Assisted Home Health

“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 record review and interview, the home health agency failed to ensure ordered services were provided according to the physician’s plan of care and failed to ensure the physician was notified when ordered home visits were missed for three of 17 sampled patients (Patients 7, 13, and 17). These failures resulted in physicians not being aware that ordered services were not provided as prescribed, which had the potential to affect the physician’s management of the patients’ plans of care and compromise the patients’ health and safety. Findings: During a review of Patient 17’s “Home Health Certification and Plan of Care,” for the certification period 12/30/25 to 2/27/26, the “plan of care” indicated the home visit order, dated 2/9/26 - 2/22/26, “Physical therapy (PT) two (2) visits per week for two (2) weeks.” During a review of Patient 17’s “PT Visit Notes,” for the certification period 12/30/25 to 2/27/26, a “Missed Visit Form (PT Visit),” dated 2/22/26, indicated Patient 17 missed a PT visit because she “attended a funeral.” The form failed to indicate however that the physician was notified of the missed visit. During a concurrent interview and record review with the agency’s Executive Director (ED) and DPCS on 2/26/26 at 12 p.m., Patient 17’s “PT Visit Notes,” for the certification period 12/30/25 to 2/27/26, were reviewed. ED and DPCS confirmed that Patient 17 missed a PT visit on 2/22/26 and acknowledged that there was no documentation in the patient’s record that the physician was notified of the missed visit. The policy and procedure titled “Missed Visits or Shifts and Refusal of Services” dated September 2022 indicated “If a visit, treatment, or service is missed that is required by the plan of care (visit frequency), then the agency must notify the responsible physician. Physician notification is documented in the clinical record”. During review of Patient 7’s clinical record on 2/23/26 at 4:00 p.m., the physician order indicated skilled nursing visits two times per week for eight weeks during the certification period 12/28/25 through 2/25/26. During review of visit documentation for the week of 2/16/26 through 2/22/26, only one skilled nursing visit was documented, which did not meet the ordered visit frequency. The clinical record did not contain documentation of a missed visit or documentation indicating the physician was notified. During an interview on 2/26/26 at 11:59 a.m., the Director of Patient Care Services (DPCS) acknowledged the missed visit. During review of Patient 13’s clinical record on 2/24/26 at 4:30 p.m., the physician order indicated physical therapy visits of one visit per week for one week and two visits per week for seven weeks during the certification period 2/8/26 through 4/8/26. Documentation dated 2/16/26 and 2/18/26 indicated missed visits. The clinical record did not contain documentation indicating the physician was notified of the missed visits. During an interview on 2/26/26 at 11:54 a.m., the Director of Patient Care Services (DPCS) acknowledged the missed visit documentation did not indicate the physician was notified.”

“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 interview and record review, the facility failed to ensure medications were reviewed and the current medication profile was updated to match the medications the patient was taking for one of 17 sampled patients (Patient 11). This facility failure has the potential for the patient to take medications that were not prescribed by the physician. Findings: During a home visit with the registered nurse (LN2) on 2/24/26 at 1:30 pm, the home health agency’s (HHA) medication list was compared to the patient’s home medication list. The HHA medication list did not match the home medication list. The following medications were not included on the HHA medication list: Alpha-Lipoic acid (dietary supplement) 600 milligrams (mg) capsule, 1 capsule by mouth daily.Metheamine (urinary tract antiseptic) 1 gram tablet, 1 tablet by mouth daily.Venlafaxine (antideppresant) 37.5 milligrams capsule, 1 capsule by mouth in the morning. Wegovy (controls blood sugar and weight loss) 0.5 mg/ 5 ml , inject 0.5 mg every Thursday.Furosemide (a diuretic) 20 mg tab, 1 tab by mouth in the morning.Gemtesa (for over active bladder) 75 mg, give 75 mg by mouth at bedtime.Magnesium oxide (antacid and for constipation) give 1 tab by mouth at bedtime.Potassium chloride (to prevent low potassium level) 10 meq tab, give 1 tab by mouth in the morning.Presser vision (support eye health) capsules, give 2 caps by mouth twice a dayDuring an interview with the director of patient care services (DPCS) on 2/26/24 at 11:44 am, the DPCS stated the nurse should check the home medication and reconcile the list to ensure the agency knows what medications the patient is taking at home. The DPCS acknowledged the medication reconciliation had not been done. During review of the facility policy titled “Medication Management,” dated September 2022, indicated “All medication a patient may be taking will be documented on the medication profile to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, and contraindicated drugs.””