Patient Care

“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 clinical records, review of agency documents and interviews with agency personnel, for one of eighteen patients reviewed (Patient #14) , the agency nurses failed to follow the physician’s orders. The findings include: Patient #14 had a start of care date of 03/01/2026 with diagnoses including bile duct carcinoma, sepsis and long-term use of insulin. Physician’s orders for the certification period of 03/01/2026 through 04/29/2026 directed skilled nursing visits three (3) times per week for assessment and education of the Patient and caregiver regarding biliary drain care. Instructions included removing the old dressing, cleansing the area with warm water, patting the site dry with gauze, applying clean gauze, and covering the site with a dressing one (1) to two (2) times per week and as needed. The physician’s orders also directed daily administration of insulin, per sliding scale. Additionally, physical and occupational therapy services were ordered. Review of the start of care nursing summary dated 03/01/2026, indicated the Patient #14 caregiver was performing the biliary drain dressing changes and that the nurse was able to flush the drain for patency, without difficulty at the visit. Review of Patient #14’s clinical and medication administration record dated 03/01/2026 failed to identify the type of solution used to flush the biliary drain, or the prescribed flush amount and frequency of flushes ordered. Review of additional nursing visit notes dated 03/02/2026, 03/06/2026, 03/14/2026 and 03/27/2026 identified that Patient #14’s caregiver was independent with biliary dressing changes and drain flushing. However, the nursing documentation failed to identify the flush solution type, amount and frequency. Review of the medication administration record indicated that Patient #14 was prescribed insulin Lispro 100 units/ml via insulin pen, before meals per a sliding scale, with instructions to notify the physician if the Patient’s blood glucose was 70 mg/dL or above 450 mg/dL., but review of the medication documentation record failed to identified the Patient’s daily blood glucose readings, and review of the care plan failed to include Patient and caregiver education for interventions regarding blood glucose monitoring, insulin administration and recognition and management of the signs and symptoms of hypoglycemia and/or hyperglycemia. Review of Patient #14’s clinical record identified an order for an Occupational Therapy evaluation, but failed to identify documentation regarding the reason for the delay in the evaluation until 03/28/26, twenty-seven days from the Patient’s start of care, and fourteen days from the Patient’s resumption of care, due to hospitalization. The clinical record also failed to include documentation that the physician was notified of the delay in service provision. Interview with the Supervisor of Clinical Services (SCS) #1 on 07/08/2026 at 09:45 AM, identified that Patient #14’s individualized care plan did not include the prescribed biliary drain flush solution, flush amount, or frequency. SCS #1 further indicated the agency’s nurses did not document the Patient’s blood glucose monitoring results and that the care plan did not include Patient and caregiver education regarding blood glucose monitoring, insulin administration, or the recognition and management of the signs or symptoms of hypoglycemia and hyperglycemia. SCS #1 identified that an occupational therapy evaluation was originally scheduled for 03/02/2026, but was postponed due to the Patient’s rehospitalization. The SCS indicated upon the Patient’s resumption of home health services on 03/14/2026, the occupational therapy evaluation was inadvertently omitted from the scheduling calendar and was not rescheduled and completed until 03/28/2026, twenty-seven days from the start of home health services, and/or fourteen days from resumption of care, and did not ensure timely completion of care per the physician order. Review of the agency’s Plan of Care policy identified the purpose of the policy was to ensure that physician/authorized practitioner’s orders are followed. Each patient has an individualized plan of care developed in consultation with the patient, physician or authorized practitioner and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals. The care plan would include medications and treatments and patient specific interventions.”

“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, agency documentation and staff interview, for one of eight patients (Patient #17) requiring wound care, the agency licensed nurses failed to ensure the completion of weekly wound measurements in accordance with agency policies. The findings include: Patient #17 had a start of care date of 3/08/26 and diagnoses that included right buttock stage III and left buttock stage I pressure ulcers, chronic obstructive pulmonary disease and hypertensive chronic kidney disease. The physician’s orders for the certification periods of 3/08/26 to 5/19/26 included nursing services twice weekly for assessments and wound care to the right and left buttocks. Review of the clinical record identified initial wound measurements of the right and left buttocks on 3/08/26 and weekly wound measurements on 3/24/26, 4/08/26, 4/16/26, 5/05/26 and 5/19/26. Interview and review of the clinical record with the Administrator on 7/08/26 at 1:30 PM identified for five out of ten weeks, (week of 3/15/26, 3/29/26, 4/19/26, 4/26/26, and 5/10/26) of wound care visits, the patient’s wounds were not measured weekly, in accordance with agency policies. Review of agency policy for Wound Assessment, Documentation and Photography directed wounds will be measured weekly for patients receiving daily wound care performed by the agency, have an infected wound or have a stage IV pressure injury with evidence of infection or as specified per state requirements if more stringent than above.”

“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, review of agency documentation and staff interviews for three of fifteen patients reviewed (Patient #2,10, 15), the agency failed to ensure coordinated care delivery with the Assisted Living Service Agency (ALSA) providers. The findings include: Patient #14 had a start of care date of 03/01/2026 with diagnoses including bile duct carcinoma, sepsis and long-term use of insulin. Physician’s orders for the certification period of 03/01/2026 through 04/29/2026 directed skilled nursing visits three (3) times per week for assessment and education of the Patient and caregiver regarding biliary drain care. Additionally, physical and occupational therapy services were ordered during the certification period. Review of Patient #14’s clinical record failed to include documentation explaining the delay in completing the occupational therapy evaluation, which was not performed until 03/28/2026 after home health services resumed on 03/14/2026. The clinical record also failed to include documentation that the physician was notified of the delay in providing the service ordered. Interview with the Supervisor of Clinical Services (SCS) #1 on 07/08/2026 at 09:45 AM, identified that an occupational therapy evaluation was originally scheduled for 03/02/2026 but was postponed due to the Patient’s hospitalization. Upon resumption of home health services on 03/14/2026, the occupational therapy evaluation was inadvertently omitted from the scheduling calendar and was not rescheduled until 03/28/2026, resulting in a delay in the ordered evaluation. Patient #2 had a start of care date of 6/15/26 and diagnoses that included umbilical hernia repair, small bowel obstruction, atrioventricular block and hypertension The physician’s orders dated 6/15/26 included nursing services once weekly for assessments, physical therapy/PT and occupational therapy/OT services. Patient #2 resided in an ALF. Review of the Memorandum of Understanding/MOU with the ALF dated 6/15/26 identified frequency of visits for nursing, PT and OT but lacked evidence of the specific care to be provided by the PT and failed to identify a signature by an ALF nurse on the MOU for the nursing services. Interview and review of the clinical record with the Administrator on 7/08/26 at 1 PM identified PT services in the ALF should include specific care to be provided, the ALF nurse should be signing the form, although, it is often difficult to find a nurse to sign it and failed to follow agency expectations. Patient #10 had a start of care date of 5/03/26 and diagnoses that included respiratory failure and hypertensive heart and chronic kidney disease with heart failure. The physician’s orders dated 5/03/26 included nursing services once weekly for assessments, physical therapy/PT and occupational therapy/OT services. Patient #10 resided in an ALF. Review of the MOU with the ALF identified frequency of visits for nursing, PT and OT but lacked evidence of the specific care to be provided by the PT and failed to identify a signature by an ALF nurse on the MOU for the nursing and OT services. Interview and review of the clinical record with the Administrator on 7/08/26 at 1:05 PM identified PT services in the ALF should include specific care to be provided, the ALF nurse should be signing the form, although, it is often difficult to find a nurse to sign it and failed to follow agency expectations. Patient #15 had a start of care date of 5/05/26 and diagnoses that included Parkinsonism, atrial fibrillation, major depressive disorder and spinal stenosis. The physician’s orders dated 5/05/26 included PT, SLP and OT services. Patient #15 resided in an ALF. Review of the MOU with the ALF dated 5/05/26 identified frequency of visits for PT, SLP and OT, ALF nursing signatures on the MOU’s but lacked evidence of the specific care to be provided by the PT and SLP. Interview and review of the clinical record with the Administrator on 7/08/26 at 1:10 PM identified PT and SLP services in the ALF should include specific care to be provided and failed to follow agency expectations. Review of agency policy for Coordination of Care directed when a patient receives services from other organizations and/or individuals, care is coordinated to ensure the patient’s needs are met efficiently to ensure staff understand the role and responsibilities of these other health care providers. Written information obtained from the plan of care will be provided to the patient and caregiver outlining visit schedule and frequency of visits and treatments to be administered by staff including therapy services. Patient #2 had a start of care date of 6/15/26 and diagnoses that included umbilical hernia repair, small bowel obstruction, atrioventricular block and hypertension The physician’s orders dated 6/15/26 included nursing services once weekly for assessments, physical therapy/PT and occupational therapy/OT services. Patient #2 resided in an Assisted Living Facility (ALF). Review of the clinical record and Memorandum of Understanding/MOU with the ALF dated 6/15/26 identified the frequency of visits/care for nursing, PT and OT, but lacked the specific care to be provided by the PT and failed to identify an authorized signature by an ALF staff within the MOU document for nursing services. Interview and review of the clinical record with the Administrator on 7/08/26 at 1 PM identified the PT services on the ALF MOU document should include the specific care, the frequency of visits, the durations (length of time) of service provision and the specific care to be provided to the patient, and did not provide documentation that an ALF nurse signed the MOU form. The Administrator indicated it is often difficult to find a nurse to sign it and failed to follow agency expectations and policy. Patient #10 had a start of care date of 5/03/26 and diagnoses that included respiratory failure and hypertensive heart and chronic kidney disease with heart failure. The physician’s orders dated 5/03/26 included nursing services once weekly for assessments, physical therapy/PT and occupational therapy/OT services. Patient #10 resided in an ALF. Review of the clinical record and MOU with the ALF identified frequency of visits for nursing, PT and OT, but lacked the specific care to be provided by the PT and failed to identify a signature by an ALF nurse on the MOU for the nursing and OT services. Interview and review of the clinical record with the Administrator on 7/08/26 at 1:05 PM identified PT services in the ALF should include the specific care to be provided, and the ALF nurse should be signing the form, although, it is often difficult to find a nurse to sign it during the visit, and staff failed to follow agency expectations and policy. Patient #15 had a start of care date of 5/05/26 and diagnoses that included Parkinsonism, atrial fibrillation, major depressive disorder and spinal stenosis. The physician’s orders dated 5/05/26 included PT, SLP and OT services. Patient #15 resided in an ALF. Review of the clinical record and MOU with the ALF dated 5/05/26 identified the frequency of visits for PT, SLP and OT, and ALF nursing signatures on the MOU’s, but lacked evidence of the specific care to be provided by the PT and SLP. Interview and review of the clinical record with the Administrator on 7/08/26 at 1:10 PM identified PT and SLP services in the ALF should include specific care to be provided and failed to follow agency expectations and policy. Review of agency policy for Coordination of Care directed when a patient receives services from other organizations and/or individuals, care is coordinated to ensure the patient’s needs are met efficiently to ensure staff understand the role and responsibilities of these other health care providers. Written information obtained from the plan of care will be provided to the patient and caregiver outlining visit schedule and frequency of visits and treatments to be administered by staff including therapy services.”

“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 clinical record reviews, review of agency documentation and staff interviews, for two of eighteen patients reviewed (Patient’s #1 & 6), the agency licensed personnel failed to ensure instruction/education for the management of a Patients’ medication. The findings include: Patient #1 had a start of care date of 5/26/26 and diagnoses that included right and left heel deep tissue injury, depression and dementia. The physician’s orders dated 5/26/26 included nursing services two times a week for two weeks and once weekly for assessments and wound care to the right and left heels and occupational therapy services once a week for three weeks. Review of the medication profile identified Albuterol Sulfate HFA 90 micrograms/mcg/actuation aerosol every four hours as needed, Benefiber Advanced 1 billion cell-4 gram oral powder, one packet daily as needed, Coricidin HBP Chest Congestion/Cough 10 milligrams/mg-200 mg capsule (2 capsules), every twelve hours as needed, Coricidin HBP Max Cold-Cough-Flu 650 mg-20 mg/15 milliliters (30 ml), every twelve hours as needed, Melatonin (sleep aid) 3 mg tablet daily as needed, Ondansetron (anti-nausea) 4 mg disintegrating tablet every eight hours as needed, Trazadone (anti-depressant) 50 mg (1/2 tablet), 25 mg every six hours as needed, Tylenol (pain reliever) 325 mg (2 tablets), 650 mg every twelve hours as needed. Interview and review of the clinical record and medication profile with the Administrator on 7/08/26 at 12 PM directed Benefiber Advanced 1 billion cell-4 gram oral powder, one packet daily as needed, but failed to identify instructions for the patient to stir and dissolve 4-8 ounces of a liquid for oral administration, and failed to include the reason for the as needed medication administration. Interview and review of the medication profile with the Administrator on 7/08/26 at 12 PM indicated orders for the administration of the as needed medications, Albuterol Sulfate, Coricidin, Melatonin, Ondansetron, Trazadone and Tylenol for administration, but failed to identify the reason for administering the as needed medications. Patient #6 had a start of care date of 7/01/26 and diagnoses that included hypothyroidism, atrial fibrillation, hypertensive heart disease with heart failure and malignant neoplasm of the large intestine. The physician’s orders dated 7/01/26 included nursing services for assessments and instruction on colostomy care, physical therapy and occupational therapy evaluations. Review of the medication profile identified Polyethylene Glycol (MiraLAX) 3350 17 gram oral powder packet daily for administration. Interview and review of the clinical record and medication profile with the Administrator on 7/08/26 at 12 PM directed the patient to take Polyethylene Glycol powder daily, but failed to identify instructions to stir and dissolve in 4-8 ounces of a liquid for administration.”

“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 clinical record review, observation, review of agency policies and interview with agency personnel, for one of seven patients (Patient #4) visited during the survey, the agency nurse failed to maintain accepted infection control practice. The findings include: Patient #4 had a start of care date of 3/27/24 and diagnoses that included fracture of the third lumbar vertebrae, dementia and type II diabetes mellitus. The physician’s orders dated 3/27/24 included nursing services one to two times a week for diabetic and general assessments. On 4/16/24, a physician’s order for wound care to the left and right heel suspected deep tissue injury/DTI indicated to apply skin prep and cover with a bordered foam dressing three times a week for two weeks. On 5/13/24, an as needed visit was conducted by LPN #1 upon notification from the ALF nurse that the left heel DTI was now open and draining. A physician’s order was obtained to cleanse the left heel with normal saline, pat dry, apply Prisma collagen and a bordered foam dressing three times a week. During a joint home visit with LPN #1 and contracted RN #3 on 5/14/24 at 11:40 AM, the surveyor observed LPN #1 use hand sanitizer to sanitize his/her hands, don gloves, remove the left heel foam dressing, discard the dressing in a bag, and then began to pick up the saline and clean 4x4 gauze dressing, when reminded by the surveyor of the need to change gloves and sanitize hands between dressing removal and cleansing the left heel. Interview and review of LPN #1’s joint home visit with the Administrator and RN #1 on 5/20/24 at 12:35 PM failed to indicate that LPN #1 followed the agency policies on changing gloves after removing a wound dressing. The agency policy on Hand Hygiene directed in part, the staff are required to perform hand hygiene using soap and water or an alcohol-based hand sanitizer before direct patient contact, before performing an aseptic task such as wound care, after contact with wound dressings and before and after removal of personal protective equipment.”

“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 clinical record reviews, review of agency policies and interview with the agency personnel, for one of three patients (Patient #13) requiring nursing assessments, the agency Registered Nurse failed to follow agency policies. The findings include a. Patient #13 had a start of care date of 01/20/2024 and diagnoses that included cellulitis of the left lower leg, hypertensive heart disease with heart failure, and falls. The physician’s orders for the certification period of 01/20/2024 to 03/19/2024 included nursing services once per week for eight weeks for nursing assessments and a physical therapy evaluation. Patient #13 resided in an Assisted Living Facility, Review of Patient #13’s sign in/sign out electronic log from the Assisted Living Facility dated 01/19/2024, identified Patient #13 was signed out of the facility for a leave of absence from 01/19/2024 at 09:29 AM and returned on 01/22/2024 at 2:22 PM. Review of Registered Nurse (RN) #2’s schedule for 01/20/2024, identified RN #2 was scheduled to visit a total of four patients. The schedule further indicated Patient #13 was admitted to the home health agency on 01/20/2024 from 11:34 AM to 12:55 PM at the Assisted Living Facility. Review of RN #2’s laptop Global Positioning System (GPS) coordinates, identified RN #2’s GPS was not enabled for the date of 01/20/2024 to establish times and locations of patient visits. Review of Patient #13’s start of care clinical documentation dated 01/20/2024, identified RN #2 started the documentation on 01/20/2024, but did not complete the documentation until 01/23/2024 at 10:19 PM. Review of the home health agency’s investigation dated 02/21/2024 and 02/22/2024, identified Regional RN #1 was notified on 02/14/2024 that RN #2 failed to conduct a start of care visit on 01/20/2024 for Patient #13 and failed to complete documentation until 01/23/2024. Additionally, when interviewed for the agency’s investigation, RN #2 indicated she admitted Patient #13 on 01/20/2024 at the Assisted Living Facility. Review of RN #2’s personnel file, identified performance concern notes dated 06/23/2023 and 05/15/2024, indicating RN #2 had repeated incidences of late documentation past the 24-hour exception of the agency’s policy resulting in discrepancies in patient visit times. Interview with Regional RN #1, Clinical Compliance RN #1 and Human Resource Supervisor on 05/15/2024 at 1:30 PM, identified RN #2 failed to enable laptop GPS coordinates on 01/20/2024, the agency’s investigation failed to identify how Patient #13 was admitted to the home health agency on 01/20/2024 as the Patient was on an established leave of absence from the Assisted Living Facility from 01/19/2024 to 01/22/2024, and identify RN #1 failed to follow the agency’s expectation for the timeliness of documentation to ensure an authentic patient record. RN #1 was removed from all cases on 02/22/2024 pending a complete investigation and returned to work on 02/23/2024. Review of the agency’s Electronic Visit Verification policy identified the purpose of the policy was to establish a process to verify when provider visits occur and document the time services begin and end. Electronic Visit Verification is used to electronically capture point of service information from some home and community-based services. Agency staff would use EVV via phone, mobile data collection device or other in-home devices from the patient’s home to record the time of the visit. Review of the agency’s Home Care Record policy identified that a medical record is maintained for all patients receiving services and care for the agency. All entries in the patient care record would also reflect state and time care performed. All entries recorded in the home care record must be legible and accurate. Review of the agency’s Information Management policy directed that all entries in the home care record must be accurate. Review of agency’s Fraud, Waste and Abuse policy directed the responsibility of all employees to immediately report suspected fraud which would include falsifying documents to show services provided when no services were provided.”

“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 review of clinical records, interviews with agency personnel, agency policies and a personnel file, for one of three of patients (Patient’s #13), the agency licensed personnel failed to follow agency policies and failed to ensure accuracy and authenticity of the documentation. The finding includes: a. Patient #13 had a start of care date of 01/20/2024 and diagnoses that included cellulitis of the left lower leg, hypertensive heart disease with heart failure, and falls. The physician’s orders for the certification period of 01/20/2024 to 03/19/2024 included nursing services once per week for eight weeks for nursing assessments and a physical therapy evaluation. Patient #13 resided in an Assisted Living Facility, Review of Patient #13’s sign in/sign out electronic log from the Assisted Living Facility dated 01/19/2024, identified Patient #13 was signed out of the facility for a leave of absence from 01/19/2024 at 09:29 AM and returned on 01/22/2024 at 2:22 PM. Review of Registered Nurse (RN) #2’s schedule for 01/20/2024, identified RN #2 was scheduled to visit a total of four patients. The schedule further indicated Patient #13 was admitted to the home health agency on 01/20/2024 from 11:34 AM to 12:55 PM at the Assisted Living Facility. Review of RN #2’s laptop Global Positioning System (GPS) coordinates, identified RN #2’s GPS was not enabled for the date of 01/20/2024 to establish times and locations of patient visits. Review of Patient #13’s start of care clinical documentation dated 01/20/2024, identified RN #2 started the documentation on 01/20/2024, but did not complete the documentation until 01/23/2024 at 10:19 PM. Review of the home health agency’s investigation dated 02/21/2024 and 02/22/2024, identified Regional RN #1 was notified on 02/14/2024 that RN #2 failed to conduct a start of care visit on 01/20/2024 for Patient #13, and failed to complete documentation until 01/23/2024. Additionally, when interviewed for the agency’s investigation, RN #2 indicated she admitted Patient #13 on 01/20/2024 at the Assisted Living Facility. Review of RN #2’s personnel file, identified performance concern notes dated 06/23/2023 and 05/15/2024, indicating RN #2 had repeated incidences of late documentation past the 24-hour exception of the agency’s policy resulting in discrepancies in patient visit times. Interview with Regional RN #1, Clinical Compliance RN #1 and Human Resource Supervisor on 05/15/2024 at 1:30 PM, identified RN #2 failed to enable laptop GPS coordinates on 01/20/2024, the agency’s investigation failed to identify how Patient #13 was admitted to the home health agency on 01/20/2024 as the Patient was on an established leave of absence from the Assisted Living Facility from 01/19/2024 to 01/22/2024, and failed to identify RN #1 followed the agency’s expectation for the timeliness of documentation to ensure an authentic patient record. RN #1 was removed from all cases on 02/22/2024 pending a complete investigation and returned to work on 02/23/2024. Review of the agency’s Electronic Visit Verification policy identified the purpose of the policy was to establish a process to verify when provider visits occur and document the time services begin and end. Electronic Visit Verification is used to electronically capture point of service information from some home and community-based services. Agency staff would use EVV via phone, mobile data collection device or other in-home devices from the patient’s home to record the time of the visit. Review of the agency’s Home Care Record policy identified that a medical record is maintained for all patients receiving services and care for the agency. All entries in the patient care record would also reflect state, and time care was performed. All entries recorded in the home care record must be legible and accurate. Review of the agency’s Information Management policy directed that all entries in the home care record must be accurate. Review of agency’s Fraud, Waste and Abuse policy directed the responsibility of all employees to immediately report suspected fraud which would include falsifying documents to show services provided when no services were provided.”

“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 review, review of agency policies and interview with agency personnel, for two of four patients (Patient’s #3 & #12) requiring blood glucose and/or weight monitoring for a diagnosis of type II diabetes mellitus and congestive heart failure, and for one of one patient (Patient #9) requiring medication administration, the agency nurses failed to ensure the plan of care addressed the patient’s individual needs and/or failed to follow physician’s orders. The findings include: Patient #3 had a start of care date of 3/25/24 and diagnoses that included acute respiratory failure, type II diabetes mellitus, chronic kidney disease and congestive heart failure. The physician’s orders dated 3/25/24 included nursing services two times a week for one week and once weekly for six weeks for diabetic instruction and assessments. Additionally, the patient received physical therapy and speech language pathology services. Interview and review of the physician’s certified plan of care dated 3/25/24 with the Administrator and RN #1 on 5/20/24 at 12:18 PM, failed to identify communication with the physician for the frequency of blood glucose monitoring/weight monitoring and parameters for reporting abnormal findings to the physician. Patient #9 had a start of care date of 7/26/21 and diagnoses that included Vitamin B deficiency, Alzheimer’s disease and dementia. The physician’s orders for the certification period of 3/12/24 to 5/10/24 included nursing services once weekly for general assessments and the administration of Vitamin B12 1000 micrograms intramuscularly every thirty days. Patient #9 resided in an Assisted Living Facility/ALF. Interview and review of the clinical record with the Administrator and RN #1 on 5/20/24 at 1 PM, identified that on 4/17/24, the monthly Vitamin B12 injection was due, although review of RN #2’s nursing note failed to identify that the injection was administered and failed to follow physician’s orders. Patient #12 had a start of care date of 3/10/24 and diagnoses that included a left femoral neck fracture, type II diabetes mellitus and acute kidney failure. The physician’s orders for the certification periods of 3/10/24 to 7/07/24 included nursing services three times a week for one week, and twice weekly for six weeks for diabetic instruction and assessments. Additionally, the patient received physical therapy, occupational therapy and medical social worker services. Interview and review of the physician’s certified plan of care dated 3/10/24 with the Administrator and RN #1 on 5/20/24 at 12:18 PM failed to identify communication with the physician for blood glucose parameters for reporting abnormal findings to the physician. Review of the agency policy for Plan of Care directed that the plan of care includes patient specific interventions and education, measurable outcomes and goals identified by the agency and patient.”

“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 review of clinical records, interview with agency personnel for two of eleven patients (Patient’s #4 & #9) who resided in an Assisted Living Facility (ALF), the agency failed to obtain/update the Memorandum of Understanding/MOU to delineate the nursing responsibilities between the agencies. The findings include: Patient #4 had a start of care date of 3/27/24 and diagnoses that included fracture of the third lumbar vertebrae, dementia and type II diabetes mellitus. The physician’s orders dated 3/27/24 included nursing services one to two times a week for diabetic and general assessments. On 4/16/24, a physician’s order for wound care to the left and right heel suspected deep tissue injury/DTI indicated to apply skin prep and cover with a bordered foam dressing three times a week for two weeks. On 5/13/24, an as needed visit was conducted by LPN #1 upon notification from the ALF nurse that the left heel DTI was now open and draining. A physician’s order was obtained to cleanse the left heel with normal saline, pat dry, apply Prisma collagen and a bordered foam dressing three times a week Interview and review of the clinical record with the Administrator and RN #1 on 5/20/24 at 1 PM, identified the MOU for nursing services on 3/27/24, but failed to identify an updated MOU between two agencies to delineate nursing responsibilities for wound care and treatment three times a week. Patient #9 had a start of care date of 7/26/21 and diagnoses that included Vitamin B deficiency, Alzheimer’s disease and dementia. The physician’s orders for the certification period of 3/12/24 to 5/10/24 included nursing services once weekly for general assessments and the administration of Vitamin B12 1000 micrograms intramuscularly every thirty days. Interview and review of the clinical record with the Administrator and RN #1 on 5/20/24 at 1 PM, failed to identify the MOU between two agencies to delineate nursing responsibilities for care and treatment on admission, and every subsequent recertification.”

“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 clinical record review and interview with agency personnel, for one of three patients (Patient #1) requiring weight monitoring for a diagnosis of congestive heart failure and/or for two of four patients (Patient #4 and #8) requiring wound care, the agency nurses failed to provide the necessary assessments. The findings include: Patient #1 had a start of care date of 4/12/24 and diagnoses that included hypertensive heart and chronic kidney disease with heart failure, right heel stage III pressure ulcer, acute on chronic congestive heart failure. The physician’s orders dated 4/12/24 included nursing services three times a week for one week, two times a week for two weeks and once weekly for five weeks for wound care, assessments and weight monitoring with notification to the physician of a three-pound weight gain in a day or a five-pound weight gain in a week. Interview and review of the nursing notes dated 4/15/24, 4/17/24 and 4/25/24 with the Administrator and RN #1 on 5/20/24 at 12:23 PM failed to identify weight monitoring during the nursing visits and failed to follow physician’s orders. Patient #4 had a start of care date of 3/27/24 and diagnoses that included fracture of the third lumbar vertebrae, dementia and type II diabetes mellitus. The physician’s orders dated 3/27/24 included nursing services one to two times a week for diabetic and general assessments. On 4/16/24, a physician’s order for wound care to the left and right heel suspected deep tissue injury/DTI indicated to apply skin prep and cover with a bordered foam dressing three times a week for two weeks. On 5/13/24, an as needed visit was conducted by LPN #1 upon notification from the ALF nurse that the left heel DTI was now open and draining. A physician’s order was obtained to cleanse the left heel with normal saline, pat dry, apply Prisma collagen and a bordered foam dressing three times a week. Interview and review of LPN #1’s as needed visit with the Administrator and RN #1 on 5/20/24 at 12:30 PM identified that the RN should have conducted the visit after notification by the ALF nurse that the heel was open and draining and failed to ensure the wound was assessed by the RN. Patient #8 had a start of care date of 01/17/2024 and diagnoses that included stroke, vascular dementia, stage II pressure ulcers to sacral region and left lower extremity, hypertension, and falls. The physician’s orders dated 03/12/2024 for the recertification period of 03/17/2024 to 05/15/2024 included nursing services twice per week for four weeks and once per week for two weeks for wound care and assessments. Interview and review of the nursing notes dated 03/19/2024, 03/21/2024, 03/22/2024, 04/15/2024, 04/17/2024, 04/19/2024, 04/30/2024, 05/03/2024, 05/07/2024 and 05/09/2024 with the Administrator at 11:30 AM failed to identify weekly wound measurements were obtained during the nursing visits in accordance with the agency’s Wound Assessment, Documentation, and Photography policy. Review of the agency’s Wound Assessment, Documentation, and Photography policy identified the purpose of the policy was to ensure the accurate and consistent assessment and documentation of wounds. Upon initial visit and subsequently as indicated, all wounds would be assessed with appropriate documentation within the medical record. Wound location and description documentation would be completed on all patients with wounds. During routine visits, wounds would be documented in the Wound Assessment Tool. Unless otherwise ordered by the physician, the qualified clinician would assess the wounds weekly. The assessment would include measurements of length, width and depth, wound drainage and condition of the surrounding tissue.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on review of agency documentation and interview with the agency personnel, the agency failed to ensure a qualified Administrator was appointed and responsible for all day-to-day operations of the Home Health Agency/HHA and actively involved in the daily responsibilities of running the HHA. The findings include: During the entrance conference on 5/14/24 at 9:15 AM with the Administrator, s/he indicated being newly hired as of 5/06/24 and the Supervisor of Clinical Services/SCS indicated s/he’s first day was 5/14/24. Further review of the agency documentation identified, the former Administrator resigned on 8/03/23, Administrator #2 was hired on 10/20/23 and resigned on 12/06/23, with the alternate Administrator being appointed at that time. The Alternate Administrator was identified through the agency document review, and staff interview, as the full time Administrator/SCS of another home health agency in the state, during the same time period. Review of the appointment documents for the alternate Administrator, and the agency scheduling timeline for the agency’s Regional support staff members, assigned to the agency staff, on 5/20/24 at 12:22 PM, with the Regional Vice President of Operations/RN #1, identified that the agency alternate Administrator was available remotely to the home health agency staff from 7/6/23 through 4/5/24, and was also serving in the role of Supervisor of Clinical Services/SCS, with support by the Regional Registered Nurses and Occupational Therapists from 8/04/23 through 5/10/24, and further identified the Regional support staff was only available remotely to the agency staff from 4/08/24 through 4/19/24, 4/23/24, 4/24/24 and 4/30/24 through 5/03/24, until the new SCS resigned on 2/09/24. The agency failed to ensure an Administrator and SCS were available onsite and on a consistent basis to the HHA staff, patient and representatives. Review of agency policy for the agency Administrator position directed, responsible for all day-to-day operations of the provider and supervision of the provider staff, ensures that the Clinical and/or Executive Director is available during all operating hours or directly provides coverage for those duties, must be immediately available on-site during business hours, or immediately available by telephone when offsite conducting agency business, supervises and ensures high quality patient care services throughout the episode of care, and oversees all survey readiness activities.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on review of agency documentation and interview with the agency personnel, the agency failed to ensure an alternate administrator was available for all day-to-day operations of the Home Health Agency/HHA and actively involved in the daily responsibilities of running the HHA. The findings include: During the entrance conference on 5/14/24 at 9:15 AM with the Administrator, s/he indicated being newly hired as of 5/06/24 and the Supervisor of Clinical Services/SCS first day was 5/14/24. Further review of the agency documentation identified, the former Administrator resigned on 8/03/23, the alternate Administrator appointed, was identified as the present fulltime Administrator/SCS of another home health agency in the state of Connecticut. Review of the appointment documentation for the alternate Administrator, and review of the agency timeline of the regional supportive staff available to the agency staff, on 5/20/24 at 12:22 PM with the Regional Vice President of Operations/RN #1, identified that the agency alternate Administrator was available remotely to staff from 7/6/23 through 4/5/24 (until terminated, from the other home health agency). The Regional Vice President of Operations.RN#1 also indicated that it was a salaried position and s/he did not have any further information, nor could s/he determine how many days the alternate Administrator was physically present in the agency.”