Nova Home Health Inc.

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure Physical Therapist Assistant (PTA) visits were conducted in accordance with the physician ordered visit frequency for one of ten sampled patients (Patient 6) when Patient 6 had one missed PTA visit. This failure had the potential to place Patient 6 at risk for delay in recovery, reduced strength and range of motion (ability to move joints), and prolong healing times. Findings: During a review of Patient 6’s “Admission Order”, it indicated Patient 6 was admitted to the agency on July 9, 2025, with diagnoses of essential hypertension (elevated blood pressure) and difficulty in walking. During a review of Patient 6’s “Admission Order” (doctors orders given upon admission into a home health agency) dated July 9, 2025, it indicated “…Therapy Services: PT (Physical Therapy- healthcare specialty that focuses on restoring, maintaining, and improving movement and function) evaluation for safety awareness…strengthening exercises, safe use of assistive devices, and home exercise program…” During a review of Patient 6’s “PT Evaluation” dated July 22, 2025, it indicated “… PT eval [evaluation] was done 7/22 [July 22] Recommending a PT frequency of 1x1 [one visit for one week], 2w4 [two visits for four weeks]…” During a review of Patient 6’s “PTA Visit” dated August 7, 2025, it indicated “…PTA reported that he called pt [patient] for a scheduled visit next week but has lots of appointments… requested to be visited in week of 8/17 [August 17] …” During a review of Patient 6’s medical record, there was no documented evidence to indicate PTA visits were conducted from August 17, 2025, through August 27, 2025. During an interview on August 27, 2025, at 3:01 PM, with the Chief Executive Officer (CEO), the CEO stated the PTA missed the visit during August 17, 2025, to August 27, 2025. The CEO further stated Patient 6 should have been seen by the PTA. During a concurrent interview and record review on August 27, 2025, at 2:55 PM, with the CEO, the agency’s policy and procedure (P&P) titled, “Ongoing Assessments” revised April 2021 was reviewed. The P&P indicated, “To provide guidelines for assessments during ongoing care… 1. During each home visit the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit… 5. Based on each reassessment, the plan of care – including problems, needs, goals, and outcomes – will be reviewed and revised by the clinician…” The CEO stated the P&P was not followed.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure patient medication profiles (a list of all the current medications used by a patient at home) were accurate for two of four patient home visits (Patients 1 and 2). These failures had the potential to place Patient 1 and 2 at risk for miscommunication, errors in medication documentation, and inadequate reconciliation of medication profile. 1. During a review of Patient 1’s “Home Health Certification and Plan of Care” dated July 28, 2025, it indicated Patient 1 was admitted to the agency with diagnoses of encounter for orthopedic aftercare following surgical amputation (aftercare after a patient has an amputation [removal of body part]) and type 2 diabetes mellitus (elevated blood sugar) with foot ulcer (wound on foot). During a review of Patient 1’s “Medication Profile” dated July 28, 2025, it indicated Patient 1 had the following medications: a. acetaminophen (medication used to treat mild pain and elevated temperature) oral tablet 500 mg (milligram-unit of measurement) by mouth twice daily PRN (as needed) b. losartan potassium (medication used to lower blood pressure) 50mg tablet by mouth daily c. amoxicillin-pot clavulanate (antibiotic medication used to treat infections) 875-125 mg tablet twice daily for ten days d. gabapentin (medication used to treat nerve pain) oral 300mg 1 capsule three times a day e. metformin (medication used to lower blood sugar levels) 1000mg take 1 tab twice daily f. ibuprofen (medication used to treat mild pain) oral 800mg tablet three times a day. During a concurrent observation and interview on August 26, 2025, at 8:12 AM, in Patient 1’s home, with Patient 1, Patient 1’s medications were on the dining table and there were only four medications: benazepril (medication used to lower blood pressure) 20 mg by mouth daily tablets, gabapentin tablets, metformin tablets, and ibuprofen tablets. Patient 1 stated he only takes four medications. During an interview on August 26, 2025, at 8:21 AM, with Licensed Vocational Nurse (LVN 1), LVN 1 stated Patient 1’s physician discontinued the losartan and prescribed the benazepril about a month ago. LVN 1 stated the benazepril should have been listed on Patient 1’s medication profile, while losartan and amoxicillin should not have been listed. During a concurrent interview and record review on August 27, 2025, at 2:50 PM, with the Chief Executive Officer (CEO), the agency’s policy and procedure (P&P) titled, “Medication Profile” revised April 2021 was reviewed. The P&P indicated “…Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications…” The CEO stated the P&P was not followed. 2. During a review of Patient 2’s “Home Health Certification and Plan of Care” dated August 4, 2025, it indicated Patient 2 was admitted to the agency with the diagnoses of type 2 diabetes mellitus with hyperglycemia (high blood sugar levels) and chronic kidney disease (kidneys lose their ability to filter waste). During a concurrent observation and interview on August 27, 2025, at 9:10 AM, with Patient 2, Patient 2’s 12 medications were on a coffee table and Patient 2 stated those were all the medications she took. During a review of Patient 2’s “Medication Profile” dated August 4, 2025, it indicated Patient 2’s medications consisted of: a. Rena-vite (vitamin for kidneys) oral tablet once a day b. Hydralazine hcl (medications used to lower blood pressure) 10mg one tablet by mouth three times a day c. Probiotic product (beneficial bacteria) once daily d. Acetaminophen 500mg 2 tablets every 6 hours as needed for pain e. Trazodone hcl (medication for depression and inability to sleep) 150mg one half tablet once daily at bedtime f. Amlodipine besylate (medication used lower blood pressure) oral 10mg once daily g. Plavix (medication used to thin the blood) 75mg once daily h. Insulin lispro (medication used to lower blood sugar) subcutaneous (under the skin) sliding scale (a scale used to determine the amount of medication to use based on blood sugar levels) three times a day before meals i. Basaglar tempo (medication used to lower blood sugar) pen subcutaneous 40mg once daily at bedtime j. Atorvastatin calcium (medication used to lower cholesterol [bad fat]) 40mg once daily in afternoon k. Vitamin D2 (vitamin for bones) 50, 000 units 1 cap by mouth once a week l. Valsartan (medication used to lower blood pressure) 40mg once daily (listed but not present) m. Atenolol (medication used to lower blood pressure) 25mg by mouth every Monday, Wednesday, Friday after dialysis (procedure to reduce waste in blood) present but not listed in medication profile. During an interview on August 27, 2025, at 9:40 AM, with Registered Nurse (RN 1), RN 1 stated she was covering for the nurse who normally visits Patient 2. RN 1 further stated Patient 2’s medications should have matched the medications Patient 2 is currently taking. During a concurrent interview and record review on August 27, 2025, at 2:50 PM, with the Chief Executive Officer (CEO), the agency’s policy and procedure (P&P) titled, “Medication Profile” revised April 2021 was reviewed. The P&P indicated “…Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications…” The CEO stated the P&P was not followed.”