Community Health Services

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview review the agency failed to ensure accurate and thorough completion of a comprehensive assessment of wounds for 1 of 1 sampled patients with wounds. (Patient #4) Failure to accurately and thoroughly complete a thorough comprehensive assessment to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition. Findings include: According to agency policy, titled Wound Measurement and Documentation, dated 8/27/25, agency staff complete wound measurement using centimeter measuring device. Use different measuring device with each wound. (Length is measured from patient’s head to toe; width is measured from one side of the patient to the other). Head to toe and side to side may not indicate longest and widest parts of wound. During an interview on 12/2/25 at 3:16 PM the Director of Nursing stated wounds are expected to be measured weekly and include length, width and depth. Patient #4 had a start of care date of 3/9/15. Clinical record review revealed the following: a. The plans of care (POCs), dated 9/12/25 to 11/10/25 and 11/11/25 to 1/9/25, identified the patient had a diagnosis of pressure ulcer of the left buttock. The POCs included orders for skilled nurse services and wound care. The POC included orders for wound care and skilled nurse to check with the wound clinic for measurements of all wounds after wound clinic visits. b. The comprehensive assessment at resumption of care, dated 11/3/25, Staff D, Registered Nurse (RN) documented the patient had a wound on the left lower posterior leg, ischial tuberosity pressure area stage 4 and left posterior leg ischial tuberosity pressure wound stage 4. The note identified family provided wound care and the document failed to include wound assessments including measurements of the wounds. d. The comprehensive assessment at recertification, dated 1163/25, Staff D, RN documented the patient had a wound on the left lower posterior leg, ischial tuberosity pressure area stage 4 and left posterior leg ischial tuberosity pressure wound stage 4. The note identified family provided wound care and the document failed to include wound assessments including measurements of the wounds. b. The skilled nurse visit note, dated 11/14/25, Staff D, RN documented the patient had a wound on the left lower posterior leg, ischial tuberosity pressure area stage 4 and left posterior leg ischial tuberosity pressure wound stage 4. The note identified family provided wound care and the document failed to include wound assessments including measurements of the wounds. c. The skilled nurse visit notes, dated 11/17/25 and 11/20/25 Staff , C, RN documented the patient had a wound on the left lower posterior leg, ischial tuberosity pressure area stage 4 and left posterior leg ischial tuberosity pressure wound stage 4. The note identified family provided wound care and the document failed to include wound assessments including measurements of the wounds. d. The skilled nurse visit notes, dated 11/26/25, Staff G, RN documented the patient had a wound on the left lower posterior leg, ischial tuberosity pressure area stage 4 and left posterior leg ischial tuberosity pressure wound stage 4. The note identified family provided wound care and the document failed to include wound assessments including measurements of the wounds. c. The clinical record lacked documentation of collaboration with the wound clinic for wound assessments including measurements. Agency failed to document wound assessments. The above findings were reviewed with the Administrator and Director of Nursing.”

“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 observations, patient interviews, staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 3 of 3 sampled patients with home observation visits (Patients #1, #2 and #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: 3. Patient #3 had a start of care date of 8/12/25. Clinical record review revealed: a. The POC, dated 10/11/25 to 12/9/25, identified the patient had a diagnosis of Diabetes Mellitus and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 10/7/25, completed by Staff C, RN, included documentation a DRR was completed. c. During a home observation visit on 12/2/25 at 10:00 AM with Staff C, RN, interview with the patient stated he/she sets up medication in a medication planner. The following medication discrepancy identified: 1) Glipizide (diabetic medication) bottle in the home says 5 mg tablets with instructions to take 1/2 tablet by mouth 2 daily in the morning. Agency medication list says Tramadol 5 mg tablets with instructions to take 0.5 mg orally daily in the morning. 2) The surveyor observed a bottle of opened Niquil on the kitchen counter. Instructions listed Aceteminiphen 650 mg, dextromethorphan 30 mg and doxylamine succinate 12.5 mg, take 30 milliliters (ml) evvery 6 hours as needed. During the same home visit the patient stated he/she takes the medication every once in a while and had it in the home quite a while. The DRR failed to include an accurate review of all medications taken by the patient. The above findings reviewed with the Administrator and Director of Nursing. According to the agency Drug Regimen Review policy, revised 2/2022, the comprehensive drug regimen review (DRR) assessment must include a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including effective/ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy. During an interview on 12/2/25 at 3:16 PM, Staff B, Clinical Manager stated the DRR is completed on admission, with each comprehensive assessment and when medication is added or changed. 1.Patient #1 had a start of care date of 7/29/25. Clinical record review revealed: a. The Plan of Care (POC), dated 9/27/25 to 11/25/25, identified the patient had a diagnosis of Compression of the brain and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 11/25/25, completed by Staff C, Registered Nurse (RN), included documentation a DRR was completed. c. During a home observation visit on 12/2/25 at 9:00 AM with Staff D, RN, interview with the patient stated he/she sets up his/her own medication with supervision from the skilled nurse. The following medication discrepancy identified: Tramadol bottle in the home says 50 milligram (mg) tablets with instructions to take 2 tablets by mouth 2 times daily as needed. Agency medication list says Tramadol 50 mg tablets with instructions to take 2 tablets orally in the morning and 1 tablet at 2:00 PM. The patient identified he/she takes Tramadol 1 tablet 3-4 times a day spaced out as needed. The DRR failed to include an accurate review of all medications taken by the patient. 2.Patient #2 had a start of care date of 7/23/25. Clinical record review revealed: a. The POC, dated 11/20/25 to 1/18/26, identified the patient had a diagnosis of Radiculopathy lumbar region and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 11/18/25, completed by Staff C, RN, included documentation a DRR was completed, medications were verified with spouse, bottles in the home and agency medication list. c. During a home observation visit on 12/2/25 at 12:35 PM with Staff F, Physical Therapy Assistant (PTA), the patient’s spouse stated he/she sets up patient’s medication. The following medication discrepancies were identified: 1) Melatonin bottle in the home contains 5 mg tablets and the spouse gives the patient 1 tablet at bedtime. Agency med list says Melatonin 10 mg oral capsule with instructions to take 1 capsule at bedtime. 2) Agency medication list identifies patient takes Tamsulosin 0.4 mg oral capsule;1 capsule at bedtime. Interview with patient’s spouse identified patient has not taken this medication for greater than 3 weeks. The DRR failed to include an accurate review of all medications taken by the patient.”

“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 visit observations, patient interviews, clinical record reviews and agency policy review, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and advanced directives used by the patient for 2 of 7 sampled patients (Patients #1 and #4). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: 2.Patient #1 had a start of care date of 7/29/25. Clinical record review revealed: a. The POC, dated 9/27/25 to 11/25/25, identified the patient had a diagnosis of Compression of the brain. The POC included the following medical equipment and supplies used by the patient: cane, grab bars/safety rails, oral medication trays, heating pad and rolling walker. b. During a home observation visit on 12/2/25 with Staff D, RN, the surveyor observed the patient to have a pill cutter. The patient identified he/she has a medication that gets cut in half and he/she uses the pill cutter to cut the medication. The patient also identified he/she uses a Cefaly device (external trigeminal nerve stimulation device) for migraine relief and has utilized this device for 3-4 years. The agency failed to include all medical equipment and supplies used by the patient on the POC. The above findings were reviewed with the Administrator and Clinical Manager. According to the agency policy titled Home Health Plan of Care (POC), dated 10/29/25, all home health care services furnished to patinets must follow an individualized written plan of care that identifies patient-specific measureable outcomes and goals, established in collaboration with the physician, the patient, the Registered Nurse (RN) case manager, and in accordance with the patinet’s needs. 1.Patient #4 had a start of care date of 3/9/15. Clinical record review revealed: a. The POCs, dated 9/12/25 to 11/10/25 and 11/11/25 to 1/9/25, identified the patient had a diagnosis of Pressure ulcer of the right buttock. The POC included the physician’s order to do not resusitate (DNR). b. Client Bill of Rights Form, dated 3/9/15, revealed the patient had a Doctor’s order for no cardiopulmonary resusitation (CPR). c. The discharge summary, dated 10/3/25, Staff D, RN, documented the patient transfered to the hospital on 9/30/25 and requested full code status (perform CPR). d. The skilled nurse visit at resumption of care, dated 10/9/25, Staff D, RN failed to document discussion of wishes for code status. e. Review of the electronic medical record failed to include discurssion of code wished following the hospital admission on 9/30/25. The agency failed to ensure correct code status per the patient’s wishes listed on the POC.”

“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 patient interview, clinical record review and agency policy review, the agency failed to provide services only as ordered by the physician for 3 of 7 sampled patients (Patients #1, #5 and #7). Failure to ensure staff obtain and follow physician orders for treatments provided by agency staff placed patients at risk for inconsistent care/treatment and possible harm. Findings include: 3. Patient #4 had a start of care date of 3/9/15. Clinical record review revealed: a. The POCs, dated 9/12/25 to 11/10/25 and 11/11/25 to 1/9/25, identified the patient had a diagnosis of Pressure ulcer left buttock and inherited spinal muscular atrophy, identified the patient utilized a heating pad and included orders for skilled nursing services every two weeks. b. Review of the clinical record failed to include physician orders for heat therapy. Agency staff failed to include physician orders for treatments administered including heat therapy. The above findings reviewed with the Administrator and Director of Nursing. According to the agency policy, titled Home Health Plan of Care, revised 11/2022, all home health care services furnished to patients must follow an individualized written Plan of Care (POC) that identifies patient-specific measurable outcomes and goals, established in collaboration with the physician, the patient, the Registered Nurse (RN) case manager and in accordance with the patient needs. The POC must reflect patient and family goals and interventions, physician orders and problems identified in the initial, comprehensive and updated comprehensive assessments. 1.Patient #1 had a start of care date of 7/29/25. Clinical record review revealed: a. The POC, dated 9/27/25 to 11/25/25, identified the patient had a diagnosis of Compression of the brain, identified the patient utilized a heating pad and included orders for skilled nursing services every two weeks. b. During a home observation visit on 12/2/25 at 9:00 AM with Staff D, RN, the patient identified he/she utilizes a heating pad for pain relief. c. Review of the clinical record failed to include physician orders for heat therapy. Agency staff failed to include physician orders for treatments administered including heat therapy. 2.Patient #5 had a start of care date of 7/3/2013. Clinical record review revealed: a. The POC, dated 10/28/25 to 12/26/25, included diagnoses of Schizophrenia and hypertensive heart disease without heart failure and included an order for skilled nursing to assess orthostatic blood pressure sitting to standing each visit. b. Skilled nurse visit notes, dated 10/28/25, 11/11/25 and 11/25/25, completed by Staff D, RN, included documentation of blood pressure sitting at rest but failed to include blood pressure standing. The skilled nurse failed to follow physician orders and assess orthostatic blood pressure sitting to standing each visit.”