Amedisys Home Health

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: The agency was NOT in compliance with the Condition of Participation: 42 CFR 484.75 for Skilled professional services. Based on a review of clinical records, review of agency documentation, and interviews, for one of four patients (Patient #1) requiring wound care, the agency licensed nurses failed to document the specific wound treatment performed and for one of fifteen patient’s (Patient #5) in the survey sample, the agency licensed personnel failed to document missed visits in accordance with agency policies. Please refer to G 702, G 706, G 714, G 720, G 726”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: The agency was NOT in compliance with the Condition of Participation: 42 CFR 484.105 for Organization and administration of services. Based on a review of clinical records, agency documentation, and interviews with agency personnel, the Governing Body failed to appoint a qualified Administrator for the responsibility of all day-to-day operations of the home health agency. Please refer to G 942 and G 958”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview with agency personnel and review of the agencies Oasis Validation Report , for three of three patients (Patients # 2, # 3, # 11) in the survey sample, the agency failed to transmit the completed Oasis assessment within 30 days of the completion of the assessment of the beneficiary. The finding includes: a. Patient #2 had a start of care date of 7/13/24 with the diagnoses that included skin graft failure, necrotizing fasciitis, type 2 diabetes mellitus, epilepsy, depression, and acquired absence of left leg above knee. The physician orders for the certification period of 1/9/25 to 3/9/25 included nursing services twice per week to perform wound care to skin graft area, cleanse, apply mupirocin and cover with calcium alginate. b. Patient #3 had a start of care date of 12/22/2024 with diagnoses that included pneumonia, dysphagia, metabolic encephalopathy, dementia, malnutrition, myocardial infarction, and falls. The physician’s orders for the certification period of 12/22/2024 to 02/19/2025 included nursing services twice per week for three weeks and once per week for six weeks for assessments, instructing the Patient’s caregiver on the care and management of a gastrotomy tube care (a small flexible tube inserted through the abdominal wall and into the stomach to provide nutrition and medication to an individual) and wound care to a stage two pressure ulceration (partial thickness skin loss) to the coccyx. Additionally, Patient #3 received physical, occupational and speech therapy services. c. Patient #11 had a start of care date of 12/22/24 with diagnoses to include pneumonitis, dysphagia and dementia. The physician orders dated 12/22/24 identified skilled nursing visits 2 times per week, and physical therapy visits 1 time for 3 weeks. Interview and review of the Oasis Validation Report with the Business Manager on 3/12/25 at 2:30 PM, identified for patients #2, #3 and #11, the agency failed to transmit the required Oasis submission document within the required 30 days from the completed beneficiary assessment.”

“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 review of the clinical record and interview with agency personnel for five of fifteen patients (Patient’s #1, 5, 8, 9 & 15) in the survey sample, the agency licensed personnel failed to provide the ordered services. The findings include: Patient #1 had a start of care date of 12/04/24 and diagnoses that included chronic venous hypertension with ulcer and inflammation of the left lower extremity, type II diabetes mellitus, Alzheimer’s disease and dementia. The physician’s orders for the certification period of 2/02/25 to 4/02/25 included nursing services for assessments and wound care to the left venous stasis wound three times a week and occupational therapy/OT services once a week for four weeks. Interview and review of the clinical record from 2/02/25 to 3/10/25 with the Vice President/VP of Clinical Services on 3/12/25 at 3 PM failed to identify OT visits were conducted weekly for four weeks and indicated that the OT was waiting for insurance authorization, which was approved, but had not been assigned to an OT thereafter. Patient #8 had a start of care date of 2/27/25 and diagnoses that included hypertensive chronic kidney disease, acute kidney failure and dementia. The physician’s orders dated 2/27/25 included nursing services once weekly for five weeks and once every two weeks for four weeks for assessments and monthly Vitamin B12 injections and a physical therapy evaluation. Patient #8 resided in an Assisted Living Facility/ALF. Review of the Inter-Agency Referral form dated 2/25/25 identified the need for skilled nursing, physical therapy and home health aide services. Interview and review of the physician’s orders dated 2/27/25 with the VP of Clinical Services on 3/12/25 at 2 PM failed to identify home health aide services were provided as ordered. Patient #15 had a start of care date of 2/08/25 and diagnoses that included metabolic encephalopathy, dysphagia and type II diabetes mellitus. The physician’s orders dated 2/08/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, physical therapy/PT services one time a week for four weeks for gait training and recording patient’s reported blood sugar levels and occupational therapy services. Patient #15 resided in an ALF. Review of the Inter-Agency Referral form dated 2/06/25 identified the need for skilled nursing, physical therapy, occupational therapy and home health aide services. Interview and review of the physician’s orders dated 2/08/25 with the VP of Clinical Services on 3/12/25 at 2:10 PM failed to identify home health aide services were provided as ordered. a. Patient #9 had a start of care date of 01/31/2025 with diagnoses that included coronary artery disease, metabolic encephalopathy, dementia, chronic kidney disease, and type two diabetes mellitus. The physician’s orders for the certification period of 01/31/2025 to 03/31/2025 included nursing services for assessments, physical therapy and occupational therapy. Patient #9 resided in an Assisted Living Facility. Review of Patient #9’s inter-agency referral form dated 01/31/2025, identified the physician ordered home healthcare services for nursing, physical therapy, occupational therapy and a home health aide for assistance with daily activities. Review of Patient #9’s start of care OASIS (Outcome and Assessment Information Set which is a tool to collect and report standardized data on patients receiving home healthcare) assessment dated 01/31/2025, identified the Patient required assistance with bathing, grooming, dressing, toileting and partial assistance with ambulating with a walker. ii. Interview and review of Patient #9’s clinical record with the Supervisor of Clinical Services (SCS) #1 on 03/12/2025 at 11:50 AM, failed to identify a home health aide was provided to the Patient as directed by a physician’s order and the OASIS assessment which indicated the Patient required assistance with activities of daily living.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on review of the clinical record, review of agency policies and interview with agency personnel, for one of four patients (Patient #1) requiring wound care, the agency licensed nurses failed to document the specific wound treatment performed, and for one of fifteen patient’s (Patient #5) in the survey sample, the agency licensed personnel failed to document missed visits in accordance with agency policies. The findings include: a. Patient #1 had a start of care date of 12/04/24 and diagnoses that included chronic venous hypertension with ulcer and inflammation of the left lower extremity, type II diabetes mellitus, Alzheimer’s disease and dementia. The physician’s orders for the certification period of 2/02/25 to 4/02/25 included nursing services for assessments and wound care to the left venous stasis wound three times a week cleansing with one quarter strength Dakin’s solution, patting dry, applying collagen, petrolatum jelly, xeroform gauze, covering with an ABD pad and securing with kerlix and tape and occupational therapy services once a week for four weeks. Interview and review of Licensed Practical Nurse/LPN #1’s nursing notes dated 2/03/25, 2/05/25, 2/07/25, 2/12/25, 2/14/25 and 2/17/25 with the Vice President of Clinical Services on 3-12-25 at 1:10 PM failed to identify the specific wound care treatment performed in accordance with agency policies. Review of agency policy for the Provision of Wound Care directed wounds will be measured at a minimum of one time a week, preferably on the first visit of the week, by the same nurse, utilizing the same tool and measurement terminology. The LPN will maintain communication with their Case Manager, Clinical Manager or another RN involved in the patient’s care for management of the patient’s plan of care and this communication is documented in the EMR/Electronic Medical Record. Documentation includes specific wound care treatment performed. b. Patient #5 had a start of care date of 1/06/25 and diagnoses that included acute kidney failure, osteoarthritis of the left knee and type II diabetes mellitus. The physician’s orders for the certification period of 1/16/25 to 3/16/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, home health aide services, physical therapy and occupational therapy services. Interview and review of the PT note dated 1/23/25 with the VP of Clinical Services on 3/12/25 at 2:12 PM identified a missed visit note which indicated the initial evaluation was rescheduled but failed to identify the reason for the delay in the initial evaluation in accordance with agency policies. Interview and review of the nursing note dated 3/04/25 with the VP of Clinical Services on 3/12/25 at 2:15 PM identified a missed visit note which indicated the patient had a physician appointment but failed to identify the rescheduling of the nursing visit in the same week in accordance with agency policies. Review of the agency policy for Coordination of Care directed to complete and document a missed visit note when a visit is unable to be completed as ordered and not able to be rescheduled within the patient’s Medicare treatment week and the reason why the visit cannot be rescheduled.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on review of the clinical records and interview with agency personnel, the Governing Body failed to appoint a qualified Administrator for the responsibility of all day-to-day operations of the home health agency. Interview and review with the newly appointed Administrator regarding his/her qualifications with the current appointment and the VP of Clinical Services on 3/10/25 at 10am, identified the Administrator as only having an Associate Nursing Degree and was presently enrolled in an on-line BSN program. The Governing Body failed to ensure the appointment of an Administrator with the qualifications of a master’s degree in nursing or public health, or a baccalaureate degree in nursing or administration, with a concentration in health services administration, per the Regulations of Connecticut State Agencies.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on clinical record review and interview with agency personnel, for two of fifteen patients (Patient’s #12 & 15) in the survey sample, the agency nurses failed to ensure a complete record. The findings include: a. Patient #12 had a start of care date of 10/15/24 and diagnoses that included right femur fracture, pneumonia, squamous cell carcinoma of the right lower limb and non-Hodgkin’s lymphoma. The physician’s orders dated 10/15/24 included nursing services one time a week for one week for assessments. Review of the clinical record with the VP of Clinical services on 3/12/25 at 1:30 PM identified the initial visit documentation and assessment, but failed to identify any further visits were conducted. Subsequent to surveyor inquiry, documentation was provided to the surveyor which identified the patient was discharged from the agency and transferred to a hospice facility on 10/16/25, but failed to document the discharge in the clinical record and failed to ensure a complete record. b. Patient #15 had a start of care date of 2/08/25 and diagnoses that included metabolic encephalopathy, dysphagia and type II diabetes mellitus. The physician’s orders dated 2/08/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, physical therapy/PT services one time a week for four weeks for gait training and recording patient’s reported blood sugar levels and occupational therapy/OT services. Patient #15 resided in an Assisted Living Facility/ALF. During a joint home visit with LPN #1 on 3/12/25 at 9:40 AM, the surveyor observed LPN #1 opening the agency binder in the nursing office and adding a summary of the visit to the binder. The surveyor observed PT and OT notes incorporated in the binder, but failed to identify nursing notes from the prior visits dated 2/14/25, 2/19/25, 2/27/25 and 3/04/25 Interview and review of the LPN’s visit with the Vice President/VP of Clinical Services on 3/12/25 at 10:30 AM identified that all disciplines should be documenting results of their visits, but failed to ensure nursing visit notes were incorporated weekly.”

“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 clinical record review and interview with agency personnel, for two of fifteen patients (Patient’s #1 & 15) in the survey sample, the agency licensed personnel failed to review all medications to identify any potential adverse effects or drug reactions. The findings include: a. Patient #1 had a start of care date of 12/04/24 and diagnoses that included chronic venous hypertension with ulcer and inflammation of the left lower extremity, type II diabetes mellitus, Alzheimer’s disease and dementia. The physician’s orders for the certification period of 2/02/25 to 4/02/25 included nursing services for assessments and wound care to the left venous stasis wound three times a week and occupational therapy services once a week for four weeks. Interview and review of the medication profile with the Vice President/VP of Clinical Services on 3-12-25 at 1 PM, directed MiraLAX 17 grams, but failed to identify the need to stir and dissolve the medication in 4-8 ounces of a liquid for administration. b. Patient #15 had a start of care date of 2/08/25 and diagnoses that included metabolic encephalopathy, dysphagia and type II diabetes mellitus. The physician’s orders dated 2/08/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, physical therapy services one time a week for four weeks for gait training and recording patient’s reported blood sugar levels, and occupational therapy services. Patient #15 resided in an Assisted Living Facility/ALF. During a joint home visit with LPN #1 on 3/12/25 at 9:40 AM, the surveyor observed LPN #1 holding transfer order documentation from the patient’s recent rehabilitation discharge from a Skilled Nursing Facility/SNF on 2/06/25. After the visit, LPN #1 conducted a medication review (the fifth nursing visit) with the ALF record in the nursing office. Interview and review of the physician’s orders with the Vice President/VP of Clinical Services on 3/12/25 at 10:30 AM failed to identify a medication profile was created and reviewed with the physician as part of the admission assessment.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on clinical record reviews, review of agency policies and interviews with agency personnel, for three of four patients (Patient’s #1, 8, 9 & 15) requiring blood glucose monitoring for a diagnosis of type II diabetes mellitus and/or residing in an Assisted Living Facility/ALF, and for one of one patient (Patient #6) requiring nephrostomy care, the agency nurses failed to ensure the plan of care addressed the patient’s individual needs and failed to follow physician’s orders. The findings include: a. Patient #6 had a start of care date of 02/12/2025 with diagnoses that included urinary tract infections, hydronephrosis with ureteral stricture, malignant neoplasm of the ovary, hypertension, migraines and acid reflux. The physician’s orders for the certification period of 02/12/2025 to 04/12/2025 included nursing services for assessments and instructing the Patient and caregiver on the care and management of a nephrostomy tube (a tube that is inserted into the kidney through the skin that drains urine into a bag) such as changing the nephrostomy dressing and bag every three days. Additionally, the Patient received physical therapy. i. Interview and review of Patient #6’s nursing notes dated 02/12/2025, 02/19/2025, 02/25/2025 and 03/04/2025 with the Supervisor of Clinical Services (SCS) #1 on 03/12/2025 at 11:50 AM, identified the Patient and caregiver were irrigating the nephrostomy tube but failed to identify a physician’s order for the irrigation was included in the Patient’s care plan dated 02/12/2025 and failed to document the irrigation procedure performed by the Patient and caregiver to include the amount of, and solution used. Review of the agency’s Percutaneous Nephrostomy Tubes policy and procedure dated 03/25/2024, identified the agency would provide effective care to patients with a nephrostomy tube to promote effective urinary output and minimize complications. The agency’s clinicians would instruct patients and caregivers on the care and management of the nephrostomy tube and would observe the patient and caregiver performing care to ensure infection control measures were followed. The agency’s clinicians would document nephrostomy tube dressing change procedures, irrigation procedures to include the amount of, and solution used, note the condition of the nephrostomy tube and surrounding tissue, the color/amount of drainage from the nephrostomy and document communication/ care coordination with healthcare team members or physicians as indicated. b. Patient #9 resided in an assisted living facility and had a start of care date of 01/31/2025 with diagnoses that included coronary artery disease, metabolic encephalopathy, dementia, chronic kidney disease, and type two diabetes mellitus. The physician’s orders for the certification period of 01/31/2025 to 03/31/2025 included nursing services for assessments, physical therapy and occupational therapy. Review of Patient #9’s inter-agency referral form dated 01/31/2025, identified the physician had ordered home healthcare services for nursing, physical therapy, occupational therapy and a home health aide for assistance with daily activities. Review of Patient #9’s start of care OASIS (Outcome and Assessment Information Set which is a tool to collect and report standardized data on patients receiving home healthcare) assessment dated 01/31/2025, identified the Patient required assistance with bathing, grooming, dressing, toileting and partial assistance with ambulating with a walker. ii. Interview and review of Patient #9’s clinical record with the SCS #1 on 03/12/2025 at 11:50 AM, failed to identify a home health aide was provided to the Patient as directed by a physician’s order and the OASIS assessment which indicated the Patient required assistance with activities of daily living. Patient #1 had a start of care date of 12/04/24 and diagnoses that included chronic venous hypertension with ulcer and inflammation of the left lower extremity, type II diabetes mellitus, Alzheimer’s disease and dementia. The physician’s orders for the certification period of 2/02/25 to 4/02/25 included nursing services for assessments and wound care to the left venous stasis wound three times a week and occupational therapy services once a week for four weeks. Interview and review of initial nursing assessment with the Vice President/VP of Clinical Services on 3-12-25 at 1 PM failed to clarify with the physician the need to monitor blood glucose levels and parameters for reporting abnormal results. Patient #5 had a start of care date of 1/06/25 and diagnoses that included acute kidney failure, osteoarthritis of the left knee and type II diabetes mellitus. The physician’s orders for the certification period of 1/16/25 to 3/16/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, home health aide services, physical therapy and occupational therapy services. Interview and review of the nursing note dated 3/04/25 with the VP of Clinical Services on 3/12/25 at 2:15 PM identified a missed visit note which identified the patient had a physician appointment but failed to identify the rescheduling of the nursing visit in the same week and failed to follow physician’s orders. Review of agency policy for Coordination of Care directed to complete and document a missed visit note when a visit is unable to be completed as ordered and not able to be rescheduled within the patient’s Medicare treatment week. Patient #8 had a start of care date of 2/27/25 and diagnoses that included hypertensive chronic kidney disease, acute kidney failure and dementia. The physician’s orders dated 2/27/25 included nursing services once weekly for five weeks and once every two weeks for four weeks for assessments and monthly Vitamin B12 injections and a physical therapy evaluation. Patient #8 resided in an ALF. Interview and review of the initial nursing assessment dated 2/27/25 with the VP of Clinical Services on 3/12/25 at 2:05 PM identified the need for assistance with activities of daily living, bathing, grooming, dressing and toileting, although, review of the plan of care failed to communicate with the physician to address the need for home health aide services. Patient #15 had a start of care date of 2/08/25 and diagnoses that included metabolic encephalopathy, dysphagia and type II diabetes mellitus. The physician’s orders dated 2/08/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, physical therapy/PT services one time a week for four weeks for gait training and recording patient’s reported blood sugar levels and occupational therapy services. Patient #15 resided in an ALF. Interview and review of initial nursing assessment with the Vice President/VP of Clinical Services on 3-12-25 at 1 PM failed to clarify with the physician the need for nursing to monitor blood glucose levels and parameters for reporting abnormal results. Interview and review of the PT initial assessment with the Vice President/VP of Clinical Services on 3-12-25 at 1 PM identified the need to monitor blood glucose levels but failed to clarify with the physician parameters for reporting abnormal results. Interview and review of the Outcome and Assessment Information Set/OASIS with the Vice President/VP of Clinical Services on 3-12-25 at 1 PM identified the need for assistance with activities of daily living, bathing, grooming, dressing and toileting, although, review of the plan of care failed to communicate with the physician to address the need for home health aide services. Subsequent to surveyor inquiry, the VP of Clinical Services indicated that the staff understood that the provision of home health aide services in an ALF would be a duplication of services.”

“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 clinical record review and interview with agency personnel, for two of three patients (Patient’s #8 & 15) who resided in an ALF, the agency Registered Nurse/RN and Physical Therapist/PT failed to ensure the completion and signage of a memorandum of understanding/MOU with the ALF. The findings include: a. Patient #8 had a start of care date of 2/27/25 and diagnoses that included hypertensive chronic kidney disease, acute kidney failure and dementia. The physician’s orders dated 2/27/25 included nursing services once weekly for five weeks and once every two weeks for four weeks for assessments and monthly Vitamin B12 injections and a physical therapy evaluation. Interview and review of the clinical record with the VP of Clinical Services on 3/12/25 at 1 PM identified nursing and physical therapy services were provided in the ALF, but failed to identify documented communication and coordination of services with the ALF staff, including the frequency of visits of nursing and PT. b. Patient #15 had a start of care date of 2/08/25 and diagnoses that included metabolic encephalopathy, dysphagia and type II diabetes mellitus. The physician’s orders dated 2/08/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, physical therapy/PT services one time a week for four weeks for gait training and recording patient’s reported blood sugar levels and occupational therapy services. Interview and review of the MOU dated 2/08/25 for nursing services, 2/12/25 for OT services and 2/13/25 for PT services with the VP of Clinical Services at 2 PM identified nursing, physical therapy and occupational therapy services to be provided, but failed to identify the frequency of nursing services and failed to identify a signature by an ALF nurse on the MOU for nursing, PT and OT services.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on review of the clinical records, review of agency policies and interviews with agency personnel, for eight of eleven current patient’s (Patient’s # 1, 2, 3, 4, 5, 6, 9 & 15) the agency licensed personnel failed to ensure ongoing interdisciplinary communication of the patient’s needs and progress. The findings include: Patient #1 had a start of care date of 12/04/24 and diagnoses that included chronic venous hypertension with ulcer and inflammation of the left lower extremity, type II diabetes mellitus, Alzheimer’s disease and dementia. The physician’s orders for the certification period of 2/02/25 to 4/02/25 included nursing services for assessments and wound care to the left venous stasis wound three times a week and occupational therapy services once a week for four weeks. i. Interview and review of LPN #1’s nursing note dated 2/12/25 with the Vice President/VP of Clinical Services on 3-12-25 at 1 PM identified signs of infection from the left venous stasis ulcer including a yellow discharge, odor and the surrounding skin was warm to touch, the physician and Registered Nurse/RN case manager was notified but failed to identify a subsequent visit was completed by the case manager after the change in condition. ii. Interview and review of the nursing notes from 2/03/25 to 3/10/25 (fifteen visits) with the VP of Clinical Services on 3-12-25 at 1:10 PM identified a wound measurement was completed on 2/17/25 by LPN #1 but failed to identify any further wound measurements in the clinical record. On 3/10/25, RN #1 conducted a wound care visit and failed to identify a wound measurement was obtained. iii. Interview and review of the nursing notes from 2/03/25 to 3/07/25 (fourteen visits) with the VP of Clinical Services on 3-12-25 at 1:50 PM identified the weekly visits were conducted by LPN’s and failed to identify documentation of communication with the RN after the visits were conducted. Patient #2 had a start of care date of 7/13/24 with the diagnoses that included skin graft failure, necrotizing fasciitis, type 2 diabetes mellitus, epilepsy, depression, and acquired absence of left leg above knee. The physician orders for the certification period of 1/9/25 to 3/9/25 included nursing services twice per week to perform wound care to skin graft area, cleanse, apply mupirocin and cover with calcium alginate. Review of the clinical record from 1/10/25 to 3/3/25 (16 visits) were all conducted by an LPN and failed to identify documentation of communication with the RN after the visits were conducted. Patient #4 had a start of care date of 2/17/25 with diagnoses that included acute respiratory failure with hypoxia, chronic kidney disease with heart failure, type 2 diabetes mellitus, and the history of falling. The physician’s orders for the certification period of 2/17/25 to 4/17/25 included nursing services two times per 2 weeks then 1 time per week for 7 weeks for respiratory, cardiac, and diabetic, and medication management. Review of the clinical record from 2/20/25 to 3/10/25 (5 visits) were all conducted by an LPN and failed to identify documentation of communication with the RN after the visits were conducted. Patient #5 had a start of care date of 1/06/25 and diagnoses that included acute kidney failure, osteoarthritis of the left knee and type II diabetes mellitus. The physician’s orders for the certification period of 1/16/25 to 3/16/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, home health aide services, physical therapy and occupational therapy services. Review of the clinical record from 1/16/25 to 3/12/25 identified the LPN conducted a visit on 1/24/25. iv. Interview and review of the nursing notes dated 1/24/25 and 3/04/25 with the VP of Clinical Services on 3-12-25 at 1:55 PM failed to identify documentation of communication with the RN after the visit was conducted. v. Interview and review of the nursing notes dated 1/24/25 and 3/04/25 with the VP of Clinical Services on 3-12-25 at 1:55 PM failed to identify evaluation of the patient’s blood glucose on 1/14/25 and 1/29/25 according to the physician’s plan of care. Patient #15 had a start of care date of 2/08/25 and diagnoses that included metabolic encephalopathy, dysphagia and type II diabetes mellitus. The physician’s orders dated 2/08/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, physical therapy services one time a week for four weeks for gait training and recording patient’s reported blood sugar levels and occupational therapy services. vi. Interview and review of the nursing notes from 2/08/25 to 3/12/25 (six visits) with the VP of Clinical Services on 3-12-25 at 1:55 PM identified 4 out of 6 visits were conducted by an LPN and failed to identify documentation of communication with the RN after the visits were conducted. vii. Interview and review of the weekly PT notes with the Vice President/VP of Clinical Services on 3-12-25 at 1 PM failed to identify evaluation of the patient’s blood glucose on 2/12/25, 2/19/25, 2/26/25 and 3/05/25 according to the physician’s plan of care. Interview and review of the clinical records of Patient’s #1, 2, 3, 4, 5, 6, 9, &15, with the VP of Clinical Services on 3-12-25 at 1:50 PM failed to ensure an RN conducted visits to monitor and evaluate LPN performance in the provision of services, provision of treatments, patient education, communication with the RN and data collection regarding the patient’s status and health needs. Review of agency policies for Services Provided/Supervision of Disciplines directed the home health agency should identify an RN to supervise care provided by the LPN. The identified RN must in turn monitor and evaluate LPN performance in the provision of services, provision of treatments, patient education, communication with the RN and data collection regarding the patient’s status and health needs. a. Patient #3 had a start of care date of 12/22/2024 with diagnoses that included pneumonia, dysphagia, metabolic encephalopathy, dementia, malnutrition, myocardial infarction, and falls. The physician’s orders for the certification period of 12/22/2024 to 02/19/2025 included nursing services twice per week for three weeks and once per week for six weeks for assessments, instructing the Patient’s caregiver on the care and management of a gastrotomy tube care (a small flexible tube inserted through the abdominal wall and into the stomach to provide nutrition and medication to an individual) and wound care to a stage two pressure ulceration (partial thickness skin loss) to the coccyx. Additionally, Patient #3 received physical, occupational and speech therapy services. Patient #3’s physician’s orders for the certification period of 02/20/2024 to 04/20/2025 included nursing services twice per week for eight weeks for assessments, instructing the Patient’s caregiver on the care and management of a gastrotomy tube care and wound care to a stage two pressure ulceration the coccyx. i. Interview and review of Patient #3’s nursing notes dated 12/22/2024 to 03/10/2025 with the Vice President (VP) of Clinical Services on 03/12/2025 at 1:00 PM, identified six out of twelve visits were conducted by an Licensed Practical Nurse (LPN) for the 12/22/2024 to 02/19/2025 certification period and four out of four visits for the period of 02/26/2025 to 03/10/2025 but failed to identify the LPNs provided case coordination with the RN case manager. Additionally, the VP of Clinical Services failed to identify the Physical Therapist coordinated care with the Patient’s RN case manager after the initial physical therapy evaluation on 12/30/2024 and failed to identify the Occupational Therapist coordinated care with the Patient’s RN case manager after the Patient’s initial occupational therapy evaluation on 01/07/2025. Furthermore, the VP of Clinical Services failed to identify the agency’s nurses measured the Patient’s wounds for the visits dates of 02/26/2025, 02/28/2025, 03/03/2025 and 03/10/2025. b. Patient #6 had a start of care date of 02/12/2025 with diagnoses that included urinary tract infections, hydronephrosis with ureteral stricture, malignant neoplasm of the ovary, hypertension, migraines and acid reflux. The physician’s orders for the certification period of 02/12/2025 to 04/12/2025 included nursing services for assessments and instructing the Patient and caregiver on the care and management of a nephrostomy tube (a tube that is inserted into the kidney through the skin that drains urine into a bag) such as changing the nephrostomy dressing and bag every three days. Additionally, the Patient received physical therapy. Review of the clinical record from 02/12/2025 to 03/10/2025 identified three out of four visits were conducted by an LPN. ii. Interview and review of Patient #6’s nursing notes dated 02/12/2025 to 03/10/2025 with the VP of Clinical Services on 03/12/2025 at 1:30 PM failed to identify documentation of communication with the RN case manager after the visit was conducted. c. Patient #9 resided in an assisted living facility and had a start of care date of 01/31/2025 with diagnoses that included coronary artery disease, metabolic encephalopathy, dementia, chronic kidney disease, and type two diabetes mellitus. The physician’s orders for the certification period of 01/31/2025 to 03/31/2025 included nursing services for assessments, physical therapy and occupational therapy. Review of the clinical record from 01/31/2025 to 03/11/2025 identified four out of six visits were conducted by an LPN. iii. Interview and review of Patient #9’s nursing notes dated 01/31/2025 to 03/11/2025 with the VP of Clinical Services on 03/12/2025 at 1:35 PM failed to identify documentation of communication with the RN case manager after the visit was conducted.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on review of the clinical records, review of an agency policy and interview with agency personnel, for two of two patients (Patient #3 and #6) who received home healthcare services, the agency’s nurses failed to provide patients and caregivers with education related to the patients’ care and individualized treatments. The findings include: a. Patient #3 had a start of care date of 12/22/2024 with diagnoses that included pneumonia, dysphagia, metabolic encephalopathy, dementia, malnutrition, a myocardial infarction, and falls. The physician’s orders for the certification period of 12/22/2024 to 02/19/2025 included nursing services twice per week for three weeks and once per week for six weeks for assessments, instructing the Patient’s caregiver on the care and management of a gastrotomy tube care (a small flexible tube inserted through the abdominal wall and into the stomach to provide nutrition and medication to an individual) and wound care to a stage two pressure ulceration (partial thickness skin loss) to the coccyx which included cleaning the wound with wound wash, applying calcium alginate to the wound bed, applying a skin barrier to the peri wound to prevent maceration, cover with a foam dressing everyday and as needed when dislodged or soiled. Additionally, Patient #3 received physical, occupational and speech therapy services.. Additionally, Patient #3 received physical, occupational and speech therapy services. Interview and review of Patient #3’s clinical record with the Supervisor of Clinical Services (SCS) #1 on 03/12/2025 at 11:30 AM, identified Patient #3’s start of care nursing assessment dated 12/22/2024 indicated the Patient’s caregiver managed the gastrostomy tube and wound care, but failed to identify the Registered Nurse (RN) case manager instructed the Patient’s caregiver on the care or management of the gastrostomy tube and wound care. Furthermore, SCS #1 failed to identify the RN case manager observed the Patient’s caregiver performing gastrostomy tube and wound care to ensure effective management and infection control measures were followed. b. Patient #6 had a start of care date of 02/12/2025 with diagnoses that included urinary tract infections, hydronephrosis with ureteral stricture, malignant neoplasm of the ovary, hypertension, migraines and acid reflux. The physician’s orders for the certification period of 02/12/2025 to 04/12/2025 included nursing services for assessments and instructing the Patient and caregiver on the care and management of a nephrostomy tube (a tube that is inserted into the kidney through the skin that drains urine into a bag) such as changing the nephrostomy dressing and bag every three days. Additionally, the Patient received physical therapy. Interview and review of Patient #6’s nursing notes dated 02/12/2025, 02/19/2025, 02/25/2025 and 03/04/2025 with SCS #1 on 03/12/2025 at 11:50 AM, failed to identify the nursing staff instructed the Patient and caregiver on the care and management of the nephrostomy tube. Furthermore, SCS #1 failed to identify the nursing staff observed the Patient and caregiver performing nephrostomy tube care to ensure infection control measures were followed in order to minimize complications. Review of the agency’s Percutaneous Nephrostomy Tubes policy and procedure dated 03/25/2024, identified the agency would provide effective care to patients with a nephrostomy tube to promote effective urinary output and minimize complications. The agency’s clinicians would instruct patients and caregivers on the care and management of the nephrostomy tube and would observe the patient and caregiver performing care to ensure infection control measures were followed. The agency’s clinicians would document nephrostomy tube dressing change procedures, irrigation procedures to include the amount of, and solution used, note the condition of the nephrostomy tube and surrounding tissue, the color/amount of drainage from the nephrostomy and document communication/ care coordination with healthcare team members or physicians as indicated.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on interview with agency personnel and review of the agencies quarterly clinical record documentation, the agency failed to complete quarterly record reviews with agency health professionals input and participation. The findings include: Interview with the Vice President of Clinical Services on 3/12/25 at 2:00 PM, identified that the former agency Administrator completed the quarterly record reviews, but failed to identify the nursing staff, physical therapists, occupational therapists, social workers, and speech therapists participation in the record reviews for the year 2024 which represented the scope of the agency’s home care services, for the assurance that the home health agency policies were followed during patient servicing.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on clinical record reviews, review of agency policy and interviews with agency personnel, for eight of eleven current patients (Patient’s #1, 2, 3, 4, 5, 6, 9, 15) in the survey sample, the agency failed to ensure nursing services were provided under the supervision of a registered nurse. The findings include: a. Patient #3 had a start of care date of 12/22/2024 with diagnoses that included pneumonia, dysphagia, metabolic encephalopathy, dementia, malnutrition, a myocardial infarction, and falls. The physician’s orders for the certification period of 12/22/2024 to 02/19/2025 included nursing services twice per week for three weeks and once per week for six weeks for assessments, instructing the Patient’s caregiver on the care and management of a gastrotomy tube care (a small flexible tube inserted through the abdominal wall and into the stomach to provide nutrition and medication to an individual) and wound care to a stage two pressure ulceration (partial thickness skin loss) to the coccyx. Additionally, Patient #3 received physical, occupational and speech therapy services. Review of the clinical record from 12/22/2024 to 02/17/2025 identified six out of twelve visits were conducted by an LPN. b. Patient #6 had a start of care date of 02/12/2025 with diagnoses that included urinary tract infections, hydronephrosis with ureteral stricture, malignant neoplasm of the ovary, hypertension, migraines and acid reflux. The physician’s orders for the certification period of 02/12/2025 to 04/12/2025 included nursing services for assessments and instructing the Patient and caregiver on the care and management of a nephrostomy tube (a tube that is inserted into the kidney through the skin that drains urine into a bag) such as changing the nephrostomy dressing and bag every three days. Additionally, the Patient received physical therapy. Review of the clinical record from 02/12/2025 to 03/10/2025 identified three out of four visits were conducted by an LPN. c. Patient #9 resided in an assisted living facility and had a start of care date of 01/31/2025 with diagnoses that included coronary artery disease, metabolic encephalopathy, dementia, chronic kidney disease, and type two diabetes mellitus. The physician’s orders for the certification period of 01/31/2025 to 03/31/2025 included nursing services for assessments, physical therapy and occupational therapy. Review of the clinical record from 01/31/2025 to 03/11/2025 identified four out of six visits were conducted by an LPN. Patient #1 had a start of care date of 12/04/24 and diagnoses that included chronic venous hypertension with ulcer and inflammation of the left lower extremity, type II diabetes mellitus, Alzheimer’s disease and dementia. The physician’s orders for the certification period of 2/02/25 to 4/02/25 included nursing services for assessments and wound care to the left venous stasis wound three times a week and occupational therapy services once a week for four weeks. Review of the clinical record from 2/03/25 to 3/07/25 identified weekly visits (fourteen) were conducted by LPN #1 & #2. b. Patient #5 had a start of care date of 1/06/25 and diagnoses that included acute kidney failure, osteoarthritis of the left knee and type II diabetes mellitus. The physician’s orders for the certification period of 1/16/25 to 3/16/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, home health aide services, physical therapy and occupational therapy services. Review of the clinical record from 1/16/25 to 3/12/25 identified the LPN conducted a visit on 1/24/25 and documented a missed visit on 3/04/25. c. Patient #15 had a start of care date of 2/08/25 and diagnoses that included metabolic encephalopathy, dysphagia and type II diabetes mellitus. The physician’s orders dated 2/08/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, physical therapy services one time a week for four weeks for gait training and recording patient’s reported blood sugar levels and occupational therapy services. Review of the clinical record from 2/08/25 to 3/12/25 identified 4 out of 6 visits were conducted by an LPN. Interview and review of the clinical records of Patient’s #1, 2, 3, 4, 5, 6, 9, &15, with the VP of Clinical Services on 3-12-25 at 1:50 PM failed to ensure an RN conducted visits to monitor and evaluate LPN performance in the provision of services, provision of treatments, patient education, communication with the RN and data collection regarding the patient’s status and health needs. Review of agency policies for Services Provided/Supervision of Disciplines directed the primary nurse is responsible for coordination of services with the patient, family and others involved in the plan of care, regular evaluation of patient progress and prompt action when any change in condition is noted or reported, the home health agency should identify an RN to supervise care provided by the LPN. The identified RN must in turn monitor and evaluate LPN performance in the provision of services, provision of treatments, patient education, communication with the RN and data collection regarding the patient’s status and health needs. Patient #2 had a start of care date of 7/13/24 with the diagnoses that included skin graft failure, necrotizing fasciitis, type 2 diabetes mellitus, epilepsy, depression, and acquired absence of left leg above knee. The physician orders for the certification period of 1/9/25 to 3/9/25 included nursing services twice per week to perform wound care to skin graft area, cleanse , apply mupirocin and cover with calcium alginate. Interview and review of Patient #2’s clinical record with the Vice President of Clinical on 3/12/25 at 2PM, LPN’s only provided care to Patient #2, on 1/10/25, 1/13, 1/17, 1/20, 1/24, 1/27, 1/31, 2/3, 2/7, 2/10, 2/14, 2/17, 2/21, 2/24, 2/28, and 3/3/25. The Registered Nurse was scheduled 3/7/25 to do the recertification visit. Documentation failed to identify supervision of the LPN’s care and services provided to Patient #2 by the case manager registered nurse. Patient #4 had a start of care date of 2/17/25 with diagnoses that included acute respiratory failure with hypoxia, chronic kidney disease with heart failure, type 2 diabetes mellitus, and the history of falling. The physician’s orders for the certification period of 2/17/25 to 4/17/25 included nursing services two times per 2 weeks then 1 time per week for 7 weeks for respiratory, cardiac, and diabetic, and medication management. For the period of 2/17/25 through 3/12/25, the registered nurse was only scheduled to complete the admission visit, all nursing visits were scheduled by the LPN on 2/20/25, 2/25, 2/27, 3/6, and 3/10/25. Documentation failed to identify supervision of the LPN’s care and services provided to Patient #4 by the case manager registered nurse. Patient #1 had a start of care date of 12/04/24 and diagnoses that included chronic venous hypertension with ulcer and inflammation of the left lower extremity, type II diabetes mellitus, Alzheimer’s disease and dementia. The physician’s orders for the certification period of 2/02/25 to 4/02/25 included nursing services for assessments and wound care to the left venous stasis wound three times a week and occupational therapy services once a week for four weeks. Review of the clinical record from 2/03/25 to 3/07/25 identified weekly visits (fourteen) were conducted by LPN #1 & #2. Patient #2 had a start of care date of 7/13/24 with the diagnoses that included skin graft failure, necrotizing fasciitis, type 2 diabetes mellitus, epilepsy, depression, and acquired absence of left leg above knee. The physician orders for the certification period of 1/9/25 to 3/9/25 included nursing services twice per week to perform wound care to skin graft area, cleanse , apply mupirocin and cover with calcium alginate. Interview and review of Patient #2’s clinical record with the Vice President of Clinical on 3/12/25 at 2PM, LPN’s only provided care to Patient #2, on 1/10/25, 1/13, 1/17, 1/20, 1/24, 1/27, 1/31, 2/3, 2/7, 2/10, 2/14, 2/17, 2/21, 2/24, 2/28, and 3/3/25. The Registered Nurse was scheduled 3/7/25 to do the recertification visit. Documentation failed to identify supervision of the LPN’s care and services provided to Patient #2 by the case manager registered nurse. Patient #3 had a start of care date of 12/22/2024 with diagnoses that included pneumonia, dysphagia, metabolic encephalopathy, dementia, malnutrition, a myocardial infarction, and falls. The physician’s orders for the certification period of 12/22/2024 to 02/19/2025 included nursing services twice per week for three weeks and once per week for six weeks for assessments, instructing the Patient’s caregiver on the care and management of a gastrotomy tube care (a small flexible tube inserted through the abdominal wall and into the stomach to provide nutrition and medication to an individual) and wound care to a stage two pressure ulceration (partial thickness skin loss) to the coccyx. Additionally, Patient #3 received physical, occupational and speech therapy services. Review of the clinical record from 12/22/2024 to 02/17/2025 identified six out of twelve visits were conducted by an LPN. Patient #4 had a start of care date of 2/17/25 with diagnoses that included acute respiratory failure with hypoxia, chronic kidney disease with heart failure, type 2 diabetes mellitus, and the history of falling. The physician’s orders for the certification period of 2/17/25 to 4/17/25 included nursing services two times per 2 weeks then 1 time per week for 7 weeks for respiratory, cardiac, and diabetic, and medication management. For the period of 2/17/25 through 3/12/25, the registered nurse was only scheduled to complete the admission visit, all nursing visits were scheduled by the LPN on 2/20/25, 2/25, 2/27, 3/6, and 3/10/25. Documentation failed to identify supervision of the LPN’s care and services provided to Patient #4 by the case manager registered nurse. b. Patient #5 had a start of care date of 1/06/25 and diagnoses that included acute kidney failure, osteoarthritis of the left knee and type II diabetes mellitus. The physician’s orders for the certification period of 1/16/25 to 3/16/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, home health aide services, physical therapy and occupational therapy services. Review of the clinical record from 1/16/25 to 3/12/25 identified the LPN conducted a visit on 1/24/25 and documented a missed visit on 3/04/25. c. Patient #6 had a start of care date of 02/12/2025 with diagnoses that included urinary tract infections, hydronephrosis with ureteral stricture, malignant neoplasm of the ovary, hypertension, migraines and acid reflux. The physician’s orders for the certification period of 02/12/2025 to 04/12/2025 included nursing services for assessments and instructing the Patient and caregiver on the care and management of a nephrostomy tube (a tube that is inserted into the kidney through the skin that drains urine into a bag) such as changing the nephrostomy dressing and bag every three days. Additionally, the Patient received physical therapy. Review of the clinical record from 02/12/2025 to 03/10/2025 identified three out of four visits were conducted by an LPN. Patient #9 resided in an assisted living facility and had a start of care date of 01/31/2025 with diagnoses that included coronary artery disease, metabolic encephalopathy, dementia, chronic kidney disease, and type two diabetes mellitus. The physician’s orders for the certification period of 01/31/2025 to 03/31/2025 included nursing services for assessments, physical therapy and occupational therapy. Review of the clinical record from 01/31/2025 to 03/11/2025 identified four out of six visits were conducted by an LPN. Patient #15 had a start of care date of 2/08/25 and diagnoses that included metabolic encephalopathy, dysphagia and type II diabetes mellitus. The physician’s orders dated 2/08/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, physical therapy services one time a week for four weeks for gait training and recording patient’s reported blood sugar levels and occupational therapy services. Review of the clinical record from 2/08/25 to 3/12/25 identified 4 out of 6 visits were conducted by an LPN. Interview and review of the clinical records of Patient’s #1, 2, 3, 4, 5, 6, 9, &15, with the VP of Clinical Services on 3-12-25 at 1:50 PM failed to ensure an RN conducted visits to monitor and evaluate LPN performance in the provision of services, provision of treatments, patient education, communication with the RN and data collection regarding the patient’s status and health needs. Review of agency policies for Services Provided/Supervision of Disciplines directed the primary nurse is responsible for coordination of services with the patient, family and others involved in the plan of care, regular evaluation of patient progress and prompt action when any change in condition is noted or reported, the home health agency should identify an RN to supervise care provided by the LPN. The identified RN must in turn monitor and evaluate LPN performance in the provision of services, provision of treatments, patient education, communication with the RN and data collection regarding the patient’s status and health needs.”

“Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This Element is not met as evidenced by: Based on clinical record reviews and interviews with agency personnel, for eight of eleven current patients (Patient #1, 2, 3, 4, 5, 6, 9 &15) in the survey sample, the Clinical Manager failed to provide oversight of all patient care services and personnel related to care coordination and patient assignments. a. Patient #3 had a start of care date of 12/22/2024 with diagnoses that included pneumonia, dysphagia, metabolic encephalopathy, dementia, malnutrition, a myocardial infarction, and falls. The physician’s orders for the certification period of 12/22/2024 to 02/19/2025 included nursing services twice per week for three weeks and once per week for six weeks for assessments, instructing the Patient’s caregiver on the care and management of a gastrotomy tube care (a small flexible tube inserted through the abdominal wall and into the stomach to provide nutrition and medication to an individual) and wound care to a stage two pressure ulceration (partial thickness skin loss) to the coccyx. Additionally, Patient #3 received physical, occupational and speech therapy services. Review of the clinical record from 12/22/2024 to 02/17/2025 identified six out of twelve visits were conducted by an LPN. b. Patient #6 had a start of care date of 02/12/2025 with diagnoses that included urinary tract infections, hydronephrosis with ureteral stricture, malignant neoplasm of the ovary, hypertension, migraines and acid reflux. The physician’s orders for the certification period of 02/12/2025 to 04/12/2025 included nursing services for assessments and instructing the Patient and caregiver on the care and management of a nephrostomy tube (a tube that is inserted into the kidney through the skin that drains urine into a bag) such as changing the nephrostomy dressing and bag every three days. Additionally, the Patient received physical therapy. Review of the clinical record from 02/12/2025 to 03/10/2025 identified three out of four visits were conducted by an LPN. c. Patient #9 resided in an assisted living facility and had a start of care date of 01/31/2025 with diagnoses that included coronary artery disease, metabolic encephalopathy, dementia, chronic kidney disease, and type two diabetes mellitus. The physician’s orders for the certification period of 01/31/2025 to 03/31/2025 included nursing services for assessments, physical therapy and occupational therapy. Review of the clinical record from 01/31/2025 to 03/11/2025 identified four out of six visits were conducted by an LPN. Patient #1 had a start of care date of 12/04/24 and diagnoses that included chronic venous hypertension with ulcer and inflammation of the left lower extremity, type II diabetes mellitus, Alzheimer’s disease and dementia. The physician’s orders for the certification period of 2/02/25 to 4/02/25 included nursing services for assessments and wound care to the left venous stasis wound three times a week and occupational therapy services once a week for four weeks. Review of the clinical record from 2/03/25 to 3/07/25 identified weekly visits (fourteen) were conducted by LPN #1 & #2. Patient #2 had a start of care date of 7/13/24 with the diagnoses that included skin graft failure, necrotizing fasciitis, type 2 diabetes mellitus, epilepsy, depression, and acquired absence of left leg above knee. The physician orders for the certification period of 1/9/25 to 3/9/25 included nursing services twice per week to perform wound care to skin graft area, cleanse, apply mupirocin and cover with calcium alginate. Review of the clinical record from 1/10/25 to 3/3/25 (16 visits) were all conducted by an LPN. Patient #4 had a start of care date of 2/17/25 with diagnoses that included acute respiratory failure with hypoxia, chronic kidney disease with heart failure, type 2 diabetes mellitus, and the history of falling. The physician’s orders for the certification period of 2/17/25 to 4/17/25 included nursing services two times per 2 weeks then 1 time per week for 7 weeks for respiratory, cardiac, and diabetic, and medication management. Review of the clinical record from 2/20/25 to 3/10/25 (5 visits) were all conducted by an LPN. b. Patient #5 had a start of care date of 1/06/25 and diagnoses that included acute kidney failure, osteoarthritis of the left knee and type II diabetes mellitus. The physician’s orders for the certification period of 1/16/25 to 3/16/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, home health aide services, physical therapy and occupational therapy services. Review of the clinical record from 1/16/25 to 3/12/25 identified the LPN conducted a visit on 1/24/25 and documented a missed visit on 3/04/25. c. Patient #15 had a start of care date of 2/08/25 and diagnoses that included metabolic encephalopathy, dysphagia and type II diabetes mellitus. The physician’s orders dated 2/08/25 included nursing services once weekly for three weeks and once every two weeks for six weeks for assessments, physical therapy services one time a week for four weeks for gait training and recording patient’s reported blood sugar levels and occupational therapy services. Review of the clinical record from 2/08/25 to 3/12/25 identified 4 out of 6 visits were conducted by an LPN. Interview and review of the clinical records of Patient’s #1, 2, 3, 4, 5, 6, 9, &15, with the VP of Clinical Services on 3-12-25 at 1:50 PM failed to ensure the Clinical Manager provided oversight of all patient care services and personnel related to care coordination and patient assignments and failed to ensure an RN conducted visits to monitor and evaluate LPN performance in the provision of services, provision of treatments, patient education, communication with the RN and data collection regarding the patient’s status and health needs. Review of agency policy for Coordination of Care directed the Clinical Manager is assigned to supervise and coordinate care for the patients. The primary clinician/case manager shall have the primary responsibility to notify the attending physician/allowed practitioner and other agency staff of any significant changes/concerns in the patient’s status.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on clinical record review and interview with agency personnel, for one of four patients (Patient #12) discharged from the agency, the agency nurses failed to complete a discharge summary and send to the physician within 5 business days of the discharge. The findings include: Patient #12 had a start of care date of 10/15/24 and diagnoses that included right femur fracture, pneumonia, squamous cell carcinoma of the right lower limb and non-Hodgkin’s lymphoma. The physician’s orders dated 10/15/24 included nursing services one time a week for one week for assessments. Review of the clinical record with the VP of Clinical services on 3/12/25 at 1:30 PM identified the initial visit documentation and assessment, but failed to identify any further visits were conducted. Subsequent to surveyor inquiry, documentation was provided to the surveyor which identified the patient was discharged from the agency and transferred to a hospice facility on 10/16/25, but failed to forward the discharge summary to the physician.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on review of the clinical record, review of agency policies and interview with agency personnel, for one of three patients (Patient #1) requiring wound care in the Assisted Living Facility/ALF, the agency licensed nurses failed to provide the necessary assessments. The findings include: Patient #1 had a start of care date of 8/31/23 and diagnoses that included open wound to the right foot, Parkinson’s disease and dementia with Lewey bodies. The physician’s orders dated 8/01/23 included nursing services for assessments and wound care to the right heel two times a week, physical therapy and occupational therapy services. On 10/27/23 (Friday) at 7:48 PM, review of the Client Coordination Note identified ALF Licensed Practical Nurse/LPN #1 called the on-call nurse, Registered Nurse/RN #2, to report a new small opening in the patient’s coccyx area and the need to treat the area at the next visit. RN #2 documented leaving a message at the ALF that a visit was scheduled for Monday, 10/30/23. A subsequent Client Coordination Note dated 10/28/23 (Saturday) at 12:47 PM, identified ALF LPN #2 called the on-call nurse, RN #2, to request a visit to treat the patient’s new coccyx wound. RN #2 indicated that there were no available weekend staff to make a visit on10/28/23 or 10/29/23. Interview and review of the clinical record with the Administrator on 7/25/24 at 1 PM identified a nursing visit was conducted on 10/30/23 by RN #1, obtained treatment orders, provided wound care to the coccyx area, and increased nursing visits to three times a week, but failed to identify a nursing visit was conducted on 10/28/23 or 10/29/23 after a reported change in condition. Review of agency policy for Back-Up services directed that after business hours and on weekends and holidays, coverage is available twenty-four hours a day, seven days a week.”