Focus Health

“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 agency failed to follow standards of practice for one of seven sampled home visit patients (Patient 3) when License Vocational Nurse (LVN) 1 did not disinfect prothrombin (PT -a blood test that measures how long it takes for blood to clot/ International Normalized Ratio (INR- standardized way to measure how long it takes for a person’s blood to clot) meter, Registered Nurses (RN 1, RN 2, RN 3) and Director or Patient Care Services (DPCS)/Vice President (VP) were not able to verbalized disinfected equipment reprocess according to the manufacturer guideline. This failure put Patient 3 and other patients who used the meter at risk for blood-borne (infectious microorganisms in human blood that can cause disease in humans) pathogen (bacterial or virus) infections and cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During an observation on 6/5/25 at 12: 00 p.m. in Patient 3’s living room, License Vocational Nurse (LVN) 1 took a Pt/INR blood sample. LVN 1 use a [brand name] disinfect wipe to cleaned the PT/INR meter and placed the Pt/INR meter into her bag. There was no contact time (the time taken for the disinfectant to bind to the microorganism to kill it). During an interview on 6/5/25 at 12:47 p.m. with LVN 1, LVN 1 stated she used [brand name] disinfect wipes to cleanse the PT/INR meter after obtaining blood sample from patients.. LVN 1 stated, “I wipe and put it away.” LVN 1 stated, “It was normal for her to clean the PT/INR meter by wiping and putting it away without no contact time. LVN 1 stated she was not sure how long the contact time was to safely disinfect the PT/INR meter. LVN 1 stated it was important to cleanse and disinfect the PT/INR meter correctly to prevent cross-contamination. LVN 1 stated improperly cleaning of the PT/INR meter had the potential for blood borne pathogen and infection. LVN 1 stated the PT/INR meter was use for different patients. LVN 1 stated she was not sure when the last time she had an in-service on disinfecting the PT/INR meter. During an interview on 6/9/25 at 2:22 p.m. with the Director of Patient Care Services/Vice President (DCPS/VP), the DPCS/VP stated, the agency used 70 percent alcohol wipes or [brand name] disinfected wipes to cleanse and disinfect the PT/INR meter. The DCPS/VP stated, “I expected it to be wiped and cleanse and put away.” The DCPS stated she expected the staff to use the same disinfected reprocess for other medical equipment such as blood pressure cuffs, stethoscopes the same way as the PT/INR meter. . The DCPS/VP stated there were no amount of contact time needed to disinfect the PT/INR meter. During an interview on 6/10/25 at 11:45 a.m. with Registered Nurse (RN) 1, RN 1 stated she cleanse the area where the strips went into with alcohol wipes. She stated the alcohol wipes should be on there for 30 seconds. RN 1 stated, “We use alcohol pad. We clean the PT/INR meter using alcohol pads.” RN 1 stated, “I am not sure how long [the contact time] should be on there.” RN 1 stated, “It is important to clean [PT/INR meter] correctly, it can be a mode of transmission, of microorganism, bloodborne pathogen.” RN 1 stated, “Patients can get HIV (human immunodeficiency virus-a virus that attacks the body’s immune system), Hep C (Hepatitis C - a viral infection that causes liver swelling) and any bloodborne blood pathogen. RN 1 stated patients were at risk to get infections. RN 1 stated she did not remember any in-services on disinfection of PT/INR meter. During an interview on 6/10/25 at 12:10 p.m. with RN 2, RN 2 stated she used the [brand name] wipes to disinfect the PT/INR meter. RN 2 stated “I wiped the machine with [brand name] wipes. I wipe it down, allowed it to dry and put away. I will let it sit for 30 seconds and put it away.” RN 2 stated it was important to clean the PT/INR meter correctly to prevent cross-contamination of blood borne pathogens. RN 2 stated patients were at risk to get infections. During an interview on 6/10/25 at 4:30 p.m. with RN 3, RN 3 stated, “I will use [brand name] wipes, let it come dry for 30 or 60 seconds then put away.” RN 3 stated, “ I use the purple top wipes for any blood product.” RN 3 stated, “It was important to cleanse and sanitize the PT/INR meter correctly with correct contact time to prevent infection.” RN 3 stated improperly disinfecting the PT/INR meter could have transmitted bloodborne pathogens among patients. RN 3 stated he did not remember the last in services for PT/INR meter cleaning techniques. During an interview on 6/12/25 at 2:15 p.m. with the DCPS/VP, the DCPS/VP stated we did not follow the manufacture guideline for cleaning and disinfecting the PT/INR meter. We did not follow the professional standard of practice. During a review of Patient 3’s “ Plan of Care (POC -document outlining the specific medical, rehabilitative, and supportive care a patient)” dated 5/19/25, the POC indicated ”.I want my INR to get between 2-3…” During a review of the manufacturer’s guidelines titled, “Cleaning/Disinfecting the Meter” dated “no date”, the manufacturer’s guideline indicated, “It is important to follow the procedures below to clean and disinfect the meter…use only the following items for cleaning/disinfecting the [brand name meter] housing for a contact time of > [greater] 1 minute…70% isopropyl alcohol…10% sodium hypochlorite solution (1 part bleach to 9 pars deionized water, made fresh every 24 hours)…wipe the meter’s exterior clean…wipe away residual moisture and fluids after cleaning the housing…Allow to wiped areas to dry for at least 10 minutes before performing a test…””

“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 agency failed to ensure Certified Occupational Therapy (COTA) /Home Health Aide (HHA) receive 12 hours in-service training during each 12 month period for two of 17 sampled patients (Patient 8 and Patient 9). This failure placed the patients at risk for receiving care by incompetent COTA/HHA. During an interview on 6/9/25 at 2:20 p.m., with the Director of Patient Care Services (DPCS)/Vice President (VP), the DPCS/VP stated, “Home Health Aide we have two patients. We use COTA. We have no HHA. We do not have any new patients with HHA services. When patient comes on services we can and will accept them using COTA. In the past the COTA was able to do it based on their competency. We did not meet the 12 hrs. It is new for me and I am learning.” During a review of COTA /HHA” s personnel file, the job description for COTA and HHA met the requirements. The date of hire was 10/25/22. The personnel file did not contain any in-service training. During a review of the agency’s policy and procedure (P&P) titled, “Training/Inservice Education” dated 4/21, the P&P indicated, “Aides (CNA {certified Nursing assistant}s HHAs) must receive at least 12 hours of in-service training per calendar year. This may be provided while the aide is furnishing care to patients.””

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to involve the patient and their caregivers to participate in the development and ongoing updates of their plan of care (POC-a written document that describes the home health services and items that a patient needs, how often they will receive them, and what outcomes are expected from the treatment) for four of seven patients with home visits (Patients, 2, 3, 4 and 5) when the patients and their caregivers were unable to locate their admission booklet (the booklet outlines the rights of patients receiving home health services, such as the right to privacy, informed consent, and the right to be involved in care decisions). This failure resulted in a lack of informed consent and compromised patient and caregiver participation in care decisions throughout the episodes of care. During a concurrent observation and interview on 6/4/25 at 3:03 p.m., with Occupational Therapy (OT) 1, in Patient 2’s bedroom, OT 1 evaluated Patient 2’s ability to get in and out of bed in her bedroom. Patient 2 stated she could manage on her own but had to exert effort and endure pain when placing her swollen legs above the pillow. OT 1 recommended that Patient 2 order a “bed caddy” to assist with getting in and out of bed and share the purchase site with Patient 2. OT 1 did not update Patient 2’s admission booklet with her findings and recommendations in writing. During a concurrent interview and record review on 6/4/25 at 3:15 p.m., following the completion of a home visit by OT 1. Patient 2 was in her living room and attempted to locate the admission booklet. Patient 2 stated she had received the booklet but was unable to find it. Patient 2 stated the agency did not explain which services and supplies were covered and which were not prior to her giving consent for treatment. A review of Patient 2’s Plan of Care (POC), which is a written comprehensive and individualized roadmap outlining the specific treatments and support services needed while receiving care at home, dated May 25, 2025, to July 26, 2025, indicated that the start of care (SOC) was on May 28, 2025. Since the SOC date, three other visits were made by PT (Physical Therapy), PTA (Physical Therapy Assistant), and OT. During a concurrent observation and interview on 6/5/25 at 12:05 p.m., with Licensed Vocational Nurse (LVN) 1, in Patient 3’s living room. After finishing her visit, LVN 1 received a verbal order from Patient 3’s physician to change the medication dose. LVN 1 instructed Patient 3’s caregiver to give Warfarin (a medication that helps prevent blood from clotting) 5 milligrams (mg-unit of measurement) daily and 7.5 mg on Fridays. LVN 1 did not ask the caregiver to write down this change in the admission booklet. During an interview on 6/5/25 at 12:55 p.m., with Patient 3’s caregiver following the completion of a home visit by LVN 1, Patient 3’s caregiver stated, Patient 3’s coagulation levels (the ability of the blood to coagulate) remained unstable, and she was unaware of when Patient 3 would be discharge from the agency. Patient 3’s caregiver stated she received an admission booklet at the beginning of the first episode of care but was unable to locate it at the time of the interview. During a review of Patient 3’s POC dated 5/21/25 to 7/19/25, the POC indicated Start of Care (SOC) began on 3/22/25. There were multiple visits conducted by SN (skilled nursing) staff, but there was no evidence the admission booklet was used to review Patient 3’s rights or to support the ongoing involvement of Patient 3 and the caregiver in updates to the POC during the second episode of care. During a concurrent observation and interview on 6/5/25 at 3 p.m., with LVN 2, in Patient 4’s living room, LVN 2 was observed completing the wound care on Patient 4’s right leg. LVN 2 praised Patient 4 for increased protein intake to support wound healing and informed Patient 4 that her wound was healing well, with no signs of redness or drainage. LVN 2 did not reference or requested the admission booklet to initiate or discuss discharge planning with Patient 4. During an interview on 6/5/25 at 3:53 p.m., with Patient 4, Patient 4 stated she recalled RN 5 conducting the initial visit and providing the admission booklet. Patient 4 stated she was unable to locate the admission booklet. Patient 4 stated no one had requested or referenced the admission booklet since the start of care. During a review of Patient 4’s POC dated 5/11/25 to 7/9/25, the POC indicated the Start of Care began on 3/12/25. There were multiple visits conducted by SN (skilled nursing) staff, but there was no evidence the admission booklet was used to review Patient 4’s rights or to support the ongoing involvement of Patient 4 and the caregiver in updates to the POC during the second episode of care. During a concurrent observation and interview on 6/9/25 at 9:30 a.m. with RN 1, in assisted living facility, RN 1 informed Patient 5 it was time to change the urinary catheter (a sterile, flexible tube inserted into the bladder to drain the urine). RN 1 stated Patient 5’s sister was the designated Responsible Party (RP) and had previously requested to be notified prior to any procedures or change in the Plan of Care. RN 1 stated she did not contact the RP prior to the visit since Patient 5 was familiar with her. During a review of Patient 5’s POC dated 5/6/25 to 7/4/25, the SOC was 11/7/24. The POC indicated the urinary catheter to be changed every 5 weeks. During a phone interview on 6/10/25 at 8:45 a.m., with Patient 5’s RP, Patient 5’s RP stated she received the admission packet on 11/6/24 but did not recall discussion regarding billing or financial matters. The RP stated she had requested agency staff to contact her prior to SN visit, since Patient 5 has consistently refused catheter changes. The RP stated agency staff had not followed up with her or made the requested calls prior to visits. During an interview on 6/12/25 at 2:24 p.m., with the Director of Patient Care Services (DPCS)/ Vice President (VP), the DPCS/VP stated, patients should receive a Start of Care booklet, and the clinician initiating the case was responsible for completing the admission process. The DPCS/VP stated this includes informing the patient and family about the complaint process, reviewing consent and financial responsibilities, and setting expectations at the SOC. The DPCS/VP stated clinicians should document updates in the admission booklet during visits unless they have confirmed patient was actively using “Family Link-provider’s website” as outlined in the admission booklet. During a review of the agency’s admission booklet, the section for “Plan of Care”, the plan of care section indicated, “we involve you, your caregiver, your representative (if any), key professionals and other staff members in developing your individualized plan of care and identifying your specific measurable outcomes and goals. Your plan of care is based upon identified problems, needs, physician orders and medications, care, treatment and services, timeframes, our specific measurable outcomes and goals. Your plan of care your environment and your personal goals whenever possible. The plan of care is designed to increase your ability to care for yourself and may include the following interventions: nursing care, personal care, medication management, rehabilitation therapy, pain management, psychosocial needs and discharge planning…You have access to this plan through our electronic medical record system, “Family Link” or you may request the plan to be provided on paper…we will notify you, your representative (if any), your caregiver and all physicians involved in your pan of care of any revisions to the plan of care due to a change in your health status…””

“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 observation interview and record review the agency failed to ensure one of seven sample patients with home visits ( Patient 3) received all services according to the plan of care (POC- a written document that describes the home health services and items that a patient needs, how often they will receive them, and what outcomes are expected from the treatment) when education was not provided for management of fluid restriction and cardiac (heart) diet. This failure had the potential to place Patient 3 at risk for fluid overload (too much fluid in the body) exacerbating his congestive heart failure(CHF- a heart disorder which causes the heart to not pump the blood efficiently to meet the body’s needs), which could lead to severe complications such as pulmonary edema (fluid build up in the lungs), cardiogenic shock (a life-threatening condition leading to inadequate blood flow to vital organ) and hospital admission . During an interview and record review on 6/5/25 at 12:47 p.m. with License Vocational Nurse (LVN) 1, LVN 1 stated, she was not aware Patient 3 was on a 1.5 Liters (L- unit of measurements) fluid restriction and cardiac diet. LVN 1 stated she should have educated Patient 3 on 1.5 L fluid restriction. LVN 1 stated it was important to educate Patient 3 on his fluid restriction and diet to prevent edema (swelling). LVN 1 stated Patient 3 could have increased swelling and could have developed open sores. LVN 1 stated nurses were responsible for educating patients about their fluids and diet. LVN 1 stated increasing fluid intake could result in increased swelling in Patient 3’s legs and possible hospital admission. During an interview on 6/5/25 at 1 p.m. with Patient 3, Patient 3 stated, the home health staff never discussed her fluid restriction and diet orders. Patient 3 stated he was on fluid restriction during the time he was in the nursing home for rehabilitation, but was never informed by the home health agency he will continue the fluid restriction at home. During an interview on 6/5/25 at 1:08 p.m. with Family Member (FM) 1, FM 1 stated the home health nursing staff did not provide education on Patient 3’s fluid restrictions. FM 1 stated it was important for the home health nursing staff to provide education on Patient 3’s fluid restrictions to prevent complications and avoid potential hospital admission. During an interview and record review on 6/11/25 at 4:04 p.m. with Clinical Manager (CM) 2, CM 2 stated Patient 3 was on a cardiac diet with 1.5 liters fluid restrictions. CM 2 stated nurses should be teaching Patient 3 about everything regarding his diet and fluids. CM 2 stated Patient 3 should be expected to learn and limit his fluids to 1.5 liter from all food sources. Patient 3 should have been checking his weight daily. CM 2 stated Patient 3 could have increase in fluid and could have fluids overload (condition where there’s too much fluid in the body, potentially leading to increased blood pressure, swelling, and breathing difficulties). CM 2 stated Patient 3’s CHF could have been could have exacerbated and Patient 3 could have return to the hospital. CM 2 stated “It is the responsibility of the nurses to educate and monitor and informed the patients and family about their diet and fluids.” During an interview and record review on 6/11/25 at 4:04 p.m. with Clinical Manager (CM) 2, CM 2 stated that Patient 3 was on a cardiac diet (a meal plan designed to reduce the risk of heart disease) with 1.5 liters fluid restrictions. CM 2 stated home health nurses should have provided education to Patient 3 and his family member on Patient 3’s diet and fluid intake and helped Patient 3’s understands to limit his fluid intake. CM 2 stated Patient 3’s increase fluid intake could lead to fluid overload (a medical condition where there is too much fluid in the body) and exacerbation of Patient 3’s CHF which could result in hospitalization. CM 2 stated it was the responsibility of the home health nurses to provide education to the patients, families and caregivers regarding the care provided. During an interview on 6/12/25 at 2 p.m. with the Director of Patient Care Services (DPCS)/Vice President (VP), the DPCS/VP stated LVN 1 should have review Patient 3’s diet POC during visits. The DCPS/VP stated LVN 1 should have educated Patient 3 about his diet and fluids restriction according to the POC. The DCPS/VP stated nurses were expected to educate patients, families and their caregivers according to the POC. DCPS/VP stated LVN 1 did not follow their policy. During an interview on 6/12/25 at 2:20 p.m. with Registered Nurse (RN), RN 3 stated she was one of the nurses who provided care to Patient 3. RN 3 stated Patient 3 should have been educated on fluid restriction and cardiac diet according to his POC. RN 3 stated Patient 3 could have experienced fluid overload and increased the risk of hospitalization. RN 3 stated, she should have documented when she educated Patient 3 on his fluid restriction and cardiac diet. RN 3 stated, “It should have been documents and it was not.” RN 3 stated Patient 3 and FM 1 did not receive services according to the POC. During a review of Patient 3’s “ Plan of Care” dated 5/19/25, the POC indicated, “Diagnoses...atrial fibrillation (type of irregular heartbeat or arrhythmia), congestive heart failure, pressure ulcers (injuries to the skin and underlying tissue caused by prolonged pressure or friction) gout (a type of arthritis characterized by sudden, severe attacks of pain, swelling, redness, and tenderness in the joints), use of anticoagulants…[line]skilled nurse to provide instructions/reinforcement of management of cardiac disease in home setting, including diet...” During a review of the facility’s policy and procedure (P&P) dated 4/2021, the P&P indicated, “Orders are review for appropriateness and accuracy before treatment and services are provided…” During a review of the agency’s admission booklet, the section for “Plan of Care”, the plan of care section indicated, “we involve you, your caregiver, your representative (if any), key professionals and other staff members in developing your individualized plan of care and identifying your specific measurable outcomes and goals. Your plan of care is based upon identified problems, needs, physician orders and medications, care, treatment and services, timeframes, our specific measurable outcomes and goals. Your plan of care your environment and your personal goals whenever possible. The plan of care is designed to increase your ability to care for yourself and may include the following interventions: nursing care, personal care, medication management, rehabilitation therapy, pain management, psychosocial needs and discharge planning…You have access to this plan through our electronic medical record system, “Family Link” or you may request the plan to be provided on paper…we will notify you, your representative (if any),, your caregiver and all physicians involved in your pan of care of any revisions to the plan of care due to a change in your health status…””

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to conduct a comprehensive assessment within five days of referral for three of 17 sampled patients (Patients, 2, 11 and 16). This failure resulted in patients not receiving their assessment by the skilled professional in a home setting in a timely manner to develop the necessary plan of care (POC- a written document that describes the home health services and items that a patient needs, how often they will receive them, and what outcomes are expected from the treatment). During an observation on 6/3/25 at 2:30 p.m., with Occupational Therapist (OT) 1 in Patient 2’s home, Patient 2 lives alone in an assisted living facility. Patient 2 was struggling to manage daily tasks independently and expressed frustration over the lack of assistance from the staff, particularly when preparing for bed. Elevating her swollen legs onto a pillow was especially difficult and painful for her. During a review of Patient 2’s “POC”, dated 5/28/25 to 7/26/25, the POC indicated, the start of care (SOC) was 5/28/25. During a review of Patient 2’s “Referral”, dated 5/20/25 , the referral indicated, Patient 2 needed SN (skilled nursing), PT (physical therapy) and OT (occupational therapy-healthcare profession that focuses on enabling people to do the things they want and need to do in their everyday lives) services from home health agency when Patient 2 was discharged from the skilled nursing facility. During a review of Patient 2’s “Client Coordination Note” dated 5/29/25 entered by RN (Registered Nurse) 4, the coordination note indicated Patient 2 needed PT and OT evaluation. During a review of Patient 2’s visit notes involving all disciplines, the visit note indicated OT 1’s evaluation visit was done on 6/4/25 (eight days from SOC). The agency’s coordination note did not contain the reason or notification to the physician for the delay of the OT evaluation. During a review of Patient 11’s “Referral” dated 4/22/25, the referral indicated Patient 11’s physician ordered home health to provide SN, PT and MSW (Master of Social Work). The POC dated from 4/24/25 to 6/22/25 indicated the SOC was 4/24/25. Patient 11’s visit notes indicated PT and MSW evaluation were done on 4/29/25. The comprehensive assessment by all discipline ordered was supposed to be conducted within five days from SOC. The evaluation assessment by PT and MSW were delayed for one day without justification. Patient 11’s primary diagnosis was orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down) and in need of community resources to receive proper care. During a review of Patient 16’s “Referral” dated 9/4/24, Patient 16’s physician ordered home health to provide SN, PT, OT and HHA (home health aide). The POC dated from 9/9/24 to 11/7/24 indicated the SOC was 9/9/24. Patient 16’s visit notes indicated PT’s evaluation was done on 9/26/24. The comprehensive assessment by all discipline ordered was supposed to be conducted within five days from SOC which were due on 9/13/24. The evaluation assessment by PT was delayed for 13 days without justification. Patient 16’s primary diagnosis was encounter for orthopedic aftercare following surgical amputation (toe amputation). During an interview on 6/12/25 at 9:28 a.m., Clinical Manager (CM) 2 stated PT 2 was expected to evaluate Patient 16 within five days to prevent any falls. CM 2 stated other disciplines had noted difficulties in contacting Patient 16 to schedule visits, but there were no notes from PT 2. CM 2 stated there was no evidence that PT 2 had made any effort to conduct the necessary evaluation. During a phone interview on 6/12/25 at 9:34 a.m., PT 2 stated she was unaware the visit was for a comprehensive assessment. PT 2 stated the agency’s standard practice was for her to make home visits when the scheduler notified her of their availability. PT 2 stated she was not informed that the visit required a comprehensive assessment to be completed within five days of the SOC when she received the notification from the scheduler. During an interview on 6/12/25 at 9:50 a.m., with the Intake Coordinator (IC), The IC stated referrals came through fax or AE. The IC stated she reviewed the necessary documents and started email threads to all involved disciplines once verified. The IC stated she was responsible for scheduling the SOC (start of care) visit and notifying the Case Manager (CM) within 48 hours if delayed, including a reason for the delay. The IC stated if additional disciplines were needed, she would add them within five days. The IC stated if a discipline could not visit, she would inform the clinical supervisor of their unavailability. The IC stated when a clinician scheduled a visit, they had to note if the patient refused the visit, and the scheduler would reschedule it. The IC stated the scheduler should inform clinicians whether the visit was rescheduled or not. The scheduler was not available for an interview during the survey. During a review of the agency’s policy and procedure (P&P) titled, “Initial and Comprehensive Assessment” dated 04/21, the P&P indicated, “A comprehensive patient assessment will be completed within five (5) calendar days of the patient’s start of care.””

“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 observations, interviews, and record reviews the home health agency failed to ensure one of seven patients with homes visits (Patient 3) was provided notification of a change in prescribed medications dosage in his admission booklet (a document provided during the start of care, that contains important information for patients and their families/caregivers for the home health agencies) when home health agency staff did not notify Patient 3 of a change in prescribed anticoagulant (a medication used to prevent blood clot) dosage. This failure placed Patient 3 at potential risk for adverse drug events (harm caused by inappropriate or appropriate use of a drug), including bleeding. During an interview on 6/5/25 at 1 p.m. with Patient 3, Patient stated he was not informed about a change in his anticoagulant medication dosage. Patient 3 stated he should have been notified of the changes for him to take the correct dose. During an interview on 6/5/25 at 1:08 p.m. with Family Member (FM) 1, FM 1 stated the home health nursing staff did not provide her a written instructions regarding the schedule and change of dosage of the anticoagulant medication. FM 1 stated she was responsible for giving Patient 3 his medication. FM 1 stated having written instructions would help her stay updated and make it easier to manage any changes in Patient 3’s medication. During an interview on 6/12/25 at 2:25 p.m. with the Director of Patient Care Services (DPCS)/Vice President (VP), the DPCS/VP stated clinician should be writing medication changes in the admission booklet. The DCPS/VP stated, “The booklet is the center for all communication.” The DCPS/VP stated nurses should have printed the forms and placed them in the booklet so the patient and family could have them. The DCPS/VP stated, the clinicians should have been checking the admission booklet regularly. The DPCS/VP stated, “We did not provide the patient and family written documents. We should have brought it out there.” The DPCS/VP stated the agency did not follow their policy and procedure. During a review of the agency’s policy and procedure (P&P), titled “Medication Profile” dated 3/2021, the P&P indicated, “Each patient will receive appropriate written material for specific medications/he she is receiving. The material will contain information on actions of the medication, potential side effects, contraindications the patients should be aware of and any special instructions when taking the specific medication.””

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on observation, interview and record review the agency failed to ensure one of seven sampled patients with home visits (Patient 3) was provided education on the Physician Order (PO-instructions written by a physician to other healthcare professionals regarding a patient’s care plan) for 1.5 liters (L-units of measurement) of fluid restriction and cardiac (heart) diet. This failure had the potential to place Patient 3 at fluid overload (too much fluid in the body) exacerbating his congestive heart failure (CHF- heart disorder which causes the heart to not pump the blood efficiently resulting in leg swelling) and returning to the hospital. During an interview and record review on 6/5/25 at 12:47 p.m. with License Vocational Nurse (LVN) 1, LVN 1 stated, she was not aware Patient 3 was on fluid restriction and cardiac diet. LVN 1 stated she did not provide education on his fluid restrictions and cardiac (heart) diet. LVN 1 stated it was important to educate Patient 3 on his fluid restriction and cardiac (heart) diet to prevent edema (swelling). LVN 1 stated Patient 3 could have increase in swelling in his legs which could have contributed to open sores. LVN 1 stated Patient 3’s CHF could have gotten worse and he could have return to the hospital. LVN 1 stated nurses were responsible for educating patients regarding their physician orders. During an interview on 6/5/25 at 1:00 p.m. with Patient 3, Patient 3 stated, “They [nurses] never went over the fluid restriction and diet with me.” Patient 3 stated, he was not aware of his current diet and fluids restriction. Patient 3stated he would like to know if he was on fluids restriction but was never informed During an interview on 6/5/25 at 1:08 p.m. with Family Member (FM) 1, FM 1 stated nursing staff asked about the amount of fluids Patient 3 drank. FM 1 stated nurses did not education her on 1.5 liters fluids restriction or cardiac diet for Patient 3. FM 1 stated she would like to be education on Patient 3 fluid restriction to prevent him from returning to the hospital. During an interview and record review on 6/11/25 at 4:04 p.m. with Clinical Manager (CM) 2, CM 2 stated Patient 3 was on a cardiac diet with 1.5 liters (amount of measurement) fluid restriction. CM 2 stated nurses should have education Patient 3 about his cardiac diet and fluid restriction. CM 2 stated Patient 3 should have known about limiting his fluids to 1.5 liters from all food sources. CM 2 stated Patients 3 should have been checking his weights daily. CM 2 stated Patient 3 could have drank more fluids beyond the PO leading to fluid overload. CM 2 stated Patient 3’s CHF could have been could have exacerbated and Patient 3 could have returned to the hospital. CM 2 stated “It is the responsibility of the nurses to educate and monitor and informed the patients and family about their diet and fluids.” During an interview on 6/12/25 at 2:00 p.m. with the Director of Patient Care Services DPCS/Vice President (DPCS/VP), the DPCS/VP stated LVNs should have access to the diet and should have update the patient about their diet and fluids restriction. The DCPS/VP stated nurses should have educated patients about daily weights. The DCPS/VP stated nurse should have provided education to the patient and family. During an interview on 6/12/25 at 2:20 p.m. with Registered Nurse (RN) 3, RN 3 stated, “I did not document.” RN 3 stated, “It should have been documents and it was not.” RN 3 stated, Patient 3 should have been educated on fluid restrictions and diet. RN 3 stated Patient 3 could have fluid overload and return to the hospital. During a review of Patient 3s “ Plan of Care (POC- a written document that describes the home health services and items that a patient needs, how often they will receive them, and what outcomes are expected from the treatment))” dated 5/19/25, the POC indicated, “[line] diagnoses... atrial fibrillation (type of irregular heartbeat or arrhythmia), congestive heart failure, pressure ulcers (injuries to the skin and underlying tissue caused by prolonged pressure or friction) gout (a type of arthritis characterized by sudden, severe attacks of pain, swelling, redness, and tenderness in the joints), use of anticoagulants…[line]skilled nurse to provide instructions/reinforcement of management of cardiac disease in home setting, including diet…” During a review of the agency’s Admission Booklet, titled, “Home Health Admission Booklet (HHAB)” dated 12/24, the HHAB indicated, “Services…Skilled Nursing is provided by an RN and LVN…services may include evaluation of patient needs…education of patient…” During a review of the agency’s Job Description, titled, “Licensed Vocational Nurse” dated no date, the JD indicated, “Provides care as ordered…provide instructions to patient/CG’s [caregiver] and staff in a timely manner…””