient’s home. LVN 1 stated that reconciling medications is important to ensure Patient 3’s safety and to prevent potential adverse outcomes. During an interview on 8/21/2026 at 12:24 p.m. with Director of Patient Care Services (DPCS, is the person in a healthcare agency who oversees all patient care) Designee (Designee, is the person chosen to act for the Director of Patient Care Services when the director is not available), the designee stated that it is essential for medications to be reconciled at every home visit to ensure patient safety. The DPCS Designee explained that failure to reconcile medications may place patients at risk for adverse outcomes, noting that excessive use of narcotic medications can lead to respiratory depression, gastrointestinal complications, dependence, or overdose. During a review of facility’s policy and procedure (P&P) titled, “Medication Regimen Review/Medication Profile”, undated, the P&P indicated, Special Instructions: 2. The Nurse/Therapist shall record on the Medication Profile all prescribed and over-the-counter OTC) medications the client is currently taking.5. If the physician changes the medication orders, the Nurse must add newly ordered drugs or medication changes to the Medication Profile. Discontinued medications shall be documented with the date it was discontinued.8. The Nurse/Therapist shall review all medications with the client and/or caregiver to ensure he/she understands how the drugs are to be stored, administered, and is aware of side effects, which could be experienced following administration. Information is also given to the client regarding prescription refills, actions when doses are missed, disposal of unused and expired medication, and avoidance of contamination.9. The Nurse shall monitor the patient on each subsequent visit for indication effectiveness, compliance with regimen, any complications or problems related to the therapy. Any discrepancies or problems are documented in the visit note. Problems are called to the physician’s and or pharmacist’s attention.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient confined to home due to illness, injury, or age) failed to ensure the physician’s medication orders for vitamin C and multivitamins were updated on the medication profile (up-to-date comprehensive record of all the medications taken by the patient, including the strengths, dosages, routes, and frequency of each medication) based on the medication bottles on hand for one of seven sampled patients (Patient 6). This failure had the potential to increase Patient 6’s risks for patient safety and medication errors (preventable event that leads to inappropriate medication use) related to possible increased adverse effects (unwanted, harmful reaction that results from a medication treatment) and/or medication overdose (patient takes an excessive amount of a medication that overwhelms the body’s ability to process it). Findings: During a review of Patient 6’s undated medical record, titled “Patient Basic Info,” the “Patient Basic Info” indicated Patient 6 was a cancer patient (person who received a medical diagnosis of a malignant disease involving abnormal, uncontrollable cell growth), ostomy patient (person who has undergone a surgical procedure to create an artificial opening on the abdomen to allow stool or urine to leave the body when normal elimination is no longer possible), surgical wound care patient (person requiring medical and home-maintenance steps to clean, protect, and monitor an incision or surgical cut so it heals properly without an infection), rehab patient (person receiving specialized therapy to recover physical or mental abilities lost due to an injury, surgery, illness, or medical event), and medication/blood pressure (BP, force of blood against the artery walls)/blood sugar (BS, main type of sugar found in the bloodstream as the body’s primary source of energy) monitoring patient. During a review of Patient 6’s “Home Health Certification and Plan of Care (POC),” for the certification period from 8/11/2026 through 10/9/2026, the POC indicated Patient 6’s start of care (SOC) date of 6/12/2026. The POC indicated Skilled Nursing (SN) visit frequency of once a week for one week and then twice a week until the end of the certification period. During a review of Patient 6’s “Patient Medication Profile,” for the episode period from 8/11/2026 through 10/9/2026, the “Patient Medication Profile” indicated the following physician’s medication orders: -Vitamin C 1000 milligrams (mg, unit of measurement of weight) per 2 soft gels take 2 soft gels” by mouth daily; given by Patient 6’s caregiver -One Daily Women’s 50 Plus 0.4 mg tablet (daily multivitamin, containing 400 microgram [mcg, unit of measurement of weight] of the active ingredient folic acid/folate, formulated to support the nutritional needs of women over 50) take 1 tablet” by mouth daily; given by Patient 6’s caregiver During a concurrent observation and interview on 8/20/2026 at 10:37 AM, with Licensed Vocational Nurse (LVN) 1 while on a joint home visit at Patient 6’s home, Patient 6’s medication bottles/medication labels were compared with Patient 6’s “Patient Medication Profile.” 1. The vitamin C medication bottle label indicated it contained five hundred (500) 1000-mg tablets. Patient 6 stated she takes 1 tablet daily. LVN 1 stated the physician’s order must be clarified and the physician’s order must be updated on Patient 6’s “Patient Medication Profile” to prevent any confusion. 2. The multivitamin bottle had a label that indicated “One Daily Women’s 50+ No Iron” and contained “800 mcg of folic acid.” Patient 6 stated she takes 1 tablet daily. LVN 1 stated the physician’s order must be clarified and updated on Patient 6’s “Patient Medication Profile” because the medication label does not match the physician’s medication order. During a concurrent interview and record review on 8/21/2026 at 12:33 PM with the Director of Patient Care Services (DPCS), DPCS designee, and Registered Nurse (RN 1), Patient 6’s current “Patient Medication Profile” and physician orders were reviewed. The DPCS stated the following: 1. During every home visit, the SN (in general) must check the medication bottles against the medication profile and ask the patient (in general) for the medications he/she is taking/not taking, including the dosage, frequency, and administration route to ensure patient safety and prevent medication errors. 2. The DPCS stated the SN must clarify Patient 6’s vitamin C order with the physician to determine the dosage to be administered to the patient and ensure the medication bottle label matched the physician’s order. The DPCS stated administering higher doses of vitamin C than prescribed by the physician could lead to overdose and/or increased adverse effects. 3. The DPCS stated the SN must clarify Patient 6’s “One Daily Women’s 50 Plus 0.4 mg” order with the physician to determine the prescribed folic acid/folate dosage for Patient 6. The DPCS stated the medication bottle label must match the physician’s medication order. During a review of the HHA’s undated policy and procedures (P&P), titled “Clinical Record,” the P&P indicated the following: 1. The patient’s clinical record must be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. 2. The HHA must establish and maintain for each patient accepted for care, a health record which must include the following information: a. Plan of treatment, plan of care, or plan for personal care services, in its entirety b. Drug, dietary, treatment, and activity orders”