Amazing Care Home Health Services

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure skilled professional services communicated with all the physicians involved in the plan of care for 1 of 3 active patients reviewed (Patient #5). Findings include: 1. The clinical record for Patient #5 was reviewed on 8/5/25. The plan of care (POC) for the certification period dated 4/27/25 to 6/25/25, revealed a start of care (SOC) date of 7/17/21; diagnoses included complications of gastrostomy, type 2 diabetes mellitus, gastroparesis, unspecified protein-calorie malnutrition, gastrostomy status, malignant neoplasm of prostate, and Barrett’s esophagus without dysplasia. POC orders included skilled nursing (SN) services once a week for 60 days for medication management, diabetic skin checks, monitor and mitigate pain, and gastrointestinal tube (G-tube) monitoring; and home health aide visits two times a week for 60 days for hygiene, showering, grooming, and activities of daily living. The POC dated 6/26/25 to 8/24/25 revealed a SOC date of 7/17/21; diagnoses included Type 2 diabetes mellitus, gastroparesis, unspecified protein-calorie malnutrition, gastrostomy status, malignant neoplasm of prostate, and Barrett’s esophagus without dysplasia. POC orders included SN services once a week for 60 days for medication management, diabetic skin checks, monitor and mitigate pain, and (G-tube) monitoring; and home health aide visits two times a week for 60 days for hygiene, showering, grooming, and activities of daily living. POC mental assessment shows status as oriented and forgetful. a) The agency failed to coordinate with the physician regarding increased pain, fluid leakage, and skin changes surrounding Patient #5’s G-tube. A Review of the comprehensive assessment dated 4/24/25 for the certification period dated 4/27/25 to 6/25/25 revealed Patient #5 required medication management services for medication compliance, pain assessment, and G-tube site monitoring for signs or symptoms of infection. The assessment of Patient #5’s G-tube revealed no signs of infection. Patient #5 reported tube leaking and occasional pain at the site as manageable. Additional review indicated Patient #5 reported no recent medication changes, Emergency Room (ER) visits, or infections. The POC assessment showed the mental status of Patient #5 as oriented and forgetful. Review of SN visit note completed on 5/15/25, revealed Patient #5 self-reported visiting the ER on 5/14/25 for severe pain and leakage at the G-tube site. RN #2’s visit note stated Patient #5 was well-versed and independent in notifying his primary care physician (PCP) regarding issues with his G-tube. Additional review revealed an intervention for the SN to notify the PCP of any signs or symptoms of infection or any other gastrointestinal abnormalities. Review of SN visit note dated 5/22/25, showed Patient #5 reported pain 7 out of 10 on the pain scale. Additional review noted an appointment for Patient #5 with his PCP the week before. Patient #5 continued to report leakage. RN #2 noted Patient #5 as independent in notifying his PCP. The review failed to reveal care coordination. Additional review of SN visit notes dated 5/29/25, 6/5/25, 6//13/25, and 6/19/25 showed similar findings of pain and leakage of the G-tube. Review of Patient #5’s coordination notes failed to reveal documented coordination of care notes during the certification period dated 4/27/25 to 6/25/25. Record review revealed RN #2 completed a comprehensive assessment on 6/26/25. The assessment summary revealed Patient #5’s mental status as oriented and forgetful. RN #2 reported Patient #5 had experienced pain and leakage from the G-tube site. The site was described as red and irritated. Patient #5 reported G-tube site pain as 7 of 10 on the pain scale. Review of additional SN visit notes between 7/3/25 and 7/30/25 showed Patient #5 continued to report pain and leakage of the G-tube site. The record review failed to reveal care coordination for Patient #5 from 6/26/25 to 8/4/25. During an interview on 8/5/25 at 4:31 p.m., RN #2 reported she did not communicate with Patient #5’s PCP, surgeon, or other providers. According to the RN, the patient could manage his appointments, orders, and G-tube. The RN admitted that the pain, leakage, and skin issues should have been discussed with the patient’s PCP. The RN acknowledged failure to coordinate care for Patient #5. An interview with the branch’s Director of Nursing (DON) on 8/6/25 at 2:02 p.m. stated she was unaware of the lack of coordination with Patient #5’s PCP.”