Interim Healthcare

“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 agency failed to include all treatments, pertinent diagnoses specific interventions and goals as relevant to the plan of care for three out of 10 sampled patients, (Patient 1, Patient 4, and Patient 10). This failure had the potential for unidentified problems, risk for hospitalization and negative clinical outcomes. Findings: During a review, of the agency’s policy dated 4/2/21, titled, “Developing a Plan to Meet Patient/Client Needs,” it indicated an individualized plan of care (POC) is developed for each patient receiving care/services to specify the care and services necessary to meet the patient’s specific needs and goals as identified in the comprehensive assessment. The development and evaluation of the plan of care in partnership of the patient, representative, and care givers. The POC directs the delivery of care/service. Care/Services are furnished in accordance with accepted standards of practice, law, and regulation. Patient 1’s clinical record was reviewed. Patient 1 was admitted to the home health agency on 12/11/24, with diagnoses that included pressure injury (any disruption of the intact skin with underlying damage to the tissues), polyneuropathy (nerve pain), Peripheral Vascular Disease, (PVD, a systemic condition that causes poor circulation, causing reduced blood flow to the arms and legs), kidney disease, hypothyroidism (the thyroid gland does not produce enough thyroid hormones needed), urinary device (Foley Catheter, (F/C) a tube inserted into the bladder to drain urine) and hyperglycemia (too much sugar in the blood). During a review, of Patient 1’s plan of care (POC, or physician orders that help nurses and other team members organize aspects of patient care with a timeline) dated 12/11/24, indicated there was no date of last change of F/C for Skilled Nurse (SN) listed. There were no interventions listed for education related to turning and positioning for prevention of more wounds. The POC did not provide education for care giver strain for 24/7 care needed or any community resources to assist for Patient 1, while waiting on a Medical Social Worker (MSW) visit that was not completed. During an interview, on 2/4/25 at 11:58 am, the Director of Nursing (DON) confirmed the MSW visit was never completed per the POC, and the care giver needed education for Patient 1. The DON confirmed, that the SN interventions were not specific to Patient 1’s medical needs and for education the care giver needed. DON stated, “We should have increased the SN visits, and revised the POC, when the MSW did not go to the home.” During a review of Patient 4’s clinical record, Patient 4 was admitted to the agency on 10/10/24 with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (G/T, surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a review, of Patient 4’s plan of care POC dated 10/10/24, it indicated there were no interventions for SN to complete care for the G/T, care giver education was not listed for the G/T, and signs and symptoms of infection of the G/T site to report to the agency and physician, as indicated were not listed. There was no education interventions related to keeping head of the bed elevated during feedings, and water administration via G/T. During a review of Patient 4’s clinical record, a document dated, 12/25/24, titled, “Discharge Orders,” indicated Patient 4 was admitted to a local hospital on 12/15/24 for severe sepsis, (the body’s extreme response to an infection), hypernatremia (too much sodium in the blood), hypokalemia (not enough potassium in the blood), pneumonia (infection in the lungs) and a Urinary Tract Infection (UTI, a bladder infection). This record also indicated Patient 4 was discharged on 12/25/24. During an interview on 2/5/24 at 1:40 pm, Registered Nurse (RN) 5 stated, “I agree I should have added G/T interventions for the Skilled Nurse (SN) to observe the G/T site. I place a dry 4 x 4 slit gauze at every visit to [Patient 4’s] G/T site. The care givers do need more education of what to report to the agency, and physician. They also need more education for pain management, turning and repositioning.” Patient 10’s clinical record was reviewed. Patient 10 was admitted to the home health agency on 1/8/25, with diagnoses that included sepsis (a severe reaction to an infection), open wound to left chest, diabetes (too much sugar in the blood), atrial fibrillation (abnormal heart rate), history of a myocardial infarction (heart attack), kidney disease and history of venous thrombosis (blood clot forms in a vein) and embolism (a blood clot that travels to the lungs, suddenly forms a blockage). During a review, of Patient 10’s plan of care POC dated 1/8/25, it indicated there were no orders or interventions for wound care if the wound vac (vac, machine used for wound healing with specific settings) was not functioning, no specific alternate wound care orders for SN, or care givers. This POC did not have orders, or interventions for education for signs and symptoms of infection related to a prolonged hospitalization with a wound infection. There were no orders, or interventions for education related to heart disease, or new onset of chest pain, and Patient 10 had a history of a heart attack. During an interview, on 2/5/25 at 12:30 pm, RN 2 confirmed, that all POCs need to be patient specific. RN 2 confirmed, that wound care order alternates should be on the POC for Patient 10. RN 5 confirmed, that G/T SN and caregivers’ orders, and interventions should be on the POC for Patient 4. During an interview, on 2/7/25 at 12:20 pm, the DON confirmed all POCs need to be patient specific and there will be more education provided to make all POCs more detailed for each diagnosis pertinent to home health, and for each intervention completed by SN.”

“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, the agency failed to ensure that three of 10 sampled patients (Patient 1, 4, and Patient 8), was evaluated by a discipline ordered by the referring physician, and was included in the Plan of Care (POC) when: 1. Patient 1, and Patient 4 did not receive a Medical Social Worker (MSW) evaluation to assess needs during home health services per orders. 2. Patient 8 did not receive a Physical Therapist (PT) evaluation to assess needs during home health services per orders. This failure could result in changes to care without physician knowledge or approval, and a lack of adequate physician oversight leading to negative clinical outcomes. Findings: A review, of the agency’s policy dated 4/2/21, titled, “Implementing the Plan of Care/Service Plan,” indicated the purpose of this policy is to ensure that the written plan of care is implemented. The Director of Health Care Services ensures resources are available, and processes are in place to implement the Plan of Care/Plan of Service. Patient 1’s clinical record was reviewed. Patient 1 was admitted to the home health agency on 12/11/24, with diagnoses that included pressure injury (any disruption of the intact skin with underlying damage to the tissues), polyneuropathy (nerve pain), Peripheral Vascular Disease, (PVD, a systemic condition that causes poor circulation, causing reduced blood flow to the arms and legs), kidney disease, hypothyroidism (the thyroid gland does not produce enough thyroid hormones needed), and hyperglycemia (too much sugar in the blood). During a review, of Patient 1’s clinical record, the POC dated 12/11/24, indicated a Medical Social Worker (MSW) ordered for the week of 12/16/24 to evaluate needs. During a review, of Patient 1’s clinical record, there were no MSW visits for Patient 1 completed, and no updates to the physician for missed visits for the MSW. During an interview, on 2/6/25 at 11:10 am, the Director of Nursing (DON) confirmed, that the MSW did not complete any visits for Patient 1, and the physician was not updated with the change in POC. The DON stated, “I confirm Patient 1 needed a MSW because we filed an Adult Protective Services Report at the discharge. The MSW did try to go on the last day 1/6/25, but the caregiver refused.” Patient’s 4 clinical record was reviewed. Patient 4 was admitted to the home health agency on 10/10/24, with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (G/T, surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a review, of Patient 4’s clinical record, the POC dated 12/31/24, indicated a MSW order for community resources, and to assist with long term planning and caregiving. During a review, of Patient 4’s clinical record, there were no MSW visits for Patient 4 completed, and no updates to the physician for missed visits for the MSW. During an interview, on 2/5/25 at 1:30 pm, Registered Nurse (RN) 5 confirmed, that the MSW did not complete any visits for Patient 4, and the physician was not updated. RN 5 stated, “We did not have a MSW, and I should have updated the physician at that time.” During an interview, on 2/6/25 at 10:58 am, the Director of Nursing (DON) confirmed the MSW did not complete any visits for Patient 4, and the physician was not updated the change in POC. DON stated, “We just hired a new MSW, and she starts in two weeks.” Patient 8’s clinical record was reviewed. Patient 8 was admitted to the home health agency on 5/9/24, with diagnoses that included open wound to the abdominal wall (stomach), acute respiratory failure (condition when the lungs cannot exchange oxygen) with hypoxia (low oxygen levels in the blood), Congestive heart failure (CHF, a long-term condition in which your heart cannot pump blood well enough to meet the body’s needs), diabetes (too much sugar in the blood), atrial fibrillation (abnormal heart rate), liver disease, and hypothyroidism (the thyroid gland does not produce enough thyroid hormones needed). During a review, of Patient 8’s clinical record, the POC dated 5/9/24, included a Physical Therapist (PT) order for an evaluation for the week of 5/13/24, to evaluate and treat as indicated. During a review, of Patient 8’s clinical record, there were no PT visits for Patient 8 completed, and no updates to the physician for missed visits for the PT from 5/9/24 to 7/7/24. During an interview, on 2/6/24 at 2:35 pm, the Director of Nursing (DON) confirmed, that there were no PT visits for the certification period from 5/9/24 to 7/7/24, for Patient 8, and this did not follow the POC. The DON also confirmed the physician had not been updated.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview, and record review, the agency failed to ensure that three of 10 sampled patients (Patient 3, 4, and Patient 5), was assessed by a Registered Nurse (RN) within 48-hours of their referral for home health care, and to notify the physician when there was a delayed start of care (admission to agency). This failure could result in changes to care without physician knowledge or approval, and a lack of adequate physician oversight leading to negative clinical outcomes. Findings: During a review of the agency’s policy dated 4/2/21, titled, “Initial Comprehensive Assessment,” indicated an initial comprehensive assessment of an individual is conducted within 48 hours of referral for home care/services, or within 48 hours of the individual’s return home, or the physician’s or allowed practitioner ordered start of care (SOC) date. If the initial comprehensive assessment cannot be completed within the time frame agreed upon at the referral, the ordering physician or practitioner is contacted for an order for an alternate date. During a review of Patient 4’s clinical record, Patient 4 was admitted to the home health agency on 10/10/24 with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (G/T, surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a review, of Patient 4’s visit documentation, it was noted that Patient 4 was referred to services on 10/7/24, but the start of care (initial comprehensive assessment) date was 10/10/24 (3 days later). There was no documentation, that the physician had been notified of this delay in the start of care. During a concurrent record review, and interview, on 2/7/25 at 11:45 am, Registered Nurse (RN) 2 confirmed there was no documentation of a reason for the delay of the start of care, and no update sent to the physician to notify that services were delayed for Patient 4. During an interview on 2/7/25 at 12:30 pm, the Director of Nursing confirmed that it was the expectation and policy of this agency, as well as a Federal regulation, to open all patients to service within 48-hours of their referral date, and to notify the physician if there was a delay. During a review of Patient 3’s record, Patient 3 was admitted to the home health agency on 11/14/2023 with diagnoses that included chronic venous hypertension (condition where the pressure in the leg veins is high,) wounds on both legs, and gout (a type of arthritis.) During a review of Patient 3’s clinical record, it was noted that a referral for home health services was received by the agency on 11/8/2023. The start of care for Patient 3 was 11/14/2023. There was no documentation to clarify the delay or indicate the physician had been notified in a timely manner. During a concurrent record review and interview on 2/6/25 at 2:40 pm with the DON she confirmed that Patient 3’s start of care was not within 48 hours of the agency receiving the referral. During a review of Patient 5’s record, Patient 5 was admitted to the home health agency on 10/18/2024 with diagnoses that included a wound of the left lower leg, chronic pain, and chronic obstructive pulmonary disorder (COPD, lung disease that makes it difficult to breathe). During a review of Patient 5’s clinical record, it was noted that a referral for home health services, labeled “Urgent” was received by the agency on 10/10/2024. The start of care for Patient 5 was 10/18/2024. There was no documentation to clarify the delay or indicate the physician had been notified in a timely manner. During an interview and concurrent record review on 2/4/25 at 4:30 pm with the scheduler (SD,) she confirmed that the referral for Patient 5 was received by the agency on 10/10/2024 and that the start of care was 10/18/2024. SD stated that, due to the type of insurance Patient 5 had, staff wait to receive notification of authorization before any visits can be scheduled, including start of care. SD verified that the agency received authorization on 10/15/2024, and the start of care visit did not occur until 10/18/2024. During a concurrent interview and record review on 2/5/25 at 2 pm with DON, she confirmed that the start of care visit for Patient 5 did not occur in a timely manner. DON clarified that all start of care assessments should occur within 48 hours of the agency receiving a patient referral.”

“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 agency failed to review and document all medications in the home for one out of 10 sampled patients, (Patient 8) during a home visit to include in the clinical record and for the physician to review for interactions. This failure had the potential to cause unrecognized medication interactions, which could cause potential negative clinical outcome. Findings: The agency’s policy titled, “Medication Reconciliation/Drug Interactions,” undated, indicated that when performing a visit, a medication reconciliation must be completed, and if a home medication(s) does not match the agency’s medication list, a medication reconciliation must be completed. If a patient notifies the nurse that they are taking a new medication, or the directions on how they are taking a medication has changed, a medication reconciliation must be completed at that time also. Patient 8’s clinical record was reviewed. Patient 8 was admitted to the home health agency on 5/9/24, with diagnoses that included open wound to the abdominal wall (stomach), acute respiratory failure (condition when the lungs cannot exchange oxygen) with hypoxia (low oxygen levels in the blood), Congestive heart failure (CHF, a long-term condition in which your heart cannot pump blood well enough to meet the body’s needs), diabetes (too much sugar in the blood), atrial fibrillation (abnormal heart rate), liver disease, and hypothyroidism (the thyroid gland does not produce enough thyroid hormones needed). During an concurrent observation, interview, and record review, on 2/5/25 at 12:28 pm, with Registered Nurse (RN) 3 , the medications in the home did not match the medication list created on 2/5/25, from Patient 8’s medication profile for Home Health Episode 1/4/25 – 3/4/25. RN 3 stated, “I ask about medications every visit, and if there are any changes, I will update the medication list.” During an interview, on 2/5/25 at 12:30 pm, Patient 8 stated, “I get busy, and don’t remember new medications, or changes in my medications sometimes.” During a review, of Patient 8’s medication profile dated 2/5/25, for Home Health Episode1/4/25 – 3/4/25, it noted that Patient 8’s medication profile had 10 medications that were either no longer being taken, days when a medication was scheduled to be taken had changed, or new medications/supplements were not added. During an interview, on 2/6/25 at 8:53 am, the Director of Nursing (DON) confirmed, that the medication profile was not accurate and up to date for Patient 8. When asked what the expectations are for medication reconciliation, the DON stated, “The medication reconciliation should be performed at each visit by the nurse.””

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on interview, and record review, the agency failed to ensure one of 10 sampled patients (Patient 4) had a Resumption of Care (ROC, a Registered Nurse assessment for the patient to resume care and home health orders) completed after a hospitalization within 48-hours. This failure could result in another hospitalization, delay in obtaining physician oversight, and other negative clinical outcomes. Findings: The agency’s policy dated 4/2/21, titled, “Resumption of Care,” indicated the policy for all employees to conduct an individual comprehensive assessment of all patients within 48-hours of (or knowledge of) the patient’s return home from an inpatient or hospital stay of 24-hours or more for any reason except diagnostic tests; or the physician ordered resumption of care (ROC) date. Patient 4’s clinical record was reviewed. Patient 4 was admitted to the home health agency on 10/10/24, with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a review, of Patient 4’s clinical record, a document dated, 12/25/24, titled, “Discharge Orders,” indicated that Patient 4 was admitted to a local hospital on 12/15/24, for severe sepsis, (the body’s extreme response to an infection), hypernatremia (too much sodium in the blood), hypokalemia (not enough potassium in the blood), pneumonia (infection in the lungs) and a Urinary Tract Infection (UTI, a bladder infection). This record also indicated, that Patient 4 was discharged on 12/25/24. During a review, of Patient 4’s clinical record, a document dated, 12/27/24, titled, “Missed Visit,” indicated Patient 4 was no longer at a local hospital entered by Registered Nurse (RN) 5 on 12/27/24 at 10:00 am. During a review, of Patient 4’s clinical record, there were no physician notifications of Patient 4 returning home from a hospitalization, or a ROC request date order. During an interview, on 2/4/25 at 3:40 pm, RN 5 confirmed the ROC was late for Patient 4. RN 5 stated, “I confirm the ROC was late, we have to call the doctor, and the ROC was not completed until 12/31/24. I did not call the doctor to update.” During an interview, on 2/4/25 at 4:15 pm, the Director of Nursing (DON) confirmed, that the ROC was late for Patient 4, completed on 12/31/24, six days after Patient 4 was discharged home on 12/25/24.”

“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, the agency failed to identify and update the physician of a significant change in condition for one of 10 sampled patients (Patient 4). This failure resulted in poor pain management, a hospitalization, and negative clinical outcomes. Findings: During a review, of the agency’s policy dated 4/2/21, titled, “Coordination of Care/Services,” is to facilitate coordination and continuity of care/service for patients/clients from time of referral through discharge. The Interdisciplinary Team (IDT, a group of health care professionals from diverse fields, physicians, allowed practitioners, nurses, therapists, home health aides, and social workers) who work in a coordinated fashion toward a common goal for the patient. The Director of Health Care Services (DHCS) establishes a process to integrate care/services, whether provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness, the coordination of care provided by all disciplines, and communication with the physician or allowed practitioners. The DHCS establishes processes for the documentation of IDT coordination of care in the patient/client record. This agency’s policy also indicated the designated employee contacts the physician or practitioner when any of the following events occur: The patient’s condition changes, the patient’s response to care/treatment changes or medications is not as expected, and changes occur in care giver support or the patient’s environment that impacts the plan of care/service plan. Patient 4’s clinical record was reviewed. Patient 4 was admitted to the home health agency on 10/10/24, with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a review, of Patient 4’s plan of care (POC, or physician orders that help nurses and other team members organize aspects of patient care with a timeline) dated 10/10/24, indicated there were no wounds (open areas of skin), no pain indicated or documented and no contractures. There was an order for Tylenol (a medication for mild pain or fever) 325 milligrams (mg, a unit of measure) 1 tablet two times daily as needed for pain via gastrostomy (G/T). During a review, of Patient’s 4 clinical record a document dated 12/12/24, titled, “Visit Note,” it indicated under pain status, patient had non-verbal symptoms of pain as follows: grimacing, moaning, and was restless. During a review, of Patient 4’s Resumption of Care Outcome and Assessment Information Set (Oasis) dated 12/31/24, J0520 question for pain status indicated Patient 4 does have pain frequently with limitation to therapy activity. This Oasis also indicated J0530 question for pain interference to daily activities is frequently for Patient 4. During a review, of Patient 4’s POC dated 12/31/24, for a resumption of care through 2/6/24, indicated new wounds, no Tylenol was listed on the medication list, or any other pain medications. During a review, of Patient 4’s clinical record, there were no physician updates documented, or faxed for Patient 4’s pain, new onset of wounds, and no change of condition or decline Oasis documented from 10/10/24 to 2/5/25. During an interview, on 2/5/25 at 12:30 pm, Registered Nurse (RN) 5 confirmed, that Patient 4 did have a change in condition and this Oasis was not completed, and the physician was not notified of increased pain during positioning. RN 5 stated, “Yes, I confirm [Patient 4] has had a decline, he has more pain, he wants to stay on his right side, he does moan and grimace during repositioning, and seven new wounds from pressure. He is also getting contractures from not getting out of bed often, and [Patient 4] lies in a fetal position most of the time. I am doing the recertification due tomorrow for Patient 4 and will update the physician of the decline and ask for something for pain management.” During an interview, on 2/7/25 at 11:55 am, RN 2 confirmed, that the physician should have been updated with the changes and decline for Patient 4. RN 2 also stated, “I don’t know which Oasis we use for a change of condition, but I will find it. I agree [Patient 4] needed a significant change of condition Oasis completed for pain, new wounds, and decreased range of motion.” During an interview, on 2/7/25 at 12:05 pm, the Director of Nursing (DON) confirmed, that Patient 4 had a change of condition and new pain that was not reported to the physician. The DON also confirmed, that a change of condition Oasis should have been completed for Patient 4. The DON stated, “The change of condition can be any decline, I know Patient 4 is declining, and is nothing by mouth (NPO), but he could have taken more supplements for new wounds via G/T.””

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on interview, and record review, the agency failed to ensure that 10 out of 10 patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, and Patient 10) had Interdisciplinary team (IDT, a group of health care professionals who work together to provide care for the patient) ongoing assessments documented in the clinical record to ensure the coordination of all services and interventions provided to the patient to include all physician orders, and the communication of progress and ongoing problems. This failure had the potential for unrecognized needs to go unmet which could lead to potential negative clinical outcomes. During a review of Patient 2’s record, Patient 2 was admitted to the home health agency on 8/22/24 with a diagnosis of chronic wound. During a review of Patient 2’s clinical record, there were no IDT notes documented in Patient 2’s clinical record from 8/22/24 through 12/19/2024 when the patient was discharged. During a review of Patient 3’s record, Patient 3 was admitted to the home health agency on 11/14/23 with diagnosis that included chronic venous hypertension (condition where the pressure in the leg veins is high,) wounds on both legs, and gout (a type of arthritis.) During a review of Patient 3’s clinical record, there were no IDT notes documented in Patient 3’s clinical record from 11/14/23 through 1/6/25 when the patient was discharged. During a review of Patient 5’s record, Patient 5 was admitted to the home health agency on 10/18/2024 with diagnoses that included a wound of the left lower leg, chronic pain, and chronic obstructive pulmonary disorder (COPD, lung disease that makes it difficult to breathe). During a review of Patient 5’s clinical record, there were no IDT notes documented in the record from 10/18/24 through 2/4/2025 at the time of review During a review of Patient 7’s record. Patient 7 was admitted to the home health agency on 5/15/24 with diagnoses that included a diabetic foot wound, cellulitis (a bacterial skin infection that causes swelling and redness,) and chronic pain. During a review of patient 7’s clinical record. There were no IDT notes documented in the record from 5/15/24 through 2/4/25 at the time of review. Findings: During a review of the agency’s policy dated 4/2/21, titled, “Coordination of Care/Services,” is to facilitate coordination and continuity of care/service for patients/clients from time of referral through discharge. The Interdisciplinary Team (IDT, a group of health care professionals from diverse fields, physicians, allowed practitioners, nurses, therapists, home health aides, and social workers) who work in a coordinated fashion toward a common goal for the patient. The Director of Health Care Services (DHCS) establishes a process to integrate care/services, whether provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness, the coordination of care provided by all disciplines, and communication with the physician or allowed practitioners. The DHCS establishes processes for the documentation of IDT coordination of care in the patient/client record. During a review of Patient 1’s clinical record, Patient 1 was admitted to the home health agency on 12/11/24 with diagnoses that included pressure ulcer (any disruption of the intact skin with underlying damage to the tissues), polyneuropathy (nerve pain), Peripheral Vascular Disease, (PVD, a systemic condition that causes poor circulation, causing reduced blood flow to the arms and legs), kidney disease, hypothyroidism (the thyroid gland does not produce enough thyroid hormones needed), and hyperglycemia (too much sugar in the blood). During a review of Patient 1’s clinical record, there were no IDT notes documented in Patient 1’s clinical record from 12/11/24 through 1/6/25, when Patient 1 was discharged from the agency. During a review of Patient 4’s clinical record, Patient 4 was admitted to the home health agency on 10/10/24 with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (G/T, surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a review of Patient 4’s clinical record, there were no IDT notes documented in Patient 4’s clinical record from 10/10/24 through 2/6/25. During a review of Patient 6’s clinical record, Patient 6 was admitted to the home health agency on 1/16/25 with diagnoses that included congestive heart failure, (CHF, a long-term condition in which your heart cannot pump blood well enough to meet the body’s needs), diabetes (too much sugar in the blood), pulmonary hypertension (a condition that affects blood vessels in the lungs with increased pressure), pulmonary embolism (a blood clot that travels to the lungs, suddenly forms a blockage), history of kidney stones and bladder cancer. During a review of Patient 6’s clinical record, there were no IDT notes documented in Patient 6’s clinical record from 1/16/25 through 2/6/25. During a review of Patient 8’s clinical record, Patient 8 was admitted to the home health agency on 5/9/24 with diagnoses that included open wound (any disruption of the intact skin with underlying damage to the tissues) to the abdominal wall, acute respiratory failure (condition when the lungs cannot exchange oxygen) with hypoxia (low oxygen levels in the blood), Congestive heart failure (CHF, a long-term condition in which your heart cannot pump blood well enough to meet the body’s needs), diabetes (too much sugar in the blood), atrial fibrillation (abnormal heart rate), liver disease, and hypothyroidism (the thyroid gland does not produce enough thyroid hormones needed). During a review of Patient 8’s clinical record, there were no IDT notes documented in Patient 8’s clinical record from 5/9/24 through 2/6/25. During a review of Patient 9’s clinical record, Patient 8 was admitted to the home health agency on 10/1/24 with diagnoses that included high blood pressure, congestive heart failure, (CHF, a long-term condition in which your heart cannot pump blood well enough to meet the body’s needs), Peripheral Vascular Disease, (PVD, a systemic condition that causes poor circulation, causing reduced blood flow to the arms and legs), history of prostate cancer, personal history of nicotine (tobacco) dependence, and a history of falling. During a review of Patient 9’s clinical record, there were no IDT notes documented in Patient 8’s clinical record from 10/1/24 through 2/6/25. During a review of Patient 10’s clinical record, Patient 10 was admitted to the home health agency on 1/8/25 with diagnoses that included sepsis (a severe reaction to an infection), open wound (any disruption of the intact skin with underlying damage to the tissues) to left chest, diabetes (too much sugar in the blood), atrial fibrillation (abnormal heart rate), history of a myocardial infarction (heart attack), kidney disease and history of venous thrombosis (blood clot forms in a vein) and embolism (a blood clot that travels to the lungs, suddenly forms a blockage). During a review of Patient 10’s clinical record, there were no IDT notes documented in Patient 10’s clinical record from 1/8/25 through 2/6/25. During an interview on 2/6/25 at 12:03 pm, Registered Nurse 2 confirmed there were not IDT notes for 10 of 10 sampled patients in the clinical records. RN 2 stated, “There has been a lot of changes since the change in owners.” During an interview on 2/6/25 at 12:10 pm, the Director of Nursing (DON) confirmed no IDT notes were documented in the clinical records for any patients. DON stated, “We do discuss the residents, but we have not added any IDT notes in the electronic medical records. We will start this process immediately.””

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview, and record review, the agency failed to provide Registered Nurse (RN) oversight for a Home Health Aide (HHA) providing direct care in the home for one of 10 sampled patients, (Patient 4) every 14-days. This failure had the potential for Patient 4’s needs to go unidentified and ongoing needs to not be provided, which could lead to negative clinical outcomes. Findings: During a review, of the agency’s policy dated 1/13/18, titled, “Supervision of Employees Who Provides Patient Care Service,” it indicated that the purpose of this policy is to define the scope and circumstance indicating in-person oversight of the employee who provides care/service to patients/clients. The nursing services are provided under the supervision of a qualified Registered Nurse (RN). During a review, of the agency’s policy dated 12/21/21, titled, “Case Supervision,” indicated the agency conducts regular cased supervision in accordance with applicable law and regulation and written contract for each patient. An appropriate qualified employee conducts case supervision onsite for each patient according to the following level of care required. Home Health Aide (HHA) Services with skilled services will be supervised no less frequently than every 14-days with or without the aide present. Patient 4’s clinical record was reviewed. Patient 4 was admitted to the home health agency on 10/10/24, with diagnoses that included diabetes (too much sugar in the blood), Cerebral Vascular Accident (CVA, or stroke), hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), gastrostomy (surgical incision in the stomach when a tube is inserted for liquid nutrition, fluids, and medications), heart disease, and depression (constant feelings of sadness and loss of interest in activities). During a record review, of Patient 4’s clinical record, Patient 4 had HHA visits weekly on 1/9/25, 1/16/25, 1/23/25, and 1/30/25. The last RN supervision of HHA was completed on 1/9/25, and no HHA supervision was completed on 1/23/25, or 1/30/25, per policy. During an interview, on 2/7/25 at 12:00 pm, RN 2 confirmed, that the HHA supervisory visits were late for Patient 4, and were not completed every 14-days per their agency’s policy. During an interview, on 2/7/25 at 12:15 pm, the Director of Nursing confirmed the HHA supervisory visits due every 14-days were late for Patient 4.”