Louisa County Phns

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on personnel file review and staff interview, the agency failed to ensure the home health aides successfully completed competencies in home health aide skills that exceed basic skills, which require a registered nurse, or other appropriate skilled professional in consultation with a registered nurse, to evaluate the competency of the aide by direct observation for 2 of 3 sampled home health aides (Staff D and E). Failure to ensure home health aides were competent in a skill which exceed the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: In an interview on 1/28/26 at 11:30 AM, the Administrator reported that she remembered performing competency training with home health aides Staff D and Staff E, but was unable to find documentation of the training. 1.Patient #1 had a start of care date of 5/5/25. Clinical record review revealed the following: a. Home health aide care plan dated 1/3/26 directed the aide to apply tubigrip to bilateral legs. The clinical record identified that Staff E provided care to the patient. b. Staff E had a hire date of 8/1/22. Staff E’s personnel file lacked documentation of competency testing to ensure competency evaluation was completed for applying tubigrip. 2.Patient #5 had a start of care date of 1/8/25. Clinical record review revealed the following: a. Home health aide care plan dated 1/3/26 directed the aides to apply tubigrip to bilateral legs. The clinical record identified that Staff D and E provided care to the patient. b. Staff D had a hire date of 3/11/19. Staff D’s personnel filed lacked documentation of competency testing to ensure competency evaluation was completed for applying tubigrip. c. Staff E had a hire date of 8/1/22. Staff E’s personnel file lacked documentation of competency testing to ensure competency evaluation was completed for applying tubigrip. The agency failed to provide competency testing for aides caring for patients requiring tubigrip. The above findings were reviewed with the Administrator and Clinical Manager.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on staff interview, agency policy review and clinical record review, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60-day certification period for 1 of 6 sampled patients requiring a recertification assessment (Patient #6). Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Documentation Guidelines, dated 1/16/26, for all patients requiring OASIS (Outcome and Assessment Information Set) data collection, the 60-day certification period must be followed. A comprehensive assessment with OASIS data collection must be completed on or within days 56-60 of the certification period. Patient #6 had a start of care date of 1/15/25 and a discharge date of 1/16/26. Clinical record review revealed: a. Plans of Care, dated 9/12/25 to 11/10/25 and 11/11/25 to 1/9/26, included primary diagnosis of Type 2 diabetes mellitus and physician orders for skilled nursing services. b. Recertification Comprehensive Assessment, dated 11/4/25, (day 54 of the certification period), 2 days prior to the recertification window, days 56-60 of the certification period. During an interview on 1/27/25 at 4:09 PM, Staff B, Clinical Manager, reported medications were set up on Tuesday’s, Staff B was not aware of not being able to move a recertification comprehensive assessment visit forward and outside the certification 5-day window, The registered nurse failed to complete the recertification comprehensive assessment within the required time frame of days 56-60 of the certification period. The findings were reviewed with Staff A, Administrator and Staff B, Clinical Manager.”

“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 home observation visits, patient interview, clinical record reviews and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care (POC), including all medical supplies/equipment, all medications, and treatments used by the patient for 3 of 7 sampled patients (Patients #1, #2 and #7). Failure to maintain complete and accurate POCs with current orders placed patients at risk to not receive services, supplies, medications and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy titled Documentation Guidelines, last revised 1/16/26, medications should be included as part of the POC and include dose. Any deviation from the POC requires documentation of communication with the physician and , when applicable, corresponding orders. 1.Patient #1 had a start of care date of 5/5/25. Clinical record review revealed: a. The POC, dated 12/31/25 to 2/28/26, identified the patient had a primary diagnosis of chronic peripheral venous insufficiency and included physician orders for medical supplies/equipment used by the patient. The POC included the following medical supplies/equipment used by the patient: shower chair, grabber, shower mat, shoe horn, ramp, grab bars, aquaphilic, lift chair, mediset, toilet riser, walker, life alert, removable shower head, and tubigrip. The same POC included a medication for the patient, Citracal + D 1 tablet daily in the morning by mouth. b. During a home observation visit on 1/27/26 at 9:15 AM with Staff B, Registered Nurse (RN), Staff B used a scale to weight the patient. The patient reported she has been weighed regularly with nursing visits. The agency failed to include all medical supplies/equipment on the patient’s POC, including a scale. The agency failed to include the dosage strength for a medication. Citracal. 2.Patient #2 had a start of care date of 12/3/19. Clinical record review revealed: a. The POC, dated 12/31/25 to 2/28/26, identified the patient had a primary diagnosis of interstitial pulmonary disease and included physician orders for medical supplies/equipment used by the patient. The POC included the following medical supplies/equipment used by the patient: oxygen tank, oxygen concentrator, oxygen tubing, cell phone, walker, grab bars, lifeline, long handled shoe horn, removable shower head, bath bench, blood pressure monitor, SPO2 monitor, mediset, visually impaired reader, tape recorder, talking watch, talking scale, portable O2 concentrator, uses wheelchair when going outside of home. The same POC included the following medications used by the patient, Citracal + D 1 tablet daily in the morning, benzonate 100 milligrams (mg) 1 capsule two times daily, and famotidine 20 mg 1 tablet daily. b. During a home observation visit on 1/27/26 at 10:15 AM with Staff B, the patient reported she has used a nebulizer machine since 2015 and that she has worn incontinence briefs since before her home health admission. Staff B filled the patient’s pill planner with a bottle of benzonate with the label indicating to take this medication every 6 hours as needed and a bottle of famotidine with the label indicating that the strength of this medication was 40 mg. The agency failed to include all medical supplies/equipment on the patient’s POC, including a nebulizer and incontinence products. The agency failed to include the dosage strength for Citracal +D. The agency failed to ensure the POC listed the correct orders for the medication available in the patient’s home. 3.Patient #7 had a start of care date of 11/10/25. Clinical record review revealed: a. The POC, dated 11/10/25 to 1/8/26, identified the patient had a primary diagnosis of nontraumatic perforation of intestine and included physician orders for medical supplies/equipment used by the patient. The POC included the following medical supplies/equipment used by the patient: IV (intravenous) supplies, alcohol wipes, syringes, midline dressing change kits, nail clippers, cell phone, scale, walker, built in shower chair, pill splitter, removeable shower head, CPAP (continuous positive airway pressure). b. The POC dated 11/10/25 to 1/8/26 indicated the patient had albuterol 2.5 mg/3 milliliters (mL) 1 inhalation every 6 hours as needed via a nebulizer. The agency failed to include all medical supplies/equipment on the patient’s POC, including a nebulizer. The above findings were reviewed with the Administrator and Clinical Manager.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on home observation visit and admission folder review, the agency failed to provide agency patients with the Clinical Manager name, business address and business phone number. The agency failed to provide this information for 1 of 1 sampled patients with home visits with admit folder provided to surveyor (Patient #2). Failure to provide the Clinical Manager name and contact information left the patients without the needed information to contact the agency Clinical Manager with any concerns that may have occurred. Findings include: During an interview on 1/28/26 at 11:45 AM, Staff A, Administrator, reported she was not aware the Clinical Manager’s name and contact information was not listed in the admit packet. Patient #1 had a start of care date of 5/5/25. Clinical record review revealed a Plan of Care, dated 12/31/25 to 2/28/26, included a primary diagnosis of venous insufficiency and interim physician orders for skilled nursing and home health aide services. During a home visit observation, on 1/27/26 at 9:15 AM, with Staff B, Clinical Manager, the surveyor reviewed the admission folder in the patient home. The folder failed to provide the agency Clinical Manager name and contact information. The agency failed to provide the agency Clinical Manager name and contact information for the patient. The above findings with Staff A, Administrator and Staff B, Clinical Manager.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on staff interview, agency policy review and clinical record review, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 1 of 3 sampled patients receiving home health aide services (Patient #3). The agency reported 10 patients who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients’ personal care needs were not adequately met. Findings include: According to the policy, titled Documentation Guidelines, dated 1/16/26, the nurse is responsible for completion of the home care aide assignment sheet at the time the aide services are ordered. During an interview on 1/27/26 at 1:35 PM, Staff B, Clinical Manager, reported the admit nurse develops the aide care plan. Patient #3 had a start of care date of 5/1/25. Clinical record review revealed: a. Plans of Care, dated 10/28/25 to 12/26/25 and 12/27/25 to 2/24/26, included primary diagnosis of left leg ulceration and physician orders for skilled nursing and home health aide services. b. Home health aide assignment, dated 10/24/25, directed the aides to assist the patient with deodorant application, help with dressing, lotion apply to lower legs per patient request, shampoo hair per pt request, transfer with walker, use assistive devices in tub, shower bath assist in/out and hard to reach areas, shower bath monitor skin for any redness and notify RN (registered nurse), and dressing keep wound care dressings in place to right outer foot and left outer ankle during shower. c. Home health aide visit notes, dated 12/29/25, 1/6/26, 1/9/26, 1/12/26 and 1/19/26, included documentation the following tasks were completed: apply deodorant, assist with dressing/undressing, apply lotion after shower per patient request, shampoo hair per patient request, use walker to transfer/ambulate, assistive devices in tub, transfer in and out of tub, notify RN if any redness or new open areas to skin and bath (shower chair). The aide visit notes failed to address the task keep wound care dressings in place to right outer foot and left outer ankle during shower. The aide visit notes addressed the task bath (shower chair) but this task was not on the aide assignment. d. Home health aide visit notes, dated 1/16/26 and 1/23/26, addressed all tasks on the aide assignment but included the task bath (shower chair) that was not on the aide assignment. The home health aide failed to follow the home health aide assignment as directed by the RN. During an interview on 1/28/26 at 11:40 AM, Staff A, Administrator, reported the aide assignment drives the aide visit note, the aide should not be able to pick a task that is not on the aide assignment. The findings were reviewed with Staff A, Administrator and Staff B, Clinical Manager.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on clinical record review, agency policy review, and staff interview, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition, and honoring patient rights for 2 of 3 patient receiving home health aide services (Patients #3 and #5). Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients’ personal care needs. Findings include: 2. Patient #3 had a start of care date of 5/1/25. Clinical record review revealed: a. Plans of Care, dated 10/28/25 to 12/26/25 and 12/27/25 to 2/24/26, included primary diagnosis of left leg ulceration and physician orders for skilled nursing and home health aide services. b. Skilled nurse visit notes, dated 12/29/25, 1/5/26, 1/12/26 and 1/19/26, included aide supervision documentation that included follows plan of care. The supervision documentation failed to address the elements: maintain open communication with patient/caregiver, demonstrate competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights. The skilled nurse failed to address all required elements of the home health aide supervision as required by agency policy and regulations. The surveyor reviewed the findings with Staff A, Administrator and Staff B, Clinical Manager. According to the agency’s policy, titled Supervision of Home Health Aide, last revised 3/28/25, home care aide supervision must ensure that aides provide care in a safe and effective manner, including but not limited to the following: following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse, maintaining an open communication process with the patient, representative, caregivers, and family, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in the patient’s condition, and honoring patient rights. In an interview on 1/28/26 at 1:46 PM, the Administrator reported that some nurses document aide supervision that includes all required elements using a form within the electronic health record (EHR) and other nurses use a different electronic charting process where the required elements are not available to document against. 1.Patient #5 had a start of care date of 1/8/25. Clinical record revealed the following: a. The Plans of Care dated 11/4/25 to 1/2/26 and 1/3/26 to 3/3/26 included orders for skilled nursing and home health aide services. b. Skilled nursing visit notes, dated 11/26/25, 112/4/25, 2/10/25, 12/16/25, 12/23/25, 12/29/25, 1/7/26, 1/14/26, and 1/21/26 documented home health aide supervision was completed and the aide followed the care plan and maintained open communication with the patient/caregiver. The agency failed to supervise home health aide services to include all required supervisory elements.”