River Valley 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 interview and record review, the facility failed to ensure a patient received the home health service as written in a plan of care (an individual plan that identifies patient’s specific goals) and the responsible physician was notified of a missed visit from a Medical Social Worker (MSW) on May 8, 2026, for one of seven sampled patients (Patient 4). This failure had the potential to negatively impact Patient 4’s assessment and delayed the physician’s opportunity to modify or provide additional plan of care for any unmet care needs. Findings: A review of Patient 4’s “Home Health Certification and Plan of Care,” (HH note-a document which contains medical and demographic information), undated, indicated a start of care date of April 28, 2026, with a certification period of April 28, 2026, to June 26, 2026. The HH note also indicated Patient 4 had diagnoses which included diabetes mellitus (a disease in which the body is unable to regulate blood sugar levels effectively), hypertension (high blood pressure), and congestive heart failure (a condition where the heart’s pumping power is reduced, making it difficult for the heart to pump enough blood to meet the body’s needs). The HH note showed a physician’s order for MSW visits to occur once a week, for a total of one week to help the patient and family cope with emotional, social, and financial issues related to illness. During a concurrent interview and record review on May 19, 2026, at 10:11 AM, with the Administrator (ADMIN), Patient 4’s Electronic Health Record (EHR), dated April 28, 2026, was reviewed. The EHR indicated there was a missed MSW visit on May 8, 2026. The ADMIN acknowledged the MSW visit was missed and stated in instances of missed home visits, the physician would need to be notified, and a note included in the patients’ clinical record indicating the physician was made aware. During a review of Patient 4’s EHR titled, “Client Coordination Note Report Missed Visit Form” (HHA Visit), dated May 8, 2026, the HHA Visit indicated, “SW [Social Worker] CONTACTED SPOUSE YESTERDAY TO SCHEDULE A VISIT. THE VISIT WAS CONFIRMED FOR 10 AM [10:00AM] TODAY. SW RECEIVED CALL AT 9:45 AM TO RESCHEDULE VISIT TO 1 PM [1:00 PM] TODAY. SW THEN RECEIVED A CALL THAT PT [Patient] WAS FEELING TIRED AND WOULD LIKE TO SCHEDULE VISIT TILL NEXT WEEK DUE TO NAUSEA AND PT NOT FEELING WELL”. During a review of the facility’s policy and procedure (P&P) titled, “MISSED VISITS,” dated November 2024, the P&P indicated, “…2. If a visit is missed and not rescheduled the clinician will: A. Notify the physician and clinical supervisor of the missed visit and reason for missed visit. B. Document in the patient’s clinical record...” During a concurrent interview and record review on May 20, 2026, at 9:30 AM, with the ADMIN, Patient 4’s EHR, dated April 28, 2026, to May 20, 2026, was reviewed. the ADMIN stated she was unable to find any documented evidence that the physician was notified of the missed MSW visit on May 8, 2026. The ADMIN further stated the physician should have been notified but was not. During a concurrent interview and record review on May 20, 2026, at 9:45 AM, with the Director of Patient Care Services (DPCS), Patient 4’s EHR, dated April 28, 2026, to May 20, 2026, was reviewed. The DPCS verified and confirmed that she was unable to find any documented evidence that the physician was notified of the missed MSW visit on May 8, 2026. The DPCS further stated the MSW in home healthcare is provided one visit to evaluate the patient’s needs, and if any additional visits are indicated, recommendations are made to physician for further orders, in this case the visit was not done and physician was not notified.”

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure written information related to the patient’s Plan of Care (POC- an individual plan that identifies patient’s specific goals and signed by a doctor) was provided and available in the home for two of three sampled patients reviewed for written patient care instructions (Patients 1 and 2), when Patient 1 and 2’s home clinical record booklets did not contain their current POCs. This deficient practice had the potential to result in the patient and caregiver not having access to the current plan of care, including the care, services, and instructions necessary to meet the patients’ needs. Findings: 1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), indicated a start of care date of April 10, 2026, with a certification period (a specific timeframe during which a patient is eligible to receive home health services) from April 10, 2026, to June 8, 2026. Patient 1 had diagnoses which included lymphedema (long-term medical condition that causes swelling, usually in the arms or legs) and atrial fibrillation (an irregular, and usually very fast, heartbeat) During a concurrent home visit observation and interview on May 19, 2026, at 9:30 AM, with License Vocational Nurse (LVN 1), in the presence of Patient 1, Patient 1’s home clinical record booklet and the surrounding area was conducted. Patient 1’s current care plan was not found in the booklet or anywhere in the house. Both LVN 1 and Patient 1 confirmed that these essential documents were not available. A review of Patient 1’s clinical record revealed Patient 1 received home health services under an individualized plan of care. However, the plan of care was not available in the home folder to guide the patient/caregiver regarding the care and services to be provided. 2. A review of Patient 2’s face sheet, indicated a start of care date of April 10, 2026, with a certification period from April 10, 2026, to June 8, 2026. Patient 2 had diagnoses which included displaced bicondylar fracture of the left tibia (the left shin bone (tibia) is broken into at least two pieces and has moved out of its normal position) and essential (primary) hypertension (medical term for high blood pressure that happens on its own, without being caused by another medical condition) During a concurrent home visit observation and interview on May 19, 2026, at 11:30 AM, with Registered Nurse (RN), in the presence of Patient 2 and Patient 2 care givers, Patient 2’s home clinical record booklet and the surrounding area was conducted. Patient 2’s current care plan was not found in the booklet or anywhere in the house. Both RN and Patient 2 care givers confirmed that these essential documents were not available. During an interview on May 21, 2026, at 9:45 AM, with the Director of Patient Care Services (DPCS), the DPCS stated, “It is the responsibility of the visiting nurse and case manager to ensure that the current care plan and other essential documents are left at the patient’s location and are easily accessible.” Furthermore, the DPCS stated that the current care plan is crucial to guide the patient/caregiver regarding the care and services to be provided and to facilitate continuity of care to meet each patient’s need. During a concurrent interview and record review on May 21, 2026, at 9:50 AM, with the DPCS, the agency’s policy and procedure (P&P) titled, “Care Planning Process,” revised November 2024 was reviewed. The P&P indicated, “…PROCEDURE. 1. At the time of the initial assessment, the clinician, along with other involved disciplines, will develop the patient plan of care based upon the patient’s identified needs and will review with the patient and family/caregiver. A Case Manager will be assigned to coordinate all activities involved in the patient’s care…17. The organization shall provide the patient and caregiver with a copy of written instructions outlining: A. Visit schedule, including the day of the week, frequency of visits by personnel and personnel acting on behalf of the organization. B. Patient medication schedule/instructions, including medication name, dosage and frequency and which medications will be administered by the organization’s personnel and personnel acting on behalf of the organization. 1. Instructions will be written in a plain language the patient can understand and that does not use medical abbreviations. C. Any treatments to be administered by the organization’s personnel and personnel acting on behalf of the organization, including therapy services. D. Any other pertinent instruction related to the patient’s care and treatments that the organization will provide, specific to the patient’s care needs...” The DPCS stated the agency did not follow the policy.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow infection control guidelines when one box of (60 wipes) Alcohol Prep pad with an expiration date of January 30, 2025, was found in the medical supply room and were available for use. This failure had the potential to put the facility’s 40 patients at an increased risk of infection (the invasion and growth of germs like bacteria, viruses or fungi in the body, which can cause illness or damage to tissues) and other complications of infectious microorganism. Findings: During a facility tour observation and interview on May 18, 2025, at 4:30 PM, with the Director of patient care Services (DPCS), in the conference room/medical supply room, one box of (60 wipes) Alcohol Prep Pads with an expiration date of January 30, 2025, was found available for use. The DPCS verified that the box of 60 Alcohol Prep Pads were expired for 473 days and should have been discarded. During a concurrent interview and record review on May 20, 2026, at 10:15 AM, with the DPCS, the facility’s policy and procedure (P&P) titled, “SAFE AND APPROPRIATE USE OF MEDICAL EQUIPMENT AND SUPPLIES”, dated, November 2, 2024, was reviewed. The P&P indicated, “PROCEDURE 3. All supplies will be checked for expiration dates upon receipt, during stocking and restocking and at routine inspection intervals. Any item found to be expired, damaged, or opened (when sterility is required) shall be removed from active stock and discarded”. The DPCS stated the medical supplies should have been checked regularly and expired items should have been discarded. The DPCS further stated the facility did not follow the infection prevention and control policy.”

“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 agency failed to ensure medication reconciliation (process to compare current medication order with what home medications patients are actually taking) was conducted for two of three sampled patients (Patients 2 and 3) when Patients 2 and 3’s Medication Profile (MP) did not accurately reflect the patients’ current medication regimen. These failures had the potential to cause ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy placing Patients 2 and 3’s health and safety at risk. Findings: 1. A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), indicated a start of care date of April 10, 2026, with a certification period (a specific timeframe during which a patient is eligible to receive home health services) from April 10, 2026, to June 8, 2026. Patient 2 had diagnoses which included displaced bicondylar fracture of the left tibia (the left shin bone (tibia) is broken into at least two pieces and has moved out of its normal position) and essential (primary) hypertension (medical term for high blood pressure that happens on its own, without being caused by another medical condition) During a home visit on May 19, 2026, at 11:30 AM, with Registered Nurse (RN), in the presence of Patient 2 care givers, an observation of Patient 2’s actual medication bottles, which were available in the home, were compared with Patient 2’s most current MP. During a concurrent observation and interview on May 19, 2026, at 11:35 AM, with RN, Patient 2’s MP, undated, was reviewed. The MP listed Carvedilol (prescription medicine used to lower high blood pressure)12.5 mg (milligrams-a unit of measure), take one tablet by mouth twice daily for hypertension (high blood pressure), and Norvasc 10 mg (prescription medicine used to lower high blood pressure), take one tablet by mouth daily for hypertension. Patient 2’s care giver stated both medications had been held (not given) since May 4, 2026. During a continued concurrent observation and interview on May 19, 2026, at 11:40 AM, with RN, Patient 2’s MP, undated, was reviewed. The MP listed Clonidine (prescription medicine used to lower high blood pressure) 0.1 mg/24 hours weekly transdermal patch (a medication patch placed on the skin and absorbed into the body over time) for hypertension. Patient 2’s care givers stated the last Clonidine patch was applied on April 27, 2026. During a follow-up interview on May 19, 2026, at 11:45 AM with RN, RN stated she was aware Patient 2’s Carvedilol, Norvasc, and Clonidine were being held, and Patient 2’s MP should have been updated to reflect the current medication use. Furthermore, RN acknowledged there was no documentation that the physician was notified regarding Patient 2’s Carvedilol, Norvasc, and Clonidine patch not being administered as ordered and there was no physician’s order to hold or discontinue the medications. 2. A review of Patient 3’s face sheet, indicated a start of care date of May 14, 2026, with a certification period from May 14, 2026, to July 12, 2026. Patient 3 had diagnoses which included displaced fracture of lower epiphysis (separation) of left femur (an injury or break to the bottom part of the left thigh bone with routine healing). During a home visit on May 19, 2026, at 12:30 PM, with Physical Therapist (PT), in the presence of Patient 3 and Patient 3’s daughter, an observation of Patient 3’s actual medication bottles, which were available in the home, were compared with Patient 3’s most current MP. During a continued concurrent observation and interview on May 19, 2026, at 12:35 PM, with PT, PT checked a bubble pack card (is a specialized, organized, and secure way for a pharmacy to package pills) of Lasix (a prescription medication used to remove extra fluid from the body ) 40 mg, give 1 tablet one time a day. PT reviewed Patient 3’s MP and confirmed that the order on Patient 3’s MP indicated, “Lasix 20 mg 1 tablet daily”. Patient 3’s daughter stated that she had been giving her mother (Patient 3) Lasix 40 mg daily, including this morning. During an interview on May 21, 2026, at 10:30 AM, with the Director of Patient Care Services (DPCS), the DPCS stated the expectation for nurses and staff was to perform medication reconciliation per agency policy. The DPCS further stated medication reconciliation should be conducted at each visit and that the medication profile must be updated if there are any changes. During a concurrent interview and record review on May 21, 2026, at 10:40 AM, with the DPCS, the agency’s policy and procedure (P&P) titled “Medication Reconciliation,” revised November 2024, was reviewed. The P&P indicated, “PURPOSE. To define the use of the medication profile in evaluating a patient’s medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals. POLICY. Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. PROCEDURE …3. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver as well as other clinicians understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of medications in the home setting. B. Using the medication profile to teach purpose of medication, dosages, routes, administration times, side effects, and contraindications… 4. Each patient will receive appropriate written material for specific medications he/she is receiving…” The DPCS stated that the agency policy was not being followed.”