American Nurses

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement an effective discharge planning process for 2 of 4 patients reviewed for discharge in a total sample of 5 patients, (#4 and #5). Findings: 1. Review of the clinical record revealed patient #4 was admitted to the Home Health Agency on 9/12/25 with diagnoses including dementia and chronic pain. Review of the Home Health Plan of Care & Certification form for the certification period 5/09/26 through 7/07/26, including a verbal order dated 5/04/26, revealed the patient was recertified to continue receiving weekly skilled nursing visits for ongoing assessment and management of disease processes, medication monitoring, pain management, and patient/caregiver education. Review of the Discharge Detail Log dated 4/01/26 through 6/25/26 revealed patient #4 was discharged on 5/05/26. The discharge reason was documented as “unknown.” During a joint interview on 6/25/26 at 3:51 PM, the Director of Nursing (DON) and the Assistant of the Director of Nursing (ADON) reviewed the record. The ADON stated she did not know why the patient was discharged and confirmed patient #4 had been recertified on 5/04/26 to continue home health services for medication management. She stated the patient’s last skilled nursing visit occurred on 5/04/26 and repeatedly indicated she did not know what happened regarding the discharge. The DON stated she could only assume the nurse contacted either the patient or physician but was unable to provide documentation supporting those actions. The ADON confirmed the patient received home health services from 9/12/25 through 5/05/26 and verified there was no discharge summary, care coordination note, or documentation demonstrating discharge planning or communication with the physician, the patient, or the representative. She further confirmed the last skilled nursing visit note dated 5/04/26 contained no indication the patient was being discharged from the agency. During a telephone interview on 6/25/26 at 5:05 PM, patient #4’s family member stated the patient temporarily relocated to Tampa in June and had informed the agency nurse to place services on hold. The family member stated she had not heard from the agency afterward. Review of patient #4’s clinical record revealed no evidence the agency assessed the patient’s ongoing needs, coordinated discharge planning with the physician or patient’s representative, or implemented discharge process before terminating home health services. 2. Patient #5 was originally admitted to the agency on 7/29/25 and discharged on 3/28/26. The patient was readmitted on 4/22/26 with diagnoses including legal blindness and neuropathy. Review of patient #5’s Home Health Plan of Care & Certification form for the certification period 4/22/26 through 6/20/26 revealed physician orders for weekly skilled nursing visits for observation and assessment of medication compliance and response, disease management, supervisory visits, and home health aide services for 35 hours per week to assist with activities of daily living. The plan of care documented the physician had been notified of the admission and included a discharge plan indicating the patient would be discharged when goals were met, the patient returned to independent level of care, or the patient understood when to contact the physician or emergency services. During a joint interview on 6/25/26 at 4:07 PM, the ADON stated patient #5 was hospitalized on 3/29/26 during the first admission but the agency did not know the reason for the hospitalization. The DON stated the agency had not received information from the hospital regarding that admission. They indicated a new referral was received from the patient’s primary care physician on 4/20/26 and the patient was readmitted on 4/22/26. The ADON further stated patient #5 returned to the hospital on 5/20/26 due to low blood sugar and was discharged from their agency on 6/15/26 because the agency did not receive new physician orders following the hospital visit. The ADON confirmed there was no documentation showing the agency contacted the hospital, physician, patient, or representative to determine the patient status or obtain necessary information to resume services. The DON confirmed the patient’s last visit was provided by the home health aide on 5/20/26, the day the patient went to the hospital. During a telephone interview on 6/25/26 at 4:43 PM, patient #5 stated she still required home health services and had not been informed the agency was discharging her. On 6/25/26 at 4:51 PM, during a telephone interview, patient #5’s family member stated the patient was in the hospital less than 24 hours following an episode of low blood sugar after insulin administration. The family member stated she notified the agency when the patient returned home and was informed services could not resume without new physician orders. She indicated did not contact the hospital to obtain the necessary information, despite her requests, and patient remained without needed services. The family member further stated she contacted both the insurance provider and the patient’s physician in an effort to have services resumed. Review of patient #5’s clinical record revealed no evidence the agency coordinated discharge planning with the physician, patient, or patient’s representative, assessed the patient’s ongoing post-hospital needs, or implemented a planned discharge process before terminating home health services. Review of the agency’s Discharge and Transfer Policy, revised on 5/15/25, revealed the agency intended to maintain a structured process for ongoing assessment of each patient’s needs to ensure appropriate discharge planning and continuity of care. The policy required advance notice of transfer or discharge and instruction regarding ongoing care or treatment at the time of discharge. The policy further required presentation of a Notice of Medicare Non-Coverage to the patient or authorized representative at least two days before covered services ended. Review of the agency’s Discharge Summary and Outcome and Assessment Information Set (OASIS) Discharge Policy, revised 7/21/25, required every discharged patient, regardless of payer source, to have completed discharge summary documenting the reason for discharge, patient condition at discharge, services provided, medication reconciliation when applicable, patient/caregiver education, goals met or remaining needs, follow-up recommendations , and physician notification when appropriate.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on interview and record review, the agency failed to complete a comprehensive discharge comprehensive assessment, including the required Discharge Outcome and Assessment Information Set (OASIS), for OASIS-eligible patients upon agency discharge for 2 of 4 patients reviewed for discharges in a total sample of 5 patients, (#4 and #5). Findings: 1. Review of the medical record revealed patient #4 was admitted to the Home Health Agency on 9/12/25. Review of patient #4’s Home Health Plan of Care & Certification form for the certification period 5/09/26 through 7/07/26 revealed the patient was recertified to receive weekly Skilled Nursing (SN) visits for ongoing assessment and management of disease process, medication monitoring, pain management and patient and caregiver education. Review of the Discharge Detail Log for the period 4/01/26 through 6/25/26 revealed patient #4 was discharged on 5/05/26. The discharge reason was documented as “unknown.” Review of patient #4’s clinical record revealed no completed discharge OASIS assessment. 2. Patient #5 was originally admitted to the agency on 7/29/25 and discharged on 3/28/26. The patient was readmitted on 4/22/26 and discharged again on 6/15/26. Review of patient #5’s Home Health Plan of Care & Certification form for the certification period 4/22/26 through 6/20/26 revealed SN orders for observation and assessment of medication compliance and response, with visits once weekly for 8 weeks for disease management and supervisory visits. The plan also included home health aide (HHA) services for 35 hours per week to assist with activities of daily living. Review of patient #5’s clinical record revealed a discharge summary dated 6/15/26 documenting discharge to the hospital. Review of the Communication Log revealed an entry dated 5/20/26 documenting patient #5 was “hospitalized.” An additional entry dated 5/21/26 documented agency staff communicated with patient #5’s family member, who reported the patient was “improving and feeling much better.” The clinical record showed patient #5 was not seen by agency staff after the hospitalization. A Communication Log entry dated 6/24/26 documented that a discharge summary was sent to the physician. Review of patient #5’s clinical record revealed no completed discharge OASIS assessment for either the 3/28/26 discharge or the 6/15/26 discharge. On 6/25/26 at 4:07 PM, during a joint interview, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed a discharge OASIS assessment was not completed for patient #4 following the 5/05/26 discharge or for patient #5 following the 3/28/26 and 6/15/26 discharges. On 6/30/26 at 6:15 PM, the Alternate Administrator stated the agency completed discharge OASIS assessments in person only when authorization was received to visit the patient. She explained that if a patient was discharged without a visit, the nurse notified the patient of the discharge and completed only a discharge summary. Review of the agency’s OASIS Assessment Policy, revised 4/07/25, revealed the purpose to ensure all OASIS assessments were completed accurately and timely in accordance with CMS (Centers for Medicare) Conditions of Participation, Home Health Quality Reporting Program (HHQRP), and agency policy. Under the required OASIS time points, the policy included discharge and stated, “Completed when the patient is discharged from agency services.” Review of the agency’s Discharge Summary and OASIS Discharge Policy, revised 7/21/25, revealed the purpose was to ensure all patients were discharged with complete documentation in accordance with agency policy and Medicare regulations. The policy further stated that an OASIS Discharge assessment shall be completed for patients who required OASIS in accordance with current CMS guidelines.”

“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 interview and record review, the agency failed to complete and send a discharge summary to the physician or other practitioner responsible for the patient’s care within five business days of discharge for 2 of 4 patients reviewed for discharges in a total sample of 5 patients, (#4 and #5). Findings: 1. Review of the medical record revealed patient #4 was admitted to the Home Health Agency on 9/12/25. Review of patient #4’s Home Health Plan of Care & Certification form for the certification period 5/09/26 through 7/07/26 revealed the patient was recertified to receive weekly Skilled Nursing (SN) visits for ongoing assessment and management of disease process, medication monitoring, pain management and patient and caregiver education. Review of the Discharge Detail Log for the period 4/01/26 through 6/25/26 revealed patient #4 was discharged on 5/05/26. The discharge reason was documented as “unknown.” On 6/25/26 at 3:51 PM, during an interview with the Director of Nursing (DON) and the Assistant of the Director of Nursing (ADON), the ADON confirmed patient #4 was discharged from the agency on 5/05/26 but did not know the reason for the discharge. The ADON further confirmed a discharge summary was not completed and there was no coordination note documenting notification of the physician or the patient regarding the discharge. Review of patient #4’s clinical record revealed no discharge summary was completed or sent to the physician. 2. Patient #5 was originally admitted to the agency on 7/29/25 and discharged on 3/28/26. The patient was readmitted on 4/22/26 and discharged again on 6/15/26. Review of patient #5’s Home Health Plan of Care & Certification form for the certification period 4/22/26 through 6/20/26 revealed SN orders for observation and assessment of medication compliance and response, with visits once weekly for 8 weeks for disease management and supervisory visits. The plan also included home health aide services for 35 hours per week to assist with activities of daily living. Review of patient #5’s clinical record revealed a discharge summary dated 6/15/26 documenting discharge to the hospital. A Communication Log entry dated 6/24/26 documented the discharge summary was sent to patient #5’s physician; more than five days after the patient’s 6/15/26 discharge from the agency. Review of the agency’s Discharge Summary and Outcome and Assessment Information Set (OASIS) Discharge Policy, revised 7/21/25, revealed the purpose was to ensure all patients were discharged with complete documentation in accordance with agency policy and Medicare regulations. The policy indicated a discharge summary shall be completed for every patient discharged from the agency, regardless of payer source. The discharge documentation included: Reason for dischargePatient’s condition at dischargeServices providedMedication reconciliation, if applicablePatient/caregiver educationGoals met or remaining needsFollow-up recommendationsThe policy further stated the physician shall be notified of the patient’s discharge when appropriate.”

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on interview and record review, the agency failed to initiate and complete a timely investigation after receiving a report of alleged misappropriation of patient property for 1 out of 7 patients reviewed, (#4). Findings: On 9/03/25, the home health agency received a complaint from patient #4 reporting that perfume and other items were missing after an agency aide’s visit. A review of the agency records showed a document listing the complaint received which detailed that the aide was written up. There was no evidence the reported allegations were reported to the appropriate authorities as required. On 2/25/26, the Director of Nursing stated the allegation had been reported but acknowledged the agency did not complete a formal investigation, and no written investigation report was created to show the report was made. Review of the agency’s Admission records revealed the agency’s Bill of Rights and Patient responsibilities, a document given to each patient on admission, read “To be informed of the disposition of complaints as follows: contact the nursing supervisor to report complaints or dissatisfaction with care or services. The Agency Director is responsible for resolving grievances and implementing corrective measures and policy or service changes.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and record review, the facility failed to provide patient visits as ordered for 1 of 5 sampled records reviewed. (#1). Findings: Review of Patient #1’s medical record revealed she was oriented and started receiving care on 7/21/2023. Her diagnosis included immunodeficiency and lymphoma with functional limitations of ambulation. Patient #1’s most recent Plan of Care, 5/11/25 to 7/9/25, Home Health Aide(HHA) orders frequency and duration of 35 hours per week. On 8/5/25 at 2:17 PM, the Director of Nursing (DON) reviewed patient #1’s electronic schedule. The schedule failed to show any HHA visits after 4/25/25. The DON stated that no HHA name was on the schedule because we had no HHA that wanted to visit the patient’s home. The DON acknowledged the facility failed to provide care as ordered. She stated the intake department always calls the doctor to let them know of missed visits. The facility was unable to provide evidence of notification to the doctor of missed visits and care not provided. A review of the facility dated 1/20/2025 read, “Any missed visit must be reported, documented, and followed up promptly to minimize disruption in the patient’s plan of care and to comply with regulatory requirements.””

“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 and record review, the Home Health Agency failed to electronically transmit each completed OASIS assessment to the Center for Medicare and Medicaid Services (CMS) system within 30 days of completing the beneficiary assessment for 8.6% of 100 percent. A review of the Internet Quality Improvement and Evaluation System (iqies) Home Health Error Report Summary reflected the agency transmitted over 3000 records. The agency submitted records to CMS more than 30 days after completing the assessment. On 4/10/25 at 3:12 PM, the Administrator said he was responsible for transmitting Oasis assessments to CMS. He stated nurses take longer than they should to submit completed assessments. The Administrator stated he transmits Oasis to CMS every 2 weeks to ensure all are submitted. The transmission reports are checked to ensure that all assessments are processed. I transmit every 2 weeks, so I should not have a late record. A review of the policy and procedure manual did not reflect a policy for the timely transmission of Assessments.”

“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 observation, interview, and record review the agency failed to ensure that a nurse performed appropriate infection control techniques when providing wound care and disinfecting a blood pressure cuff and glucometer for 1 of 17 sampled patients (#1). Review of patient #1’s medical record revealed a start of care date of 12/23/24. On his plan of care with a certification period of 12/23/24 to 2/20/25 it indicated a principal diagnosis of unspecified open wound, left lower leg. During the home visit conducted on 4/8/25 at 10:35 AM, RN #A removed a blood pressure cuff from his nursing bag, wiped the blood pressure cuff with a non-disinfecting disposable wipe, and applied the blood pressure cuff to patient #1’s arm. RN #A returned the blood pressure cuff to his nurse bag without cleaning nor disinfecting the blood pressure cuff after removing it from patient #1’s arm. RN #A used scissors to cut the old dressing from patient #1’s left lower leg. Removal of the old dressing revealed there were multiple open wound areas which varied in length and width with superficial depths. RN #A used normal saline to clean patient #1’s left lower leg wounds, and the excess fluid dripped onto patient #1’s floor. RN #A did not do hand hygiene and was encouraged to change his gloves before providing a clean dressing. RN #A used his gloved finger, rather than a sterile applicator, to apply Solosite, a wound gel, to the left lower leg wound beds. RN #A used the scissors which had visible residue from the old dressing he had removed on their blade length to cut the clean Aquacel Advantage Ag, an absorbant sheet dressing, before he applied several pieces of it over the wounds. RN #A did not disinfect the soiled fluid that had dripped from patient #1’s leg onto the floor during wound care before putting patient #1’s cloth slipper on and patient #1 moving his foot through the soiled fluid. RN #A used a glucometer and lancet pen he took from his nursing bag to take patient #1’s blood sugar. He did not disinfect them before returning them to his nursing bag. On 4/8/25 at 11:30 AM RN #A verified that the disposable wipe he used on his blood pressure cuff prior to its application did not contain any healthcare grade disinfecting chemicals. He verified that he did not disinfect the scissors he used to remove the old dressing before using them to cut the clean Aquacel Advantage Ag dressing material. He also verified that he didn’t disinfect his glucometer and lancet pen device before returning them to his bag. He said he was nervous being watched during a home visit and should have disinfected those items. He said he was throwing away his glucometer that day. On 4/8/25 at 3:02 PM the Alternate Administrator/Supervising Nurse verified that the style of wipe used by RN #A did not contain a disinfectant, and the blood pressure cuff should have been disinfected after use with patient #1 so as not to transmit potential infectious organisms between patients. The Alternate Administrator/Supervising Nurse verified RN #A should have disinfected his scissors used to remove the dirty dressing so as not to potentially contaminate clean dressing material. The Alternate Administrator/Supervising Nurse said that RN #A should have performed hand hygiene and then donned new gloves before applying clean dressing materials. The Alternate Administrator/Supervising Nurse verified that RN #A should have used an applicator and not his gloved finger to apply the Solosite to the wound beds. The Alternate Administrator/Supervising Nurse also verified that RN #A should have used a disposable field under patient #1’s leg to capture the soiled fluid that had fallen on the patient’s floor in order to support the patient to maintain a clean environment. The Alternate Administrator/Supervising Nurse said that she expects nurses to follow manufacturer’s guidelines for maintaining glucometers regarding calibrating and disinfecting them according to manufacturer’s guidelines. The Alternate Administrator/Supervising Nurse said the agency does not provide nurses with glucometers. She said the nurses should not be using their own glucometers to do cbg testing for patients. On a directive provided by the agency regarding admissions it notes regarding wound care that supplies must be used individually for each patient and always to implement aseptic measures. It also notes to clean supplies during wound care and staff should clean their hands. The glucometer user’s manual that the product Super Sani-Cloth has been approved for cleaning and disinfecting. It also states to not use any other cleaning or disinfecting solutions. Using solutions other than the Super Sani-Cloth could result in damage to the meter and lancing device.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review and interview the agency failed to document clearly or accurately the frequency of visits from disciplines the patient was consenting to for 2 of 17 sampled patients (#15, #17). 1. Review of patient #15’s medical record revealed a consent for treatment dated 7/8/24 in which there was an “X” symbol indicated on the line adjacent to the skilled nursing frequency and RN #H signed this form. On patient #15’s plan of care dated 7/8/24 signed by RN #H for the certification period 7/8/24 to 9/5/24 it indicated nursing visits would occur 2 times a week. On 4/9/25 at 1:18 PM the Homecare Compliance Representative verified that on patient #15’s consent for treatment dated 7/8/24 there should be a number of visits per discipline indicated on the consent for treatment form and not a symbol so that the patient would know how many visits to expect regarding their care. 2. Review of patient #17’s medical record revealed a consent for treatment dated 10/20/24 in which the word yes appeared next to the frequencies indicated for skilled nursing, speech therapy, physical therapy, and home health aide and RN #I signed this form. On patient #17’s plan of care dated 10/20/24 signed by RN #I for certification period 10/20/24 to 12/18/24 it indicated skilled nursing visits would occur 1 time a week for 3 weeks, physical therapy visits 3 times a week for 3 weeks, and occupational therapy visits 3 times a week for 3 weeks. There was no documentation in the record that speech therapy services nor home health aide services were provided. On 4/10/25 at 9:30AM the Quality Assurance/Quality Improvement staff person verified that on the consent for treatment dated 10/20/24 and signed by patient #17 there was no number of frequencies noted which should be indicated adjacent to the disciplines. She also verified that it was not clear nor accurate on the consent for treatment that home health aide services and speech therapy services were going to be provided since those disciplines were not noted on the physician ordered plan of care nor were they provided during the certification period of 10/20/24 to 12/18/24.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on interview and record review, the agency failed to notify the patient, immediate family, or representative of the right to report. A review of the admission folder failed to reflect an agency-written description of Medicaid fraud and the state toll-free telephone number for the central Medicaid fraud hotline. On 4/10/25 at 1:20 PM, the Clinical Director (CD) stated, “We don’t see patients with Medicaid, so I don’t know why I should have that number”. Reviewing the agency’s policy and procedure manual revealed no policy and procedure for informing patients about Medicaid fraud or hotline numbers.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review the agency failed to conduct an initial assessment visit within 48 hours of the referral for 3 of 17 patients (#1, #2, #16). 1. Review of patient #1’s medical record revealed a physician order with a fax cover sheet dated 12/19/24 requesting visits for wound care. Patient #1’s record also revealed that the first nursing visit to the home occurred 12/23/24. There was no additional documentation in patient #1’s record that there was communication with the physician that the start of care would be longer than 48 hours after the referral was received nor was there any documentation that the patient had refused a visit within the 48 hours from the referral time. On 4/8/25 at 3:02 PM the Alternate Administrator/Supervising Nurse and the Quality Assurance/Quality Improvement (QA/QI) staff person were present during interview. They said they would review patient #1’s medical record to see if there was documentation regarding why there was a late start of care for patient #1, referral on 12/19/24 and start of care visit on 12/23/24. They verified that an initial assessment should occur within 48 hours of the referral. They noted challenges they face from healthcare insurances they work with in not receiving timely authorizations. No additional information was provided by the survey’s end. 2. Review of patient #2’s medical record revealed a physician referral with a fax cover sheet of receipt dated 1/3/25 which requested nursing to perform wound care. Patient #2’s record revealed the first nursing visit to the home occurred 1/6/25. There was no additional documentation in patient #2’s record that there was communication with the physician that the start of care would be longer than 48 hours after the referral was received nor was there any documentation that the patient had refused a visit within the 48 hours from the referral time. On 4/9/25 at 9:08 AM the Homecare Compliance Representative verified regarding patient #2 that there was no documented communication in patient #2’s medical record with the physician that the start of care, 1/6/25, would be longer than 48 hours after the referral was received, 1/3/25, nor was there any documentation that the patient had refused a visit within the 48 hours from the referral time. 3. Review of patient #16’s medical record revealed a physician referral dated 1/6/25 which requested nursing and physical therapy services. Patient #16’s record revealed the first visit to the home was by nursing and occurred 1/17/25. There was no additional documentation in patient #2’s record that there was communication with the physician that the start of care would be longer than 48 hours after the referral was received nor was there any documentation that the patient had refused a visit within the 48 hours from the referral time. On 4/9/25 at 3:35 PM the Homecare Compliance Representative said she reviewed patient #16’s medical record and verified that his initial assessment visit, 1/17/25, was later than 48 hours after having accepted the referral, 1/6/25, and there was no communication to the physician nor the patient regarding agreement for a delayed start of care.”

“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 observation, interview, and record review, the Home Health Agency failed to review and update all the medications patients were taking to the plan of care for 4 of 7 patients during home visits of a total sample of 17 patients, (#4, #5, #7, and #8). 1.Review of patient #4’s medical record revealed a Start of Care (SOC) date of 10/24/23. Her diagnoses included osteoarthritis, disc degeneration, heart failure and chronic obstructive pulmonary disease. Review of patient #4’s Plan of Care (POC) for the recertification period of 2/15/25 to 4/15/25 revealed the following medications: Albuterol 2.5 milligrams (mg)/0.5 milliliters (ml) 2 ml, Amoxicillin 875 mg, Budesonide 0.5 mg, Carvedilol 12.5 mg, Cefdinir 300 mg, Ciprofloxacin 500 mg, Gabapentin 300 mg, Isosorbide 60 mg, Loradamed10 mg, Metformin 500 mg, Norvasc 10 mg, Omeprazole 20 mg, Percocet 5-325 mg, Spironolactone 25 mg, Torsemide 20 mg. During a home visit on 4/08/25 at 2:45 PM, patient #4’s caregiver provided the medications taken by the patient. The following medications were not listed in the POC: Calcitriol 0.25 microgram (mcg), Magnesium 500 mg, Vitamin C 1000 mg, Zinc 50 mg, Vitamin D3 50 mcg, Vitamin B12 1000 mcg, Cranberry 500 mg, Turmeric 1500 mg, Senokot-S 50 mg, Silver Sulfadiazine 1% cream 500-gram, Oxygen (O2) 4 liters per minute (LPM) continuous. Patient #4’s caregiver stated the patient was no longer taking the following medications, which were listed in the POC: Amoxicillin 875 mg, Ciprofloxacin 500 mg, and Norvasc 10 mg. On 4/09/25 at 1:39 PM during a telephone interview, Registered Nurse (RN) K confirmed patient #4 used O2 and he stated the order was for 2 LPM. He mentioned he spoke with the physician once and the physician told him the order was for the “minimum required dose.” He indicated he did not document it on the medical record and was unaware he needed to update the medication list to include O2. 2. Review of patient #5’s medical record revealed a SOC date of 8/28/24. His diagnoses included non-pressure chronic ulcer of the skin. Review of patient #5’s POC for the recertification period of 2/24/25 to 4/24/25 revealed the following medications: Aspirin 81 mg, Atorvastatin 40 mg, Lantus 10-unit, Levothyroxine 25 mcg, Loratadine 10 mg, Metformin 500 mg, Metoprolol 25 mg, Plavix 75 mg, Protonix 40 mg, and Sertraline 100 mg. During a home visit on 4/08/25 at 1:07 PM, the caregiver provided the medications taken by patient #5. The following medications were not listed in the POC: Vitamin C 500 mg, Ferosul 325 mg, Tamsulosin 0.4 mg, Trazadone 150 mg, and Meloxicam 15 mg. Patient #5’s caregiver stated the patient was no longer taking the following medications, which were listed in the POC: Loratadine 10 mg, Plavix 75 mg, and Sertraline 100 mg. The Metformin dose was 1000 mg with meals. On 4/08/25 at 1:25 PM, RN K stated he revised the list of medications for patient #5 previously but did not compare it with the medical record. RN K stated after patient #5’s last visit with the physician, he looked at the lab results and medications but did not document it. He indicated he was not aware he needed to review the medications and update the medical records if needed at each visit. 3. Review of patient #7’s medical record revealed a SOC date of 2/17/25. Her diagnoses included hypertension and dizziness. Review of patient #7’s POC for the recertification period of 2/17/25 to 4/16/25 revealed the following medications: Atorvastatin 20 mg, Lisinopril 40 mg, Metformin 850 mg, and Xarelto 20 mg. During a home visit on 4/08/25 at 9:05 AM, the patient provided the medications she took. The following medications were not listed in the POC: Vascepa 0.5 mg, Meclizine 12.5 mg, Venlafaxine 25 mg, and Ferrous Sulfate 325 mg. The Lisinopril dose was 40 mg. On 4/08/25 at 9:52 AM, patient #7 stated nurses visited her weekly on Thursday. She did not recall if they reviewed the medications she was taking during the visit. On 4/08/25 at 9:56 AM, Physical Therapy Assistant J stated he did not look at medications during his visits because the nurse checked on that. 4. Review of patient #8’s medical record revealed a SOC date of 8/08/24. Her diagnoses included type 2 diabetes and hyperlipidemia. Review of patient #8’s POC for the recertification period of 4/05/25 to 6/03/25 revealed the following medications: Alendronate 70 mg, Amlodipine 10 mg, Atorvastatin 20 mg, Clonidine 0.1 mg / 0.2 mg, Donepezil 10 mg, Lisinopril 20 mg, Metformin 1000 mg, and Vascazen 1 gram. During a home visit on 4/08/25 at 11:30 AM, the caregiver provided the medications taken by patient #5. The following medication was not listed in the POC: Glimepiride 2 mg. On 4/08/25 at 11:52 AM, RN C stated she had been visiting patient #8 since 2/18/25. She indicated she had not looked at the medications. She shared she completed a recertification visit last week and did not compare the medications in the patient’s house with the list in the POC. She stated she only asked the caregiver if there were any changes. On 4/09/25 at 4:04 PM, the Director of Nursing explained nurses were expected to reconcile medications on admission and at each visit. She indicated it was important the medications were updated and accurate. She stated vitamins and O2 were to be included, if ordered.”

“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 observation, interview, and record review the agency failed to ensure that a nurse obtained complete wound care orders for a patient (#1), obtained orders to test a patient’s blood sugar (#1), obtained complete orders regarding flushing a patient’s peripherally inserted central catheter (PICC) line (#13), and obtained an order to remove a client’s PICC line (#13). There were 17 sampled patients. 1. Review of patient #1’s medical record revealed a physician referral dated 12/19/24. This referral indicated that the home health agency was to do wound care and the diagnosis indicated below this reason was wound of the left lower extremity. Review of patient #1’s medical record included a start of care comprehensive assessment which included Outcome Assessment Information Set (OASIS) dated 12/23/24. It indicated in the wounds section that patient #1 had a pressure ulcer on the right gluteal area that was 1.0 centimeter length, 1.0 cm width, and 0.1 cm in depth. In another section of this assessment it was indicated that patient #1 had no pressure ulcers. There was no additional documentation regarding this wound in patient #1’s medical record. Review of patient #1’s medical record revealed a plan of care with the certification period of 12/23/24 to 2/20/24 and that there was no documentation regarding the right gluteal wound noted on the 12/23/24 dated comprehensive assessment. There was no documentation about the wound on the left lower extremity which was noted on the referral dated 12/19/24. This plan of care included in the direct care section to provide wound care and that the dressing change was to be done according to the physician’s order. Below this statement, it was blank on the document regarding the wound care procedure and the frequency of the procedure. A verbal order to start care regarding the plan of care was not documented as having been obtained nor had a physician signed the plan of care. Review of patient #1’s communication note dated 12/24/24 and signed by RN #A on 12/25/24 indicated that patient #1’s right leg was amputated, the left leg had multiple small scabs, and that there was a small wound on the right buttock. There were no wound orders on this communication nor were wound orders requested. Review of patient #1’s skilled nursing note dated 12/27/24 by RN #A noted that there was a diabetic wound on the left lower leg which the nurse described as 1.0 cm length, 1.0 cm width, 0.2 cm depth. The intervention provided was removed the old dressing, cleaned with normal saline, applied Solosite wound gel, covered with Aquacel Ag dressing, and held with gauze. This intervention was also noted as having been provided on patient #1’s skilled nursing notes dated 12/30/24, 1/1/25, 1/6/25, 1/9/25, 1/15/25, 1/21/25, 1/23/25, 1/28/25, 1/30/25, 2/4/25, 2/6/25, 2/11/25, 2/13/25, and 2/20/25. Review of patient #1’s recertification assessment dated 2/17/2025 by RN #1 indicated in the wounds section that patient #1 had a venous ulcer on the left lower leg as indicated by the body diagram. In this document’s wound note section it was documented that the wound care was cleaned with normal saline, pat dry, apply Alginate dressing, cover with gauze, and ACE wrap. Review of patient #1’s recertification plan of care signed 2/18/25 by RN #A with a certification period of 2/21/25 to 4/21/25 noted in the direct care section to provide wound care and that the dressing change was to be done according to the physician’s order. Below this statement, it was blank on the document regarding the wound care procedure and the frequency of the procedure. Review of patient #1’s nursing note dated 2/25/25 by RN #A noted there was a wound on the left leg. The intervention documented was that he removed the old dressing, cleaned with normal saline, applied Solosite wound gel, covered with Aquacel Ag dressing, and held with gauze. On the nursing note dated 2/27/25 by RN #A this intervention was provided with the addition after the gauze of an ACE wrap. The wound care provided to the left leg documented like 2/25/25 was repeated 3/4/25, 3/6/25, 3/11/25, 3/13/25, 3/18/25, 3/20/25, 3/25/25, 3/27/25, 4/1/25, and 4/3/25 home nursing visits. During a home visit with patient #1 conducted on 4/8/25 at 10:35 AM RN #A removed patient #1’s old dressing from his left lower leg. He sprayed an adhesive removal spray which he carried in his nursing bag to assist in the old dressing removal. There were multiple open wound areas which varied in length and width with superficial depths. RN #A cleaned the wounds with normal saline, applied Solosite wound gel to the wound beds, covered the wounds with Aquacel Advantage Ag dressing, wrapped with gauze, and then wrapped with an ACE wrap. Patient #1 said he no longer had the right gluteal wound, and denied pain in the area. Patient #1 could not recall when it had healed. RN #A said he could not recall precisely when patient #1’s right gluteal wound had healed but he thought it was 1-2 months ago. RN #A used his glucometer to take patient #1’s capillary blood sugar. RN #A said he sometimes used his glucometer and sometimes used patient #1’s glucometer to test patient #1’s blood sugar during his visit. On 4/8/25 9:24 AM the Quality Assurance/Quality Improvement (QA/QI) staff person verified that neither of patient #1’s plans of care, 12/23/24 to 2/20/24 nor 2/21/25 to 4/21/25, indicated that verbal orders had been received from the physician nor had physician signatures been obtained yet for either plan of care. On 4/8/25 at 11:30 AM RN #A said that he never called patient #1’s physician to receive verbal orders for patient #1’s care since the start of care 12/23/24 to present nor had he updated the physician about the progress of the right gluteal wound, lower leg wounds, nor blood sugar values obtained. He said that patient #1 received some wound supplies from his physician; so, he decided to use them and he decided on the frequency of visits he would do. He verified he never received a physician’s order to do capillary blood glucose monitoring for patient #1. On 4/8/25 at 3:02 PM the Alternate Administrator/Supervising nurse, with the QA/QI staff person present, stated that nurses should have a physician’s order to perform a capillary blood sugar test for a patient and it should be on the plan of care. They said wound care orders should be obtained from a physician and include how often and with what products a wound should be cleaned and dressed. They said they would review patient #1’s medical record. No additional information was provided by survey’s end. On 4/9/25 at 9:30 AM the Homecare Compliance Representative verified that there was a right gluteal wound documented on the 12/23/24 comprehensive assessment and that there was no additional documentation in patient #1’s medical record about it. She said RN #A should not have used a adhesive removal spray on patient #1 since it was not ordered for use on patient #1 nor was it patient #1’s own prescribed supply. 2. Review of patient #13’s medical record revealed a physician referral dated 2/24/25 with a referral reason of other which included a diagnosis of infection and inflammatory reaction related to left knee prosthesis. It included orders for daptomycin 500 milligrams daily and ceftriaxone 2 grams daily to be provided intravenously until 4/2/25. This referral did not include the flushes, type or quantity, that should be done to maintain the patency of the intravenous line, nor orders to remove the PICC line on completion of the antibiotics ordered. Review of patient #13’s start of care comprehensive assessment completed by RN #B and dated 2/26/25 noted a PICC line present in the right upper arm. Review of patient #13’s plan of care for the period 2/26/25 to 4/26/25 signed by RN #B revealed no detail regarding the intravenous flushes, type or quantity, that should be done to maintain the patency of the intravenous line, nor orders to remove the PICC line on completion of the antibiotics ordered. Patient #13’s medical record also contained a discharge date of 4/4/25. Review of patient #13’s communication admission note dated 2/26/25 and signed by RN #B also did not contain any clarification regarding the intravenous flushes, type or quantity, that should be done to maintain the patency of the intravenous line nor orders to remove the PICC line on completion of the antibiotics ordered. Review of patient #13’s skilled nursing visits completed by RN #B on 3/2/25, 3/9/25, 3/11/25, 3/15/25, 3/16/25, 3/17/25, 3/23/25, 3/24/25, 3/28/25, 3/29/25, 3/30/25, 4/2/25, 4/3/25, and 4/4/25 indicated in the IV therapy notes section daptomycin 500 milligrams daily and ceftriaxone 2 grams daily. On nursing notes 3/9/25, 3/11/25, 3/15/25, 3/16/25, 3/17/25, 3/23/25, 3/24/25, 3/28/25, 3/29/25, 3/30/25, 4/2/25 it was documented that the patient and home health agency staff would flush the PICC line with heparin and saline. There were no volumes indicated of the flushes used nor was it noted regarding heparin how many units per milliliter were used to administer the flush. There was no documentation regarding if the PICC line was in place or removed on discharge. On 4/10/25 at 12:03 PM RN #B said that he had taught patient #13’s family to flush the PICC line and he said they did that daily. He said he taught the family to flush the line with heparin and normal saline, but he could not recall the dosage of the heparin used. He stated that he removed patient #13’s PICC line on 4/2/25 because the intravenous antibiotics course that had been ordered was completed. He did not call a physician for an order to remove the PICC line. On 4/10/25 at 12:39 PM the Alternate Administrator/Supervising Nurse stated that there should be a physician’s order documented in patient #13’s medical record regarding flushes to be administered to the PICC line detailing when flushes should be done, which solutions should be used for the flushing, including their volumes, and regarding heparin the dosage. She said the nurse should document when they administer a flush, the solution type, its volume and regarding heparin its dosage. She also verified that a nurse should have a physician’s order to remove an intravenous line. She said she would review patient #13’s medical record. No additional information was provided by the survey’s end.”

“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 interviews and a review of agency documentation, the administrator failed to ensure the agency was organized, managed and administered its resources to maintain an accurate, functional and practicable patient census. Upon entrance to the agency at 10:30 AM on 4/7/25, the Administrator and the Clinical Director (CD) were asked to provide a number of the unduplicated census for the last year that is required to perform the recertification survey. At 11:45 AM, the CEO and the CD stated that the unduplicated census includes all patients serviced by the agency, which was the nurse registry and home health agency. The CD stated they did not have a way to separate patients who received care through the registry, a non-skilled program, or the Skilled Home Health Agency. Therefore, the sample number selected was the maximum sample.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on observation, interview, and record review the agency failed to ensure nurses followed manufacturer’s guidelines for the use and disinfection of a glucometer for a patient (#1). The agency also failed to ensure that when a peripherally inserted central catheter (PICC) was flushed the order of the fluids administered was according to professional standards and when the PICC was removed its length was assessed compared to its insertion length for a patient (#13). There were 17 sampled patients. Findings include: 1. During a home visit on 4/8/25 at 10:35 AM RN #A administered a capillary blood glucose (cbg) test on patient #1 using a AccuChek Guide glucometer that he removed from his nursing bag. On 4/8/25 at 11:30 AM RN #A said that the glucometer he used with patient #1 was a glucometer he had purchased in 2023 or possibly 2024. He stated he had never calibrated it since 2023 or 2024. He said he should have calibrated it. He said he had used it to do cbg testing with another patient. He said he was going to throw the glucometer away today. 4/8/25 3:02 PM the Alternate Administrator/Supervising Nurse said that she expects nurses to follow manufacturer’s guidelines for maintaining glucometers regarding calibrating and disinfecting them according to manufacturer’s guidelines. The Alternate Administrator/Supervising Nurse said the agency does not provide nurses with glucometers. She said the nurses should not be using their own glucometers to do cbg testing for patients. The glucometer user’s manual noted it was to be used by a single person and should not be shared. The control test section of the manual notes a control test should be performed to ensure test accuracy. 2. Review of patient #13’s medical record revealed a physician referral dated 2/24/25 due to infection and inflammatory reaction related to left knee prosthesis. It included orders for daptomycin 500 milligrams daily and ceftriaxone 2 grams daily to be provided intravenously until 4/2/25. Review of patient #13’s start of care comprehensive assessment completed by RN #B and dated 2/26/25 noted a PICC line present in the right upper arm. There was no documentation in patient #13’s medical record the length of the PICC line. Review of patient #13’s medical record revealed home visit nursing notes dated 3/9/25, 3/11/25, 3/15/25, 3/16/25, 3/17/25, 3/23/25, 3/24/25, 3/28/25, 3/29/25, 3/30/25, 4/2/25 and it was documented on those notes that the patient/family and home health agency staff would flush the PICC line with heparin and saline. On 4/10/25 at 12:03 PM RN #B said that he had taught patient #13’s family to flush the PICC line. He said he instructed the family to do a heparin flush, then normal saline flush, then administer the antibiotic and then do a flush with normal saline daily. He could not recall the dosage of the heparin used for the flush. He stated that he removed patient #13’s PICC line on 4/2/25 because the intravenous antibiotics course that had been ordered was completed. He said he did not know the length of the PICC line the hospital had inserted and he said he did not measure the PICC line after he removed it from patient #13. On 4/10/25 at 12:39 PM, patient #13 was discussed with Alternate Administrator/Supervising Nurse who could not provide physician’s order which noted the volume and type of flush used for paitent #13’s PICC line. She was also informed RN #B had documented in the medical record heparin and saline were used to flush the PICC line. RN #B instructed the patient’s family to first flush and administer the antibiotic with the following sequence: Heparin, Saline, Antibiotic, Saline. The Alternate Administrator/Supervising Nurse said the PICC line should had been flushed using the Mnemonic, “SASH.” Which means Saline, Antibiotic, Saline, Heparin. She added, RN #B should have inspected the PICC line after it was removed to ensure it was intact and all of the line was removed. The Alternate Administrator/Supervising Nurse was informed RN #B did not know the length of the PICC line and did not measure it after it had been removed. The journal called Nursing 32(5):p30, May 2002, accessed at https://journals.lww.com/nursing/citation/2002/05000/how_to_remove_a_picc_with_ease.27.aspx, in an article titled “How to Remove a PICC with Ease” noted that a upon removal a PICC line and its tip should be inspected and measure the length for comparison with the length documented at insertion. It is suspected the PICC has been broken internally if the measurement is shorter than the inserted length.”