Quincy Home Medical Services

“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 observation, interview, and record review, the agency failed to individualize all treatments, pertinent diagnoses interventions and goals as relevant to the plan of care for one out of 10 sampled patients, (Patient 5). This failure had the potential for unidentified problems, risk for hospitalization and negative clinical outcomes. Findings: A review, of the agency’s undated policy titled, “Plan of Care,” indicated that home care services are furnished under the supervision and direction of the client’s physician. The plan of care (POC) is based on a comprehensive assessment and information provided by the client/family and health team members. Planning for care is a dynamic process that addresses the care, treatment, and services to be provided. The plan will be consistently reviewed to ensure that client needs are met, and will be updated as necessary, but at least every sixty days. The purpose of this policy is to provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs. Patient 5’s record was reviewed. Patient 5 was admitted to the home health agency on 4/15/24, with diagnoses that included Peripheral Venous Deficiency (PVD, circulation problem with reduced blood flow to the arms and legs, causing pain, tingling, and numbness), venous stasis ulcers (non-pressure open sores that develop on the les or ankles from poor circulation), Urinary Tract Infection (UTI, infection of the urinary tract, most common human bacterial infection) high blood pressure, cellulitis (inflammation and infection of the skin and underlying tissues), and history of falling. During an interview, on 3/26/25 at 2:10 pm, Patient 5 stated, “I do not remember being in the hospital for 5 days with a UTI, I was out of it. I couldn’t believe how sick you can get; I don’t remember a lot. That was before my husband of 52 years passed away. He passed in August, just a few months ago, and I just had to put my dog down. It is just me now, but my neighbors do stop by and check in on me.” During a follow up interview, on 3/26/25 at 2:30 pm, Patient 5 stated, “I do not know how to prevent a UTI, and I did not know the nurse can collect a urine sample. Since I can no longer drive, that would be wonderful if I need to be checked. I never want to go back to the hospital for that again.” During a review of Patient 5’s record, a document dated 4/15/24, titled, “Plan of Care (POC),” indicated that Patient 5 had no orders, interventions, or goals for education, prevention, or knowing when to report signs and symptoms of a UTI. Despite a diagnosis of UTI being listed on her POC. During an interview, on 3/27/25 at 10 am, the Clinical Supervisor (CS) confirmed, that Patient 5’s POC was not specific, and individualized on the POC on admission for a history of a recent UTI, and not listed on any POCs following. During an interview, on 3/27/25 at 11 am, the Quality Assurance RN (QA) confirmed, that Patient 5 should have specific orders, interventions and goals for a UTI, especially since there was a history, and diagnosis to support these interventions.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to have an effective governing body (GB) legally responsible for establishing and implementing management and operational policies to ensure effective administration of the agency to provide care and services within acceptable standards of practice when the agency failed to: Ensure the Quality Assurance Performance Improvement (QAPI) is up to date, defined, implemented and maintained. Areas included in the QAPI are areas to track and trend infections, root cause analysis, falls, update the Medical Director at least annually and as needed, and to include clinical oversight for accuracy and positive clinical outcomes by using the Outcome and Assessment Information Set (Oasis) data to measure outcomes. Ensure there were care coordination conferences for all patients on service to discuss ongoing assessments of patients. Ensure the Executive Director, or Clinical Supervisor provided oversight to make decisions on accepting new home health referrals and initiating the initial assessment within 48-hours, or updating the physician before the start of care (SOC). Ensure there is a Director of Patient Care Services, or Clinical Supervisor on site in both branches to provide clinical oversight for all nurses and staff. Ensure there were a written copy of fingerprints available for the Administrator, and designee in the branch for the agency. Ensure there is a Clinical Laboratory Improvement Amendment (CLIA, allows facilities to perform simple, low risk laboratory tests while ensuring quality control compliance with federal regulations) waiver for labs obtained in both branches of the agency. These failures had the potential to lead to poor case management, and negative clinical outcomes. Findings: 1. During a concurrent interview, and record review, on 3/27/25 at 3:45 pm, the Administrative Assistant (AA), provided the most recent copy of their QAPI report. The AA confirmed they are working on a new process to track and trend infections, falls, and include all the needed components to measure patient outcomes. 2. During an interview, on 3/26/25 at 4:15 pm, the Administrative Assistant (AA), and the Quality Assurance Registered Nurse (QA) confirmed, that there were no IDT notes for case conference for any of the 10 sampled patients. The QA confirmed, that IDT meetings are needed to discuss the patient needs, and revisions to provide quality care and individualized care of every patient on service. 3. During an interview, on 3/28/25 at 10 am, the Clinical Supervisor (SC), confirmed that Patients 1, 3, 4, 5, 7, 9, and Patient 10, did not have a timely initiation of their SOC, and the physicians were not updated. 4. During a phone interview, on 3/28/25 at 12:25 pm, the Administrator, confirmed that he would provide needed clinical oversight for both branches of the agency, and utilize his present clinical supervisor with years of experience in home health. 5. During an interview, on 3/27/25 at 4:30 pm, the AA confirmed, that there were no written copy of fingerprints on file for the Administrator, and the designee, but both were completed. AA reported, they were done at the local police department, we are waiting on the copies to be sent. 6. During an interview, on 3/28/25 at 12 pm, the AA confirmed, that the agency does not have a CLIA waiver for both branches of the agency.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview, and record review, the agency failed to ensure seven of 10 sampled patients (Patient 1, 3, 4, 5, 7, 9, and Patient 10), was assessed by a Registered Nurse (RN) within 48-hours of their referral for home health care, or notify the physician when there was a delayed start of care (admission to agency). This failure could result in changes to care without physician knowledge or approval, and a lack of adequate physician oversight leading to negative clinical outcomes. Findings: During a review of the agency’s policy undated, titled, “Comprehensive Client Assessment,” indicated the initial assessment visit must be held either within 48 hours of referral or within 48 hours of the client’s return home, or the physician’s start of care date. The initial assessment bridges the gap between the first client encounter until a plan of care can be implemented. The purpose of this policy is to determine the appropriate care, treatment and services to meet client initial needs and his/her changing needs. During a review of Patient 1’s clinical record, Patient 1 was admitted to the home health agency on 5/31/24 with diagnoses that included left femur fracture (broken bone of the thigh, the largest bone in the body), Atrial Fibrillation (irregular and fast heart rate), congestive heart failure (long term condition when your heart cannot pump enough blood for the body’s needs), diabetes (too much sugar in the blood), anxiety (a feeling of worry, nervousness or fear), and acute embolism (sudden obstruction of a blood vessel that travels in the bloodstream). During a review of Patient 1’s clinical record, a review of Patient 1’s visit documentation, it was noted that Patient 1 was referred to services on 5/27/24, but the start of care (SOC, initial comprehensive assessment) date was 5/31/24 (4 days later). There was no documentation, that the physician had been notified of this delay in the start of care. During a concurrent record review, and interview, on 3/25/25 at 2:30 pm, Administrative Assistant (AA) confirmed the SOC was not initiated within 48 hours for Patient 1. AA confirmed there was no documentation of a reason for the delay of the SOC, and no update sent to the physician to notify that services were delayed for Patient 1. During a review of Patient 4’s clinical record, Patient 1 was admitted to the home health agency on 2/25/25 with diagnoses that included respiratory failure with hypoxia (serious lung condition when there is not enough oxygen in the blood), pneumonia (a lung infection with inflammation and fluid making it hard to breathe), chronic kidney disease stage 3 (mild to moderate kidney damage, kidneys struggle to filter waste from the blood), myocardial injury (heart attack with heart damage), depression (persistent sadness, or loss of interest with activities that affect daily life), pulmonary embolism (condition when a blood clot travels to the lungs and blocks one or more blood vessels), and transient ischemic attacks (mini strokes, when the oxygen supply is briefly blocked in the brain resolving in minutes). During a review of Patient 4’s clinical record, a review of Patient 4’s visit documentation, it was noted that Patient 4 was referred to services on 2/17/25, but the SOC date was 2/25/25 (8 days later). There was no documentation, that the physician had been notified of this delay in the start of care. During a concurrent interview and record review on 3/25/25 at 4:40 pm, the AA confirmed the SOC was not initiated within 48 hours for Patient 4. AA confirmed there was no documentation of a reason for the delay of the start of care, and no update was sent to the physician to notify that services were delayed for Patient 4. During a review of Patient 5’s clinical record, Patient 5 was admitted to the home health agency on 4/15/24 with diagnoses that included Peripheral Venous Deficiency (PVD, circulation problem with reduced blood flow to the arms and legs, causing pain, tingling, and numbness), venous stasis ulcers (non-pressure open sores that develop on the les or ankles from poor circulation), Urinary Tract Infection (UTI, infection of the urinary tract, most common human bacterial infection) high blood pressure, cellulitis (inflammation and infection of the skin and underlying tissues), and history of falling. During a review of Patient 5’s clinical record, a review of Patient 5’s visit documentation, it was noted that Patient 5 was referred to services on 4/8/24, but the SOC date was 4/15/24 (7 days later). There was no documentation, that the physician had been notified of this delay in the start of care. During a concurrent interview and record review on 3/27/25 at 1:30 pm, the AA and the Clinical Supervisor (CS) confirmed the SOC was not initiated within 48 hours for Patient 5. AA and CS confirmed there was no documentation of a reason for the delay of the start of care, and no update was sent to the physician to notify that services were delayed for Patient 5. During a review of Patient 9’s clinical record, Patient 9 was admitted to the home health agency on 1/20/25 with diagnoses that included subdural hematoma, chronic stage 3 kidney disease (mild to moderate kidney damage, kidneys struggle to filter waste from the blood), hypothyroidism, depression (persistent sadness, or loss of interest with activities that affect daily life), anxiety (a feeling of worry, nervousness or fear), post-traumatic stress disorder (PTSD, mental health condition after experiencing trauma, leading to persistent distress, anxiety, nightmares, and flashbacks), macular degeneration (progressive, gradual loss of central vision), and repeated falls. During a review of Patient 9’s clinical record, a review of Patient 9’s visit documentation, it was noted that Patient 9 was referred to services on 1/15/25, but the SOC date was 1/20/25 (5 days later). There was no documentation, that the physician had been notified of this delay in the start of care. During a concurrent interview and record review on 3/27/25 at 3:55 pm, the AA and the CS confirmed the SOC was not initiated within 48 hours for Patient 9. AA and CS confirmed there was no documentation of a reason for the delay of the start of care, and no update was sent to the physician to notify that services were delayed for Patient 5. During a follow up interview on 3/28/25 at 10:00 am, the CS confirmed Patient 1, 3, 4, 5, 7, 9 and Patient 10 did not have a timely initiation of their SOC, and the physicians were not updated. CS stated, “We will work on a new process to make sure we meet this need moving forward, or we can ask the physician for a SOC date if indicated.” A review of Patient 3’s record indicated she had a referral date for admission for services from the agency on 5/6/24 and was admitted (start of care) on 5/13/24 (seven days later). Patient 3’s diagnoses included heart failure, high blood pressure, weakness and falls. A review of Patient 3’s physicians plan of care indicated orders for skilled nursing (SN) one time a week for 2 weeks (1W2) and 2 prn (as needed) for a change of condition. A “Delay in Initial Assessment …(Start of Care)” dated 5/8/24 notifying the physician of the delay of SOC was presented during the survey but failed to be signed by the physician. A review of Patient 7’s record indicated she had a referral date for admission for services from the agency on 3/6/25 and was admitted (start of care) on 3/11/25 (five days later). Patient 7’s diagnoses included a fractured left and right femur (thigh bone), history of falls, anemia, urinary tract infection and urinary incontinence. A review of Patient 7’s physicians plan of care indicated orders for SN one time a week for 8 weeks (1W8) and 4 prn visits for catheter and wound problems. During an interview and record review with the agency Clinical Supervisor (CS) on 3/27/25 at 4:10 pm she acknowledged Patient 7’s SOC was late stating it was not completed within 48 hours of the referral. A review of Patient 10’s record indicated she had a referral date for admission for services from the agency on 2/17/25 and was admitted (start of care) on 2/21/25 (four days later). Patient 10’s diagnoses included heart failure, hypertension and history of falling. A review of Patient 10’s physicians plan of care indicated orders for SN one time a week for 8 weeks (1W8) and 2 prn for change of condition. During an interview and record review with the agency CS on 3/28/25 at 9:34 am she acknowledged Patient 10’s SOC was late for nursing services.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to review and document all medications in the home for one out of four patients, (Patient 6) during the initial assessment and follow up home visits to include in the clinical record and for the physician to review for interactions. This failure had the potential to for unrecognized medication interactions to go unnoticed which could cause a negative clinical outcome. Findings: Patient 6’s record was reviewed. Patient 6’s record indicated she was admitted (start of care) on 3/4/25, with diagnoses that included a fractured right lower leg, atrial fibrillation (irregular heart rate), long term use of anticoagulants (blood thinners) and a history of falling. The plan of care indicated the skilled nurse would visit one time a week for three weeks (1wk3), and 2 PRN (as needed) for change of condition. Physical Therapy (PT) would visit after their evaluation for 1 time a week for 5 weeks (1wk5). The POC indicated that SN would perform medication reconciliation to ensure safe medication management. The POC included that PT would assess functional status, structural barriers in the environment, rehabilitation potential, gait training, safety precautions and pain management. On 3/26/25 at 9:30 am, a visit to Patient 6’s home was conducted with Physical Therapist (PT) E. Patient 6 was observed sitting in her recliner with her legs elevated upon arrival. PT E was observed asking Patient 6 what her pain level was on her right foot and she replied “6” (a standardized pain scale of 1 to 10 with 0 being the least pain and 10 the highest). During the exercise session PT E frequently inquired about Patient 6’s pain level and instructed her to stop the exercises with increased pain. He never inquired what Patient 6 was taking for pain, and if it was effective. PT E only instructed on elevation and the application of ice. PT E never reconciled (observed) her medications she was taking in the home against her Medication Profile. After PT E left the home, concurrently at 11 am Patient 6’s medication bottles were reviewed with her while reviewing her Medication Profile. The Medication Profile indicated she was taking Acetaminophen (Tylenol) 650 milligrams (mg) one tablet every six hours as needed for pain. She stated the Tylenol was effective. Additionally, the Medication Profile indicated Patient 6 was receiving Potassium Chloride 10 milliequivalents (mEQ) one tablet daily by mouth. The bottle indicated Patient 6 was taking Potassium Chloride ER (extended release)10 mEq one tablet daily by mouth. There was also a bottle of Turmeric 500 mg per tablet with Patient 6’s medications. She stated at this time she takes two tablets every day. The Turmeric medication was not listed on her Medication Profile. Concurrently, at 10:40 am, Patient 6 also stated she takes Ultra Flora (a probiotic) supplement one tablet every day that was observed in Patient 6’s refrigerator. Both the Turmeric and the Ultra Flora medication were not documented on the Medication Profile. The Potassium Chloride failed to be documented on the profile as being extended release. A follow up interview, was conducted with PT E on 3/27/25 at 3:40 pm. He confirmed, that he did not ask Patient 6 what she was taking for pain, and did not look at her medication she was taking. He stated he usually focuses on ice, and elevation. A review, of the facility’s undated “Medication Reconciliation and Documentation,” policy indicated the purpose was to ensure safe and correct administration of medication in patients’ homes. It directed that during the start of care or the resumption of care all bottles and containers including prescribed, over the counter medications, ointments and herbal supplements would be reviewed and evaluated for compliance to the physician’s orders. The policy directs on each follow up visit nursing, and therapy would verify the patient is still following the previous Medication Profile list.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to identify and update the physician of a significant change in condition for three of 10 sampled patients (Patient 1, 3, and Patient 6) when: 1. Patient 1 had an elevated blood pressure (B/P) that was not immediately reported to the physician. 2. Patient 3 had an unwitnessed fall not reported to the physician. 3. Patient 6 had a new onset of edema (swelling) at the surgical site of the right ankle not reported to the physician. These failures had the potential for medical complications, hospitalizations, and did result in changes of conditions not reported to the physician which could cause a delay in treatment leading to negative clinical outcomes. Findings: During a review of the agency’s policy undated, titled, “Medical Supervision,” indicated physicians will be informed, at the same time their clients are admitted to the agency. The physician will be contacted when any of the following occurs: condition changes, expected response to treatment or medication changes, laboratory results are received, caregiver support or home environment changes, any change in client condition or agency services. In the event the primary physician is not available, the on-call physician for that clinic will be utilized. If the agency staff is unable to obtain orders from the on-call physician in a timely manner, the agency medical director will be utilized. During a review of the agency’s policy not dated, titled, “Coordination of Care,” indicated the agency will integrate services, whether they are provided directly or under contract, to assure the identification of client needs and factors that could affect client safety and the effectiveness of treatment. The coordination of care is provided by all disciplines and communication with the physician. This policy also indicated Coordination of care means assuring that the client needs are continually assessed, addressed in the plan of care (POC), that care is delivered in a timely and effective manner, and goals are achieved.” During a review of Patient 1’s clinical record, Patient 1 was admitted to the home health agency on 5/31/24 with diagnoses that included left femur fracture (broken bone of the thigh, the largest bone in the body), Atrial Fibrillation (irregular and fast heart rate), congestive heart failure (long term condition when your heart cannot pump enough blood for the body’s needs), high blood pressure, diabetes (too much sugar in the blood), anxiety (a feeling of worry, nervousness or fear), and acute embolism (sudden obstruction of a blood vessel that travels in the bloodstream). During a review of Patient 1’s clinical record, a document dated 5/31/25, titled, “Plan of Care (POC, physician orders that help nurses and other team members organize aspects of patient care with a timeline),” indicated on page 3 for skilled nursing to instruct on disease process for high (normal blood pressure for an adult is blood pressure (B/P) less than 130/80 millimeters of mercury (mmHg, a unit of measure) and expressed in two separate numbers, including medications, home management, monitoring B/P, and related nutrition, salt intake. During a review of Patient 1’s clinical record, a document dated 5/31/25, titled, “POC,” indicated on page 4 for high blood pressure goals: Patient will achieve a stable B/P. During a review of Patient 1’s clinical record, a document dated 6/4/24, titled, “Communication Note,” to the physician indicated Patient 1 had a B/P of 180/79 mmHg at the home visit on 6/4/24 with a history of hypertension (high blood pressure) and falls. This document for communication was signed on 6/12/24, 8 days after the elevated blood pressure was reported via fax. This document had a note added by the physician as follows: “Recheck blood pressure and monitor symptoms.” During an interview on 3/25/25 at 3:30 pm, the Quality Assurance Registered Nurse (QA) confirmed this B/P for Patient 1 was too high, and it should have been called to the physician for a timely response, and completed an additional nurse visit to follow up with Patient 1 to re-check and monitor the B/P and symptoms. QA confirmed an untreated high blood pressure could cause many complications and needed immediate attention. QA stated, “I agree, there are specific problems that cannot wait, and the physician should be called at the visit.” Kim: Patient 6 had new onset of edema in Rt ankle area. (Documented by PT and SN after full weight bearing, no update). Patient 3 had a fall with no physician update. During a review of Patient 3’s clinical record, Patient 3 was admitted to the home health agency on 5/13/24 with diagnoses that included heart failure, high blood pressure, weakness and falls. A review of Patient 3’s physicians plan of care indicated orders for skilled nursing (SN) one time a week for 2 weeks (1W2) and 2 prn (as needed) for a change of condition. There was also an order for Physical Therapy (PT) for one time a week (1wk1) to evaluate and treat. After the PT evaluation the services were ordered one time a week for 4 weeks (1W4). During a review of Patient 3’s record an Incident Log dated 5/22/24, showed a Registered Nurse documented during a home visit Patient 3 stated she had fallen stepping off the sidewalk and feel backwards on her back. She stated she was uninjured and she was helped by a bystander. Additionally, the RN documented this day Patient 3 was reaching in her refrigerator to put food away, lost balance and feel backwards and EMS (emergency medical response) was called. A review of a Physical Therapy (PT) visit note dated 5/22/24 (the same day) indicated Patient 3 informed the visiting PT she feel in the kitchen since her last visit attempting to put food away. There was no documentation of Patient 3’s physician being notified of her stated unwitnessed falls by the visiting RN or the PT. During an interview with the Clinical Supervisor (CS) on 3/27/25 at 1:45 pm she stated it is the agencies expectation that nursing staff are to notify the physician of falls. She concurrently stated she could not find any physician notification from nursing or therapy which saw Patient 3 the same day. During a review of Patient 6’s clinical record, Patient 6 was admitted to the home health agency on 3/4/25 with diagnoses that included a fractured right lower leg, atrial fibrillation (irregular heart rate), long term use of anticoagulants (blood thinners) and a history of falling. The plan of care indicated the skilled nurse would visit one time a week for three weeks (1wk3) and 2 prn (as needed) for change of condition and the Physical Therapy (PT) would visit after their evaluation for 1 time a week for 5 weeks (1wk5). The POC included that PT would assess functional status, structural barriers in the environment, rehabilitation potential, gait training, safety precautions, home exercise program and pain management. On 3/26/25 at 9:30 am a visit to Patient 6’s home was conducted with Physical Therapist (PT) E. Prior to entrance PT E stated Patient 6 is now full weight bearing to her right foot and was previously ordered non weight bearing. Patient 6 was observed sitting in her recliner with her legs elevated upon arrival. Concurrently at 9:40 am PT E stated Patient 6’s right foot had slight redness and swelling since his last visit. Patient 6 stated her right foot pain level was a “6” (a standardized pain scale of 1 to 10 with 1 being the least pain and 10 being the highest). PT E did not assess Patient 6’s pulses on her right foot (ensure circulation was adequate). A review of PT E’s 3/26/25 visit note was reviewed after the visit. Under assessment, PT E documented he noted mild redness on Patient 6’s right lateral malleolus (prominent bone on the outside of the ankle) and increased swelling since her previous session. He also indicated Patient 6 was having mild pain since she has been walking more. A follow up interview was conducted with PT E on 3/27/25 at 3:40 pm. He confirmed he did not notify Patient 6’s physician of her increased swelling and redness to her right ankle area. During a interview and record review with the CS on 3/27/25 at 4 pm she stated the physicians should be notified of any changes of condition. She stated the agency does have a doppler (a device that can detect blood flow) to check Patients pulses.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on interview, and record review, the agency failed to ensure 10 out of 10 patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, and Patient 10) had Interdisciplinary (IDT, contributions of various health care disciplines and their interactions with each other to meet the patient’s needs) ongoing assessments documented in the clinical record. This failure had the potential for unrecognized needs to go unmet with negative clinical outcomes. Findings: During a review of the agency’s policy not dated, titled, “Coordination of Care,” indicated the agency will integrate services, whether they are provided directly or under contract, to assure the identification of client needs and factors that could affect client safety and the effectiveness of treatment. The coordination of care is provided by all disciplines and communication with the physician. This policy also indicated Coordination of care means assuring that the client needs are continually assessed, addressed in the plan of care (POC), that care is delivered in a timely and effective manner, and goals are achieved.” During a review of Patient 1’s clinical record, Patient 1 was admitted to the home health agency on 5/31/24 with diagnoses that included left femur fracture (broken bone of the thigh, the largest bone in the body), Atrial Fibrillation (irregular and fast heart rate), congestive heart failure (long term condition when your heart cannot pump enough blood for the body’s needs), diabetes (too much sugar in the blood), anxiety (a feeling of worry, nervousness or fear), and acute embolism (sudden obstruction of a blood vessel that travels in the bloodstream). During a review of Patient 1’s clinical record, there were no IDT notes documented in Patient 1’s clinical record from 5/31/24 through 7/3/24, when Patient 1 was discharged from the agency. During a review of Patient 4’s clinical record, Patient 1 was admitted to the home health agency on 2/25/25 with diagnoses that included respiratory failure with hypoxia (serious lung condition when there is not enough oxygen in the blood), pneumonia (a lung infection with inflammation and fluid making it hard to breathe), chronic kidney disease stage 3 (mild to moderate kidney damage, kidneys struggle to filter waste from the blood), myocardial injury (heart attack with heart damage), depression (persistent sadness, or loss of interest with activities that affect daily life), pulmonary embolism (condition when a blood clot travels to the lungs and blocks one or more blood vessels), and transient ischemic attacks (mini strokes, when the oxygen supply is briefly blocked in the brain resolving in minutes). During a review of Patient 4’s clinical record, there were no IDT notes documented in Patient 4’s clinical record from 2/25/25 through 3/27/25. During a review of Patient 5’s clinical record, Patient 1 was admitted to the home health agency on 4/15/24 with diagnoses that included Peripheral Venous Deficiency (PVD, circulation problem with reduced blood flow to the arms and legs, causing pain, tingling, and numbness), venous stasis ulcers (non-pressure open sores that develop on the les or ankles from poor circulation), Urinary Tract Infection (UTI, infection of the urinary tract, most common human bacterial infection) high blood pressure, cellulitis (inflammation and infection of the skin and underlying tissues), and history of falling. During a review of Patient 5’s clinical record, there were no IDT notes documented in Patient 5’s clinical record from 4/15/24 through 3/27/25. During a review of Patient 8’s clinical record, Patient 1 was admitted to the home health agency on 2/19/25 with diagnoses that included neoplasm of the liver (growth of tumor in the liver), liver disease (damaged liver which cleanses the blood and aids in digestion by secreting bile), diabetes (too much sugar in the blood), and elevated white blood cell (wbc) count (abnormal high number of wbcs, cells used to fight infection), hypothyroidism (underactive thyroid not producing enough hormones), and repeated falls. During a review of Patient 8’s clinical record, there were no IDT notes documented in Patient 8’s clinical record from 2/19/25 through 3/27/25. During a review of Patient 9’s clinical record, Patient 9 was admitted to the home health agency on 1/20/25 with diagnoses that included subdural hematoma, chronic stage 3 kidney disease (mild to moderate kidney damage, kidneys struggle to filter waste from the blood), hypothyroidism, depression (persistent sadness, or loss of interest with activities that affect daily life), anxiety (a feeling of worry, nervousness or fear), post-traumatic stress disorder (PTSD, mental health condition after experiencing trauma, leading to persistent distress, anxiety, nightmares, and flashbacks), macular degeneration (progressive, gradual loss of central vision), and repeated falls. During a review of Patient 9’s clinical record, there were no IDT notes documented in Patient 9’s clinical record from 1/20/25 through 3/27/25. During an interview on 3/26/25 at 4:15 pm, the Administrative Assistant (AA) and the Quality Assurance Registered Nurse (QA) confirmed there were no IDT notes for case conference for any of the 10 sampled patients. QA confirmed IDT meetings are needed to discuss the patient needs, and revisions to provide quality care and individualized care of every patient on service. QA stated, “We will begin case conference meetings immediately in both branches and record in the medical record.” During a review of Patient 2’s clinical record, Patient 2 was admitted to the home health agency on 11/11/24 with diagnoses that included heart failure, diabetes and severe protein and calorie malnutrition. During a review of Patient 2’s clinical record, there were no IDT notes documented in Patient 2’s clinical record from 11/11/24 through 12/24/24, when Patient 2 was discharged from the agency. During a review of Patient 3’s clinical record, Patient 3 was admitted to the home health agency on 5/13/24 with diagnoses that included heart failure, high blood pressure, weakness and falls. During a review of Patient 3’s clinical record, there were no IDT notes documented in Patient 3’s clinical record from 5/13/24 through 6/21/24, when Patient 2 was discharged from the agency. During a review of Patient 6’s clinical record, Patient 6 was admitted to the home health agency on 3/4/25 with diagnoses that included a fractured right lower leg, atrial fibrillation (irregular heart rate), long term use of anticoagulants (blood thinners) and a history of falling. During a review of Patient 6’s clinical record, there were no IDT notes documented in Patient 6’s clinical record from 3/4/25 through 3/27/25. During a review of Patient 7’s clinical record, Patient 7 was admitted to the home health agency on 3/11/25 with diagnoses that included fractured left and right femur (thigh bone) history of falls, anemia, urinary tract infection and urinary incontinence. During a review of Patient 7’s clinical record, there were no IDT notes documented in Patient 7’s clinical record from 3/11/25 through to 3/27/25. During a review of Patient 10’s clinical record, Patient 10 was admitted to the home health agency on 2/21/25 with diagnoses that included heart failure, hypertension and history of falling. During a review of Patient 10s’s clinical record, there were no IDT notes documented in Patient 10s’s clinical record from 2/21/25 through to 3/27/25.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview, and record review, the agency failed to ensure three of 10 sampled patients (Patient 3, 7, and 10), were evaluated by a discipline ordered by the referring physician in a timely manner included in the plan of care (POC), when Patient 1, 7, and 10’s Physical Therapy (PT) evaluation was late. This failure could result in changes to care without physician knowledge or approval, and a lack of adequate physician oversight which could lead to negative clinical outcomes. Findings: Patient 3’s record was reviewed. A review of Patient 3’s record indicated she had a referral date for admission for services from the agency on 5/6/24, and was admitted (start of care) on 5/13/24 (seven days later). Patient 3’s diagnoses included heart failure, high blood pressure, weakness and falls. A review, of Patient 3’s physician’s plan of care included orders for for Physical Therapy (PT) for one time a week (1wk1) to evaluate and treat. The first PT visit was documented on 5/15/24 (nine days after the referral). A “Delay in Initial Assessment…(Start of Care)” dated 5/8/24, notifying the physician of the delay of SOC was presented during the survey, but failed to be signed by the physician. During an interview, with the Clinical Supervisor (CS) on 3/27/25 at 2 pm, she stated, that Patient 3’s PT SOC was late. Patient 7’s record was reviewed. Patient 7’s record indicated, that she had a referral date for admission for services from the agency on 3/6/25, and was admitted (start of care) on 3/11/25 (five days later). Patient 7’s diagnoses included fractured left and right femur (thigh bones) history of falls, anemia, urinary tract infection, and urinary incontinence. A review, of Patient 7’s physician’s plan of care included for PT to visit one time a week (1wk1) to evaluate and treat. The first PT visit was documented on 3/17/24, eleven days after the referral. During an interview, and record review, with the CS on 3/27/25 at 4:10 pm, she acknowledged, that Patient 7’s PT SOC was late. Patient 10’s record was reviewed. Patient 10’s record indicated, that she had a referral date for admission for services from the agency on 2/17/25, and was admitted (start of care) on 2/21/25 (four days later). Patient 10’s diagnoses included heart failure, hypertension and history of falling. A review, of Patient 10’s physician’s plan of care indicated included orders for PT for one time a week (1wk1) to evaluate and treat. The first PT visit was documented on 2/26/25 (nine days from the referral date). During an interview, and record review, with the agency CS on 3/28/25 at 9:34 am, she acknowledged, that Patient 10’s SOC was late for physical therapy services.”