Family Care Visiting Nurse & Home Care Agency, LLC

“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 a review of agency documentation and staff interviews, for two of seventeen patient’s (Patient #13 and #16) in the survey sample, the agency failed to provide the home health aide services and/or failed to ensure complete documentation in the patient’s clinical record. The findings include: Patient #13 had a start of care date of 9/05/25 and diagnoses that included congestive heart failure and atrial fibrillation. The physician’s orders dated 9/05/25 included nursing services once weekly for assessments, home health aide services not to exceed (14) fourteen hours weekly and physical therapy services. Review of the Intake information dated 8/31/25 identified nursing, home health aide services and physical therapy were requested. Interview and review of the physician’s orders dated 9/05/25 with the Administrator on 11/20/25 at 11 AM identified that home health aide services were ordered although they were not covered by insurance but failed to identify documentation in the clinical record. Subsequent to surveyor inquiry, a change order dated 9/09/25 but facsimiled on 11/19/25 and signed by the physician on 11/19/25 discontinuing the home health aide services was provided. a. Patient #16 had a start of care date of 05/17/2025 with diagnoses that included opened wound to the left lower leg, dog bite, chronic kidney disease and hypertension. The physician’s orders for the certification period of 07/16/2025 through 09/13/2025 included nursing services three times per week for wound care and nursing assessments. Review of Patient #16’s clinical record identified missed nursing visits for the dates of 07/30/2025 and 08/01/2025 but failed to provide a reason for the missed visits and whether rescheduling was attempted. i. Interview with the Administrator on 11/20/2025 at 12:40 PM, identified the home health agency’s expectation was for the clinicians to document the reason for the missed visit, attempts at rescheduling the visit, notification of the Supervisor of Clinical Services and the patient’s physician. Review of the agency’s Not Home/Not Found policy, identified all attempts would be made to visit the patient and/or make contact with the patient, if the visit is missed the clinician would document the reason for the missed visit in the patient’s clinical record, notify the Supervisor of Clinical Services and the patient’s physician.”

“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 a review of agency documentation and staff interviews, for two of five patients (Patient #5 and #9), who were reviewed for medication management, the agency licensed personnel failed to follow agency policies for medication reconciliation and pre-pouring. The findings include: Patient #5 had a start of care date of 8/24/22 and diagnoses that included schizoaffective disorder, traumatic brain injury and chronic pain syndrome. The physician’s orders for the certification period of 10/15/25 through 12/13/25 included nursing services weekly for the pre-pouring of medications and assessments. Physician’s orders included, in part, Bupropion 150 milligrams (mg)/12 hours Sustained Release daily, Gabapentin 300 mg, 2 capsules (600 mg) four times daily and Morphine 30 mg/8 to 12-hour tablet Extended Release daily. During a joint home visit for medication pre-pouring using an electronic medication planner with RN #1 and the Supervisor of Clinical Services/SCS on 11/17/25 at 1:50 PM, the surveyor observed the pre-pouring of two of the patient’s medications without the benefit of the electronic medication profile and/or a paper medication profile. Subsequent to surveyor inquiry, RN #1 opened his tablet and accessed the electronic medication profile. Additionally, the surveyor observed the pre-pouring of Bupropion 200 mg Sustained Release in the morning souffle cup daily, Gabapentin 400 mg four times daily and Morphine Extended Release in the morning and bedtime souffle cup. Interview with RN #1 identified that the patient had medication changes on the physician visit dated 11/11/25, therefore, the medication dosages were changed. Review of the physician’s visit documentation identified that Bupropion 150 milligrams (mg)/12 hours Sustained Release daily, Gabapentin 300 mg, 2 capsules (600 mg) four times daily were identified on the visit information and Morphine 30 mg/8 to 12-hour tablet Extended Release every 12 hours was indicated. Interview and review of the home visit with the Administrator and SCS on 11/18/25 at 12 PM identified RN #1 failed to follow agency policies for medication pre-pouring consistent with the most recent medication profile and reconciling medications clarifying any discrepancies with the physician/pharmacy. Review of agency policies for Medication Administration directed that all pre-poured medications shall be consistent with the most recent Medication Profile. Review of agency policies for Medication Reconciliation directed to contact the physician/pharmacy to verify the patient’s current medications and clarify any discrepancies in medications. Patient #9 had a start of care date of 01/10/2024 with diagnoses that included congestive heart failure, essential hypertension, type II diabetes and opioid dependence. The physician’s orders for the certification period of 10/31/2025 through 12/28/2025 included nursing services weekly for pre-pouring medications and assessments. Review of the nursing visits dated 11/14/2025, 11/11/2025 and 11/18/2025, identified Patient #9’s medications were pre-poured for one week but failed to identify the to and from dates for the weekly pre-pour. Interview with the Administrator on 11/20/2025 at 12:40 PM, identified the home health agency’s expectation was to document the to and from dates of each weekly pre-pour.”

“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 a review of clinical records, agency documentation and staff interviews for two of seventeen patients (Patient #10 & 13) in the survey sample, the agency failed to ensure accuracy and authenticity of the agency documentation. The findings include: a. Patient #10 had a start of care date of 03/09/2017 with diagnoses of type II diabetes, morbid obesity, congestive heart failure and legal blindness. The physician’s orders for the certification period of 09/24/2025 to 11/22/2025 included once per week for nursing assessments for blood glucose, weight, lower extremity and abdominal circumference monitoring and insulin administration. Additionally, nursing staff was to teach the Patient to weigh self daily, assess for shortness of breath, obtain the instep, ankle and calf measurements at each visit as apart of the home health agency’s congestive heart failure protocol. Review of Patient #10’s certification periods of 01/27/2025 to 03/27/2025, 03/28/2025 to 05/26/2025, 05/27/2025 to 07/25/2025, 07/26/2025 to 09/23/2025 and 09/24/2025 to 11/22/2025 failed to identify the Patient’s weights, lower extremities and abdominal circumferences were monitored. Subsequent to the surveyor’s inquiry, the Patient’s weights, lower extremity and abdominal circumferences documentation was added in the Patient’s record on 11/18/2025 for the following nursing visits dated 08/08/2025, 08/15/2025, 08/22/2025, 08/29/2025, 09/05/2025, 09/12/2025, 09/26/2025, 10/03/2025, 10/10/2025, 10/17/2025, 10/24/2025, 10/31/2025 and 11/14/2025. i. Interview and review of the clinical record with the Administrator on 11/20/2025 at 12:40 PM, failed to identify Patient #10’s weights, lower extremity and abdominal circumferences were documented in the Patient’s record at the time of skilled nursing visits dated 08/08/2025, 08/15/2025, 08/22/2025, 08/29/2025, 09/05/2025, 09/12/2025, 09/26/2025, 10/03/2025, 10/10/2025, 10/17/2025, 10/24/2025, 10/31/2025 and 11/14/2025 and were subsequently added in the Patient’s record on 11/18/2025. Patient #13 had a start of care date of 9/05/25 and diagnoses that included congestive heart failure and atrial fibrillation. The physician’s orders dated 9/05/25 included nursing services once weekly for assessments, home health aide services not to exceed (14) fourteen hours weekly and physical therapy services. Review of the Intake information dated 8/31/25 identified nursing, home health aide services and physical therapy were requested. i. Interview and review of the physician’s orders dated 9/05/25 with the Administrator on 11/20/25 at 11 AM identified that home health aide services were ordered although they were not covered by insurance but failed to identify documentation in the clinical record. Subsequent to surveyor inquiry, a change order dated 9/09/25 but facsimiled on 11/19/25 and signed by the physician on 11/19/25 discontinuing the home health aide services was provided. Review of the clinical record from 9/05/25 to 9/26/25 identified a missed visit due to a medical appointment documented by the nurse on 9/11/25. ii. Interview and review of the clinical record with the Administrator on 11/20/25 at 12:55 PM failed to identify attempts to visit the patient on 9/12/25 or 9/13/25 (within the same Medicare week) in order to meet the nursing frequency of once weekly. Review of the clinical record from 9/05/25 to 9/26/25 identified a missed visit documented by the nurse on 9/25/25 with an attempt to reschedule on 9/26/25. iii. Interview and review of the clinical record with the Administrator on 11/20/25 at 12:55 PM failed to identify physician notification of the missed visit. Subsequent to surveyor inquiry, documentation from the Administrator dated 11/18/25 identified an order was created for the missed visit notification to the physician.”

“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 a review of agency documentation and staff interviews, for four of eleven patients (Patient’s # 6, 10, 13 & 15) requiring blood glucose and/or weight monitoring for a diagnosis of type II diabetes mellitus and congestive heart failure, 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: a. Patient #6 had a start of care date of 06/08/2025 with diagnoses that included Di George’s syndrome and spastic cerebral palsy. The physician’s orders for the certification period of 10/04/2025 and 12/02/2025 included nursing services once per week for nursing assessments, monitoring the Patient’s weight for stability and occupational therapy once per week. Patient #6 had a gastrostomy tube, received formula via the tube overnight and was able to eat by mouth during the day. Additionally, the Patient was non-ambulatory and wheelchair bound. Review of Patient #6’s nursing visits for 10/11/2025, 10/17/2025, 10/25/2025, 11/01/2025, 11/08/2025 and 11/10/2025 failed to identify the nurses monitored the Patient’s weight for stability such as measuring the Patient’s arm and/or thigh circumference. b. Patient #10 had a start of care date of 03/09/2017 with diagnoses of type II diabetes, morbid obesity, congestive heart failure and legal blindness. The physician’s orders for the certification period of 09/24/2025 to 11/22/2025 included once per week for nursing assessments for blood glucose, weight, lower extremity and abdominal circumference monitoring and insulin administration. Additionally, nursing staff was to teach the Patient to weigh self daily, assess for shortness of breath, obtain the instep, ankle and calf measurements at each visit as apart of the home health agency’s congestive heart failure protocol. Review of Patient #10’s certification periods of 01/27/2025 to 03/27/2025, 03/28/2025 to 05/26/2025, 05/27/2025 to 07/25/2025, 07/26/2025 to 09/23/2025 and 09/24/2025 to 11/22/2025 failed to identify the Patient’s weights, lower extremities and abdominal circumferences were monitored. Subsequent to the surveyor’s inquiry, the Patient’s weights, lower extremity and abdominal circumferences were documented in the Patient’s record on 11/18/2025 for the following nursing visits dated 08/08/2025, 08/15/2025, 08/22/2025, 08/29/2025, 09/05/2025, 09/12/2025, 09/26/2025, 10/03/2025, 10/10/2025, 10/17/2025, 10/24/2025, 10/31/2025 and 11/14/2025. c. Patient #15 had a start of care date of 10/03/2025 with diagnoses of chronic kidney disease, morbid obesity, type II diabetes and heart failure. The physician’s orders for the certification period of 10/03/2025 to 12/01/2025 included once per week for nursing assessments which included weight and edema monitoring and physical therapy twice per week. Review of Patient #15’s nursing notes dated 10/07/2025, 10/15/2025 and 10/22/2025 failed to identify the Patient’s weights were monitored and the Patient’s care plan failed to include assessment of and interventions for monitoring type II diabetes monitoring, therefore, blood glucoses were not monitored on 10/07/2025, 10/15/2025 and 10/22/2025. i. Interview and review of the clinical record with the Administrator on 11/20/2025 at 12:30 PM, identified the nurses should have documented the Patient’s blood glucose levels, weights and /or measurements for each visit, therefore, failing to follow physician’s orders. Additionally the Administrator, failed to identify Patient #15’s care plan included assessment of and interventions to address the Patient’s penitent diagnosis of type II diabetes. Patient #13 had a start of care date of 9/05/25 and diagnoses that included congestive heart failure and atrial fibrillation. The physician’s orders dated 9/05/25 included nursing services once weekly for assessments, home health aide services not to exceed (14) fourteen hours weekly and physical therapy services. Review of the physician’s certified care plan lacked documentation of the need for weight monitoring and parameters for reporting abnormal findings to the physician i. Interview and review of the plan of care dated 9/05/25 with the Administrator on 11/20/25 at 12:50 PM failed to identify communication with the physician for the frequency of weight monitoring and parameters for reporting abnormal findings to the physician. Review of the clinical record from 9/05/25 to 9/26/25 identified a missed visit due to a medical appointment documented by the nurse on 9/11/25. ii. Interview and review of the clinical record with the Administrator on 11/20/25 at 12:55 PM failed to identify attempts to visit the patient on 9/12/25 or 9/13/25 (within the same Medicare week) in order to meet the nursing frequency of once weekly. Review of the clinical record from 9/05/25 to 9/26/25 identified a missed visit documented by the nurse on 9/25/25 with an attempt to reschedule on 9/26/25. iii. Interview and review of the clinical record with the Administrator on 11/20/25 at 12:55 PM failed to identify physician notification of the missed visit. Subsequent to surveyor inquiry, documentation from the Administrator dated 11/18/25 identified an order was created for the missed visit notification to the physician. Review of the agency policy for Comprehensive Patient Assessment directed the individualized plan of care must include types of services, all medications and treatments.”

“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 a review of agency documentation and staff interviews, for one of one patient (Patient #14) who was reviewed for intravenous therapy, the agency failed to ensure completion of a comprehensive Memorandum of Understanding/MOU to delineate the nursing responsibilities between the agencies. The findings include: Patient #14 had a start of care date of 4/03/25 and diagnoses that included type II diabetes mellitus, open wound on the left foot and osteomyelitis. The physician’s orders dated 4/03/25 included nursing services twice weekly for general assessments and wound care to the left foot and nursing services weekly from Agency #2 Registered Nurse/RN #2 for Peripherally Inserted Central Catheter/PICC line dressing changes weekly and intravenous/IV medication management. Physician’s orders included Vancomycin 1.5 grams intravenously daily via the PICC line. Review of the Agency #2 nursing notes dated 4/03/25 and 4/10/25 identified weekly dressing changes to the PICC line and lab work drawing rom the left upper arm PICC line. On 4/16/25, Agency #2’s RN #2 identified that the PICC line was removed. Review of the MOU dated 4/03/25 lacked documentation of the services to be provided by Agency #2 including the weekly PICC line dressing change and the lab work to be obtained. Interview and review of the clinical record with the Administrator on 11/19/25 at 1 PM failed to identify a comprehensive MOU between the two agencies to delineate nursing responsibilities for care and treatment of the PICC line. Review of agency policies for Memo of Understanding directed the purpose is to identify the responsibilities and tasks of both parties who provide care to the home care patient and to confirm the documentation that the secondary provider will provide to the home care patient.”

“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 a review of agency documentation, staff interviews and review of an agency policy, for three of three patient (Patient #6, #10 and #15) in the survey sample, the agency nurses failed to perform the necessary nursing assessments. The findings include: a. Patient #6 had a start of care date of 06/08/2025 with diagnoses that included Di George’s syndrome and spastic cerebral palsy. The physician’s orders for the certification period of 10/04/2025 and 12/02/2025 included nursing services once per week for nursing assessments, monitoring the Patient’s weight for stability and occupational therapy once per week. Patient #6 had a gastrostomy tube, received formula via the tube overnight and was able to eat by mouth during the day. Additionally, the Patient was non-ambulatory and wheelchair bound. Review of Patient #6’s nursing visits for 10/11/2025, 10/17/2025, 10/25/2025, 11/01/2025, 11/08/2025 and 11/10/2025 failed to identify the nurses monitored the Patient’s weight for stability, and/or utilized assessments such as measuring the Patient’s arm and/or thigh circumference. b. Patient #10 had a start of care date of 03/09/2017 with diagnoses of type II diabetes, morbid obesity, congestive heart failure and legal blindness. The physician’s orders for the certification period of 09/24/2025 to 11/22/2025 included once per week for nursing assessments for blood glucose, weight, lower extremity and abdominal circumference monitoring and insulin administration. Additionally, nursing staff was to teach the Patient to weigh self daily, assess for shortness of breath, obtain the instep, ankle and calf measurements at each visit as a part of the home health agency’s congestive heart failure protocol. Review of Patient #10’s certification periods of 01/27/2025 to 03/27/2025, 03/28/2025 to 05/26/2025, 05/27/2025 to 07/25/2025, 07/26/2025 to 09/23/2025 and 09/24/2025 to 11/22/2025 failed to identify the Patient’s weights, lower extremities and abdominal circumferences were monitored. Subsequent to the surveyor’s inquiry, the Patient’s weights, lower extremity and abdominal circumferences were documented in the Patient’s record on 11/18/2025 for the following nursing visits dated 08/08/2025, 08/15/2025, 08/22/2025, 08/29/2025, 09/05/2025, 09/12/2025, 09/26/2025, 10/03/2025, 10/10/2025, 10/17/2025, 10/24/2025, 10/31/2025 and 11/14/2025. c. Patient #15 had a start of care date of 10/03/2025 with diagnoses of chronic kidney disease, morbid obesity, type II diabetes and heart failure. The physician’s orders for the certification period of 10/03/2025 to 12/01/2025 included once per week for nursing assessments which included weight and edema monitoring and physical therapy twice per week. Review of Patient #15’s nursing notes dated 10/07/2025, 10/15/2025 and 10/22/2025 failed to identify the Patient’s weights were monitored and the Patient’s care plan failed to include assessment of and interventions for monitoring type II diabetes monitoring, therefore, blood glucoses were not monitored on 10/07/2025, 10/15/2025 and 10/22/2025. Interview and review of the clinical record with the Administrator on 11/20/2025 at 12:30 PM, identified the nurses should have documented the Patient’s blood glucose levels, weights and /or measurements for each visit, therefore, failing to perform all necessary assessments. Additionally, the Administrator, failed to identify Patient #15’s care plan included assessment of and interventions to address the Patient’s pertinent diagnosis of type II diabetes. Review of the agency Comprehensive Patient Assessment by RN or OT identifies in part, to determine the appropriate care, treatment and services to meet patient initial needs and his/her changing needs. To collect data about the patient’s health history, (physical, functional and psychological) and their needs as appropriate to the home care setting. To make care, treatment or service decisions based on information developed about each patient’s needs and the individuals’ response to care. facilitating factors and possible barriers to patient reaching his or her goals including presenting problems. The depth and frequency of ongoing assessments will depend on patient needs, goals, and the care treatment and services provided, but will be done at least once in every sixty (60) day period.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on a review of agency documentation and staff interviews, for one of five patients (Patient #5), who were reviewed for medication management, the agency licensed personnel failed to communicate medication discrepancies with the physician prior to medication pre-pouring. The findings include: Patient #5 had a start of care date of 8/24/22 and diagnoses that included schizoaffective disorder, traumatic brain injury and chronic pain syndrome. The physician’s orders for the certification period of 10/15/25 through 12/13/25 included nursing services weekly for the pre-pouring of medications and assessments. Physician’s orders included, in part, Bupropion 150 milligrams (mg)/12 hours Sustained Release daily, Gabapentin 300 mg, 2 capsules (600 mg) four times daily and Morphine 30 mg/8 to 12-hour tablet Extended Release daily. During a joint home visit for medication pre-pouring into an electronic medication planner with RN #1 and the Supervisor of Clinical Services/SCS on 11/17/25 at 1:50 PM, the surveyor observed the pre-pouring of two of the patient’s medications without the benefit of the electronic medication profile and/or a paper medication profile. Subsequent to surveyor inquiry, RN #1 opened his tablet and accessed the electronic medication profile. Additionally, the surveyor observed the pre-pouring of Bupropion 200 mg Sustained Release (order reads 150 mg) in the morning souffle cup daily, Gabapentin 400 mg (order reads 300 mg/2 capsules) four times daily and Morphine Extended Release 30 mg (order reads daily) in the morning and bedtime souffle cup. Interview with RN #1 identified that the patient had medication changes on the physician visit dated 11/11/25, therefore, the medication dosages were changed. Review of the physician’s visit documentation dated 11/11/25, identified that Bupropion 150 milligrams (mg)/12 hours Sustained Release daily, Gabapentin 300 mg, 2 capsules (600 mg) four times daily were identified on the visit information and Morphine 30 mg/8 to 12-hour tablet Extended Release every 12 hours was indicated. Interview and review of the home visit with the Administrator and SCS on 11/18/25 at 12 PM identified RN #1 failed to follow agency policies for reconciling medications, and failed to identify the clarification of medication discrepancies with the physician/pharmacy prior to pre-pouring. Review of agency policies for Medication Reconciliation directed to contact the physician/pharmacy to verify the patient’s current medications and clarify any discrepancies in medications.”

“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 clinical record reviews, review of agency documentation, interviews with agency staff and review of the agency’s policies and procedures for one of two patients (Patient #2) in the survey sample. The agency failed to follow a physician’s orders to ensure a patient’s needs were met. The findings include: Patient #2 had a start of care date of 02/23/2022 with diagnoses that included autistic disorder, generalized anxiety disorder, eczema and allergic rhinitis. The physician’s orders for the certification period of 02/07/2025 to 04/07/2025 included nursing services one to two times per week for ten weeks for nursing assessments, assisting the Patient with pre-filling a medication box and ensuring medication compliance. Additionally, Patient #2 received Home Health Aide services twenty-eight hours per week for ten weeks to assist with personal care and homemaking. Interview with the Supervisor of Clinical Services (SCS)#1 on 02/27/2025 at 1:30 PM, identified Patient #2 had a Home Health Aide scheduled for 02/22/2025 and 02/23/2025, but the Home Health Aide that was schedule for 02/22/2025 and 02/23/2025 called out sick. Patient #2’s responsible person notified the Home Health Agency’s answering service on 02/23/2025 that the Patient had not received Home Health Aide services. SCS #1 identified the Home Health Agency failed to provide Patient #2 with a Home Health Aide on 02/22/2025 and 02/23/2025 to ensure the Patient’s needs were met in accordance with the physician’s ordered plan of care.”

“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 documentation, interviews with agency staff and review of the agency’s policies and procedures for one of two patients (Patient #1) in the survey sample. The Home Health Agency clinicians failed to practice according to the Home Health Agency’s expectation and policy and procedure. The findings include: a. Patient #1 had a start of care date of 06/05/2021 with diagnoses that included hypertension, type two diabetes, moderate intellectual disabilities, attention-deficit disorder, and fetal alcohol syndrome. The physician’s orders for the certification period of 01/15/2025 to 03/15/2025 included nursing services for the administration of Lantus 100 units/milliliters (ml) (80 units) of insulin every morning for ten weeks. Review of the Home Health Agency’s investigation dated 02/11/2025 identified on the morning of 02/08/2025, Licensed Practical Nurse (LPN) #1 administered Lantus insulin 80 units to Patient #1’s right arm. During the administration of the insulin the Patient moved his/her arm. LPN #1 identified removing the syringe from the Patient’s arm and observed the needle was missing. LPN #1 indicated palpating a small bump under the Patient’s skin, therefore, LPN #1 called 911 and the Patient was transported to the hospital. Patient #1 had an x-ray of the right arm which showed a small needle was present. The emergency department physician indicated a surgical intervention was not necessary and the Patient was discharged on 02/08/2025. Subsequent to the investigation, LPN #1 was removed from Patient #1’s case and provided with insulin administration re-education. Review of Patient #1’s nursing notes from 02/01/2025 to 02/26/2025, identified the Patient was administered Lantus insulin every morning, but failed to identify clinicians documented anatomical sites of where the insulin was administered. i. Interview with the Supervisor of Clinical Services (SCS)#1 on 02/27/2025 at 1:45 PM, failed to identify clinicians documented the anatomical sites of where the insulin was administered for the month of 02/2025. Review of the agency’s Medication Administration policy identified medication administration to patients by the Home Health Agency’s clinicians would be in compliance with all state and federal regulations.”