Grandcare Home Health Services

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation (refers to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Comprehensive Assessment (a tool used by nurses to evaluate a patient’s complete health status) of Patients as follows: The Home Health Agency (HHA) failed to review all the medications and clarify discrepancies in medication administration with the physician for three of 19 sampled patients (Patient 1, Patient 3 and Patient 4). This deficient practice had the potential to place Patients 1, 3 and 4 at risk for medication errors and adverse drug reactions defined as harmful, unintended responses resulting from the use of medications (Refer to G536). The cumulative effect of these systemic failures resulted in the HHA’s failure to deliver mandated compliance (in a way that is decided and controlled by law) with Federal regulations for Comprehensive Assessment of Patients to ensure the provision of health care services in a safe manner is provided to patients.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, agency providing care to a love one in the comfort of home) failed to ensure compliance with the Condition of Participation for Care Planning, Coordination, and Quality of Care, resulting in failure to meet Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) participation requirements, as evidenced by the following: The Physical Therapist Aide (PTA 1) failed to notify the physician of a change in condition for one of 17 sampled patients (Patient 3). On 1/16/2026, while assisting Patient 3 with ambulation on the sidewalk, Patient 3 experienced dizziness and lightheadedness, nearly resulting in a fall. The physician was not notified of this change in condition. This deficient practice increased the risk of syncope episodes and potential fall-related injury for Patient 3. (Refer to G590.) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Care planning, Coordination, Quality of care to ensure the highest quality of care was provided to the patients who were assessed to receive care and 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 Home Health Agency (HHA) failed to review all the medications and to clarify discrepancies in medication administration with the physician for four of nineteen sampled patients (Patients 1, 3, 4 and 11). This deficient practice had the potential to place Patients 1, 3 and 4 at risk for medication errors and adverse drug reactions defined as harmful, unintended responses resulting from the use of medications. d. During a review of Patient 11’s Start of Care (SOC) record, the SOC indicated that the Home Health Agency (HHA) admitted Patient 11 on 1/16/2026 with diagnoses that included aftercare following joint replacement surgery, presence of right artificial hip joint, and Type 2 diabetes mellitus with diabetic chronic kidney disease (uncontrolled high blood sugar levels that lead to kidney failure). During a review of Patient 11’s Plan of Care (POC) for the certification period of 1/16/2026 through 3/16/2026, the POC indicated that the Skilled Nurse (SN) was ordered to visit one time per week for two weeks to evaluate the patient and develop the plan of care. The POC further indicated that the SN was responsible for reviewing the medication profile and reconciling medications as needed. The POC also included physician orders for the Physical Therapist (PT) and PT Aide to review the medication profile and reconcile medications as needed, instruct and reinforce medication teaching related to medications used to treat the disease process, and report vital signs falling outside the following established parameters: systolic blood pressure less than 90 or greater than 180, diastolic blood pressure less than 50 or greater than 100, and pulse less than 60 or greater than 100. During a home visit observation on 1/21/2026 at 1:00 p.m. at Patient 11’s residence, Patient 11 was observed sitting on a couch in the living room. During a review of Patient 11’s HHA medication profile during the same visit, the medication profile listed the following medications: Losartan 50 mg, one tablet by mouth dailyCarvedilol Phosphate 10 mg extended-release capsule, one capsule dailyPregabalin 75 mg, one capsule by mouth twice daily During a concurrent interview with Patient 11 on 1/21/2026 at 1:00 p.m., Patient 11 stated he had not taken the above medications since approximately three weeks prior to his surgery on 1/15/2026. During an interview on 1/26/2026 at 11:00 a.m. with the Director of Patient Care Services (DPCS) at the HHA office, the DPCS stated that the Skilled Nurse and Physical Therapist were expected to check the patient’s actual medications and ask the patient whether medications were being taken as ordered. During a review of the HHA’s policy and procedure titled “Medication Profile,” revised April 2018, the policy indicated that medication profiles are to be updated with each change to reflect current medications, including newly prescribed and discontinued medications. a. During a review of Patient 1’s Start of Care (SOC) record, the SOC indicated the HHA admitted Patient 1 on 1/3/2026, with a diagnosis of bilateral osteoarthritis (a degenerative joint disease causing pain, stiffness and reduced mobility when protective cartilage wears down) of the knees. During a review of Patient 1’s Plan of Care (POC) for the certification period 1/3/2026 to 3/3/2026, the POC indicated that the Physical Therapist (PT) and PT Aide were responsible for reviewing the medication profile and reconciling medications as needed, instructing and reinforcing medication education related to the medication treatment of the patient’s disease processes, and reporting vital signs signs that fell outside the following established parameters: systolic blood pressure less than 90 and greater than 180, diastolic blood pressure 50 and greater than 100, pulse less than 60 and greater than 100. The POC included a physician’s order dated 1/3/2026 for the following prescribed medication: 1. Quetiapine 25 mg tablet, an antipsychotic medication used to treat depressive disorders with instructions to administer one-half (0.5) tablet orally once daily for mood stabilization. During an observation on 1/21/2026, at 1:30 p.m., a home visit was conducted at Patient 1’s residence. Patient 1 was observed sitting in a chair in the dining room and appeared confused. Family Member 1 (FM 1) was seen heading towards the kitchen to grab all of Patient 1’s medication in one container to show the surveyor. During a concurrent observation and interview on 1/21/2026, at 1:45 p.m., while reviewing Patient 1’s medication, one bottle of Quetiapine 25 mg tablets was observed in the medication tray. FM 1 stated she had been administering one 25 mg tablet daily to Patient 1 since 1/3/2026. FM 1 further stated that the Physical Therapist (PT ) and PT Aide did not review or check Patient 1’s medications during any of their visits. During an interview on 1/26/2026, at 11 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated the PT (in general) and the PT aide needed to check the patient’s actual medications and needed to ask the patients if they were taking the medications or not. b. During a review of Patient 3’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 (SOC) date of 1/7/2026, diagnoses that included essential hypertension (high blood pressure- the force of blood pushing against with the artery walls is consistently too high) and unspecified atrial fibrillation (irregular heart beat) and atrial flutter (an electrical short circuit in the heart’s right atrium that causes it to contract rapidly). During a review of Patient 3’s Plan of Care (POC) for the certification period of 1/7/2026 through 3/7/2026, the POC indicated that the Physical Therapist (PT)/PT Aide was responsible for reviewing the medication profile and reconciling medications as needed, instructing and reinforcing medication teaching related to medications used to treat the disease process, and reporting vital signs falling outside the following established parameters: systolic blood pressure less than 90 or greater than 180, diastolic blood pressure less than 50 or greater than 100, and pulse less than 60 or greater than 100. The POC included a physician’s order dated 1/7/2026 for the following medication: Eliquis (blood thinner medication) 2.5 mg, one tablet by mouth twice daily. During an observation on 1/22/2026 at 1:30 p.m., a home visit was conducted at Patient 3’s residence. Patient 3 was observed sitting in a chair in the living room with Family Member 2 (FM 2) present. During the concurrent observation and interview on 1/22/2026 at 1:45 p.m., while reviewing Patient 3’s medications, there was one bottle of Eliquis 5 mg, with directions to take one tablet twice daily, and a refill date of 11/22/2025. Patient 3 stated she had been taking Eliquis 5 mg, one tablet twice daily, for approximately one month. Patient 3 further stated that the PT aide did not check her medications during visits. During an interview on 1/26/2026 at 11:00 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated that the PT and PT aide were expected to check the patient’s actual medications and ask patients whether they were taking the medications as ordered. c. During a review of Patient 4’s Start of Care (SOC) record, the SOC indicated that the HHA admitted Patient 4 on 1/14/2026 with a diagnosis of aftercare following joint replacement surgery. During a review of Patient 4’s Plan of Care (POC) for the certification period of 1/14/2026 through 3/14/2026, the POC indicated that the Physical Therapist (PT) and PT Aide were responsible for reviewing the medication profile and reconciling medications as needed, instructing and reinforcing medication teaching related to medications used to treat the disease process, and reporting vital signs falling outside the following established parameters: systolic blood pressure less than 90 or greater than 180, diastolic blood pressure less than 50 or greater than 100, and pulse less than 60 or greater than 100. During an observation on 1/23/2026 at 10:30 a.m., a home visit was conducted at Patient 4’s residence. Patient 4 was observed sitting in a chair in the dining room, alert, oriented, and well groomed. During a concurrent observation and interview on 1/23/2026 at 10:45 a.m., while reviewing Patient 4’s medications, there was one bottle of Zofran 4 mg, with directions to take one tablet every six hours as needed for nausea, and a refill date of 1/12/2026. The Zofran medication was not listed on the agency’s medication profile. Patient 4 stated she had been taking the Zofran medication since 1/12/2026 for nausea. During an interview on 1/26/2026 at 11:00 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated that the PT and PT aide were expected to check the patient’s actual medications and ask patients whether they were taking the medications as ordered. During a review of the HHA’s policy and procedure titled “Medication Profile,” revised April 2018, the policy indicated that medication profiles are to be updated with each change to reflect current medications, including newly prescribed and discontinued medications.”

“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 Physical Therapist Aide (PTA 1) failed to notify the physician of a change in condition for one of 17 sampled patients (Patient 3). On 1/16/2026, PTA 1 assisted Patient 3 with ambulation on a sidewalk when the patient experienced dizziness and lightheadedness, nearly resulting in a fall. The physician was not notified of this change in condition. This deficient practice increased the risk of syncope and fall-related injury for Patient 3. During a review of Patient 3’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 (SOC) date of 1/7/2026, with diagnoses that included essential hypertension (high blood pressure- the force of blood pushing against with the artery walls is consistently too high) and unspecified atrial fibrillation (irregular heart beat) and atrial flutter (an electrical short circuit in the heart’s right atrium that causes it to contract rapidly. During a review of Patient 3’s Plan of Care (POC) for the certification period of 1/7/2026 through 3/7/2026, the POC indicated that the Physical Therapist (PT) and PTA were responsible for reviewing the medication profile and reconciling medications as needed, instructing and reinforcing medication teaching related to medications used to treat the disease process, and reporting vital signs falling outside the following established parameters: systolic blood pressure less than 90 or greater than 180, diastolic blood pressure less than 50 or greater than 100, and pulse less than 60 or greater than 100. The POC included a physician’s order dated 1/7/2026 for the following medications: Amiodarone 200 mg, one-half tablet daily Amlodipine 5 mg, one tablet at bedtime Metoprolol 25 mg, one-half tablet twice daily Telmisartan 80 mg, one tablet daily On 1/22/2026 at 1:30 p.m., a home visit was conducted at Patient 3’s residence with Physical Therapist (PT 1). Patient 3 was observed sitting on a couch in the living room, alert and oriented. On 1/22/2026 at 1:45 p.m., during an interview with Patient 3 in the presence of PT 1, Patient 3 stated she had experienced low blood pressure readings for the previous several weeks and believed her blood pressure medications required adjustment. Patient 3 further stated she had experienced episodes of dizziness and lightheadedness when standing and ambulating. Patient 3 reported that on 1/16/2026, PTA 1 assisted her with ambulation on a sidewalk when she experienced dizziness and lightheadedness, nearly resulting in a fall. A review of Patient 3’s blood pressure log revealed the following documented readings: 1/16/2026 at 9:00 a.m.: 90/48, pulse 62 1/18/2026 at 10:00 a.m.: 93/57, pulse 61 1/18/2026 at 2:00 p.m.: 102/54, pulse 65 1/19/2026 at 10:30 a.m.: 100/48, pulse 60 1/19/2026 at 2:00 p.m.: 90/44, pulse 60 1/20/2026 at 10:30 a.m.: 107/59, pulse 60 1/20/2026 at 4:00 p.m.: 88/47, pulse 74 1/21/2026 at 11:00 a.m.: 90/55, pulse 65 1/21/2026 at 2:00 p.m.: 106/53 1/22/2026 at 10:00 a.m.: 90/49, pulse 65 During a telephone interview with PTA 1 on 1/22/2026 at 4:00 p.m., PTA 1 stated he assisted Patient 3 with ambulation on 1/16/2026, during which Patient 3 experienced dizziness and lightheadedness and nearly fell. PTA 1 stated he prevented the fall, discontinued ambulation, and assisted the patient to a seated position. When asked whether he notified the agency, PT 1, the Director of Patient Care Services (DPCS), or the physician regarding the incident, PTA 1 stated he did not notify any of them. PTA 1 further stated he did not review Patient 3’s blood pressure log. A review of Patient 3’s Visit Note Reports dated 1/16/2026 and 1/20/2026 revealed no documented evidence that PTA 1 notified the physician of Patient 3’s low blood pressure readings or change in condition. On 1/23/2026 at 2:00 p.m., during a record review and telephone interview with the Director of Patient Care Services (DPCS), the DPCS stated she was unaware of Patient 3’s change in condition related to low blood pressure readings. The DPCS stated neither PT 1 nor PTA 1 reported a change in condition for Patient 3. The DPCS further stated Patient 3 demonstrated a change in condition and the physician should have been notified right away that the patient could be having orthostatic hypotension (sudden drop in blood pressure upon standing) and could lead to a risk for falls. A review of the agency’s undated policy titled “Monitoring Patient’s Response/Reporting to Physician” indicated that the physician is to be contacted the same day when there is a significant change in the patient’s condition.”