Vision Home Health Care

“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: The Agency failed to meet the Condition of Participation for Care Planning, Coordination and Quality of Care. The cumulative severity and intensity of these deficiencies resulted in the failure of the Agency to meet 484.60, Care Planning, Coordination, Quality of Care. See tags G0580, G0590, and G0606.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on observation, interview and record review, for one of 12 sampled patients (Patient 5), the agency failed to ensure skilled nursing visit records were accurate. This failure had the potential to result in poor coordination of care. During a review of Patient 5’s “Home Health Certification and Plan of Care (HHCPC)” for certification period 4/24/25-6/22/25, the “HHCPC” indicated, Patient 5’s start of care was 4/24/25. Diagnoses included type 2 diabetes mellitus (a chronic metabolic disorder characterized by persistently high blood sugar levels due to the body’s inability to produce or properly use insulin) with other specified complications, hypoglycemia (low blood sugar level), and chronic congestive heart failure (a long-term condition where the heart can’t pump enough blood to meet the body’s needs, leading to fluid build-up and other symptoms). The plan of care indicated interventions that included: assess vital signs, circulation, oxygen saturation (measurement of how much oxygen your blood is carrying as a percentage of the total amount it can carry), weight gain intake and output, assess diabetes management to include checking blood sugar levels, signs and symptoms of hypoglycemia. During a home visit observation on 4/29/25 at 11:02 a.m. with Registered Nurse (RN) 1, RN 1 assessed Patient 5’s vital signs and noted the following: BP (blood pressure) 103/61, pulse rate 56, temperature 97.2 degrees Fahrenheit (deg. F), blood sugar 76 mg/dl. RN 1 attempted to assess Patient 5’s oxygen saturation but the pulse oximeter (a small device that measures oxygen saturation) did not show reading. RN 1 took pulse oximeter off Patient 5’s finger, placed it on the table and stated he was not going to wait for the machine to read Patient 5’s oxygen saturation. During a review of RN 1’s “Nursing Visit Record (NVR),” dated 4/29/25, the “NVR” indicated Patient 5’s vital signs as follows: BP 103/61, Pulse Rate 58, blood glucose (blood sugar) 89 mg/dl, temperature 97.2 F, oxygen saturation 96 percent (%) at room air. During a review of the agency’s policy and procedure (P&P) titled “Entries Into The Clinical Record,” last revised November 2021, the P&P indicated documentation in the clinical record will be timely, detailed, accurate and will reflect the care or services provided to the patient.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency did not maintain educational records for the Home Health Aide (HHA). This resulted in an inability to assess whether the HHA’s skills were current. Record review of the document “Home Health Aide Training,” dated November 2021, showed the purpose was to “Outline a home health aide training program to ensure the competence and skills of home care aides. The organization will offer 12 hours of inservice training annually.” During an interview on 5/1/2025 at 1:45 p.m. the agency’s Administrator (ADM) stated they had no documented training records for the HHA. During an interview on 5/1/2025 at 1:50 p.m. the agency’s Clinical Supervisor (CS) confirmed the missing records and stated it was important to maintain them so “We know the HHA is up to date and can verify they have met the standards to do their job.””

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on interview and record review, for three of 12 sampled patients (Patient 3, 5 and 6), the agency did not provide services as outlined in the plan of care when: 1. The agency’s licensed nursing staff did not complete a full physical assessment for Patient 3’s edema in the lower extremities (edema is swelling which indicates fluid retention and possible cardiac strain). This resulted in the potential for worsening cardiac status. 2. Registered Nurse (RN) 1 did not provide health education on diabetes management during a home visit when Patient 5’s blood sugar level was 76 mg/dl. This failure had the potential to result in complications related to hypoglycemia (abnormally low blood sugar level). 3. Negative pressure wound therapy (also called wound vac/vac machine, a wound management technique that uses a specialized dressing system to apply negative pressure to the wound surface, drawing out fluids and debris from the wound. This process can also help draw edges together and promote blood flow to the area) was not provided as indicated in the plan of care. This failure had the potential to result in a lack of coordination among clinicians and delayed wound healing for Patient 6. Definition: Centers for Disease Control (CDC), is the nation’s leading science-based, data-driven service organization that protects the public’s health. According to CDC, the normal blood sugar is between 80 to 130 milligrams (mg) per deciliter (dL) before a meal, blood sugar below 70 is considered low (hypoglycemia) which can be caused by missing a meal, taking too much insulin or taking other diabetic medications. [Reference:https://www.cdc.gov/diabetes/treatment/index.html#:~:text=Before%20a%20meal:%2080%20to,Less%20than%20180%20mg/dL]. It is important to treat low blood sugar as they can quickly become dangerous. [Reference:https://diabetes.org/living-with-diabetes/hypoglycemia-low-blood-glucose]. Record review of the document “Ongoing Assessments” dated November 2021, showed the purpose was “To provide guidelines for assessments of patients during ongoing care. During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits.” Record review of the document “Home Health Certification and Plan of Care” showed Patient 3’s Start of Care was 3/10/2025 with the current certification period 3/10/2025 – 5/8/2025. Diagnoses included high blood pressure and Atrial Fibrillation (irregular heart rhythm). Cardiovascular interventions included skilled nursing was to assess “Peripheral pulses, color and temperature of extremities, swelling of extremities.” Record review of the documents “Nursing Visit Record(s)” (NVR) dated 3/24/2025 and 3/26/2025 showed Patient 3 had no edema. Record review of the NVR dated 3/31/2025 showed Registered Nurse 2 (RN 2) had instructed Patient 3 to “…Elevate legs and put tight socks for edema.” There was no documentation in the clinical record which showed the level of edema. (edema is measured by pressing a finger on the area showing edema to see how long it takes for the skin to rise back up: + 1, +2, +3 or +4) During an interview and concurrent record review on 4/28/2025 at 3:14 p.m., the Agency’s Clinical Supervisor (CS) confirmed RN 2 had not assessed the edema. The CS stated it was important to monitor and measure the level of the edema as it is a cardiac concern. If the swelling were to increase staff would need to notify the doctor since it may require a medication adjustment. 2. During a review of Patient 5’s “Home Health Certification and Plan of Care” for certification period 4/24/25-6/22/25, the “Home Health Certification Plan of Care” indicated Patient 5’s start of care date was 4/24/25. Diagnoses included type 2 diabetes mellitus (a chronic metabolic disorder characterized by persistently high blood sugar levels due to the body’s inability to produce or properly use insulin) with other specified complications. The plan of care indicated interventions to address Patient 5’s diabetes that included for the clinician to assess diabetic status and reinforce teaching on diabetes management. During a home visit observation and concurrent interview on 4/29/25 at 11:05 a.m. with Registered Nurse (RN) 1, RN 1 checked Patient 5’s blood sugar and noted it was 76 mg/dl. Patient 5 stated taking all morning medications that included two anti-diabetic medications upon waking up but missing breakfast. RN 1 did not provide education on the time of taking antidiabetic medication related to mealtimes. RN 1 stated Patient 5’s blood sugar level at 76 mg/dl was not a concern. RN 1 then talked to Patient 5 about the importance of taking Entresto (treats heart failure) for congestive heart failure and discussed how Patient 5 had very low ejection fraction (total amount of blood in your heart that is pumped out with each heartbeat). During a review of the agency’s policy and procedure (P&P) titled “Job Description Summary” last revised November 2021, the P&P indicated, the Registered Nurse’s Essential Job Functions/Responsibilities included providing health care instructions to the patient as appropriate. 3. During a review of Patient 6’s “Home Health Certification and Plan of Care” for certification period 10/15/24-12/13/24, the plan of care indicated, Patient 6’s start of care was 6/17/24, with diagnoses that included a stage 4 pressure ulcer (also known as bedsores or pressure sores, these are injuries to the skin and underlying tissues caused by prolonged pressure, often over bony prominences) on the sacral region (sacrum, lower part of the spine). The plan of care indicated interventions to address pressure ulcer that included, cleanse wound on sacrococcygeal (refers to the sacrum and the coccyx, the tailbone) area with normal saline, pat dry and apply skin prep around the wound, pack wound with black foam, and cover with transparent dressing bridge to connect to vac machine at 125 mmHg (millimeters of mercury, a unit of pressure) intermittent suction 24/7. The dressing change was to be done three times weekly. If the vac machine is not working, pack the wound with wet to dry dressing and cover with 4x4 dry gauze, ABD (Abdominal, gauze pads used to absorb discharges from abdominal and other heavily draining wounds) pad and secure with Medi pore daily (surgical tape used to secure dressing) and as needed. During a concurrent interview and record review on 4/30/25 at 1:22 p.m. with Clinical Supervisor (CS), Patient 6’s “Nursing Visit Record(s)” (NVR) dated 10/16/24, 10/18/24, 10/23/24, 11/2/24, 11/7/24, 11/9/24, 11/14/25 were reviewed. CS stated Patient 6 did not have a wound vac, and the “NVR” did not indicate a wound vac was used on Patient 6’s sacrococcygeal pressure ulcer as indicated in the plan of care. During a telephone interview on 5/1/25 at 12:02 p.m. with Licensed Vocational Nurse (LVN), LVN stated wound treatment was done alternately with a contracted wound care specialist, but wound vac was not used by either LVN or the wound care specialist. During a review of the agency’s policy and procedure (P&P) titled, “Care Planning Process” last revised November 2021, the P&P indicated, based on the assessment and conclusions, the plan of care will include specific services and treatments to be provided, including services furnished via telecommunications, patient and caregiver education and training specific to the patient’s care needs.”

“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’s licensed nursing staff provided services without a doctor’s orders for two of 12 sampled patients (Patient 4 and 9) when: 1. Staff discharged Patient 4 without a doctor’s signed order. This failure had the potential to cause Patient 4 to not get needed care. 2. Registered Nurse (RN) 1 instructed Patient 9 to take CBD gummies (cannabidiol, derived from hemp plant, a cousin of marijuana) for pain relief without a doctor’s order. This failure had the potential to result in CBD increasing side effects of and possible interaction with Patient 9’s medications. 2. During a review of Patient 9’s “Home Health Certification & Plan of Care” for certification period 1/28/25-3/28/25, the plan of care indicated Patient 9 was admitted for home health services with diagnoses that included heart failure (occurs when the heart can’t pump enough blood to meet the body’s needs), schizophrenia (a chronic mental disorder that disrupts thought process, perceptions, emotional responses, and social interactions, leading to a disconnection from reality), and depression (a mood disorder characterized by persistent sadness and loss of interest in activities). The plan of care indicated Patient 9 received the following medications: aripiprazole (an antipsychotic), quetiapine fumarate (antipsychotic), fluoxetine hydrochloride (anti-depressant) and hydrocodone-acetaminophen 5-325 mg (an opioid pain medication) 1 tablet every 6 hours as needed for moderate pain. Pain interventions included for clinician to assess/instruct patient/caregiver pain management measures, pain medication, rest, body alignment, range of motion, non-pharmacological methods of relieving pain, and to notify physician for pain not relieved by pain medication. Neurological interventions included clinicians to instruct patient/caregiver signs and symptoms of anxiety, depression, ineffective coping, orientation techniques, positive coping skills, relaxation techniques and stress management skills. During a review of Patient 9’s “Nursing Visit Record (NVR)” dated 2/11/25, the record indicated, RN 1 called the pharmacy to get refill for hydrocodone-acetaminophen 5/325 but was told to have the physician send a prescription refill. [Patient 9] still indulges in taking CBD infused gummy worms, but according to Patient 9’s caregiver, Patient 9 would become disruptive and belligerent after taking them. RN 1 instructed Patient 9 of the benefits of CBD-infused edibles like relieving anxiety, pain and sleep, increased concentration, elevated mood, reduced anxiety, reduced inflammatory-related pain, improved energy, support for restful sleep but it could cause negative effects like disruptive behavior. The plan for the next visit was to have medication and home safety instruction with the patient/caregiver. The record also indicated there was no documentation that the physician was contacted regarding Patient 9’s use of CBD gummies and Patient 9’s reaction to the edibles. During a review of Patient 9’s “Skilled Nurse Discharge/Transfer Visit/Summary” dated 2/16/25, the summary indicated, Registered Nurse (RN) 1 called the physician asking to refill Patient 9’s hydrocodone-acetaminophen but the physician refused to refill the medication. RN 1 instructed Patient 9 “With regards to the use [of] edibles (CBD), [Patient 9] can get half of the gummy worms to prevent any untoward psychological effect like belligerence.” Patient 9 was discharged from home health services effective 2/16/25. During an interview on 5/1/25 at 11:02 a.m. with Clinical Supervisor (CS), CS stated, skilled nurses should not discuss edibles with patients. CS stated the agency’s policy is for the clinician to discuss any medication concerns with the physician and not to give unsolicited advice because of the risk of addiction and one would not know how the patient is going to react with the edibles. During a review of the agency’s policy and procedure (P&P) titled “Medication Profile” last revised November 2021, the P&P indicated, “Any conclusions and findings of patient medication use, including herbal and over the counter medication or monitoring should be communicated to the pharmacist, physicians, and other clinicians, when appropriate…Deviations in taking medications as ordered will be documented in clinical notes, and the physician (or other authorized licensed independent practitioner) will be notified. An incident report will be filed as necessary.” Review of the document “Verification of Physician Orders” dated November 2021, showed “Orders will be obtained from a licensed physician (or allowed practitioner) for care and services to be provided to home health patients.” Record review of the document “Home Health Certification and Plan of Care” showed Patient 4’s Start of Care was 3/38/2025 with the current certification period 3/28/2025 – 5/26/2025. Diagnoses included a clavicle fracture. Discharge planning included “Discharge when medical condition stable and patient no longer in need of skilled care.” Record review of the document “Chart” showed Patient 4’s doctor’s discharge order was not completed on 4/24/2024. The “Oasis -E1 Discharge note” dated 4/24/2024 indicated Patient 4 was discharged from service on that day. During an interview and concurrent record review on4/28/2025 at 3:14 p.m. the Agency’s Clinical Supervisor (CS) confirmed the missing discharge order. The CS stated the staff nurse determines when the patient is ready for discharge which had been discussed with the physician “Early on.” The CS confirmed the order was not sent to the physician regarding the discharge so there was no way to know if the doctor would have reported he/she felt Patient 4 “Needed more time.” The CS stated the doctor may have wanted to extend the timeline for Patient 4’s care but “We have no idea.””

“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 interview and record review, for three of 12 sampled patients (Patient 2, 11 and 6), the Agency’s licensed nursing staff did not notify the physician for a change in condition when: 1. Patient 2’s blood pressure had dropped; she complained of back pain and had no appetite. 2. Patient 11 developed hematuria (blood in his urine). 3. Patient 6’s respiratory status changed. These failures had the potential to result in delayed care and worsening of medical condition. Record review of the document “Monitoring Patient’s Response/Reporting to Physician” dated November 2021, showed “The patient’s physician (or other authorized independent practitioner) will be contacted on the same day when any of the following occur: ...Changes in the patient’s condition.” Record review of the document “Home Health Certification and Plan of Care” (HHCPC) showed Patient 2’s Start of Care was 1/30/2025 with the current certification period 3/31/2025 – 5/29/2025. Diagnoses included heart failure. Interventions included staff were to notify the physician for a pain rating over 7 out of 10 and systolic blood pressure less than 90. (pain scale 0 is no pain and 10 is the highest) (systolic is the top number of a blood pressure reading) Record review of the document “Oasis Nursing Services SOC/ROC” (start of care) dated 1/30/2025 showed Patient 2 had no pain. Record review of the document “Skilled Nursing visit Record” (SNVR) dated 4/7/2025 showed Patient 2 had 4/10 lower back pain. Patient 2 reported to Registered Nurse 1 (RN 1) that the pain medication prescribed for her was not effective. There was no documentation which showed the doctor had been notified. Record review of the SNVR dated 4/14/2025 showed Patient 2 had “…No appetite, not sleeping well, and with 7/10 lower back pain” with a blood pressure of 81/55. There was no documentation which showed the doctor had been notified. During an interview on 4/28/2025 at 3:14 p.m., the Agency’s Clinical Supervisor (CS) confirmed the doctor had not been notified. The CS stated the doctor should have been notified about the low blood pressure as it could be “Part of the cardiovascular issue.” The CS stated the pain and loss of appetite should have also been reported as it may have indicated a need to readjust Patient 2’s medications. Record review of the HHCPC showed Patient 11’s start of care was 4/22/2025 with the current certification period 4/22/2025 – 6/20/2025. Diagnoses included kidney disease. Genitourinary interventions included assessments for difficulty urinating and hematuria. Record review of the document “Oasis Nursing Services SOC/ROC” dated 4/22/2025 showed Patient 11’s urine was cloudy. Record review of the SNVRs dated 4/26/2025 and 4/28/2025 showed Patient 11 had “Gross hematuria.” There was no documentation in the clinical record which showed the doctor had been notified. During an interview and concurrent record review on 4/30/2025 at 11:14 a.m., the CS confirmed the doctor had not been notified. The CS stated the potential outcome is that it could involve the kidneys and develop “Other malignancies.” During a review of Patient 6’s “Home Health Certification and Plan of Care” for certification period 10/15/24- 12/13/24, the plan of care indicated Patient 6 was admitted for home health services with diagnoses that included malignant neoplasm (cancerous tumor) of the left breast, secondary malignant neoplasm of bone, and a stage 4 pressure ulcer (also known as bedsores or pressure sores, these are injuries to the skin and underlying tissues caused by prolonged pressure, often over bony prominences) on the sacral region (sacrum, lower part of the spine, stage 4 is the most severe stage, characterized by full-thickness tissue loss with exposed muscle, tendons, or bone) on the sacral region. During a review of Patient 6’s OASIS Nurse Recertification date 10/14/24, the recertification indicated Patient 6’s lung sounds were all clear and present and respirations were easy and non-labored. During a concurrent interview and record review on 5/1/25 at 11:02 a.m. with Clinical Supervisor (CS), the following “Nursing Visit Record(s) NVR” were reviewed: -On 10/18/24, Patient 6’s respiratory status, “Denies SOB (shortness of breath) … oxygen saturation (the percentage of hemoglobin in your blood that is carrying oxygen) 96% RA (room air) …LCTA (lungs clear at auscultation), breathing even and unlabored, no respiratory distress noted.” -On 10/23/24, Patient 6’s respiratory status, “Denies SOB (shortness of breath) … oxygen saturation 96% RA (room air) …LCTA (lungs clear at auscultation), breathing even and unlabored, no respiratory distress noted.” -On 10/26/24, Patient 6 had a missed visit. -On 10/31/24, Patient 6 had a missed visit. -On 11/2/24, Patient 6’s respiratory status, “SOB, mild to moderate exertion… oxygen saturation 93% RA…LCTA, the patient’s airflow is weak resulting in a weak voice hampered by a dry throat…The patient was advised to see PCP.” CS stated the visit record indicated the physician was not notified. CS also stated the change in Patient 6’s condition after two missed visits warranted notification of the physician which was not done. During a telephone interview on 5/1/25 at 12:02 with Licensed Vocational Nurse (LVN), LVN stated, during the nursing visit on 11/2/25, physical assessment was completed, the physician and case manager should have been notified but they were not. During a review of the agency’s policy and procedure (P&P) titled “Monitoring Patient’s Response/Reporting to Physician” last revised November 2021, the P&P indicated the “Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient.” The patient’s physician will be contacted on the same day when any of the following occur: changes in patient’s condition, changes that have occurred regarding diagnoses, prognosis, or treatment. All conferences or attempts to communicate with the physician will be documented in the clinical record and will include, date and time physician was contacted, name of the physician, reason for notification, physician’s response, action taken and professional’s signature and title. Documentation of attempted physician notification will include the date and time, name of physician, reason for notification and name of person taking message.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on interview and record review, for one of 12 sampled patients (Patient 6), the agency failed to coordinate wound treatment orders with a contracted wound care specialist. This failure had the potential to result in delayed wound healing. During a review of Patient 6’s “Home Health Certification and Plan of Care (HHCPC)” for certification period 10/15/24-12/13/24, the plan of care indicated, Patient 6 was admitted for home health services on 6/17/24 with diagnoses that included a stage 4 pressure ulcer (an injury to the skin and underlying tissues caused by prolonged pressure, often over bony prominences, stage 4, the most severe stage, characterized by full-thickness tissue loss with exposed muscle, tendons, or bone) on the sacrococcygeal region (sacrum, lower part of the spine). The plan of care indicated the following interventions: 1. Pressure ulcer on sacrococcygeal area, cleanse with normal saline, pat dry, and apply skin prep around the wound, pack wound with black foam, and cover with transparent dressing bridge to connect to vac machine at 125 mmHg (millimeters of mercury, a unit of pressure) intermittent suction 24/7. The dressing change was to be done three times weekly. If the vac machine is not working, pack the wound with wet to dry dressing and cover with 4x4 dry gauze, ABD (Abdominal, gauze pads used to absorb discharges from abdominal and other heavily draining wounds) pad and secure with Medi pore (surgical tape used to secure dressing) daily and as needed. “Patient/caregiver to perform wound care once competence demonstrated.” 2. “Wound care to sacrococcygeal: Cleanse the open wound with cleanser pat dry, apply tetracyte (a topical product containing tetracycline hydrochloride, an antibiotic used to help prevent skin infections in minor cuts, scrapes, or burns) and medical grade honey to wound bed followed by oil emulsion gauze, cover with bordered foam dressing 3x a week and PRN (as needed) for soiled or loose dressing, use bordered foam between scheduled dressing change. Re-educated patient and family on wound care, diet, repositioning…” During a review of the contracted wound care specialist “Progress Report(s),” dated 10/14/24 and 10/21/24, the reports indicated Patient 6 had three areas of pressure ulcer with the following treatment orders: 1. Sacral stage 3, “Cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte and Mupirocin (topical cream used to treat secondarily infected traumatic skin lesions due to specific bacteria) to the wound bed, followed by collagen (clinician’s supply) and oil emulsion gauze. Cover with foam with silicone bordered dressing 3x weekly and PRN for soiled or loose dressing. Use absorbent pad dressing and bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing.” 2. Right medial gluteal fold (right buttock), “Cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte and medical grade honey to the wound bed followed by emulsion gauze (patient’s supply). Cover with non-bordered foam dressing 3x weekly and PRN for soiled or loose dressing. Use absorbent pad dressing between scheduled dressing changes and PRN for soiled or loose dressing. Secure dressing with tape as needed.” 3. Left posterior buttock, stage 2, Cleanse the wound with cleanser, pat dry with gauze. Apply skin prep to the periwound (area surrounding the wound). Apply Tetracyte and medical grade honey to the wound bed, followed by oil emulsion gauze. Cover with foam with silicone bordered dressing 3x weekly and PR for soiled or loose dressing. Use bordered gauze between scheduled dressing changes and PRM for soiled or loose dressing. The patient’s compliance is good, and he/she demonstrates understanding of the instruction given. During a review of the agency’s “Nursing Visit Record(s) (NVR),” dated 10/16/24, 10/18/24, and 10/23/24, the “NVR” indicated the following wound care was done: 1. Sacrococcygeal wound, cleanse with cleanser and pat dry with gauze, apply Tetracyte on wound bed. Apply Mupirocin ointment around the wound area, the pack wound with collagen, top with silver alginate, cover with foam with silicone-bordered dressing 3x weekly and PRN if soiled or loose and wrap with rolled gauze. 2. Right gluteal wound, cleanse with cleanser and gauze, apply Tetracyte, followed by Mupirocin ointment. Applied emulsion gauze and covered wound with 4x4 silicone foam dressing. The “NVR” did not indicate Patient 6’s pressure ulcer on the left buttock. During a concurrent interview and record review on 5/1/25 at 11:02 a.m. with Clinical Supervisor (CS), CS stated the contracted wound care specialist and Licensed Vocational Nurse (LVN) alternately provided wound care for Patient 6. CS stated the wound care specialist provided wound care once weekly while LVN did twice weekly. CS also stated both provided different wound care treatments on each visit, because of the wound care specialist’s inability to coordinate wound care orders with the agency.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and record review, the agency’s licensed nursing staff provided education on pain control measures which were outside his scope of practice and not ordered by the doctor. This resulted in the potential for harm and adverse interaction with other medications to Patient 2. Record review of the document “Job Description Summary” dated 2021, showed the Registered Nurse “Initiates appropriate preventative and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.” Record review of the document “Home health Certification and Plan of Care” showed Patient 2’s Start of Care was 1/30/2025 with the current certification period 3/31/2025 – 5/29/2025. Diagnoses included heart failure. Interventions included “Adherence and compliance to medication regimen…” Pain relief medications prescribed included Hydrocodone-Acetaminophen. Record review of the document “Skilled Nursing Visit Record” dated 4/7/2025 showed Patient 2 had 4 out of 10 lower back pain (scale: 0 no pain and 10 the highest). Review of the record visit notes showed Registered Nurse 1 (RN 1) documented “Patient still has lower back pain, I instructed her to take her Hydrocodone/Acetaminophen, she informed me that she’s not so much into this kind of medication. I brought the idea of “edibles” which a lot of patients would respond to.” During an interview and concurrent record review on 4/28/2025 at 3:14 p.m., the Clinical Supervisor (CS) stated the discussion regarding the edibles was “Not appropriate.” The CS stated RN 1 had proposed an intervention without a doctor’s consent. The CS stated “A lot could go wrong” and Patient 2 could potentially be unable to tolerate edibles. 2. During a review of Patient 9’s “Home Health Certification & Plan of Care” for certification period 1/28/25-3/28/25, the plan of care indicated Patient 9 was admitted for home health services with diagnoses that included heart failure (occurs when the heart can’t pump enough blood to meet the body’s needs), schizophrenia (a chronic mental disorder that disrupts thought process, perceptions, emotional responses, and social interactions, leading to a disconnection from reality), and depression (a mood disorder characterized by persistent sadness and loss of interest in activities). The plan of care indicated Patient 9 received the following medications: aripiprazole (an antipsychotic), quetiapine fumarate (antipsychotic), fluoxetine hydrochloride (anti-depressant) and hydrocodone-acetaminophen 5-325 mg (an opioid pain medication) 1 tablet every 6 hours as needed for moderate pain. Pain interventions included for clinician to assess/instruct patient/caregiver pain management measures, pain medication, rest, body alignment, range of motion, non-pharmacological methods of relieving pain, and to notify physician for pain not relieved by pain medication. Neurological interventions included clinicians to instruct patient/caregiver signs and symptoms of anxiety, depression, ineffective coping, orientation techniques, positive coping skills, relaxation techniques and stress management skills. During a review of Patient 9’s “Nursing Visit Record (NVR)” dated 2/11/25, the record indicated, RN 1 called the pharmacy to get refill for hydrocodone-acetaminophen 5/325 but was told to have the physician send a prescription refill. [Patient 9] still indulges in taking CBD infused gummy worms, but according to Patient 9’s caregiver, Patient 9 would become disruptive and belligerent after taking them. RN 1 instructed Patient 9 of the benefits of CBD-infused edibles like relieving anxiety, pain and sleep, increased concentration, elevated mood, reduced anxiety, reduced inflammatory-related pain, improved energy, support for restful sleep but it could cause negative effects like disruptive behavior. The plan for the next visit was to have medication and home safety instruction with the patient/caregiver. The record also indicated there was no documentation that the physician was contacted regarding Patient 9’s use of CBD gummies and Patient 9’s reaction to the edibles. During a review of Patient 9’s “Skilled Nurse Discharge/Transfer Visit/Summary” dated 2/16/25, the summary indicated, Registered Nurse (RN) 1 called the physician asking to refill Patient 9’s hydrocodone-acetaminophen but the physician refused to refill the medication. RN 1 instructed Patient 9 “With regards to the use [of] edibles (CBD), [Patient 9] can get half of the gummy worms to prevent any untoward psychological effect like belligerence.” Patient 9 was discharged from home health services effective 2/16/25. During an interview on 5/1/25 at 11:02 a.m. with Clinical Supervisor (CS), CS stated, skilled nurses should not discuss edibles with patients. CS stated the agency’s policy is for the clinician to discuss any medication concerns with the physician and not to give unsolicited advice because of the risk of addiction and one would not know how the patient is going to react with the edibles. During a review of the agency’s policy and procedure (P&P) titled “Medication Profile” last revised November 2021, the P&P indicated, “Any conclusions and findings of patient medication use, including herbal and over the counter medication or monitoring should be communicated to the pharmacist, physicians, and other clinicians, when appropriate…Deviations in taking medications as ordered will be documented in clinical notes, and the physician (or other authorized licensed independent practitioner) will be notified. An incident report will be filed as necessary.””

“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 licensed nursing staff did not maintain a complete and up-to-date clinical record for 4 of 12 sampled patients (Patients 3, 4, 10 and 12) when visit notes were not completed. This resulted in an inability to assess the status of identified healthcare goals and interventions. Record review of the document “Entries Into The Clinical Record,” dated November 2021, showed “Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical record will be made on the day care is provided to the patient.” Record review of the document “Home Health Certification and Plan of Care” (HHCPC) showed Patient 3’s start of care was 3/10/2025 with the current certification period 3/10/2025 – 5/8/2025. Diagnoses included High Blood Pressure (BP). Cardiovascular Goals included “BP range will be within physician established parameters. Pt will demonstrate increased endurance and improved circulation.” Record review of the document “Chart” showed no visit notes for Patient 3 on 3/12/2025 and 4/2/2025. Record review of the HHCPC showed Patient 4’s start of care was 3/28/2025 with the current certification period 3/28/2025 – 5/26/2025. Diagnoses included a clavicle fracture. Musculoskeletal Interventions included “Assess Musculoskeletal status; Assess/Instruct Pt/PCG (patient and caregiver) Measures to promote circulation…Proper body alignment…ROM (range of motion)/strengthening exercises…safety measures to prevent injury…” Record review of the document “Chart” showed no documented nursing visit notes for 3/31/2025, 4/2/2025, 4/7/2025, 4/9/2025, 4/16/2025. There was no discharge note for 4/24/2025 During an interview on 4/28/2025 at 2:54 p.m., the agency’s Clinical Supervisor (CS) confirmed the missing notes and stated the Agency required completed visit notes on the day of the visit. She stated it was important to complete the notes so “Other disciplines can see what is going on with the patient.” Record review of the “HHCPC” showed Patient 10’s start of care was 4/18/2025 with the current certification period 4/18/2025 – 6/16/2025. Diagnoses included heart failure. Cardiovascular interventions included the skilled nurse was to “Assess cardiopulmonary status and reinforce teaching on heart failure management to include vital signs, heart sounds, lung sounds, dyspnea (shortness of breath), cough, secretions, hemoptysis (coughing up blood from the lungs), circulation, edema, cyanosis (when skin, lips or nails turn blue due to lack of oxygen) chest pain, activity tolerance and endurance…” Record review of the document “Chart” showed no completed visit notes for Patient 10 on 4/18/2025 and 4/25/2025. Record review of the “HHCPC” showed Patient 12’s start of care was 4/10/2025 with the current certification period 4/10/2025 – 6/8/2025. Diagnoses included chronic obstructive pulmonary disease. Goals/interventions included staff were to assess “Breath sounds, rate, pulse oximetry (pulse ox or oximetry: measurement of oxygen in the blood) every manifestation of respiratory distress. Notify MD for Pulse ox 90% or less.” Record review of the clinical record showed missing visit notes for Patient 12 on 4/11/2025, 4/14/2025, and 4/16/2025. During an interview on 4/30/2025 at 11:14 a.m., the CS confirmed the missing visit notes and stated as a result, the patient’s healthcare status was “Not known” and it “Negatively impacts the care to be provided in the future.””