Providence at Home With Compassus Home Health, Orange County South

“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 physician was notified of the missed visit for one of three sampled patients (Patient 1). This failure had the potential for not addressing the care needs for this patient. Review of the agency’s P&P titled Written and Verbal Orders revised 1/31/24, showed if a physician order cannot be carried out, the professional who identifies the issue notifies the physician of the concern and obtains new orders to clarify the delivery of care, for example: missed visits (patient declines a visit and declines to reschedule, patient is hospitalized, etc.) Review of Patient 1’s closed clinical record was initiated on 5/6/26. The clinical record showed the SOC was 1/29/26. The patient was certified for home health services during the certification period from 1/29/26 to 3/3/29/26. The patient was discharged on 3/11/26. Review of the Home Health Certification and Plan of Care for certification period from 1/29/26 to 3/29/26, showed MSW visits 1WK1 (one visit a week for one week), effective 2/1/26. However, there was no documented evidence of the MSW visit during the week of 2/1/26 - 2/7/26. DCS 2 was asked and stated the MSW had a missed visit on 2/6/26, and it was rescheduled. However, DCS 2 was unable to provide documentation why the visit was missed and if the physician was notified of the missed rescheduled visit. On 5/8/26 at 0952 hours, an interview and concurrent clinical record review was conducted with the ED, HH Director of Quality Outcomes, DCS 1 and 2. DCS 2 acknowledged and verified 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 reaction for one of three sampled patients (Patient 3). 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. Review of the agency’s P&P titled Initial and Comprehensive Assessments Recertification Assessment and Timing revised 2/27/26, showed the purpose of the procedure was to provide specific guidance to the members of the home health interdisciplinary team licensed professionals regarding the performance of the initial home health assessment and ongoing comprehensive assessments to ensure information is collected, documented, and presented to the patient’s provider in a timely and consistent manner. Procedures showed medication inventory to include medications the patient is actively prescribed, medications the patient has on hand, over-the-counter medications, and herbal preparations as well as any substances the patient use recreationally or for permitted medical use. Medication inventory provides the basis for medication reconciliation and appropriate medication management to support patient goals for care, and medication inventory ensures medications which are high risk or high-alert are recognized and address quickly by the home health clinical team members. Review of Patient 3’s clinical record was initiated on 5/7/26. The clinical record showed the SOC was 1/1/25. The patient was certified for home health services during the certification periods from 12/31/24 to 3/23/25, 3/24/25 to 3/24/25, 3/25/25 to 10/27/25, 10/28/25 to 12/26/25, 12/27/25 to 2/24/26, 2/25/26 to 4/25/26, and 4/26/26 to 6/24/26. The Client Medication Report for the certification period 4/26/26 to 6/24/26, showed the patient’s medications included the following: -Basaglar KwikPen insulin (used to manage blood sugar levels) 100 unit/ml (3 ml) subcutaneous inject 10 ml at bedtime for diabetes. -Dermal Wound Cleanser as ordered prior to applying unna boot (used to treat venous insufficiency). -Ozempic (used to improve blood sugar control) 0.25 mg or 0.5 mg (2 mg/3 ml) subcutaneous pen injector 0.5 mg weekly for diabetes. However, the medications at the patient’s home showed the following: -Basaglar KwikPen insulin 100 unit/ml (3 ml) subcutaneous inject 35 units in the morning for diabetes. -Ozempic 0.25 mg or 0.5 mg (2 mg/3 ml) subcutaneous pen injector 0.25 mg every Sunday for diabetes. Both medications’ dosage were not consistent with the Client Medication Report. In addition, The Home Health Certification and Plan of Care for the certification period from 4/26/26 to 6/24/26, did not include an order for the application of the unna boot and the following medications that the patient was on: -loperamide (antidiarrheal) 2 mg one tablet as needed. -Centrum 50 + (supplement) one tablet daily. -triple action joint health (supplement) one pill a day. -Benefiber probiotic (fiber supplement) one gummy daily. A joint home visit with RN 1 and DCS 2 was conducted on 5/7/26 at 1200 hours, to Patient 3’s home. RN 1 confirmed the medication profiles were not updated. DCS 2 was observing and acknowledged the findings. On 5/8/26 at 1037 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1 and 2. DCS 2 acknowledged and verified the findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patient received care and services as per the written POCs for one of three sampled patients (Patient 3). This failure created the risk of not providing appropriate, consistent, and quality care to this patient. Findings: Review of Patient 3’s clinical record was initiated on 5/7/26. The clinical record showed the SOC was 1/1/25. The patient was certified for home health services during the certification period from 12/31/24 to 3/23/25, 3/24/25 to 3/24/25, 3/25/25 to 10/27/25, 10/28/25 to 12/26/25, 12/27/25 to 2/24/26, 2/25/26 to 4/25/26, and 4/26/26 to 6/24/26. The POC, for the certification period 2/25/26 to 4/25/26, showed SN visits 1WK9 for skilled nurse to evaluate and develop the plan of care to be countersigned by the physician. Review of the Visit Note Report dated 4/2/26, showed wound care to the right lower leg was performed and collagen dressing was applied with a four-by-four gauze covering for nighttime protection. However, the POC, for the certification period 2/25/26 to 4/25/26, did not include an order for the application of collagen dressing with four-by-four gauze covering the patient’s right lower leg for nighttime protection. On 5/8/26 at 1037 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1 and 2. DCS 2 acknowledged and verified the findings.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the coordination with the physician regarding obtaining the patient’s weight for one of three sampled patients (Patient 3). This failure created the risk of not providing appropriate, consistent, and quality care to this patient. Findings: Review of Patient 3’s clinical record was initiated on 5/7/26. The clinical record showed the SOC was 1/1/25. The patient was certified for home health services during the certification period from 12/31/24 to 3/23/25, 3/24/25 to 3/24/25, 3/25/25 to 10/27/25, 10/28/25 to 12/26/25, 12/27/25 to 2/24/26, 2/25/26 to 4/25/26, and 4/26/26 to 6/24/26. The POC for certification period 4/26/26 to 6/24/26, showed SN visit 1WK9. The POC included for the SN to notify physician if patient gains more than three pounds for 24 hours or five pounds in a week. However, there was no documented evidence of coordination with the physician to clarify who was responsible for obtaining the patient’s weight. Review of the Visit Note Report dated 4/30/26, showed no documented evidence of the patient’s weight. Moreover, during a joint home visit with RN 1 and DCS 2 conducted on 5/7/26 at 1200 hours, to Patient 3’s home, RN 1 confirmed the patient’s weight was not obtained during the visit. On 5/8/26 at 1037 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1, and DCS 2. DCS 2 acknowledged and verified the findings. Review of Patient 3’s clinical record was initiated on 5/7/26. The clinical record showed the SOC was 1/1/25. The patient was certified for home health services during the certification period from 12/31/24 to 3/23/25, 3/24/25 to 3/24/25, 3/25/25 to 10/27/25, 10/28/25 to 12/26/25, 12/27/25 to 2/24/26, 2/25/26 to 4/25/26, and 4/26/26 to 6/24/26. The POC for certification period 4/26/26 to 6/24/26, showed SN visit 1WK9. The POC included for the SN to notify the physician if the patient gains more than three pounds for 24 hours or five pounds in a week. However, there was no documented evidence of coordination with the physician to clarify who was responsible for obtaining the patient’s weight and how often to weight the patient. Review of the Visit Note Report dated 4/30/26, showed no documented evidence of the patient’s weight. Moreover, during a joint home visit with RN 1 and DCS 2 conducted on 5/7/26 at 1200 hours, to Patient 3’s home, RN 1 confirmed the patient’s weight was not obtained during the visit. On 5/8/26 at 1037 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1 and 2. DCS 2 acknowledged and verified the findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s skilled professionals prepared accurate clinical notes for two of three sampled patients (Patients 1 and 2). This failure created the increased risk of substandard healthcare outcomes for these patients as their clinical information was not accurate. Findings: 1. Review of Patient 1’s closed clinical record was initiated on 5/6/26. The clinical record showed the SOC was 1/29/26. The patient was certified for home health services during the certification period from 1/29/26 to 3/3/29/26. The patient was discharged on 3/11/26. The Client Medication Report for the certification period 1/29/26 to 3/29/26, showed the patient’s medications included the following: -simvastatin (lipid lowering medication) 20 mg taken daily for cholesterol. -tamsulosin (medication used to treat enlarged prostate) 0.4 mg two times daily for prostate. -trazodone (antidepressant) 100 mg daily for insomnia. Review of the Visit Note Reports showed Patient 1 was assessed for pain. For example, the Visit Note Reports dated on the following dates indicated pain was managed by medications, rest, position changes and distraction: -On 2/3/26, 2/10 (0=no pain, 1-3=mild pain and 10=worst pain) left knee pain. -On 2/5/26, 1/10 left knee pain. -On 2/13/26, right hip pain. *However, there was no documented evidence of the pain medication in the patient’s Client Medication Report. On 5/8/26 at 0940 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1, and DCS 2. The HH Director of Quality Outcomes acknowledged and verified the findings. 2. Review of Patient 2’s clinical record was initiated on 5/6/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification period from 1/16/26 to 3/16/26 and 3/17/26 to 5/15/26. The Client Medication Report for the certification period 3/17/26 to 5/15/26, showed the patient’s medications included the following: -bupropion HcL (antidepressant) 100 mg one tablet twice daily. -Eliquis (blood thinner) 5 mg one tablet twice daily. -metoprolol tartrate (antihypertensive medication) 25 mg one half tablet twice daily. Review of the Visit Note Reports showed Patient 2 was assessed for pain. For example, the Visit Note Reports dated 4/1 and 4/30/26 showed the patient’s pain was managed by medications, rest, position changes, and distraction. *However, there was no documented evidence of the pain medication in the patient’s Client Medication Report. On 5/8/26 at 0952 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1 and DCS 2. The HH Director of Quality Outcomes acknowledged and verified the findings. 1. Review of Patient 1’s closed clinical record was initiated on 5/6/26. The clinical record showed the SOC was 1/29/26. The patient was certified for home health services during the certification period from 1/29/26 to 3/3/29/26. The patient was discharged on 3/11/26. The Client Medication Report for the certification period 1/29/26 to 3/29/26, showed the patient’s medications included the following: -simvastatin (lipid lowering medication) 20 mg taken daily for cholesterol. -tamsulosin (medication used to treat enlarged prostate) 0.4 mg two times daily for prostate. -trazodone (antidepressant) 100 mg daily for insomnia. Review of the Visit Note Reports showed Patient 1 was assessed for pain as follows: -On 2/3/26, 2/10 (0=no pain, 1-3=mild pain and 10=worst pain) left knee pain. -On 2/5/26, 1/10 left knee pain. -On 2/13/26, right hip pain. The documents showed the pain was managed by medications, rest, position changes and distraction. *However, there was no documented evidence of the pain medication in the patient’s Client Medication Report. On 5/8/26 at 0940 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS and 2. The HH Director of Quality Outcomes acknowledged and verified the findings. 2. Review of Patient 2’s clinical record was initiated on 5/6/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification period from 1/16/26 to 3/16/26 and 3/17/26 to 5/15/26. The Client Medication Report for the certification period 3/17/26 to 5/15/26, showed the patient’s medications included the following: -bupropion HcL (antidepressant) 100 mg one tablet twice daily. -Eliquis (blood thinner) 5 mg one tablet twice daily. -metoprolol tartrate (antihypertensive medication) 25 mg one-half tablet twice daily. Review of the Visit Note Reports showed Patient 2 was assessed for pain. For example, the Visit Note Reports dated 4/1 and 4/30/26, showed the patient’s pain was managed by medications, rest, position changes, and distraction. *However, there was no documented evidence of the pain medication in the patient’s Client Medication Report. On 5/8/26 at 0952 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1 and 2. The HH Director of Quality Outcomes acknowledged and verified the findings.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency’s RN or other appropriately skilled professional provided the onsite supervision for the HHA no less frequently than every 14 days to ensure quality of care and services provided for one of three sampled patients (Patient 1). This failure had the potential for substandard health outcomes to this patient. Review of Patient 1’s closed clinical record was initiated on 5/6/26. The clinical record showed the SOC was 1/29/26. The patient was certified for home health services during the certification period from 1/29/26 to 3/3/29/26. The patient was discharged on 3/11/26. Review of the Home Health Certification and Plan of Care for the certification period from 1/29/26 to 3/29/26, showed CHHA visits 1WK1, 2WK2, and 1WK1, effective 2/1/26. The HHA notes showed the CHHA visits were conducted during Week 2 (2/1/26 to 2/7/26), Week 3 (2/8/26 to 2/14/26, Week 4 (2/15/26 to 2/21/26), and Week 5 (2/22/26 to 2/28/26). Review of the physician’s order dated 3/4/26, showed a request for CHHA once weekly for four weeks, effective 3/1/26. The CHHA notes showed the CHHA visits were conducted during Week 6 (3/1/26 to 3/7/26) and Week 7 (3/8/26 to 3/11/26). However, there was no documented evidence the RN or other appropriately skilled professional completed a supervisory visit for the CHHA no less frequently than every 14 days from 2/1/26 to 3/11 26. On 5/8/26 at 0952 hours, an interview and concurrent clinical record review were conducted with the ED, HH Director of Quality Outcomes, DCS 1 and 2. The Director of Quality Outcomes verified the findings.”