Access Home Health Care, LLC

“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 Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure interventions and reassessment for pain were implemented in accordance with the plan of care for one of seven sampled patients (Patient 1). This deficient practice had the potential to place Patient 1 at risk for unresolved and/or increased pain. Findings: During a review of Patient 1’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 10/2/2025, with diagnoses that included multiple sclerosis (a disease that causes breakdown of the protective covering of nerves that can cause numbness, weakness, trouble walking, vision changes and other symptoms), functional quadriplegia (a paralysis that affects arms and legs), and epilepsy (a brain disorder characterized by recurrent seizures [a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness]). During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) for the certification period of 10/2/2025 to 11/30/2025, the POC included an order for skilled nurse (SN) to visit Patient 1 twice a week for 2 weeks, once a week times for 5 weeks, and then once a week for 1 week for comprehensive skilled nursing assessment, observation and evaluation of all body systems, assessment of vital signs (measures the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and to assess pain level using the pain scale 0-10/10 (0 = no pain; 10 = unbearable pain), instruct on pain management/compliance to pain medications, implement pain relief measures and evaluate its effectiveness. During a joint home visit at Patent 1’s residence on 1/7/2026 at 10:38 a.m., with the licensed vocational nurse (LVN 1), Patient 1 was observed laying in a hospital bed, awake, alert, and oriented x 2 (to person and place) with slurred speech, accompanied by family member. During a review of Patient 1’s Skilled Nursing Visit Records, dated 11/6/2025 and 11/7/2025, the visit records indicated Patient 1 was experiencing pain 5 out of 10 (using pain rating scale of 0 to 10: 0 = no pain; 10 = unbearable pain) during the visits. There was no documented evidence that pain relief measures were implemented and a follow-up pain reassessment performed for Patient 1. During a concurrent interview and record review on 1/8/2026 at 12:50 p.m. with the Director of Patient Care Services (DPCS), Patient 1’s Skilled Nursing Visit Records, dated 11/6/2025 and 11/7/2025 were reviewed. The DPCS stated pain assessment should include intervention and reassessment to evaluate effectiveness of pain release measures. The DPCS stated that pain intervention and reassessment was not performed for Patient 1. During a review of the agency’s policy and procedure (P&P) titled, “Pain Assessment”, dated April 2010, the P&P indicated all patients will receive at least an initial pain assessment. When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible: pain intensity using a rating scale (on a scale of 0 – 10: 0=no pain; 10=unbearable pain), pain location, quality, onset, duration, alleviating and aggravating factors, and present pain management regimen and effectiveness.”

“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, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to maintain an accurate and current medication profile for one of seven sampled patients (Patient 5). This failure had the potential to place Patient 5 at increased risk for medication errors and adverse drug reactions. During a review of Patient 5’s Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) for the recertification period of 11/12/2025 to 1/10/2026, the POC indicated that Patient 5 was admitted to the HHA on 7/15/2025 with a primary diagnosis of type 2 diabetes mellitus (a chronic metabolic condition where the body either does not produce enough insulin or cannot use insulin effectively, leading to consistently high blood sugar [glucose] levels/hyperglycemia) with diabetic chronic kidney disease (a serious complication where high blood sugar damages the kidneys’ tiny filters [glomeruli], causing them to leak protein and become less effective at removing waste, eventually leading to kidney scarring, declining function, and potentially kidney failure, requiring dialysis or transplant). Patient 5’s POC indicated that the frequency for Registered Nurse (RN)/Licensed Vocational Nurse (LVN) visit was once a week for nine weeks starting 11/12/2025. The intervention section of Patient 5’s POC indicated medication management as follows: Assess patient/caregiver for medication compliance and instruct on medication actions, uses, frequency, dose, side effects, interactions of all new/changed medications, and importance of compliance. During a review of Patient 5’s Medication Profile for the certification period of 11/12/2025 to 1/10/2026, the Medication Profile indicated the following medications: Isosorbide Mononitrate (a medication used to prevent angina [chest pain]) ER(Extended-release, slow release medication to blood stream) 60 mg (milligram, a measurement unit) tablet, 1 tablet every morning. Diltiazem Hydrochloride (a medication used to treat high blood pressure and angina) ER 120 mg capsule, 2 capsules every afternoon. During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) at Patient 5’s residence on 1/7/2026 at 10:30 a.m., Patient 5 was observed alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 5 was able to ambulate (walk) using a walker (a mobility aid, often a lightweight metal frame with four legs and handles, that provides stability and support for people with balance issues, weakness, or recovering from injury, helping them bear weight and reduce the risk of falls). During the joint home visit, a medication review was conducted with LVN 2. The following medications were observed at the patient’s home: Isosorbide Mononitrate ER 30 mg tablet, 2 tablets daily. Diltiazem Hydrochloride ER 240 mg capsule, 1 capsule daily.Patient 5 stated that she took 2 tablets of Isosorbide Mononitrate ER 30 mg and 1 capsule of Diltiazem Hydrochloride ER 240 mg daily. During an interview with LVN 2 on 1/7/2026 at 11:45 a.m., LVN 2 stated that patient’s medication profile had to match the actual medications the patient was taking. LVN 2 stated that medication reconciliation needed to be done with each visit to make sure the medication profile was updated. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/8/2026 at 11:16 a.m., the DPCS reviewed Patient 5’s Medication Profile for the certification period of 11/12/2025 to 1/10/2026. The DPCS stated that even though daily total dosage was same for Patient 5, but it was important to have the correct dose and quantity of pills as indicated in the Medication Profile to avoid medication errors. During a review of the HHA’s policy and procedure (P & P) titled, “Medication Profile”, dated April 2010, the P & P indicated that patients receiving medication would have a current, accurate medication profile in the clinical record. Medications profiles would be updated for each change to reflect current medications and new and/or discontinued medications.”

“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 observation, interview, and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home)) failed to include information required in the Plan of Care (POC, a document where a doctor certifies a patient needs home health services, outlining the patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient) for one of seven sampled patients (Patient 5). This failure resulted in Patient 5 not understanding the importance of medication management, which may result in medication error and harm to the patient. During a review of Patient 5’s POC for the recertification period of 11/12/2025 to 1/10/2026, the POC indicated that Patient 5 was admitted to the HHA on 7/15/2025 with a primary diagnosis of type 2 diabetes mellitus (a chronic metabolic condition where the body either does not produce enough insulin or cannot use insulin effectively, leading to consistently high blood sugar [glucose] levels/hyperglycemia) with diabetic chronic kidney disease (a serious complication where high blood sugar damages the kidneys’ tiny filters [glomeruli], causing them to leak protein and become less effective at removing waste, eventually leading to kidney scarring, declining function, and potentially kidney failure, requiring dialysis or transplant). The POC indicated that the frequency for Registered Nurse (RN)/Licensed Vocational Nurse (LVN) visit was once a week for nine weeks starting 11/12/2025. The intervention section of Patient 5’s POC included medication management as follows: Assess patient/caregiver for medication compliance and instruct on medication actions, uses, frequency, dose, side effects, interactions of all new/changed medications, and importance of compliance. The goals of medication management were as follows: Compliance with dose, route and schedule/actions, …safe preparation and storage of medication. The POC did not indicate any issues with noncompliance related to medication management. There was no patient education information included in the POC. During a review of Patient 5’s Medication Profile for the certification period of 11/12/2025 to 1/10/2026, the Medication Profile included Nitroglycerin (a medication primarily used to prevent and treat angina [chest pain]) 0.4 mg (milligram, a unit measurement) tablet sublingual (under the tongue), 1 tablet every 5 minutes as needed for chest pain, do not take more than 3 tablets total. During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) at Patient 5’s residence on 1/7/2026 at 10:30 a.m., Patient 5 was observed alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 5 was able to ambulate (walk) using a walker (a mobility aid, often a lightweight metal frame with four legs and handles, that provides stability and support for people with balance issues, weakness, or recovering from injury, helping them bear weight and reduce the risk of falls). During the joint home visit, a medication review was conducted with LVN 2. Nitroglycerin 0.4 mg sublingual tablet was not observed in the tray where Patient 5 kept her medications. When LVN 2 asked Patient 5 if she still had Nitroglycerin tablets, Patient 5 took out a pill organizer and showed it to LVN 2. The pill organizer’s compartments were observed filled with different pills. There was no label indicating what medications were kept in each compartment. Patient 5 pointed to one of the compartments in the pill organizer and told LVN 2 that those were the Nitroglycerin tablets. Patient 5 stated that she kept her “emergency pills” in the pill organizer. When LVN 2 asked Patient 5 for the original container with the label for Nitroglycerin 0.4 mg, Patient 5 stated she did not have it anymore. During an interview with LVN 2 on 1/7/2026 at 11:45 a.m., LVN 2 stated that it was not safe to take out medications from the original, labelled containers and placed them into unlabeled containers. LVN 2 stated that keeping medications in unlabeled containers or mislabeled containers might place the patient at risk for medication errors. LVN 2 stated she had been providing teaching regarding medication management including medication storage at every visit. During a review of Nursing Visit Record for Patient 5, dated 12/4/2025 and 12/23/2025, the Nursing Visit Record indicated that LVN 2 visited Patient 5 on both dates. The Skilled Intervention/Teaching/Patient Response section of the Nursing Visit Record did not indicate that teaching on medication storage/management was provided to Patient 5. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/8/2026 at 11:16 a.m., the DPCS reviewed Patient 5’s POC for the certification period of 11/12/2025 to 1/10/2026, Medication Profile for the certification period of 11/12/2025 to 1/10/2026, and Nursing Visit Record dated 12/4/2025 and 12/23/2025. The DPCS stated that the POC should have the patient’s diagnosis, allergies, medications, interventions and goals. The DPCS stated that patient education is considered an intervention and needed to be part of the POC. The DPCS stated that the POC served as a guidance for the HHA staff on what they needed to do for a patient. The DPCS stated that Patient 5 had a history of noncompliance with medication management, which made it very important to continuing educate the patient. During a review of the HHA’s policy and procedure (P & P) titled, “Care Planning Process”, dated April 2010, the P & P indicated that the clinical plan of care included pertinent diagnoses, mental status, types of service/equipment, frequency of visits, goals and interventions appropriate to each discipline…instructions, discharge plan. During a review of the HHA’s P & P titled, “Patient Education Process,” dated April 2010, the P & P indicated that education would be the responsibility of each clinician and would focus on facilitating the patient’s and family/caregiver’s understanding of his/her health status, health care options, and consequences of options.”