Kaiser Foundation Hospital Anaheim Home Health Agency

“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 interview and record review, the agency failed to ensure the care and services were provided as per the POC for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential for not addressing the care needs for these patients. Findings: 1. Review of Patient 2’s clinical record was initiated on 11/4/25. The clinical record showed the SOC was 3/11/25. The patient was certified for home health services during the certification periods from 3/4/25 to 5/2/25, 5/3/25 to 7/1/25, 7/2/25 to 8/30/25, 8/31/25 to 10/29/25 and 10/30/25 to 12/28/25. The Home Health Plan of Care Recertification dated 10/30/25, for the certification period from 10/30/25 to 12/28/25, cited SN visits one visit every two days for 10 days then reassess. The comment showed for wound care every other day for 10 days and reassess. Review of the SN visit notes dated 10/31 and 11/2/25, showed the SN had performed wound care assessment and treatment for the patients pressure injuries to the medial back and right upper back. However, there was no documented evidenced of the measurement was taken for the pressure injuries to the medial back and right upper back. In addition, there was no documented evidenced of the stage of the pressure injury to the medial back and right upper back as part of the assessment. Further review of the SN visit notes dated 10/31 and 11/2/25, showed the patient was assessed to have pressure injury to the left buttocks. The assessment included the wound measurement. However, there was no documented evidenced of the stage of the pressure injury to the left buttocks. Moreover, review of the SN visit notes dated 10/31/25, showed the SN had performed wound assessment and treatment for the patients pressure injuries to the medial back, right upper back and left buttock. However, there was no documented evidenced of a wound care assessment and treatment was provided to the patients pressure injury to the right posterior buttock. On 11/5/25 at 1252 hours, an interview and concurrent clinical record review was conducted with the Nurse Manager 1. The Nurse Manager 1 was informed and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 10/31/25. The clinical record showed the SOC was 6/1/25. The patient was certified for home health services during the certification periods from 6/1/25 to 7/30/25, 7/31/25 to 928/25, 9/29/25 to 11/27/25. a. The Home Health Plan of Care Recertification dated 9/29/25, for the certification period from 9/29/25 to 11/27/25, cited SN visits 2W4 (two visits every week for four weeks) for wound care and reassess. The POC showed a wound care order for the patients pressure injury to the right trochanter and sacrum. Review of the SN visit notes dated 9/30 and 10/8/25, showed the SN had performed wound assessment and treatment for the patients pressure injuries to the right heel and posterior sacrum. However, there was no documented evidenced the SN had performed wound assessment and treatment to the patients pressure injury to the right hip/trochanter as ordered in the POC. On 11/5/25 at 1347 hours, an interview and concurrent clinical record review was conducted with the Nurse Manager 1. The Nurse Manager 1 was asked if the wound assessment and treatment was provided for the patients pressure injury to the right hip/trochanter. The Nurse Manager 1 reviewed the clinical records. The Nurse Manager 1 replied, don’t see it. The Nurse Manager 1 was informed and acknowledged the findings. b. Review of the Physician Order dated 7/31/25 for the recertification period from 7/31/25 to 9/28/25, showed an order for Wound Patients. The wound order include status and changes (size, amount and description of drainage, stage of pressure ulcer and condition of surrounding skin). Review of the SN notes on the section of LDA and Wound Assessment dated 8/5, 8/8, 8/12, 8/16, 8/19, 8/22, 8/26, 8/29, 9/2, 9/5, 9/9, 9/17, 9/19 and 9/23/25 showed the patient was assessed to have a pressure injury to the right heel. However there was no assessment for the stage of the pressure injury to the right heel. Further review of the SN notes dated 8/8/25 showed a pressure injury to the posterior sacrum was assessed as “U”. However, on 8/5, 8/12, 8/22, 8/26, 8/29, 9/2, 9/5, 9/9, 9/17 and 9/23/25 failed to show documented evidenced of the pressure injury to the posterior sacrum was stage as per physicians order. On 11/5/25 at 1508 hours, an interview and concurrent clinical record review was conducted with the Nurse Manager 1. The Nurse Manager 1 was informed and acknowledged the findings. The agency’s P&P titled Care Planning Process revised 8/2017 showed the care planning process will be documented on the plan of care and individualized discipline specific care plans. The procedure included at the time of the initial assessment the clinician along with other involved disciplines will develop the patient plan of care based upon the patients identified needs. Based on the assessments and conclusions, the plan of care will include but not limited to types of services, type , frequency, and duration of visits to be made. Missed visit frequency requires a physician verbal order. 1.Review of Patient 1’s clinical record was initiated on 10/31/25. The clinical record showed the SOC was 2/19/25. The patient was certified for home health services during the certification periods from 2/19/25 to 4/19/25, 4/20/25 to 6/18/25, 6/19/25 8/17/25 and 8/18/25 to 10/16/25. The patient was discharged on 10/24/25. a.Review of the Home Health Plan of Care dated 8/18/25, showed the following visits for Skilled Nursing: -2 visits every week for 8 weeks (8/18/25 to 10/11/25), discontinued as of 8/26/25 -3 visits every week for 2 weeks (8/24/25 to 9/6/25) -2 visits every week for 2 weeks (9/7/25 to 9/20/25) -2 visits every week for 4 weeks (9/21/25 to 10/16/25) Review of the clinical record showed Week 5 (9/14/25 to 9/20/25), the SN had missed visits for 9/16, 9/19 and 9/20/25. However, the missed visit on 9/20/25 showed no documented evidence the physician was notified of the missed visit as per agency’s P&P. On 10/31/25 at 1330 hours, an interview and concurrent clinical record review was conducted with the Nurse Manager 2. The Nurse Manager 2 confirmed the findings and stated the physician should be notified of the missed visit. b.Review of the Wound and Ostomy Nurse Video Consult dated 10/8/25 showed the wound care orders to the following: Saccrococcyx (sacrum and coccyx, fused bones at the base of the spine) PI: -cleanse with peri wound: wound cleanser, pat dry -soak wound bed with Vashe five to ten minutes, pat dry -protect surrounding skin with: skin barrier cream (Calmoseptine) -apply triad paste -cover with gauze or ABD pad Bilateral buttock: -cleanse periwound with: wound cleanser, pat dry -soak open areas (multiple/patchy) with Vashe five to ten minutes, pat dry -protect surrounding skin with: skin barrier cream (Calmoseptin) -apply: pectin powder (thick until wound bed unseen) -cover with ABD pad Review of the Home Care Visit dated 10/11/25, the SN provided the wound care treatment for the following: Buttock and coccyx: -Vashe to open wounds for five minutes, wound cleanser to skin around wound -applied barrier cream/ointment -applied triad paste to sacrococcyx and right, left buttocks open area -covered with ABD pad However, the wound care treatment provided failed to apply pectin powder to bilateral buttocks. On 11/5/25 at 1304 hours, an interview and concurrent clinical record review was conducted with the Quality Coordinator. The Quality Coordinator stated the SN was doing the wound care treatment for the coccyx but not for the bilateral buttocks. The Quality Coordinator confirmed and acknowledged the findings. c.The Agency’s P&P titled Rover/Tissue Analytics Wound Photo and Assessment Documentation revised 12/2023 showed a comprehensive wound/skin assessment and treatment flow sheet is shared to improve timely and accurate communication between physicians and bedside/field clinicians. Frequency of using Rover Flowsheet/Tissue Analytics Photo Documentation Platform will be once a week on the first visit of the week (Sunday to Saturday) for ALL patients who receive skilled wound care visits. Review of the Home Health Plan of Care dated 8/18/25, for the certification period 8/18/25 to 10/16/25, cited SN two visits every week for eight weeks. The POC showed a wound care order for the patient’s sacrococcygeal (triangular bone at the base of the spine) and right ischial tuberosity (bony points on the bottom of the pelvis). The SN visit notes for week two (8/24/25 to 8/30/25) showed the SN had performed wound assessment and treatment for the patient’s coccyx and buttocks. However, there were no documented evidence the SN had measured the wounds as per facility’s P&P. The SN visit note dated 9/2/25 (week three from 8/31/25 to 9/6/25) showed the SN performed wound assessment and treatment for the patient’s coccyx and buttocks. The undermining location and depth measurement of the wound were taken. However, there was no documented evidence the length and width of the wound were measured. Furthermore, review of the SN visit note dated 9/5/25, showed the SN had performed wound assessment and treatment for the patient’s coccyx and buttocks. However, there were no documented evidence the SN had measured the wounds as per P&P. The SN visit notes for week four (9/7/25 to 9/13/25) showed the SN had performed wound assessment and treatment for the patient’s coccyx and buttocks. However, there were no documented evidence the SN had measured the wounds as per facility’s P&P. The SN visit note dated 9/23/25 (week six from 9/21/25 to 9/27/25) showed the SN performed wound assessment and treatment for the patient’s coccyx and buttocks. The length and width measurement of the wound were taken. However, there was no documented evidence the depth and undermining location of the wound was measured. Furthermore, review of the SN visit note dated 9/26/25, showed the SN had performed wound assessment and treatment for the patient’s coccyx and buttocks. However, there were no documented evidence the SN had measured the wounds as per P&P. The SN visit note dated 10/8/25 (week eight from 10/5/25 to 10/11/25) showed the SN performed wound assessment and treatment for the patient’s coccyx and buttocks. The length and width measurement of the wound were taken. However, there was no documented evidence the depth and undermining location of the wound was measured. Furthermore, review of the SN visit note dated 10/11/25, showed the SN had performed wound assessment and treatment for the patient’s coccyx and buttocks. However, there were no documented evidence the SN had measured the wounds as per P&P. On 11/5/25 at 1304 hours, an interview and concurrent clinical record review was conducted with the Quality Coordinator and Nurse Manager 2. The Quality Coordinator and Nurse Manager 2 both stated measurement and photo of each wound should be taken weekly. The Quality Coordinator and Nurse Manager 2 acknowledged the findings. The agency’s P&P titled Care Planning Process revised 8/2017 showed the care planning process will be documented on the plan of care and individualized discipline specific care plans. The procedure included at the time of the initial assessment the clinician along with other involved disciplines will develop the patient plan of care based upon the patient’s identified needs. Based on the assessments and conclusions, the plan of care will include but not limited to types of services, type, frequency, and duration of visits to be made. Missed visit frequency requires a physician verbal order. 1. Review of Patient 1’s clinical record was initiated on 10/31/25. The clinical record showed the SOC was 2/19/25. The patient was certified for home health services during the certification periods from 2/19/25 to 4/19/25, 4/20/25 to 6/18/25, 6/19/25 to 8/17/25, and 8/18/25 to 10/16/25. The patient was discharged on 10/24/25. a.Review of the Home Health Plan of Care dated 8/18/25, showed the following visits for Skilled Nursing: -2 visits every week for 8 weeks (8/18/25 to 10/11/25), discontinued as of 8/26/25 -3 visits every week for 2 weeks (8/24/25 to 9/6/25) -2 visits every week for 2 weeks (9/7/25 to 9/20/25) -2 visits every week for 4 weeks (9/21/25 to 10/16/25) Review of the clinical record showed on Week 5 (9/14/25 to 9/20/25), the SN had missed visits on 9/16, 9/19, and 9/20/25. However, the missed visit on 9/20/25, showed no documented evidence the physician was notified of the missed visit as per the agency’s P&P. On 10/31/25 at 1330 hours, an interview and concurrent clinical record review was conducted with Nurse Manager 2. Nurse Manager 2 confirmed the findings and stated the physician should be notified of the missed visit. b.Review of the Wound and Ostomy Nurse Video Consult dated 10/8/25, showed the wound care orders were the following: Saccrococcyx PI: -cleanse peri wound with wound cleanser, pat dry -soak wound bed with “”vashe” five to ten minutes, pat dry -protect surrounding skin with skin barrier cream (Calmoseptine) -apply triad paste (wound dressing) -cover with gauze or “ABD” pad Bilateral buttock: -cleanse peri wound with wound cleanser, pat dry -soak open areas (multiple/patchy) with “vashe” five to ten minutes, pat dry -protect surrounding skin with: skin barrier cream (Calmoseptin) -apply pectin powder (used for wound care) thick until wound bed unseen -cover with “ABD” pad Review of the Home Care Visit dated 10/11/25, showed the SN provided wound care treatment for the following: Buttock and coccyx: -“vashe” to open wounds for five minutes, wound cleanser to skin around wound -applied barrier cream/ointment -applied triad paste to sacrococcyx and the right and left buttocks open area -covered with “ABD” pad However, the wound care treatment provided failed to apply pectin powder to the bilateral buttocks. On 11/5/25 at 1304 hours, an interview and concurrent clinical record review was conducted with the Quality Coordinator. The Quality Coordinator stated the SN was doing the wound care treatment for the coccyx but not for the bilateral buttocks. The Quality Coordinator confirmed and acknowledged the findings. c.The Agency’s P&P titled Rover/Tissue Analytics Wound Photo and Assessment Documentation revised 12/2023 showed a comprehensive wound/skin assessment and treatment flow sheet is shared to improve timely and accurate communication between physicians and bedside/field clinicians. Frequency of using Rover Flowsheet/Tissue Analytics Photo Documentation Platform will be once a week on the first visit of the week (Sunday to Saturday) for ALL patients who receive skilled wound care visits. Review of the Home Health Plan of Care dated 8/18/25, for the certification period 8/18/25 to 10/16/25, cited SN two visits every week for eight weeks. The POC showed wound care orders for the patient’s sacrococcygeal and right ischial tuberosity. The SN visit notes for Week 2 (8/24/25 to 8/30/25) showed the SN had performed wound assessment and treatment for the patient’s coccyx and buttocks. However, there were no documented evidence the SN had measured the wounds as per facility’s P&P. The SN visit note dated 9/2/25 on Week 3 (8/31/25 to 9/6/25) showed the SN performed wound assessment and treatment for the patient’s coccyx and buttocks. The undermining location and depth measurements of the wounds were taken. However, there was no documented evidence the length and width of the wound were measured. Furthermore, review of the SN visit note dated 9/5/25, showed the SN had performed wound assessment and treatment for the patient’s coccyx and buttocks. However, there were no documented evidence the SN had measured the wounds as per P&P. The SN visit notes for Week 4 (9/7/25 to 9/13/25) showed the SN had performed wound assessment and treatment for the patient’s coccyx and buttocks. However, there were no documented evidence the SN had measured the wounds as per facility’s P&P. The SN visit note dated 9/23/25 on Week 6 (9/21/25 to 9/27/25) showed the SN performed wound assessment and treatment for the patient’s coccyx and buttocks. The length and width measurement of the wound were taken. However, there was no documented evidence the depth and undermining location of the wound was measured. Furthermore, review of the SN visit note dated 9/26/25, showed the SN had performed wound assessment and treatment for the patient’s coccyx and buttocks. However, there were no documented evidence the SN had measured the wounds as per P&P. The SN visit note dated 10/8/25 on Week 8 (10/5/25 to 10/11/25) showed the SN performed wound assessment and treatment for the patient’s coccyx and buttocks. The length and width measurement of the wound were taken. However, there was no documented evidence the depth and undermining location of the wound was measured. Furthermore, review of the SN visit note dated 10/11/25, showed the SN had performed wound assessment and treatment for the patient’s coccyx and buttocks. However, there were no documented evidence the SN had measured the wounds as per P&P. On 11/5/25 at 1304 hours, an interview and concurrent clinical record review was conducted with the Quality Coordinator and Nurse Manager 2. The Quality Coordinator and Nurse Manager 2 both stated the measurement and photo of each wound should be taken weekly. The Quality Coordinator and Nurse Manager 2 acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 11/4/25. The clinical record showed the SOC was 3/11/25. The patient was certified for home health services during the certification periods from 3/4/25 to 5/2/25, 5/3/25 to 7/1/25, 7/2/25 to 8/30/25, 8/31/25 to 10/29/25, and 10/30/25 to 12/28/25. The Home Health Plan of Care Recertification dated 10/30/25, for the certification period from 10/30/25 to 12/28/25, cited SN visits one visit every two days for 10 days then reassess. The comment showed for wound care every other day for 10 days and reassess. Review of the SN visit notes dated 10/31 and 11/2/25, showed the SN had performed wound care assessment and treatment for the patient’s pressure injuries to the medial back and right upper back. However, there was no documented evidenced of the measurement was taken for the pressure injuries to the medial back and right upper back. In addition, there was no documented evidence of the stage of the pressure injury to the medial back and right upper back as part of the assessment. Further review of the SN visit notes dated 10/31 and 11/2/25, showed the patient was assessed to have pressure injury to the left buttocks. The assessment included the wound measurement. However, there was no documented evidence of the stage of the pressure injury to the left buttocks. Moreover, review of the SN visit note dated 10/31/25, showed the SN had performed wound assessment and treatment for the patients pressure injuries to the medial back, right upper back and left buttock. However, there was no documented evidence of a wound care assessment and treatment was provided to the patients pressure injury to the right posterior buttock. On 11/5/25 at 1252 hours, an interview and concurrent clinical record review was conducted with Nurse Manager 1. Nurse Manager 1 was informed and acknowledged the findings. 3. Review of Patient 3’s clinical record was initiated on 10/31/25. The clinical record showed the SOC was 6/1/25. The patient was certified for home health services during the certification periods from 6/1/25 to 7/30/25, 7/31/25 to 928/25, and 9/29/25 to 11/27/25. a. The Home Health Plan of Care Recertification dated 9/29/25, for the certification period from 9/29/25 to 11/27/25, cited SN visits 2W4 (two visits every week for four weeks) for wound care and reassess. The POC showed a wound care order for the patient’s pressure injury to the right trochanter and sacrum. Review of the SN visit notes dated 9/30 and 10/8/25, showed the SN had performed wound assessment and treatment for the patients pressure injuries to the right heel and posterior sacrum. However, there was no documented evidencd the SN had performed wound assessment and treatment to the patient’s pressure injury to the right hip/trochanter as ordered in the POC. On 11/5/25 at 1347 hours, an interview and concurrent clinical record review was conducted with Nurse Manager 1. Nurse Manager 1 was asked if the wound assessment and treatment was provided for the patient’s pressure injury to the right hip/trochanter. Nurse Manager 1 reviewed the clinical records. Nurse Manager 1 stated she did not see it. Nurse Manager 1 was informed and acknowledged the findings. b. Review of the Physician Order dated 7/31/25, for the recertification period from 7/31/25 to 9/28/25, showed an order for “Wound Patients: include status and changes (size, amount and description of drainage, stage of pressure ulcer and condition of surrounding skin).” Review of the SN notes on the section of “LDA and Wound Assessment” dated 8/5, 8/8, 8/12, 8/16, 8/19, 8/22, 8/26, 8/29, 9/2, 9/5, 9/9, 9/17, 9/19 and 9/23/25 showed the patient was assessed to have a pressure injury to the right heel. However there was no assessment for the stage of the pressure injury to the right heel. Further review of the SN notes dated 8/8/25, showed a pressure injury to the posterior sacrum was assessed as “U”. However, the SN notes on 8/5, 8/12, 8/22, 8/26, 8/29, 9/2, 9/5, 9/9, 9/17, and 9/23/25 failed to show documented evidenced of the pressure injury to the posterior sacrum was staged as per physicians order. On 11/5/25 at 1508 hours, an interview and concurrent clinical record review was conducted with the Nurse Manager 1. The Nurse Manager 1 was informed and acknowledged the findings.”

“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 reactions for one of three sampled patients (Patient 2). 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: The agency’s P&P titled Care Planning Process revised 8/2017 showed the care planning process will be documented on the plan of care, individualized discipline specific care plans, and medication profiles. The procedure included at the time of the initial assessment the clinician along with other involved disciplines will develop the patient plan of care based upon the patients identified needs. Based on the assessment and conclusions, the plan of care will include all medications and treatments. Review of Patient 2’s clinical record was initiated on 11/4/25. The clinical record showed the SOC was 3/4/25. The patient was certified for home health services during the certification period from 8/31/25 to 10/29/25. The Medication Profile for the certification period from 8/31/25 to 10/29/25, showed the patient’s medications included Santyl (for wound debridement) 250 unit/gram ointment, applied to affected area(s) daily or as directed and vitamin B complex – vitamin C 0.8 mg (supplement) one tablet by mouth daily. A joint home visit with RN 1 and the Director for Home Care Services was conducted on 11/4/25 at 1200 hours, to Patient 2’s home. The PCG reported the patient never used Santyl and was not taking the vitamin B complex – vitamin C 0.8 mg tablet. *The HHA failed to ensure the medication profile was updated to reflect the patient’s current medications, not to include Santyl and vitamin B complex-vitamin C. On 11/4/25 at 1340 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 confirmed there was no physician’s order to use or discontinue Santyl. Furthermore, RN 1 confirmed there was no physician order to discontinue vitamin B complex – vitamin C 0.8 mg tablet. The Director for Home Care Services acknowledged the findings.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for two of three sampled patients (Patients 2 and 3). This failure had the potential for not addressing the care needs for these patients. Findings: The agency’s P&P titled Initial and Comprehensive Assessment revised 4/2025 showed during the initial and comprehensive patient assessments, all baseline data to be used in measuring the patients’ progress towards goals and other relevant information will be documented in the patient’s clinical record, including at least the following information, if applicable: a physical assessment including height/weight, skin and other relevant data related to pertinent physical findings. The agency’s P&P titled Rover/Tissue Analytics Wound Photo and Assessment Documentation revised 12/2023 showed the frequency of the using Rover LDA Flowsheet/Tissue Analytics Photo Documentation Platform is once a week on the first visit of the week (Sunday -Saturday) for all patients who receive skilled wound care visits. Other instances where Rover/TA MUST be used by the nurse include the recertification. 1. Review of Patient 2’s clinical record was initiated on 11/4/25. The clinical record showed the SOC was 3/11/25. The patient was certified for home health services during the certification periods from 3/4/25 to 5/2/25, 5/3/25 to 7/1/25, 7/2/25 to 8/30/25, 8/31/25 to 10/29/25, and 10/30/25 to 12/28/25. Review of the OASIS Recertification dated 10/27/25, showed the RN had performed a comprehensive assessment. However, there was no documented evidence of the patient’s height and weight taken as part of the comprehensive assessment. Further review of the OASIS Recertification dated 10/27/25, showed the section of LDA and Wound Assessment showing the patient was assessed to have the active wounds as follows: -“Wound Pressure Injury 3/5/25 Medial Back” -“Wound Pressure Injury 3/5/25 Right Upper Back” -“Wound Pressure Injury 7/14/25 Left Buttock. However, the wound assessment failed to include the stages of the pressure injury to the medial back, right upper back, and left buttock as part of the comprehensive wound assessment. In addition, the wound assessment failed to include the measurements for the pressure injury to the medial back and right upper back as part of the comprehensive wound assessment. Further review of the clinical record showed, “Wound Images images linked:1” for the patient’s pressure injury to the left buttock. *However, there was no documented evidence of the wound images for the patient’s pressure injuries to the medial back and right upper back as per the agency’s P&P. On 11/5/25 at 1252 hours, an interview and concurrent clinical record review was conducted with Nurse Manager 1. Nurse Manager 1 was asked if the comprehensive wound assessment was complete. Nurse Manager 1 reviewed the clinical record. Nurse Manager 1 stated no, there should be a measurement and staging of the wound. Nurse Manager 1 was also asked if there was photograph taken for the pressure injuries to the medial back and right upper back. Nurse Manager 1 reviewed the photographs and replied she did not see any. Nurse Manager 1 was informed and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 10/31/25. The clinical record showed the SOC was 6/1/25. The patient was certified for home health services during the certification periods from 6/1/25 to 7/30/25, 7/31/25 to 928/25, and 9/29/25 to 11/27/25. Review of the OASIS Recertification dated 9/26/25, showed the section of “LDA and Wound Assessment” showing the patient was assessed to have the active wounds which included the pressure injuries to the right heel, posterior sacrum, and right hip/trochanter. The SN had performed wound assessment to the patient’s pressure injuries to the right heel, posterior sacrum, and right hip /trochanter. However, there was no documented evidence for the staging of the identified pressure injuries as part of the comprehensive wound assessment. On 11/5/25 at 1347 hours, an interview and concurrent clinical record review was conducted with Nurse Manager 1. Nurse Manager 1 was asked if the comprehensive wound assessment was complete. Nurse Manager 1 reviewed the clinical record. Nurse Manager 1 replied based on the staging, it was incomplete. Nurse Manager 1 was informed and 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 POCs included the specific interventions and measurable outcomes related to the identified diagnoses and comorbidities for two of three sampled patients (Patients 1 and 3). This failure had the potential risk of not addressing the care needs for these patients. Findings: 3. Review of Patient 1’s closed clinical record was initiated on 10/31/25. The clinical record showed the SOC was 2/19/25. The patient was certified for home health services during the certification periods from 2/19/25 to 4/19/25, 4/20/25 to 6/18/25, 6/19/25 8/17/25 and 8/18/25 to 10/16/25. The patient was discharged on 10/24/25. The Home Health Plan of Care dated 8/18/25, for the period 8/18/25 to 10/16/25 showed a care plan problem and goals. The care plan problem, goals and intervention included the following: -Patient is at risk for falls. The goal showed the patient and family will implement strategies to reduce fall risk. However, the POC failed to include the specific strategies to be implemented to reduce fall risk. -Knowledge deficit regarding infection prevention/control measures in the home and community. The goal showed patient and family will verbalize understanding of infection prevention strategies and methods to prevent development or worsening of infection. However, the POC failed to include strategies and methods to prevent or worsening of infection. - Medications/medication management. The interventions include instruction on special precautions for antibiotics and antiplatelets and how and when to report problems that may occur. However, there were no specific instructions as to what signs and symptoms to report related to special precautions for antibiotics and antiplatelets. -Patient is experiencing pain/discomfort. The goal showed patient/caregiver will demonstrate safe use of appropriate modality for pain management. However, the POC failed to explain the appropriate modality of pain. On 11/5/25 at 1304 hours, an interview and concurrent clinical record review was conducted with the Quality Coordinator. The Quality Coordinator confirmed and acknowledged the findings. 1. The agency’s P&P titled Care Planning Process reviewed 10/2023 showed the care planning process will be documented on the plan of care, individualized discipline-specific care plans (if applicable). The procedure includes based on the assessment and conclusions, the plan of care will include, but is not limited to: all pertinent diagnoses, all medications and treatments; all necessary interventions to address underlying risk factors; patient specific interventions and education; measurable outcomes and goals identified by the home health agency and patient. Review of Patient 2’s clinical record was initiated on 11/4/25. The clinical record showed the SOC was 3/11/25. The patient was certified for home health services during the certification periods from 3/4/25 to 5/2/25, 5/3/25 to 7/1/25, 7/2/25 to 8/30/25, 8/31/25 to 10/29/25 and 10/30/25 to 12/28/25. The Home Health Plan of Care - Recertification 10/30/25, for certification period from 10/30/25 to 12/28/25 showed a care plan problem and goals. The care plan problem and goals included the following: -Patient requires monitoring of vital signs/weights. The goal showed the clinician will monitor and report vital signs outside of physician ordered parameters throughout the plan of care. However, the POC failed to include specific instructions as to what the outside vital signs parameters was. In addition, the care plan includes an intervention: Patients Weight Monitored - Instruct. SN to monitor and obtain weekly MAC and notify the physician for any significant changes in size. However, the POC failed to include the assessment parameters needed to call the physician related to the significant changes in size was. -Medications/medication management. The interventions include instruct on special precautions for antibiotics and antiplatelets and how and when to report problems that may occur. However, there was no specific instructions as to what signs and symptoms to report related to special precautions for antibiotics and antiplatelets. On 11/5/25 at 1252 hours, an interview and concurrent clinical record review was conducted wit the Nurse Manager 1. Th Nurse Manager 1 was asked if the care plan goals and interventions were specific and measurable. The Nurse Manager 1 reviewed the clinical record. The Nurse Manager 1 replied, no, they should have included the parameters needed to report to the physician. The Nurse Manager 1 was informed and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 10/31/25. The clinical record showed the SOC was 6/1/25. The patient was certified for home health services during the certification periods from 6/1/25 to 7/30/25, 7/31/25 to 928/25, 9/29/25 to 11/27/25. a. The Home Health Plan of Care Recertification dated 9/29/25, for the certification period from 9/29/25 to 11/27/25, showed the other pertinent diagnoses. The other diagnoses includes Hyperglycemia, unspecified and Type 2 diabetes mellitus. The POC also showed the care plan problems and goals. The care plan problem and goals included the following: -Cardiac disease management: The intervention includes to instruct patient and family in HTN (hypertensive) disease process, symptom management, pulse and blood pressure monitoring and signs and symptoms to report and when to contact the agency/physician/911. However, the POC failed to include specific assessment parameters related to the symptom management, pulse and blood pressure monitoring and signs and symptoms to report and when to contact the agency/physician/911. -Medications/Medication Management: The interventions include to instruct on special precautions for antibiotics, antiplatelets, hypoglycemics including insulin and narcotics/opioids and how and when to report problems that may occur. However, the POC failed to include specific instructions related to the special precautions for antibiotics, antiplatelets, hypoglycemics including insulin and narcotics/opioids. Further review of the Home Health Plan of Care Recertification dated 7/31/25, for the certification period from 7/31/25 to 9/28/25 showed the medication list. The medications included Insulin Glargine-yfgn (SEMGLEE PEN) 100 unit/ml (3 ml) SubQ insulin Pen, inject 12 units subcutaneously daily to control blood sugar. Prime with two units before each dose and Insulin Regular Human ( Humulin R/Novolin R) 100 unit/ml injection solution, inject four units subcutaneously three times a day 30 minutes before meals. However, the care plan related to the use of hypoglycemics including insulin failed to include specific parameters to give and when to report when problems occur. b. The Home Health Plan of Care Recertification dated 7/31/25, for the certification period from 7/31/25 to 9/28/25, showed the other pertinent diagnoses. The other diagnoses includes Hyperglycemia, unspecified and Type 2 diabetes mellitus. The POC also showed the care plan problems and goals. The care plan problem and goals included the following: -Cardiac disease management: The intervention includes to instruct patient and family in HTN (hypertensive) disease process, symptom management, pulse and blood pressure monitoring and signs and symptoms to report and when to contact the agency/physician/911. However, the POC failed to include specific assessment parameters related to the symptom management, pulse and blood pressure monitoring and signs and symptoms to report and when to contact the agency/physician/911. -Medications/Medication Management: The interventions include to instruct on special precautions for antibiotics, antiplatelets, hypoglycemics including insulin and narcotics/opioids and how and when to report problems that may occur. However, the POC failed to include specific instructions related to the special precautions for antibiotics, antiplatelets, hypoglycemics including insulin and narcotics/opioids. Further review of the Home Health Plan of Care Recertification dated 7/31/25, for the certification period from 7/31/25 to 9/28/25 showed the medication list. The medications included Insulin Glargine-yfgn (SEMGLEE PEN) 100 unit/ml (3 ml) SubQ insulin Pen, inject 12 units subcutaneously daily to control blood sugar. Prime with two units before each dose and Insulin Regular Human ( Humulin R/Novolin R) 100 unit/ml injection solution, inject four units subcutaneously three times a day 30 minutes before meals. However, the care plan related to the use of hypoglycemics including insulin failed to include specific parameters to give and when to report when problems occur. On 11/5/25 at 1347 hours, an interview and concurrent clinical record review was conducted with the Nurse Manager 1. The Nurse Manager 1 was asked if the care plan goals and intervention were measurable and included specific parameters to report. The Nurse Manager 1 reviewed the clinical record. The Nurse Manager 1 replied no. The Nurse Manager 1 was informed and acknowledged the findings.”

“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 interview and record review, the agency failed to ensure the care and services were provided as per the POC for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential for not addressing the care needs for these patients. Findings: 3. Review of Patient 3’s clinical record was initiated on 7/9/25. The clinical record showed the SOC was 5/13/25. The patient was certified for home health services during the certification periods from 5/13/25 to 7/11/25. The POC, for the certification period from 5/13/25 to 7/11/25, cited SN visits two visits per week for two weeks beginning 6/1 to 6/14/25. However, review of SN visit notes showed the SN conducted visits on 6/1, 6/3, and 6/6/25, three visits instead of two visits in a week as per the patient’s POC. Further review of the clinical record did not show documented evidence for the reason of the extra one visit in a week. On 7/9/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Senior Clinical Practice Nurse. The Senior Clinical Practice Nurse was informed and acknowledged the finding. The agency’s P&P titled Care Planning Process revised 8/2017 showed the care planning process will be documented on the plan of care, individualized discipline specific care plans. The procedure includes at the time of the initial assessment the clinician, along with other involved disciplines will develop the patient plan of care based upon the patients identified needs. Based on the assessments and conclusions, the plan of care will include but not limited to types of services, type , frequency and duration of visits to be made. Missed visit frequency requires a physician verbal order. 1. Review of Patient 1’s clinical record was initiated on 7/8/25. The clinical record showed the SOC was 5/11/25. The patient was certified for home health services during the certification period from 5/11/25 to 7/9/25. The Home Health Plan of Care 5/11/25, for the certification period from 5/11/25 to 7/9/25, cited for SN visit 2W4. In addition, review of the Physicians Order titled Visit Frequency showed the updated visits for Skilled Nursing showed as follows: -2 visits every week for 4 weeks (5/11/25 to 6/7/25) discontinued as of 5/19/25, -2 visits every week for 3 weeks (5/18/25 to 6/7/25) for NPWT (negative pressure wound therapy), then re-assess, -2 visits as needed (5/18/25 to 7/9/25), 2 PRN visits for NPWT malfunction/complications management during certified period. -2 visits every week for 3 weeks (6/8/25 to 6/28/25), -1 visit every week for one week (6/26/25 to 6/28/25) and -3 visits every week for 1 week (6/29/25 to 7/5/25) Review of the clinical record showed on Week 5 (from 6/8/25 to 6/14/25), the SN had visited the patient one time on 6/10/25 instead of two times as ordered by the physician. Further review of the clinical record showed on Week 8 (from 6/29/25 to 7/5/25) the SN had visited the patient two times on 7/2 and 7/5/25 instead of three times as ordered by the physician. In addition, there was no documented evidenced of the physician was notified of the missed visits as per P&P. On 7/9/25 at 1412 hours, an interview and concurrent clinical record review was conducted with the Regional Nurse Accreditation, Regulatory & Licensing Consultant, Supporting Care at Home, Interim Senior Manager Regional Clinical Services and the Nurse Manager 1. They were asked if there was a missed visit on Weeks 5 and 8. They reviewed the clinical record. The Interim Senior Manager Regional Clinical Services replied, there was an MD visit on 6/13/25 but there was no communication notes documented for the missed visits. They were also asked if they needed to notify MD of the missed visits. They reviewed the clinical record. The Nurse Manager 1 replied yes, we should but there was no notes. They were informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 7/8/25. The clinical record showed the SOC was 5/31/25. The patient was certified for home health services during the certification period from 5/31/25 to 7/29/25. Review of the Physicians Referral Order dated 5/30/25, showed an order for the patients needed services. The order includes a primary services requested for RN and PT. The additional services requested includes OT for ADL trainings and Social Worker Services - counselling for severe ETOH and DUI. However, review of the clinical record failed to show documented evidenced of the Social Worker Services was provided as ordered by the physician. On 7/9/25 at 1430 hours, an interview and concurrent clinical record review was conducted with the Regional Nurse Accreditation, Regulatory & Licensing Consultant, Supporting Care at Home, Interim Senior Manager Regional Clinical Services and the Nurse Manager 1. They were asked as to the timeline for the Social Worker needed to see the patient. The Nurse Manager 1 replied within five days from the referral order. They were also asked if the order was missed. The Nurse Manager 1 replied yes, it was missed. They were further asked if there was a communication notes from the Social Worker. The Interim Senior Manager Regional Clinical Services replied, no communication notes. They were informed and acknowledged the finding.”

“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 POCs included the specific interventions, measurable outcomes, and goals related to the identified diagnoses and comorbidities for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential risk of not addressing the care needs for these patients. Findings. 3. Review of Patient 3’s clinical record was initiated on 7/9/25. The clinical record showed the SOC was 5/13/25. The patient was certified for home health services during the certification periods from 5/13/25 to 7/11/25. The POC, for the certification period from 5/13/25 to 7/11/25, showed the patient’s medications included bumetanide (Bumex, a drug used to treat swelling or fluid retention in the body) 1 mg oral tab, take 1 tablet by mouth daily. If weight gain is 2 pounds or greater overnight, 5 pounds over 1 week, or if you experience swelling or shortness of breath, then take 1 additional tablet for 1 to 3 days then return to your previous dose. *However, there was no documented evidence of intervention included in the POC to monitor the patient’s weight due to the special instructions of the administration of bumetanide. On 7/9/25 at 1509 hours, an interview and concurrent clinical record review was conducted with the Senior Clinical Practice Nurse. The Senior Clinical Practice Nurse was informed and acknowledged the finding. The Senior Clinical Practice Nurse stated the POC should include monitoring of the patient’s weight. The agency’s P&P titled Care Planning Process revised 8/2017 showed the care planning process will be documented on the plan of care, individualized discipline specific care plans. The plan of care includes types of services, goals and interventions appropriate to each discipline, medications, treatments and instructions. Documents include plan of treatment and plans of care. The procedure includes at the time of the initial assessment the clinician, along with other involved disciplines will develop the patient plan of care based upon the patients identified needs. Based on the assessments and conclusions, the plan of care will include but not limited to types of services, all medications and treatments, all necessary interventions to address the underlying risk factors and patient specific interventions, measurable outcomes and goals identified by the home health agency and patient. 1. Review of Patient 1’s clinical record was initiated on 7/8/25. The clinical record showed the SOC was 5/11/25. The patient was certified for home health services during the certification period from 5/11/25 to 7/9/25. The Home Health Plan of Care 5/11/25, for the certification period from 5/11/25 to 7/9/25, showed the medication list. The medication includes Acetaminophen (analgesic) 650 mg Oral SR Tab take one tablet PO Q8H PRN. Do not exceed three tablets in 24 hours for pain and Ibuprofen (NSAID) 800 mg one tablet PO Q8H PRN for pain. However, the instructions for the medication failed to include specific pain level when to take the medication to address pain. On 7/9/25 at 1412 hours, an interview and concurrent clinical record review was conducted with the Regional Nurse Accreditation, Regulatory & Licensing Consultant, Supporting Care at Home, the Interim Senior Manager Regional Clinical Services and the Nurse Manager 1. They were asked which pain medication needed to give first. They reviewed the clinical record. The Interim Senior Manager Regional Clinical Services replied it was not written on the PPC, there should be a pain scale. They were informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 7/8/25. The clinical record showed the SOC was 5/31/25. The patient was certified for home health services during the certification period from 5/31/25 to 7/29/25. The Home Health Plan of Care 5/31/25, for the certification period from 5/31/25 to 7/29/25, cited SN visit 1W1, 3W3 for wound care, MWF. The POC showed the patients principal diagnosis was Encounter for change or removal of surgical wound dressing. The Other pertinent diagnoses included Type 2 Diabetes Mellitus with Diabetic chronic kidney disease. The POC also showed medications list. The medication included Insulin Glargin -yfgn (SEMGLEE PEN) 100 units/ml (3 ml) Sub Q Insulin Pen inject four units subcutaneously daily at bedtime for type 2 diabetes mellitus. Blood sugar diagnostic (ONE TOUCH VERIO TEST STRIPS) check blood sugar two times a day every morning and every evening before dinner (blood sugar check supplies). Further review of the POC showed care plan problem: diabetes disease management. The goals and intervention included blood glucose monitoring and instruct in the diabetes disease process, signs and symptoms of hyper/hypoglycemia. However, the POC failed to include specific instructions when to inject insulin related to the blood sugar level. In addition, the medication list included Furosemide (diuretics) 80 mg oral tablet take one tablet by mouth every other day for high blood pressure. Moreover, the POC showed a care plan problem: CHF - knowledge deficit. The goal for CHF disease management includes patient and caregiver will verbalize understanding of long term CHF management of disease process by one week. The interventions included to instruct patient and caregiver in CHF disease process and signs and symptoms to report swelling of feet, ankles or abdomen not related to inactivity, increased dyspnea or inability to breathe lying down within the past 24 to 48 hours and cough that does not go away unrelated to medications or flu like symptoms. However, the POC failed to include specific instructions when to report related to the level of edema. Further, review of the POC showed a care plan problem: Patient requires monitoring of vital signs and weight. The interventions include assessment of patients vital signs and the parameters needed to contact the physician. However, the care plan failed to include the assessment parameters needed to call the physician related to the patients weight. On 7/9/25 at 1430 hours, an interview and concurrent clinical record review was conducted with the Regional Nurse Accreditation, Regulatory & Licensing Consultant, Supporting Care at Home, the Interim Senior Manager Regional Clinical Services and the Nurse Manager 1. They were informed and acknowledged the findings. Furthermore, the POC showed a care plan problem: Wound Care. The intervention includes Negative Pressure Wound Therapy. However, the care plan failed to include specific instructions related to leakage or malfunctioning of the negative pressure wound therapy. On 7/9/25 at 1144 hours an interview and concurrent clinical record review was conducted with the Regional Nurse Accreditation, Regulatory & Licensing Consultant, Supporting Care at Home, the Interim Senior Manager Regional Clinical Services, the Nurse Manager 1 and the Regional Nurse Consultant. They were asked if they needed to develop a care plan related to malfunction or leakage of the negative pressure wound therapy. They reviewed the clinical records. The Regional Nurse Consultant replied, yes we should but it was not created. On 7/9/25 at 1430 hours, an interview and concurrent clinical record review was conducted with the Regional Nurse Accreditation, Regulatory & Licensing Consultant, Supporting Care at Home, Interim Senior Manager Regional Clinical Services and the Nurse Manager 1. They were informed and acknowledged 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 record review and interview, the agency failed to ensure the wound treatments were provided only with the physician’s order for two of the three sampled patients (Patients 1 and 2). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. Findings: 1.Review of Patient 1’s clinical record was initiated on 7/8/25. The clinical record showed the SOC was 5/11/25. The patient was certified for home health services during the certification period from 5/11/25 to 7/9/25. The Home Health Plan of Care dated 5/11/25, for the certification period from 5/11/25 to 7/9/25, cited SN visits 2W4. The POC showed the patients principal diagnosis was cellulitis of the left lower limb. The POC included the wound care management/prevention and intervention for the patient’s left thigh surgical wound. The wound care instructions showed SN to perform wound care two times a week and PRN if loose leaking wound vac occurs. Documentation showed to turn off the machine, gently remove the old dressing with copious amount of NS for comfort, may soak wound bed with “VASHE” (when available) for five minutes then rinse with NS, pat dry, “skin prep” to parameter of peri wound for protection, cut one piece of black foam to fit wound bed, do not overpack, may wrap one piece of “mepitel 1” around one black foam and place into wound bed to reduce pain during removal, apply drape for adherence, cut the hole into black foam about quarter size, place the connector on top of wound bed to allow for suction, cover with the clear drape, and turn the wound vac on. Review of the SN note dated 6/19/25, showed the SN had performed wound assessment and treatment to the patient’s anterior left proximal leg. The treatment showed the primary dressing was “Alginate” and the secondary packing material was “Calcium Alginate Dressing.” However, review of the clinical record failed to show documented evidence of a physician’s order for the primary dressing of “Alginate” and the secondary packing material for “Calcium Alginate Dressing.” On 7/9/25 at 1412 hours, an interview and concurrent clinical record review was conducted with the Regional Nurse Accreditation/Regulatory & Licensing Consultant/Supporting Care at Home, Interim Senior Manager Regional Clinical Services, and Nurse Manager 1. They were asked if there was an order for “Alginate” and “Calcium Alginate Dressing.” They reviewed the clinical record. The Interim Senior Manager Regional Clinical Services replied, no order was documented. They were also asked if they needed to get an order. The Interim Senior Manager Regional Clinical Services and Nurse Manager 1 both replied, yes, they needed an order. They were informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 7/8/25. The clinical record showed the SOC was 5/31/25. The patient was certified for home health services during the certification period from 5/31/25 to 7/29/25. The Home Health Plan of Care dated 5/31/25, for the certification period from 5/31/25 to 7/29/25, cited SN visits 1W1 and 3W3 for wound care, MWF (Monday, Wednesday, Friday). The POC showed the patient’s principal diagnosis was encounter for change or removal of surgical wound dressing. The care plan included wound care to the patient’s right foot and left elbow wounds. The interventions included negative pressure wound therapy and wound care. The wound care included starting 5/31/25, SN to perform negative pressure wound therapy dressing change three times per week as follows: cleanse with “VASHE”, pat dry, apply “skin prep” to surrounding area, apply Duoderm (wound dressing) to peri wound, apply “mepitel,” cover black foam to wound bed, cover with drape, apply disc, and attach to 75 mmHg continuous suction. Review of the SN notes dated 6/2 and 6/4/25, showed the SN had performed wound assessment and treatment to the patient’s foot. The treatment included wound cleansing with normal saline and the primary dressing was moist gauze “Dakin’s.” However, review of the clinical record failed to show documented evidence of the physician’s order for the use of “Dakin’s” as part of the wound treatment. On 7/9/25 at 1430 hours, an interview and concurrent clinical record review was conducted with the Regional Nurse Accreditation/Regulatory & Licensing Consultant/Supporting Care at Home, the Interim Senior Manager Regional Clinical Services and Nurse Manager 1. They were asked if there was an order for “Dakin’s.” They reviewed the clinical record. The Interim Senior Manager Regional Clinical Services replied, did not see an order. They were informed and acknowledged the finding.”

“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 record review and interview, the agency failed to ensure the designated staff integrated the physician’s referral orders for OT and Social Worker services needed by the patient for one of three sampled patients (Patient 2). This failure had the potential for not providing appropriate, consistent, and quality care to this patient. Findings: Review of Patient 2’s clinical record was initiated on 7/8/25. The clinical record showed the SOC was 5/31/25. The patient was certified for home health services during the certification period from 5/31/25 to 7/29/25. Review of the Physicians Referral Order dated 5/30/25, showed an order for the patient needed services. The order included primary services requested were RN and PT. The additional services requested included OT for ADL training and Social Worker services for counselling for severe ETOH and DUI. The SN OASIS Start of Care dated 5/31/25, showed the RN performed the comprehensive assessment. The RN documented on the section of Encounter Notes showed the SN visit frequency. However, the RN failed to integrate the physician’s order for OT and MSW. However, review of the the Home Health Plan of Care dated 5/31/25, for the certification period from 5/31/25 to 7/29/25, showed only SN and PT services for the patient, no OT and social worker services in the POC. There was no documentation showing the OT and Social Worker services were no longer needed for the patient. On 7/9/25 at 1430 hours, an interview and concurrent clinical record review was conducted with the Regional Nurse Accreditation/Regulatory & Licensing Consultant/Supporting Care at Home, Interim Senior Manager Regional Clinical Services, and Nurse Manager 1. They were asked if the orders for OT and Social Worker services needed to be included in the SOC comprehensive assessment. They reviewed the clinical record. Nurse Manager 1 replied did not see it and it should have been included in the SOC OASIS. They were further asked if the OT and Social Worker services needed to be included in the POC. Nurse Manager 1 replied yes, it should, and it was on the referral. They were informed and acknowledged 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 manage the OT visits to be done timely as per the agency’s P&P for one of three sampled patients (Patient 3). This failure created the risk of not providing quality of care and services to the patient receiving services from the HHA. Findings: 1. Review of Patient 2’s clinical record was initiated on 7/8/25. The clinical record showed the SOC was 5/31/25. The patient was certified for home health services during the certification period from 5/31/25 to 7/29/25. Review of the Physicians Referral Order dated 5/30/25, showed an order for the patients needed services. The order included an additional services for OT and Social Worker Services. Review of the OT Telephone Encounter date 6/5/25 showed, the OT offered to have the MSW assist the patient and the patient declined. However, review of the clinical record failed to show documented evidenced of the OT had coordinated/communicated with the HHA team related to the patients declination for the MSW assistance. On 7/9/25 at 1430 hours, an interview and concurrent clinical record review was conducted with the Regional Nurse Accreditation, Regulatory & Licensing Consultant, Supporting Care at Home, the Interim Senior Manager Regional Clinical Services and the Nurse Manager 1. They were asked if the OT coordinated/communicated with the HHA team of the patients declination for MSW assistance. The reviewed the clinical record. The Interim Senior Manager Regional Clinical Services replied, no communication notes. They were informed and acknowledged the finding. cross ref. G-572 The agency’s P&P titled Initial and Comprehensive Assessment revised 9/2023, showed patient assessment by secondary discipline will be completed based on patient need but no more than 5 days from the referral date or as ordered by the physician. #. Review of Patient 3’s clinical record was initiated on 7/9/25. The clinical record showed the SOC was 5/13/25. The patient was certified for home health services during the certification periods from 5/13/25 to 7/11/25. Review of the referral dated 5/9/25, showed the patient was going to be discharged from a skilled nursing facility on 5/11/25 and patient requested to delay start of care for 5/13/25. In addition, the referral physician’s order showed a request for RN, PT, and OT. The POC, for the certification period from 5/13/25 to 7/11/25, showed other disciplines for PT and OT services. The OT Evaluation Home Care Visit dated 5/19/25 showed the OT had conducted a visit. * However, the OT evaluation visit was not timely per agency’s P&P as the visit occurred six days after the start of care was received on 5/13/25. Further review of the clinical records failed to show documented evidence the OT coordinated/communicated the reason for the delay of the initial visit to the interdisciplinary team. On 7/9/25 at 1415 hours, an interview and concurrent clinical record review was conducted with the Senior Clinical Practice Nurse. The Senior Clinical Practice Nurse was informed and acknowledged the finding. The Senior Clinical Practice Nurse verified she could not find documented evidence to show why there was a delay with the OT’s initial visit. The agency’s P&P titled Initial and Comprehensive Assessment revised 9/2023, showed the patient assessment by secondary discipline will be completed based on the patient need but no more than 5 days from the referral date or as ordered by the physician. Review of Patient 3’s clinical record was initiated on 7/9/25. The clinical record showed the SOC was 5/13/25. The patient was certified for home health services during the certification period from 5/13/25 to 7/11/25. Review of the referral dated 5/9/25, showed the patient was going to be discharged from a skilled nursing facility on 5/11/25, and the patient requested to delay the start of care for 5/13/25. In addition, the referral physician’s order showed a request for RN, PT, and OT. The POC, for the certification period from 5/13/25 to 7/11/25, showed other disciplines for PT and OT services. The OT Evaluation Home Care Visit dated 5/19/25, showed the OT conducted a visit. * However, the OT evaluation visit was not timely as per the agency’s P&P as the visit occurred six days after the start of care was on 5/13/25. Further review of the clinical records failed to show documented evidence the reason for the delay of the initial visit to the interdisciplinary team. On 7/9/25 at 1415 hours, an interview and concurrent clinical record review was conducted with the Senior Clinical Practice Nurse. The Senior Clinical Practice Nurse was informed and acknowledged the finding. The Senior Clinical Practice Nurse verified she could not find documented evidence to show why there was a delay with the OT’s initial visit.”

“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 POCs included the specific interventions, measurable outcomes, and goals related to the identified diagnoses and comorbidities for three of three sampled patients (Patients 1, 2, and 3), creating the risk of not addressing the care needs for these patients. Findings: 1. The agency’s P&P titled Initial and Comprehensive Assessment revised 4/2018 showed the purpose included to provide guidelines for completing plans of care. The plan of care will be developed from the information gathered during the initial and comprehensive assessments. The policy includes the assessment which will be patient specific and comprehensive and measure patient outcomes from the data collected at the start of care and following defined intervals. The procedure includes the specific, individualized patient needs and problems pertinent to the care being provided. Review of Patient 1’s closed clinical record was initiated on 12/12/24. The clinical record showed the SOC was 5/24/23. The patient was certified for home health services during the certification periods from 5/24/23 to 7/22/23, 7/23/23 to 9/20/23, and 9/21/23 to 11/19/23. The POC, for the certification periods 7/23/23 to 9/20/23 and 9/21/23 to 11/19/23, showed the patient’s principal diagnosis was dehydration and other pertinent diagnoses included orthostatic hypotension. The POC showed the interventions for dehydration included to provide the weekly intravenous hydration. However, the POC failed to include to check the patient’s weights as part of the measurable outcomes and goals to address the dehydration. In addition, the POC failed to include the specific goals and intervention to address the patient’s other pertinent diagnosis of orthostatic hypotension. On 12/17/24 at 1143 hours, an interview and concurrent closed clinical record review was conducted with Clinical Supervisors 1 and 2. They were asked how they would know if the patient had orthostatic hypotension. They reviewed the closed clinical record and Clinical Supervisor 1 replied none was documented regarding the orthostatic blood pressure. They were also asked if the weights needed to be included in the POC. Clinical Supervisor 1 replied it was not there and the nurse should have coordinated with the physician. They were informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 12/13/24. The clinical record showed the SOC was 10/10/24. The patient was certified for home health services during the certification periods from 10/10/24 to 12/8/24, and 12/9/24 to 2/6/25. The POC, for the certification periods from 10/10/24 to 12/8/24 and 12/9/24 to 2/6/25, showed the patient’s principal diagnosis was dehydration. The POC also showed the interventions for dehydration included to provide the intravenous hydration with multivitamins every two weeks. The POC also showed the ED/Hospital readmission risks included an unintentional weight loss, a total of 10 lbs. or more in the past 12 months However, the POC failed to include to check the patient’s weights as part of the measurable outcomes and goals to address the dehydration. On 12/17/24 at 1114 hours, an interview and concurrent clinical record review was conducted with Clinical Supervisors 1 and 2. They were asked if the patient’s weights needed to be addressed in the POC. They reviewed the POC and Clinical Supervisor 1 replied it was not addressed in the POC. They were informed and acknowledged the findings. 3. Review of Patient 3’s clinical record was initiated on 12/13/24. The clinical record showed the SOC was 7/4/24. The patient was certified for home health services during the certification periods from 9/2/24 to 10/31/24, and 11/1/24 to 12/30/24. a. The POC for the certification period from 9/2/24 to 10/31/24, showed the patient’s principal diagnosis was unspecified severe protein calorie malnutrition. The POC showed the patient had a PICC line to provide the total parenteral nutrition daily. The care plan problem showed the patient required monitoring of the vital signs/weights. The specific goals and interventions for the vital signs were included in the POC. However, the POC failed to include the specific instructions, measurable outcomes, and goals for checking or monitoring of the patient’s weights. On 12/17/24 at 1057 hours, an interview and concurrent clinical record review was conducted with Clinical Supervisors 1 and 2. They were asked if the instructions and goals for the weights were needed to be in the POC. They reviewed the clinical record, and Clinical Supervisor 1 replied no weight was addressed and it was not included in the POC. They were informed and acknowledged the findings. b. The POC for the certification period from 11/1/24 to 12/30/24, showed the patient’s principal diagnosis was unspecified severe protein calorie malnutrition. The POC showed the patient had a PICC to provide total parenteral nutrition daily. However, the POC failed to include checking/monitoring of the patient’s weights as part of measurable outcomes and goals to address the patient’s principal diagnosis of unspecified severe protein calorie malnutrition. On 12/17/24 at 1027 hours, an interview and concurrent clinical record review was conducted with Clinical Supervisors1 and 2. They were asked if the weights needed to be included in the POC. They reviewed the clinical records and Clinical Supervisor 1 replied they were checking the weights, but it was not included in the POC which should be individualized. They were informed and acknowledged the findings.”

“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 interview and record review, the agency failed to ensure the necessary care and services for three of three sampled patients (Patients 1, 2 and 3) were coordinated, creating the risk for patients not to receive the necessary care and services. Findings: Review of the agency’s P&P tiled Care Coordination revised 6/2021 showed the timely and ongoing communication is the responsibility of each team member, will be appropriate to the needs and abilities of the patient, and will be relevant to the care provided. Written evidence of care coordination will be recorded during the case conferences and repeated in the skilled nursing visit reports in the patients’ clinical records. 1. Review of Patient 1’s closed clinical record was initiated on 12/12/24. The clinical record showed the SOC was 5/24/23. The patient was certified for home health services during the certification periods from 5/24/23 to 7/22/23, 7/23/23 to 9/20/23, and 9/21/23 to 11/19/23. The POC, for the certification periods from 7/23/23 to 9/20/23 and 9/21/23 to 11/19/23, showed the patient’s principal diagnosis was dehydration and other pertinent diagnoses included orthostatic hypotension. The intervention for dehydration included IV NS one liter weekly. However, review of the clinical record failed to show documented evidence the needs for checking the patient’s weights and orthostatic BPs were coordinated with the physician as part of the specific goals and interventions in the plan of care. On 12/17/24 at 1143 hours, an interview and concurrent closed clinical record review was conducted with Clinical Supervisors 1 and 2. They were asked if the checking of the weight was coordinated with the physician. They reviewed the clinical record and Clinical Supervisor 1 replied, “no”. They were also asked if the checking the orthostatic BPs was coordinated with the MD. Clinical Supervisor 2 replied they still had to check the notes. They were informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 12/13/24. The clinical record showed the SOC was 10/10/24. The patient was certified for home health services during the certification periods from 10/10/24 to 12/8/24, and 12/9/24 to 2/6/25. The POC, for the certification periods from 10/10/24 to 12/8/24, and 12/9/24 to 2/6/25, showed the patient’s principal diagnosis was dehydration. The POC showed the interventions for dehydration included to provide the intravenous hydration with multivitamins every two weeks. The POC also showed the ED/Hospital readmission risks included an unintentional weight loss, a total of 10 lbs or more in the past 12 months. However, review of the clinical record failed to show documented evidenced the need for checking the patient’s weights was coordinated with the physician as part of the specific goals and interventions in the plan of care. On 12/17/24 at 1105 hours, an interview and concurrent clinical record review was conducted with Clinical Supervisors 1 and 2. They were asked if the checking of the patient’s weights was coordinated with the physician. They reviewed the clinical record and Clinical Supervisor 1 replied she did not see any documentation of the coordination. They were informed and acknowledged the findings. 3. Review of Patient 3’s clinical record was initiated on 12/13/23. The clinical record showed the SOC was 7/4/23. The patient was certified for home health services during the certification periods from 9/2/24 to 10/31/24 and 11/1/24 to 12/30/24. The POC, for the certification period from 9/2/24 to 10/31/24 and 11/1/24 to 12/30/24, showed the patient’s principal diagnosis was unspecified severe protein calorie malnutrition. The POC showed the patient had a PICC to provide total parenteral nutrition daily. However, review of the clinical record failed to show documented evidence the need for checking/monitoring the patient’s weights was coordinated with the physician as part of the specific goals and interventions in the plan of care. On 12/17/24 at 1051 hours, an interview and concurrent clinical record review was conducted with Clinical Supervisor 1 and 2. They were asked if the need for weight monitoring was coordinated with the physician. Clinical Supervisor 1 replied there was no documentation in the communication notes. They were informed and acknowledged the findings. Cross reference to G574.”