Accurate Home Health Care, Inc.

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition 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’s personal residence) failed to meet the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Infection Prevention and Control was met as follows: - HHA failed to follow accepted standards of practice, including standard precautions, to prevent the transmission of infections, related to the use of nasal cannula (a medical device used to deliver supplemental oxygen directly into the nostrils for patients who require additional oxygen therapy), suction tubing (a medical device used to remove fluid, mucus, or other material from the airway or other body cavities; it is a long, flexible tube with a suctioning tip at the end and is typically connected to a suction machine or a vacuum source), and Yankauer suction tip (a rigid, curved medical device with a bulbous tip used to suction fluids and debris from a patient’s mouth) for one of seven sampled patients (Patient 1).This failure had the potential to put the patient at increased risk for infection. (Refer to G682). -The HHA failed to provide infection control education to the family and/or caregiver for one of seven sampled patients (Patient 1). This failure had the potential to result in a lack of awareness of infection control, compliance with infection prevention routine, and increased risk of infection. Refer to (G686). The cumulative effect of these systemic practices resulted in the failure of the Home Health Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Infection Prevention and Control to ensure the quality of care is provided to patients certified to receive home health benefits.”

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing [a specialized level of medical care provided to patients who require assistance with daily activities and medical treatments] and other therapeutic service to a patient at home) failed to ensure a copy of the current plan of care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) was provided to two of 7 sampled patients (Patient 1 and Patient 5). This failure had the potential to result in patients and families not understanding what services to expect from the HHA, the purpose of each service, and when to expect the services. Findings: During a review of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care date (SOC) of 8/2/2025, with a diagnosis which included atherosclerosis of native arteries of the extremities (a condition where fatty deposits [plaques] build up in the arteries of the legs, arms, and feet, narrowing them and reducing blood flow) with rest pain, and generalized muscle weakness. During a review of Patient 5’s Home Health Certification and POC (a form that a physician signs to attest to a patient’s need for home health care and to outline the services to be provided) for the certification period starting from 8/2/2025 to 9/30/2025, the Home Health Certification and POC form indicated the skilled nurse (provides advanced medical care, often requiring specialized training and certifications) frequency of visits to one visit for 1 week, two visits for 3 weeks and then one visit for 5 weeks for skilled observation and assessment of vital signs (essential measurements that indicate a person’s basic physiological status, which includes body temperature, pulse rate [the number of times the heart beats per minute], respiratory rate [the number of breaths taken per minute], and blood pressure [the force of blood against the artery walls]) and all body systems, with emphasis on circulatory status (refers to the overall state of blood circulation in the body) for pain/comfort/color of left toes, compliance with prescribed medication/diet regimen, home safety and emergency protocol. During a joint home visit at Patent 5’s residence, on 8/26/2025 at 10:35 a.m., with the registered nurse (RN 1), Patient 5 was observed laying in a hospital bed, awake, alert, and oriented x 3 (to person, place and time) but forgetful, accompanied by a family member (FM 1). During the home visit. a review of Patient 5’s home health agency folder located in the patient’s home indicated there was no copy of Home Health Certification and POC form. During an interview, FM 1 stated she was not aware about the POC form, as it was not provided to them by the HHA. During an interview, on 8/27/2025 at 1:05 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated the HHA should provide all patients a copy of their current POC at home, stating “it’s our bible and guides the actions of the care team.” The DPCSD stated and acknowledged the finding. During a review of the HHA’s policy and procedure (P&P) titled “Plan of Care”, dated 4/26/2018, the P&P indicated plan of care is the term used for physician’s orders that staff follow in the management of a patient’s care while on home health service. Development of the plan of care involves the physician(s), staff, the patient and/or caregiver. It is based on needs identified in the comprehensive assessment of the patient and the assessment made by each discipline involved in the patient’s care and collaboration with the physician and patient to establish appropriate interventions and measurable goals. a. During a review of Patient 1’s Patient Information, the Patient Information indicated that Patient 1 was admitted to the HHA on 6/22/2025 with a primary diagnosis of pneumonia (an infection of the lungs that causes inflammation of the air sacs [alveoli]; it can be caused by various microorganisms, including bacteria, viruses, and fungi [microorganisms such as yeasts and molds]), unspecified organism. During a review of Patient 1’s Home Health Certification and Plan of Care – (also known as Plan of Care or POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), effective from 8/21/2025 to 10/19/2025, the Home Health Certification and Plan of Care indicated the frequency of Skilled Nurse (SN, licensed nurse in general) visit was once a week for nine weeks. During a joint home visit with the Director of Patient Care Services (DPCSD) on 8/26/2025 at 10:20 a.m., Patient 1 was observed lying in a hospital bed (a specialized bed designed for use in healthcare settings, offering features and adjustability not found in standard beds to support patient comfort, mobility, and care) with his eyes open. Patient 1 was observed to be nonverbal (having little to no functional use of spoken language to communicate). Patient 1 had a live-in caregiver (PCG 1). PCG 1 stated that she provided day-to-day care for Patient 1, such as turning the patient, administering tube feeding (providing nutrition through a tube inserted into the digestive system), wound care, and suctioning the patient. During the joint home visit, Patient 1’s home folder was reviewed with the DPCSD. There was no copy of the Home Health Certification and Plan of Care observed inside the home folder. The DPCSD stated the home health did not provide a copy of the POC for the patient/family. During an interview with the DPCSD on 8/27/2025 at 11:30 a.m., the DPCSD stated that a care plan was a document that the nurses would use as guidance for instructions, procedures, treatments, and education. The DPCSD stated that care plain contained the patient’s diagnoses, goals, interventions, medications, functional and cognitive limitations, and also DME (durable medical equipment; medical equipment that is used repeatedly and is primarily used for medical purposes) and supplies.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard 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’s personal residence) failed to follow accepted standards of practice, including standard precautions, to prevent the transmission of infection for one of seven sampled patients (Patient 1). Patient 1’s plan of care (POC) included a primary diagnosis of pneumonia. Skilled nurse (SN) services were provided once a week for 9 weeks. SN was to instruct the patient caregiver (FM2) on proper cleaning of the equipment. Patient1’s DME (durable medical equipment) used was a suction machine connected to a suction canister (a container used in medical settings to collect and store fluids or secretions suctioned from a patient). Suction tubing and suction tip were attached to the suction canister. The suction tubing was stained with dried-up, clumpy, brown colored, mucus-like substance. The suction tip was left uncovered at the bedside table. Patient 1 had a nasal cannula connected to an oxygen concentrator. FM2 had no knowledge how often the suction tubing, suction tip, and nasal cannula will be replaced or cleansed. This failure had the potential to put the patient at risk for further respiratory infection that could compromise the patient’s health status and wellbeing. During a review of Patient 1’s Patient Information, the Patient Information indicated that Patient 1 was admitted to the HHA on 6/22/2025 with a primary diagnosis of pneumonia (an infection of the lungs that causes inflammation of the air sacs [alveoli]; it can be caused by various microorganisms, including bacteria, viruses, and fungi [microorganisms such as yeasts and molds]), unspecified organism. During a review of Patient 1’s Home Health Certification and Plan of Care – (also known as Plan of Care or POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), effective from 8/21/2025 to 10/19/2025, the Home Health Certification and Plan of Care indicated the frequency of Skilled Nurse (SN, licensed nurse in general) visit was once a week for nine weeks. The DME (durable medical equipment; medical equipment that is used repeatedly and is primarily used for medical purposes) and Supplies section of the Home Health Certification and Plan of care included oxygen and suction machine (a medical device that removes fluids like mucus, blood, and saliva from a patient’s airway to help them breathe, especially when they are unconscious or unable to clear secretions themselves). The orders and treatment section of the Home Health Certification and Plan of Care indicated for the SN to instruct on the proper use and precaution of oxygen, and to teach caregiver on proper cleaning of equipment. The orders and treatment section did not specify how often the respiratory therapy equipment (such as nasal cannula [a medical device used to deliver supplemental oxygen directly into the nostrils for patients who require additional oxygen therapy], suction tubing [a medical device used to remove fluid, mucus, or other material from the airway or other body cavities; it is a long, flexible tube with a suctioning tip at the end and is typically connected to a suction machine or a vacuum source], and Yankauer suction tip [a rigid, curved medical device with a bulbous tip used to suction fluids and debris from a patient’s mouth]) needed to be replaced. During a joint home visit with the Director of Patient Care Services (DPCSD) on 8/26/2025 at 10:20 a.m., Patient 1 was observed lying in a hospital bed (a specialized bed designed for use in healthcare settings, offering features and adjustability not found in standard beds to support patient comfort, mobility, and care) with his eyes open. Patient 1 was observed to be nonverbal (having little to no functional use of spoken language to communicate). Patient 1 had a live-in caregiver (PCG 1). PCG 1 stated she provided day-to-day care for Patient 1, such as turning the patient, administering tube feeding (providing nutrition through a tube inserted into the digestive system), wound care, and suctioning the patient. During the home visit, observed Patient 1 with a nasal cannula. The nasal cannula was connected to an oxygen concentrator (a medical device that separates oxygen from the air, providing patients with a continuous, medical-grade supply of concentrated oxygen for therapy), which was set to deliver 2 liters (a measurement unit) of oxygen per minute. Also observed a suction machine connected to a suction canister (a container used in medical settings to collect and store fluids or secretions suctioned from a patient). Suction tubing and suction tip were attached to the suction canister. The suction tubing was visibly stained with dried-up, clumpy, brown colored, mucus-like substance. The suction tip was lying on the bedside table, uncovered. During the home visit, PCG 1 was asked, in her native language, the last time the nasal cannula, suction tubing, and suction tip were replaced. PCG 1 stated they were changed probably about 2 or 3 months ago. PCG 1 stated she used the suction machine daily to clear up Patient 1’s secretion. During a telephone interview with Patient 1’s family member (FM 2) on 8/26/2025 at 11:30 a.m., FM 2 stated Patient 1’s suction tubing, suction tip, and nasal cannula have not been changed since his admission to home health. FM 2 stated the HHA did not provide them with extra nasal cannula and suction tubing. FM 2 stated she took home a nasal cannula and “some tubing” for the suction machine that Patient 1 used in the hospital and then cleaned it. FM 2 stated she was not sure how often the nasal cannula, suction tubing, and suction tip needed to be changed. FM 2 added, “Probably two to three months.” During an interview with the DPCSD on 8/26/2025 at 11:46 a.m., the DPCSD stated the nasal cannula, suction tubing, and suction tip were supposed to be replaced every 30 days, or sooner if needed, for example if the nasal cannula or suction tip dropped on the floor. The DPCSD stated that nasal cannula, suction tubing, and suction tip needed to be replaced, per facility policy, for infection control purposes. The DPCSD stated that using dirty respiratory supplies could lead to infection. During a review of RN – Skilled Nursing Visit for Patient 1, dated 7/28/2025, 8/5/2025, 8/11/2025, and 8/21/2025, there was no documentation in the respiratory section and Skilled Intervention section regarding if or when the nasal cannula, suction tubing, and suction tip were replaced. There was no documentation regarding if the nurse provided instruction and/or education to PCG 1 or FM 2 regarding how often nasal cannula, suction tubing, and suction tip should be replaced. During a review of the HHA’s policy and procedure (P & P), titled “Oxygen Use at Home,” revised 05/27/24, the P & P indicated that nasal cannula should be replaced every month. During a review of the HHA’s P & P, titled “Infection Control Procedures – Equipment Cleaning,” dated 8/19/01, the P & P indicated that soap and water are effective for cleaning equipment such as nasal cannulas, masks, tubing, the cap and mouthpiece of inhalers, humidifiers, and surfaces of most respiratory therapy equipment. The HHA was not able to provide a policy regarding the frequency suction tubing including nasal cannula are to be replaced.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to provide infection control education to the family and/or caregiver for one of seven sampled patients (Patient 1). This failure had the potential to result in a lack of awareness of infection control, compliance with infection prevention routine, and increased risk of infection. During a review of Patient 1’s Patient Information, the Patient Information indicated that Patient 1 was admitted to the HHA on 6/22/2025 with a primary diagnosis of pneumonia (an infection of the lungs that causes inflammation of the air sacs [alveoli]; it can be caused by various microorganisms, including bacteria, viruses, and fungi [microorganisms such as yeasts and molds]), unspecified organism. During a review of Patient 1’s Home Health Certification and Plan of Care – (also known as Plan of Care or POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), effective from 8/21/2025 to 10/19/2025, the Home Health Certification and Plan of Care indicated the frequency of Skilled Nurse (SN, licensed nurse in general) visit was once a week for nine weeks. The orders and treatment section of the Home Health Certification and Plan of Care indicated that the SN would continue to instruct on the proper use and precaution of oxygen, and to teach caregiver on proper cleaning of equipment. The orders and treatment section did not specify how often the respiratory therapy equipment (such as nasal cannula, suction tubing, and suction tip) needed to be replaced. During a joint home visit with the Director of Patient Care Services (DPCSD) on 8/26/2025 at 10:20 a.m., Patient 1 was observed lying in a hospital bed (a specialized bed designed for use in healthcare settings, offering features and adjustability not found in standard beds to support patient comfort, mobility, and care) with his eyes open. Patient 1 was observed to be nonverbal (having little to no functional use of spoken language to communicate). Patient 1 had a live-in caregiver (PCG 1). PCG 1 stated that she provided day-to-day care for Patient 1, such as turning the patient, administering tube feeding (providing nutrition through a tube inserted into the digestive system), wound care, and suctioning the patient. During the home visit, observed Patient 1 with a nasal cannula. The nasal cannula was connected to an oxygen concentrator (a medical device that separates oxygen from the air, providing patients with a continuous, medical-grade supply of concentrated oxygen for therapy), which was set to deliver 2 liters (a measurement unit) of oxygen per minute. Also observed a suction machine connected to a suction canister (a container used in medical settings to collect and store fluids or secretions suctioned from a patient). Suction tubing and suction tip were attached to the suction canister. The suction tubing was visibly stained with dried-up, clumpy, brown colored, mucus-like substance. The suction tip was lying on the bedside table, uncovered. During the home visit, PCG 1 was asked, in her native language, the last time the nasal cannula, suction tubing, and suction tip were replaced. PCG 1 stated they were changed probably about 2 or 3 months ago. PCG 1 stated she used the suction machine daily to clear up Patient 1’s secretion. During a telephone interview with Patient 1’s family member (FM 2) on 8/26/2025 at approximately 11:30 a.m., FM 2 stated that Patient 1’s suction tubing, suction tip, and nasal cannula have not been changed since his admission to home health. FM 2 stated the HHA did not provide them with extra nasal cannula and suction tubing. FM 2 stated she took home a nasal cannula and “some tubing” for the suction machine that Patient 1 used in the hospital and then cleaned it. FM 2 stated she was not sure how often the nasal cannula, suction tubing, and suction tip needed to be changed. FM 2 added, “Probably two to three months.” During an interview with the DPCSD on 8/26/2025 at 11:46 a.m., the DPCSD stated the nasal cannula, suction tubing, and suction tip were supposed to be replaced every 30 days, or sooner if needed, for example if the nasal cannula or suction tip dropped on the floor. The DPCSD stated that nasal cannula, suction tubing, and suction tip needed to be replaced, per facility policy, for infection control purposes. The DPCSD stated that using dirty respiratory supplies could lead to infection. During a review of RN – Skilled Nursing Visit for Patient 1, dated 7/28/2025, 8/5/2025, 8/11/2025, and 8/21/2025, there was no documentation in the respiratory section and Skilled Intervention section regarding if or when the nasal cannula, suction tubing, and suction tip were replaced. There was no documentation regarding whether the nurse provided instruction and/or education to PCG 1 or FM 2 regarding how often nasal cannula, suction tubing, and suction tip should be replaced. During an interview with the DPCSD on 8/27/2025 at 11:30 a.m., the DPCSD stated that patient/family education was very important in home health. The DPCSD stated that the HHA would reinforce patient education to make sure the caregiver and family member understand how to properly care for the patient. During a telephone interview with FM 2 on 8/27/2025 at 1:24 p.m., FM 2 stated she was never informed by the home health nurse that the nasal cannula, suction tubing, and suction tip needed to be periodically replaced. During a review of the HHA’s policy and procedure (P & P), titled “Oxygen Use at Home,” revised 05/27/24, the P & P indicated that nasal cannula should be replaced every month. During a review of the HHA’s P & P, titled “Infection Control Procedures – Equipment Cleaning,” dated 8/19/01, the P & P indicated that soap and water are effective for cleaning equipment such as nasal cannulas, masks, tubing, the cap and mouthpiece of inhalers, humidifiers, and surfaces of most respiratory therapy equipment. The HHA was not able to provide a policy regarding how often suction tubing needed to be cleansed or replaced. During a review of the HHA’s P & P, titled “Patient Education,” dated 5/7/01, the P & P indicated that routine patient teaching is general and includes, but is not limited to: d. How to assume responsibility for his own care at home.”

“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, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to maintain an accurate, current medication profile for one of seven sampled patients (Patient 1). This failure put Patient 1 at risk for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. During a review of Patient 1’s Patient Information, the Patient Information indicated that Patient 1 was admitted to the HHA on 6/22/2025 with a primary diagnosis of pneumonia (an infection of the lungs that causes inflammation of the air sacs [alveoli]; it can be caused by various microorganisms, including bacteria, viruses, and fungi [microorganisms such as yeasts and molds]), unspecified organism. During a review of Patient 1’s Home Health Certification and Plan of Care – (also known as Plan of Care or POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), effective from 8/21/2025 to 10/19/2025, the Home Health Certification and Plan of Care indicated the frequency of Skilled Nurse (SN, licensed nurse in general) visit was once a week for nine weeks. The orders and Treatments section of the Home Health Certification and Plan of Care indicated that the SN would continue to instruct caregiver regrading changes in medication regimen on action, side effects, dosage, and schedule. During a joint home visit with the Director of Patient Care Services (DPCSD) on 8/26/2025 at 10:20 a.m., Patient 1 was observed lying in a hospital bed (a specialized bed designed for use in healthcare settings, offering features and adjustability not found in standard beds to support patient comfort, mobility, and care) with his eyes open. Patient 1 was observed to be nonverbal (having little to no functional use of spoken language to communicate). Patient 1 had a live-in caregiver (PCG 1). PCG 1 stated that she provided day-to-day care for Patient 1, such as turning the patient, administering tube feeding (providing nutrition through a tube inserted into the digestive system), wound care, and suctioning the patient. During the joint home visit, a review of Patient 1’s available medications at home and Medication Profile was conducted with the DPCSD. Escitalopram Oxalate (a medication commonly used to treat major depressive disorder and generalized anxiety disorder) Oral 5 mg (milligram, a measurement unit) was listed on the Medication Profile. The instruction was to give one tablet every day by gastronomy tube (a thin, flexible tube inserted through the abdominal wall directly into the stomach; it is used to provide nutrition and medications to individuals who cannot eat or drink adequately on their own). The medication found at the patient’s home was Escitalopram Oxalate10 mg 1 tablet, with the instruction to take one tablet by mouth every day. During the home visit, PCG 1 was interviewed in her native language. PCG 1 stated that there was bottle or dose available for Escitalopram Oxalate, and the Escitalopram Oxalate 10 mg was the one she had been administering for Patient 1. During an interview with the DPCSD on 8/26/2025 at 11:50 a.m., the DPCSD stated there he saw a bottle of Escitalopram Oxalate 5 mg a couple weeks before he visited Patient 1 on 8/21/2025 for the recertification (the process where a physician confirms a patient’s continued need for home health services after an initial 60-day episode of care; it ensures the patient still meets the eligibility criteria, including being homebound and requiring skilled care) assessment. The DPCSD stated he did not know where PCG 1 kept it. On 8/27/2025 at 1:24 p.m., during a telephone interview with Family Member 2 (FM 2), who lives with Patient 1 and oversees his care, FM 2 stated that Patient 1 had always been taking Escitalopram Oxalate 10 mg. FM 2 stated that she was not aware the HHA listed Escitalopram Oxalate 5 mg as the dose being taken by her father. FM 2 stated that if the dose had been changed to 5 mg, nobody had informed her. FM 2 restated that as far as she knew, the dose was still 10 mg. FM 2 stated there was no other bottle of Escitalopram at her house. During an interview with the DPCSD on 8/27/2025 at 1:58 p.m., the DPCSD stated that patient’s medications needed to be checked with each visit. Any discrepancies in dose, frequency, and route should be reported to the physician. The DPCSD stated that keeping an accurate and updated medication profile was important so that the nurse would be able to monitor side effects, provide appropriate teaching, and monitor effectiveness of the medications. During a review of the HHA’s policy and procedure (P & P), titled “Medication Policy,” revised 10/29/10, the P & P indicated that all medications should be verified with the physicians. Skilled Nurse, Registered Nurse or LVN will check all medications including over-the-counter medications, verified and approved by a physician.”

“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 observation, interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that the plan of care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) included all medications, treatments, equipment and supplies, patient-specific intervention and education for two of seven sampled patients (Patient 1 and Patient 5). This failure had the potential to affect the quality of care and the safety of Patient 1 and Patient 5. b. During a review of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care date (SOC) of 8/2/2025, with a diagnosis which included atherosclerosis of native arteries of the extremities (a condition where fatty deposits [plaques] build up in the arteries of the legs, arms, and feet, narrowing them and reducing blood flow) with rest pain, and generalized muscle weakness. During a review of Patient 5’s Home Health Certification and POC (a form that a physician signs to attest to a patient’s need for home health care and to outline the services to be provided) for the certification period starting from 8/2/2025 to 9/30/2025, the Home Health Certification and POC form indicated the skilled nurse (provides advanced medical care, often requiring specialized training and certifications) frequency of visits to one visit for 1 week, two visits for 3 weeks and then one visit for 5 weeks for skilled observation and assessment of vital signs (essential measurements that indicate a person’s basic physiological status, which includes body temperature, pulse rate [the number of times the heart beats per minute], respiratory rate [the number of breaths taken per minute], and blood pressure [the force of blood against the artery walls]) and all body systems, with emphasis on circulatory status (refers to the overall state of blood circulation in the body) for pain/comfort/color of left toes, compliance with prescribed medication/diet regimen, home safety and emergency protocol. During a review of Patient 5’s Medication Profile sheet, the Medication Profile indicated Patient 5 was taking Eliquis (a type of anticoagulant) 5 milligrams (mg, a unit of measurement) one tablet by mouth twice a day. During a joint home visit at Patent 5’s residence, on 8/26/2025 at 10:35 a.m., with the registered nurse (RN 1), Patient 5 was observed laying in a hospital bed, awake, alert, and oriented x 3 (to person, place and time) but forgetful, accompanied by a family member (FM 1). During a review of Patient 5’s medication, there was a bottle of Eliquis 5 mg found at the bedside. During an interview with FM 1, FM 1 stated Patient 5 has been taking Eliquis for more than a month. During a concurrent interview and record review, on 8/27/2025 at 1:05 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD reviewed Patient 5’s most current Home Health Certification and POC dated 8/2/2025 to 9/30/2025. The DPCSD stated and acknowledged there was no care plan developed with specific goals and interventions regarding the patient’s use of Eliquis. The DPCSD stated patients on anticoagulant should have a care plan to monitor the patient for bleeding. During a review of the HHA’s policy and procedure (P&P) titled “Plan of Care”, dated 4/26/2018, the P&P indicated plan of care is the term used for physician’s orders that staff follow in the management of a patient’s care while on home health service. Development of the plan of care involves the physician(s), staff, the patient and/or caregiver. It is based on needs identified in the comprehensive assessment of the patient and the assessment made by each discipline involved in the patient’s care and collaboration with the physician and patient to establish appropriate interventions and measurable goals. a. During a review of Patient 1’s Patient Information, the Patient Information indicated that Patient 1 was admitted to the HHA on 6/22/2025 with a primary diagnosis of pneumonia (an infection of the lungs that causes inflammation of the air sacs [alveoli]; it can be caused by various microorganisms, including bacteria, viruses, and fungi [microorganisms such as yeasts and molds]), unspecified organism. During a review of Patient 1’s Home Health Certification and Plan of Care – (also known as Plan of Care or POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), effective from 8/21/2025 to 10/19/2025, the Home Health Certification and Plan of Care indicated the frequency of Skilled Nurse (SN, licensed nurse in general) visit was once a week for nine weeks. The DME (durable medical equipment; medical equipment that is used repeatedly and is primarily used for medical purposes) and Supplies section of the Home Health Certification and Plan of care included oxygen and suction machine (a medical device that removes fluids like mucus, blood, and saliva from a patient’s airway to help them breathe, especially when they are unconscious or unable to clear secretions themselves). The orders and treatment section of the Home Health Certification and Plan of Care indicated that the SN would continue to instruct on the proper use and precaution of oxygen, and to teach caregiver on proper cleaning of equipment. During a joint home visit with the Director of Patient Care Services (DPCSD) on 8/26/2025 at 10:20 a.m., Patient 1 was observed lying in a hospital bed (a specialized bed designed for use in healthcare settings, offering features and adjustability not found in standard beds to support patient comfort, mobility, and care) with his eyes open. Patient 1 was observed to be nonverbal (having little to no functional use of spoken language to communicate). Patient 1 had a live-in caregiver (PCG 1). PCG 1 stated that she provided day-to-day care for Patient 1, such as turning the patient, administering tube feeding (providing nutrition through a tube inserted into the digestive system), wound care, and suctioning the patient. During the home visit, observed Patient 1 with a nasal cannula. The nasal cannula was connected to an oxygen concentrator (a medical device that separates oxygen from the air, providing patients with a continuous, medical-grade supply of concentrated oxygen for therapy), which was set to deliver 2 liters (a measurement unit) of oxygen per minute. Also observed a suction machine connected to a suction canister (a container used in medical settings to collect and store fluids or secretions suctioned from a patient). Suction tubing and suction tip were attached to the suction canister. The suction tubing was visibly stained with dried-up, clumpy, brown colored, mucus-like substance. The suction tip was lying on the bedside table, uncovered. During the home visit, PCG 1 was asked, in her native language, the last time the nasal cannula, suction tubing, and suction tip were replaced. PCG 1 stated they were changed probably about 2 or 3 months ago. PCG 1 stated she used the suction machine daily to clear up Patient 1’s secretion. During a telephone interview with Patient 1’s family member (FM 2) on 8/26/2025 at approximately 11:30 a.m., FM 2 stated that Patient 1’s suction tubing, suction tip, and nasal cannula have not been changed since his admission to home health. FM 2 stated the HHA did not provide them with extra nasal cannula and suction tubing. FM 2 stated she took home a nasal cannula and “some tubing” for the suction machine that Patient 1 used in the hospital and then cleaned it. FM 2 stated she was not sure how often the nasal cannula, suction tubing, and suction tip needed to be changed. FM 2 added, “Probably two to three months.” During an interview with the DPCSD on 8/26/2025 at 11:46 a.m., the DPCSD stated the nasal cannula, suction tubing, and suction tip were supposed to be replaced every 30 days, or sooner if needed, for example if the nasal cannula or suction tip dropped on the floor. The DPCSD stated that nasal cannula, suction tubing, and suction tip needed to be replaced, per facility policy, for infection control purposes. The DPCSD stated that using dirty respiratory supplies could lead to infection. During a concurrent interview and record review with the DPCSD on 8/27/2025 at 11:42 a.m., the DPCSD reviewed Patient 1’s Home Health Certification and Plan of Care, effective from 8/21/2025 to 10/19/2025. The DPCSD stated that oxygen and suction machine were part of the DMEs for Patient 1, and the supplies related to the use of both should have been provided for the patient. The DPCSD stated he was not aware that Patient 1 did not have extra nasal cannula and suction tubing. During a review of the HHA’s policy and procedure (P & P), titled “Oxygen Use at Home,” revised 05/27/24, the P & P indicated that nasal cannula should be replaced every month. During a review of the HHA’s P & P, titled “Plan of Care,” revised 4/26/18, the P & P indicated the plan of care includes medical supplies, appliances, and durable medical equipment.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. 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 [a specialized level of medical care provided to patients who require assistance with daily activities and medical treatments] and other therapeutic service to a patient at home) failed to revise (update) the plan of care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) for one of 7 sampled patients (Patient 5), who developed eschar (dead tissue) on the left heel. This failure could lead to patient not receiving necessary services, causing a decline in health and impacting their quality of care and well-being. Findings: During a review of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care date (SOC) of 8/2/2025, with a diagnosis which included atherosclerosis of native arteries of the extremities (a condition where fatty deposits [plaques] build up in the arteries of the legs, arms, and feet, narrowing them and reducing blood flow) with rest pain, and generalized muscle weakness. During a review of Patient 5’s Home Health Certification and POC (a form that a physician signs to attest to a patient’s need for home health care and to outline the services to be provided) for the certification period starting from 8/2/2025 to 9/30/2025, the Home Health Certification and POC form indicated the skilled nurse (provides advanced medical care, often requiring specialized training and certifications) frequency of visits to one visit for 1 week, two visits for 3 weeks and then one visit for 5 weeks for skilled observation and assessment of vital signs (essential measurements that indicate a person’s basic physiological status, which includes body temperature, pulse rate [the number of times the heart beats per minute], respiratory rate [the number of breaths taken per minute], and blood pressure [the force of blood against the artery walls]) and all body systems, with emphasis on circulatory status (refers to the overall state of blood circulation in the body) for pain/comfort/color of left toes, compliance with prescribed medication/diet regimen, home safety and emergency protocol. During a review of Patient 5’s medical record form titled “Physician Order” dated 8/25/2025, the Physician’s Order indicated that Patient 5 has a new left lateral heel eschar, with instructions to clean it daily using a betadine swab (a convenient, single-use applicator stick used as an antiseptic to prevent skin infections). During a joint home visit at Patent 5’s residence, on 8/26/2025 at 10:35 a.m., with the registered nurse (RN 1), Patient 5 was observed lying in a hospital bed, awake, alert, and oriented x 3 (to person, place and time) but forgetful, accompanied by a family member (FM 1). An eschar was noted on the left lateral heel, which RN 1 cleaned with a betadine swab. During a concurrent interview and record review, on 8/27/2025 at 1:05 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD reviewed Patient 5’s most current Home Health Certification and POC dated 8/2/2025 to 9/30/2025, and the Physician Order form dated 8/25/2025. The DPCSD stated Patient 5 has a new treatment order for left heel eschar, but the plan of care was not updated with the new order. The DPCSD stated care plan should have been updated to reflect the current wound care treatment for the patient. During a review of the HHA’s policy and procedure (P&P) titled “Plan of Care”, dated 4/26/2018, the P&P indicated plan of care is the term used for physician’s orders that staff follow in the management of a patient’s care while on home health service. An individualized plan of care is developed for each patient, with the patient and/or caregiver participating in the care planning process. The plan of care is reviewed and revised by the physician and agency personnel as often as the patient’s condition requires and at least once every 60 days.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure each patient and his or her caregiver received education and training regarding the care and services identified in the plan of care one of seven sampled patients (Patient 1). This failure resulted in Patient 1’s caregiver lack of knowledge on how to properly provide care, which may lead to cause harm to the patient. During a review of Patient 1’s Patient Information, the Patient Information indicated that Patient 1 was admitted to the HHA on 6/22/2025 with a primary diagnosis of pneumonia (an infection of the lungs that causes inflammation of the air sacs [alveoli]; it can be caused by various microorganisms, including bacteria, viruses, and fungi [microorganisms such as yeasts and molds]), unspecified organism. During a review of Patient 1’s Home Health Certification and Plan of Care – (also known as Plan of Care or POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), effective from 8/21/2025 to 10/19/2025, the Home Health Certification and Plan of Care indicated the frequency of Skilled Nurse (SN, licensed nurse in general) visit was once a week for nine weeks. The orders and treatment section of the Home Health Certification and Plan of Care indicated that the SN would continue to instruct the caregiver on proper care of gastronomy tube (a thin, flexible tube inserted through the abdominal wall directly into the stomach; it is used to provide nutrition and medications to individuals who cannot eat or drink adequately on their own) as follows: Check residual before each feeding, if more than 100 ml (milliliter; a unit measurement for volume), hold feeding for 1 hour and recheck again after an hour. If the residual is less than 100 ml, resume feeding; may give water 100 ml after each feeding or medication via gastronomy tube. In tube feeding, residual refers to the volume of stomach contents, including formula, digestive fluids, and gastric acid, that remains in the stomach after feeding has been administered. High residual volumes can indicate that the stomach is not emptying properly, increasing the risk of pulmonary aspiration (a condition where foreign substances, such as food, liquids, vomit, or saliva, enter the lungs). The medications sections of the Home Health Certification and Plan of Care, effective from 8/21/2025 to 10/19/2025, indicated that Patient 1 be given Diabetisource AC (a medical nutrition product in the form of a tube-feeding formula designed to provide complete nutrition for individuals with diabetes), 1.5 carton in the morning, 1 carton at noon, p.m., and evening via gastronomy tube. During a joint home visit with the Director of Patient Care Services (DPCSD) on 8/26/2025 at 10:20 a.m., Patient 1 was observed lying in a hospital bed (a specialized bed designed for use in healthcare settings, offering features and adjustability not found in standard beds to support patient comfort, mobility, and care) with his eyes open. Patient 1 was observed to be nonverbal (having little to no functional use of spoken language to communicate). Patient 1 had a live-in caregiver (PCG 1). PCG 1 stated that she provided day-to-day care for Patient 1, such as turning the patient, administering tube feeding (providing nutrition through a tube inserted into the digestive system), wound care, and suctioning the patient. During the home visit, PCG 1 was interviewed in her native language. PCG 1 was asked to describe how she would check for the residual before administering the tube feeding for Patient 1. PCG 1 stated that Patient 1 was okay and therefore did not need to be checked. PCG 1 was not able to describe what needed to be done when checking for residual. During an interview with the DPCSD on 8/26/2025 at 11:40 a.m., the DPCSD stated he was not aware that PCG 1 had not been checking the residual prior to administering tube feeding. The DPCSD stated that PCG 1 told him she was a nurse in her native country. The DPCSD stated that checking residual was very important to prevent aspiration, especially since Patient 1 had a history of pneumonia. During a review of RN – Skilled Nursing Visit for Patient 1, dated 7/28/2025, 8/5/2025, 8/11/2025, and 8/21/2025, there was no documentation on whether the nurse provided PCG 1 with the education and training related to tube feeding administration. During a review of the HHA’s policy and procedure (P & P), titled “Gastronomy Tube Guidelines,” dated 10/3/06, the P & P indicated the following: Check for residual before each feeding and medications. Hold if residual is more than 100 ml for an hour an recheck. Return aspirates contents to stomach.”

“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 interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing [a specialized level of medical care provided to patients who require assistance with daily activities and medical treatments] and other therapeutic service to a patient at home) field staff failed to submit their clinical notes within the timeframe as indicated in the agency’s policy and procedure for one of 7 sampled patients (Patient 5). This failure resulted in Patient 5’s incomplete clinical record that could lead to misinformation and lack of care and services provided to the patient. Findings: During a review of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care date (SOC) of 8/2/2025, with a diagnosis which included atherosclerosis of native arteries of the extremities (a condition where fatty deposits [plaques] build up in the arteries of the legs, arms, and feet, narrowing them and reducing blood flow) with rest pain, and generalized muscle weakness. During a review of Patient 5’s Home Health Certification and POC (a form that a physician signs to attest to a patient’s need for home health care and to outline the services to be provided) for the certification period starting from 8/2/2025 to 9/30/2025, the Home Health Certification and POC form indicated the skilled nurse (provides advanced medical care, often requiring specialized training and certifications) frequency of visits to one visit for 1 week, two visits for 3 weeks and then one visit for 5 weeks. The skilled nurse was to conduct observation and assessment of vital signs (essential measurements that indicate a person’s basic physiological status, which includes body temperature, pulse rate [the number of times the heart beats per minute], respiratory rate [the number of breaths taken per minute], and blood pressure [the force of blood against the artery walls]) and all body systems, with emphasis on circulatory status (refers to the overall state of blood circulation in the body) for pain/comfort/color of left toes, compliance with prescribed medication/diet regimen, home safety and emergency protocol. The POC further indicated for the home health aide (CHHA, a trained and certified individual who provides personal care and assistance with daily living activities to patients in their homes) to visit Patient 5 twice a week for 8 weeks, and then once a week for 1 week, and the physical therapist (PT, helps people improve or restore movement and function after illness, injury, or disability through exercise, hands-on techniques, and specialized equipment to reduce pain and prevent future problems) to evaluate and recommend treatment for therapeutic (relating to the healing of disease) and strengthening exercises, transfer/gait/balance training, and home safety instructions. During a review of Patient 5’s PT visit calendar, on 8/25/2025, the PT calendar indicated Patient 5 was visited and treated by a physical therapist on 8/8/2025, 8/12/2025, and 8/15/2025. However, the PT notes dated 8/8/2025, 8/12/2025, and 8/15/2025 were empty/blank and unsigned. During a review of Patient 5’s CHHA visit calendar, on 8/25/2025, the CHHA calendar indicated Patient 5 was visited by the CHHA on 8/6/2025, 8/8/2025, 8/13/2025, and 8/15/2025. However, there was no documented evidence the CHHA submitted her visit notes on 8/6/2025, 8/8/2025, 8/13/2025, and 8/15/2025 timely in accordance with the HHA’s policy. During a concurrent interview and record review, on 8/27/2025 at 1:05 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD reviewed Patient 5’s PT visit notes dated 8/8/2025, 8/12/2025, and 8/15/2025, and CHHA visit calendar for the month of August 2025. The DPCSD stated field staff needed to submit their clinical documentation completed accurately every Tuesday in accordance with the HHA’s policy. The DPCSD stated and acknowledged there was a delay in the submission of PT and CHHA clinical notes for the month of August for Patient 5. During a review of the agency’s policy and procedure (P&P) titled, “Submission of Notes,” dated 2/15/2010, the P&P indicated timely documentation and submission of clinical patient’s data and visit progress notes is a measure of the agency’s efficiency. Timely submission will facilitate billing, QA, payroll, and most of all, compliance to Department of Health and HCFA regulations. Progress notes/clinical documentation for all disciplines must be submitted to the office every Tuesday no later than 5:30 p.m.”