Advanced Home Health Care Agency, Inc.

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observations, clinical record review and staff interviews, for one of eleven patients reviewed (Patient #1), the agency failed to ensure a review of the patients medication profile, and an assessment of medication compliance and understanding of there use during a skilled nursing visit. The findings include: Patient #1 had a start of care date of 06/06/2025 with diagnoses including bipolar disorder, paranoid schizophrenia, depression, type II diabetes, asthma and legal blindness. The physician’s orders for the certification period 04/02/2026 through 05/31/2026 included nursing services five (5) days per week for general and psychiatric health assessments, daily morning medication administration due to a history of medication noncompliance, and pre-pouring of afternoon, bedtime and weekend medications to support self-administration. The plan of care also required ongoing instruction, education and reinforcement regarding medication compliance. Review of Patient #1’s medication profile dated 04/10/2026, identified physician’s orders for Acetaminophen 650 milligrams (mg) by mouth every six (6) hours as needed for pain, Albuterol Ventolin 90 mcg/inhaler two (2) inhalations every six (6) hours as needed for shortness of breath/wheezing and Docusate Sodium 50 mg capsule one (1) capsule by mouth once a day as needed for constipation. During the home care visit with Registered Nurse (RN) #1 on 04/27/2026 at 09:45 AM, the surveyor observed the nurse administer the Patients’ morning medications, and pre-pour the afternoon and bedtime medications into a standard medication box. RN #1 did not review the patient’s’ medications, or provide reinforcement on education regarding the prescribed routine and “as needed” medications’ purpose, proper use, frequency, last used and response. Interview with the Administrator on 04/28/2026 at 11:30 AM, indicated the agency staff are expected to review the patient’s medication, and document at every visit. The Administrator indicated RN #1 had not completed an assessment of the patient’s medication compliance, or complete ongoing patient education and reinforcement of all prescribed medications, per the physician ordered plan of care, and agency policy. Review of the agency’s Monitoring and Instructions of Medications policy identified all medications ordered by the patient’s physician should be monitored for their effectiveness and recorded in the clinical record. Over the counter drugs which the patient takes must be noted in the patient’s clinical record. Agency staff shall check all medications that patients may be taking to identify possible ineffective drug therapy or adverse reactions, side effects, and compliance.”

“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 clinical records, agency documentation, surveyor observations and staff interviews, for two of two patients reviewed (Patient #1 and 2), the agency failed to ensure completion and documentation of the patient/caregiver education and reinforcement for the use of prescribed medications and a pressure relief device. The findings include: Patient #1 had a start of care date of 06/06/2025 with diagnoses of bipolar disorder, paranoid schizophrenia, depression, type II diabetes, asthma and legal blindness. The physician’s orders for the certification period 04/02/2026 through 05/31/2026 included nursing services five (5) days per week for general and psychiatric health assessments, daily morning medication administration due to a history of medication noncompliance, and pre-pouring of afternoon, bedtime, and weekend medications to support self-administration. The plan of care also required ongoing instruction, education, and reinforcement regarding medication compliance. Review of Patient #1’s medication profile dated 04/10/2026, identified physician orders for Acetaminophen 650 milligrams (mg) by mouth every six (6) hours as needed for pain, Albuterol Ventolin 90 mcg/inhaler two (2) inhalations every six (6) hours as needed for shortness of breath/wheezing and Docusate Sodium 50 mg capsule one (1) capsule by mouth once a day as needed for constipation. During a home care visit with Registered Nurse (RN) #1 on 04/27/2026 at 09:45 AM, the surveyor observed the nurse administer the morning medications to the patient and pre-pour the afternoon and bedtime medications into a standard medication box. RN #1 did not review or assess the patient’s understanding of the routine and “as needed” medications proper use, purpose, frequency, last dose taken, patient’s response and compliance with the medication, or any adverse effects or effectiveness. Interview with the Administrator on 04/28/2026 at 11:30 AM, indicated the clinical staff should complete a medication review at every visit, per the agency policy on Medication Management. Review of the agency’s Medication Management policy identified the purpose of the policy was to reduce errors and improve quality of care and promote safety throughout the home care program. Medications in the home are reviewed with the patient/family to determine current medications and patient understanding of the medication’s actions and side effects. Specific instructions for how and when to take the medications will be reviewed and documented. Patient #2 had a start of care date of 12/31/25 and diagnoses that included stage II pressure ulcer of the sacrum, type II diabetes mellitus and dementia. The physician’s orders for the certification period of 3/01/26 to 4/29/26 included nursing services two to three times a week for weekly pre-pouring of medications, wound care to the posterior lower back three times a week and teaching interventions to reduce pressure on areas at risk for skin breakdown and use of pressure-relieving devices. During a joint home visit with Registered Nurse/RN #4 on 4/27/26 at 12:30 PM, the surveyor observed the patient standing up from the electric recliner chair for wound care to the lower back. On the seat of the recliner chair, a round “donut” cushion was present. After wound care, the RN lowered the patient’s brief to observe the buttock area. At this time, the surveyor observed an approximate 3 centimeter/cm x 3 cm scabbed area on the left lower buttock and redness to the lower right buttock. RN #4 applied barrier cream to both buttocks and replaced the brief. Subsequent interview with the RN indicated that the “donut” cushion was purchased by the Conservator and it is what the patient likes to sit on for buttock pain relief. Review of RN #4’s nursing note dated 3/20/26 identified that she placed barrier cream on the left buttock due to a dried scab, and the right inner buttock due to redness. The note indicated the patient wanted a new “neck pillow” to place under his/her buttocks to alleviate pressure. The Conservator was notified and indicated s/he would order a “donut pillow” for the patient for comfort. Interview on 4/28/26 at 11:40 AM with the agency Wound Consultant, RN #2, indicated that if the patient is sitting/sleeping in the electric recliner chair, s/he should have a pressure relieving/reducing device, but the patient refused it. Interview on 4/28/26 at 11:55 AM with the Registered Physical Therapist/RPT indicated an evaluation was completed in January 2026, and the patient was more ambulatory at that time. RPT indicated that a “donut” pillow would not be an appropriate pressure relief device for a healed pressure ulcer on the patient’s buttocks. Interview and review of the home visit and clinical record with the Administrator and Supervisor of Clinical Services/SCS on 4/27/26 at 2 PM and at 4/28/26 at 12 PM, indicated that it was the patient’s choice to have that “donut’ cushion to sit on, and there were no open areas on the buttocks identified. The Administrator and SCS did not indicate any patient teaching, or documentation in the clinical records for alternate and appropriate pressure relief cushions to use, for the relief of pressure injuries and skin breakdown. There was no policy to review for pressure relieving/reducing devices in response to wound management.”

“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 policies and interview with agency personnel, for two of two patients (Patient #5 and #9) who required nursing services, the agency failed to follow the physician ordered plan of care. The findings include: Patient #5 had a start of care date of 10/5/2017 with diagnosis that included Major Depressive Disorder, recurrent with severe psychotic symptoms, Alcohol Dependency, chronic pain, anxiety disorder, vitamin B deficiency, Hypercholestrolemia, vitamin D deficiency, Gastro-esophageal reflux disease, Type 2 Diabetes Mellitus, pruritis. The physician’s orders for the certification period dated 11/3/2023 to 1/1/2024 included nursing services Review of the nursing clinical notes dated 11/3/2023 and 11/13/2023, identified that patient # 5 cancelled the skilled nursing visit scheduled on those dates, but failed to identify any communication with patient’s physician related to the cancelled/missed visits. Patient #9 had a start of care date of 04/25/2023 with diagnosis that included high blood pressure, acid reflux and bipolar disorder. The physician’s orders for the certification period of 04/25/2023 to 06/23/2023 included nursing services eight (8) to ten (10) times per week for one (1) week and twelve (12) to fourteen (14) times per week for eight (8) weeks for assessments and twice per day medication administration. Review of a physician’s interim order dated 05/12/2023, identified Patient #9’s visit frequency was reduced to twice (2) per week for six (6) weeks starting 05/14/2023. Review of Patient #9’s clinical nurses’ notes from 04/25/2023 to 06/05/2023, identified the Patient declined skilled nursing visits on 05/06/2023, 05/08/2023, 05/09/2023, 05/10/2023, 05/11/2023, and 05/12/2023 but failed to identify the Patient’s physician was notified of the missed visits until 05/12/2023. Interview and review of Patient #5 and #9’s clinical records with the Supervisor of Clinical Services (SCS) on 11/29/2023 at 11:45 AM, failed to identify the Patients’ physicians were notified of missed visits which resulted in a change in the visit frequency from the physician ordered plan of care.”

“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 clinical record reviews, review of agency policies and interview with agency personnel, for two of two patients (Patient #5 and #9) who required nursing services, the agency failed to coordinate care with the patients’ physicians. The findings include: Patient #5 had a start of care date of 10/5/2017 with diagnosis that included Major Depressive Disorder, recurrent with severe psychotic symptoms, Alcohol Dependency, chronic pain, anxiety disorder, vitamin B deficiency, Hypercholesterolemia, Vitamin D deficiency, Gastro-esophageal reflux disease, Type 2 Diabetes Mellitus, pruritic. The physicians orders for certification period 6/20/23 to 8/18/23 included nursing services one (1) to two (2) times per week for four (4) weeks and one (1) time a week for five (5) weeks for reality orientation, skilled nursing assessments for Vital signs every week and as needed, Medication compliance, Assessment of Agitation, Depression, Psychosis, Substance Abuse Behaviors, Social Isolation/Withdrawal, Anxiety, and skilled assessment for Suicidal behaviors. Review of the nursing clinical notes dated 11/3/2023 and 11/13/2023, identified that patient # 5 cancelled the skilled nursing visit scheduled on those dates, but failed to identify any communication with patient’s physician related to the cancelled/missed visits. Patient #9 had a start of care date of 04/25/2023 with diagnosis that included high blood pressure, acid reflux and bipolar disorder. The physician’s orders for the certification period of 04/25/2023 to 06/23/2023 included nursing services eight (8) to ten (10) times per week for one (1) week and twelve (12) to fourteen (14) times per week for eight (8) weeks for assessments and twice per day medication administration. Review of a physician’s interim order dated 05/12/2023, identified Patient #9’s visit frequency was reduced to twice (2) per week for six (6) weeks starting 05/14/2023. Review of Patient #9’s clinical nurses’ notes from 04/25/2023 to 06/05/2023, identified the Patient declined skilled nursing visits on 05/06/2023, 05/08/2023, 05/09/2023, 05/10/2023, 05/11/2023, and 05/12/2023 but failed to identify the Patient’s physician was notified of the missed visits until 05/12/2023. Interview and review of Patient #5 and #9’s clinical records with the Supervisor of Clinical Services (SCS) on 11/29/2023 at 11:45 AM, failed to identify the Patients’ physicians were notified of missed visits which resulted in a change in the visit frequency from the physician ordered plan of care. Review of the agency’s policy for Missed Visits, identified if a skilled nursing visit is missed, the nurse must notify the physician that the patient missed a scheduled visit, and document the information on the Missed Visit report, including who was notified.”