Community Health Services

“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 agency staff interview and clinical record reviews, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan of Care for 3 of 5 sampled patients with missed visits (Patients #1, #3 and #7). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient’s health care needs. Findings include: 3. Patient #1 had a start of care date of 1/17/26. Clinical record review revealed: a. The POC, dated 1/17/26 to 3/7/26, identified the patient had a primary diagnosis of acute encephalopathy and included physician orders for physical therapy services 2 times a week for 8 weeks. b. The electronic medical record identified physical therapy missed visits on 2/16/26. The clinical record lacked documentation of physician notification of the missed physical therapy visit on 2/16/26. The agency failed to notify the physician of the missed physical therapy visit. The above findings reviewed with the Administrator and Clinical Manager. During an interview on 2/24/26 at 10:23 AM, Staff B, Clinical Manager identified the agency does not have a policy on missed visits; however, agency staff are expected to identify the missed visit and notify the physician if visit frequency is not met. 1.Patient #3 had a start of care date of 9/22/25. Clinical record review revealed: a. The Plan of Care (POC), dated 1/20/26 to 3/20/26, identified the patient had a primary diagnosis of multiple sclerosis and included physician orders for physical therapy services 2 times a week for 8 weeks. b. The electronic medical record identified physical therapy missed visits on 2/6/26 and 2/16/26. The clinical record lacked documentation of physician notification of the two missed physical therapy visits. The agency failed to notify the physician of the missed physical therapy visits. 2. Patient #7 had a start of care date of 6/10/25 and a discharge date of 7/17/25. Clinical record review revealed: a. The POC, dated 6/10/25 to 8/8/25, identified the patient had a primary diagnosis of traumatic subarachnoid hemorrhage and included physician orders for physical therapy services 2 times a week for 8 weeks. b. The electronic medical record identified physical therapy missed visits on 6/13/25 and 7/4/25. The clinical record lacked documentation of physician notification of the two missed physical therapy visits. The agency failed to notify the physician of the missed physical therapy visits.”

“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 staff interview, clinical record reviews and agency policy review, the agency failed to provide a complete comprehensive assessment for patients with wounds during start of care for 1 of 3 sampled patients with wounds (Patient #7). Failure to accurately and thoroughly complete wound assessments or provide a comprehensive assessment placed patients at an increased risk of unidentified condition changes. Findings include: According to the agency policy titled Wound Care Assessment and Documentation, dated 6/2025, the Registered Nurse (RN) is responsible for completing a thorough head-to-toe assessment on admission; including completing the wound assessment documentation in the patient’s electronic medical record. A complete wound assessment, including measurement of the wound is to be completed at a minimum of weekly. During an interview on 2/24/26 at 10:23 AM, Staff B, Clinical Manager, stated wound care assessments, measurements and documentation are completed within the RN’s visit note. Staff B, Clinical Manager also stated wounds are to be measured on the first visit of each week. Patient #7 had a start of care date of 6/10/25 and a discharge date of 7/14/25. Clinical record review revealed: a. The Plan of Care (POC), dated 6/10/25 to 8/8/25, identified the patient had diagnoses of traumatic subarachnoid hemorrhage and pressure ulcer, stage 2 to the sacral region. The POC included physician orders for skilled nursing services to assess skin integrity and overall condition of the skin and to provide wound care. b. The comprehensive assessment at start of care, dated 6/10/25, completed by Staff F, RN, identified the patient had a small laceration to right forehead with glue intact and the patient had three pressure ulcers to the coccyx. The clinical record lacked wound assessments/measurements for the identified wounds. The RN failed to complete a wound assessment/measurements for all identified wounds on admission. The findings were reviewed with the Administrator and Clinical Manager.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on staff interview, clinical record reviews and agency policy review, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency’s knowledge of patient’s return home from an inpatient facility for 1 of 2 sampled patients requiring a resumption of care assessment (Patient #6). Failure to complete a resumption of care comprehensive assessment 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’s policy titled Initial and Comprehensive Update to the Comprehensive Assessment, dated 6/2025, the comprehensive assessment must be updated and revised within 48 hours of the patient’s return home from a hospital admission of 24 hours or more for any reason other than diagnostic tests or physician ordered resumption date. During an interview on 2/24/26 at 10:23 AM, Staff B, Clinical Manager, stated resumptions of care are to be completed within 48 hours of patient’s return home. Patient #6 had a start of care date of 10/17/24 and a discharge date of 4/2/25. Clinical record review revealed: a. The patient’s electronic medical record identified the patient was discharged from the hospital on 11/1/24 and the agency received an order for resumption of care on the same date. b. The resumption of care comprehensive assessment, dated 11/4/24, completed by Staff H, Registered Nurse, 1 day late per regulation. The agency failed to complete the resumption of care comprehensive assessment within 48 hours of the patient’s return home from an inpatient stay. The findings were reviewed with the Administrator and 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 2 of 3 sampled patients with home visits (Patients #2 and #3). 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: 2. Patient #3 had a start of care date of 9/22/25. Clinical record review revealed: a. The POCs, dated 11/21/25 to 1/19/26 and 1/20/26 to 3/20/26, identified the patient had a primary diagnosis of multiple sclerosis and included physician orders for medical supplies and equipment used by the patient. The POC included the following medical supplies and equipment used by the patient: incontinent supplies, reacher, shower chair, grab bars/safety rails, lift chair, heating pad, medication planner, pill cutter and four wheeled walker. b. The skilled nurse visit note, dated 12/18/25, completed by Staff F, RN, identified the patient uses a cane. c. During a home observation visit on 2/24/26 at 2:30 PM with Staff G, RN, the surveyor identified a cane in the patient’s living room. The patient identified he/she utilizes the cane and it is not new. The agency failed to include all medical equipment/supplies on the patient’s POC, including cane. The above findings were reviewed with the Administrator and Clinical Manager. According to the agency plicy titled Care Planning & Coordination, dated 5/2025, the individualized plan of care must include the types of services, supplies, and equipment required. 1.Patient #2 had a start of care date of 2/11/26. Clinical record review revealed: a. The plan of care (POC), dated 2/11/26 to 4/11/26, identified the patient had a primary diagnosis of after care following joint replacement surgery and included physician orders for medical supplies and equipment used by the patient. The POC included the following medical supplies and equipment used by the patient: adult diapers, walker, shower bench, rolling walker, gait/transfer belt, reacher, hand held shower, grab bars/safety rails, shower mat, glasses, CPAP (continuous positive pressure), incontinence products, lift chair, medication planner, bike, bistro, ice machine, zero degree knee pillow, scale, electric bed, wound vac, heating pad, incentive spirometer and 4 wheeled walker. b. During a home observation visit on 2/24/26 at 2:15 PM with Staff C, Registered Nurse (RN), the patient stated he/she utilized Ted hose (anti-thrombosis stockings) and had them since the start of home health services following surgery. The agency failed to include all medical equipment/supplies on the patient’s POC, including Ted hose.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure nurses taking verbal orders from a physician documented the orders in the clinical record (signed, dated and timed) sending the orders to the physician for authentication, including signature and date of signature for 1 of 1 sampled patients with a catheter (Patient #4). Failure to document physician orders taken into patient clinical records placed the patient at risk for inappropriate, inadequate care resulting in potential injury or harm. Findings include: According to the agency policy, titled Care Planning & Coordination, dated 5/2025, all drugs, services, and treatments in the plan of care are administered only as ordered by a physician. Patient #4 had a start of care date of 12/11/25. Clinical record review revealed: a. The plans of care, dated 12/10/25 to 2/7/26 and 2/8/26 to 4/8/26, identified the patient had diagnoses of pressure ulcer of the sacral region, quadriplegia and neurogenic bladder. The POC included orders for skilled nursing services and suprapubic catheter change every month and as needed with size16 French catheter. b. The skilled nurse visit note, dated 1/14/26, Staff F, Registered Nurse, identified the suprapubic catheter changed with a size 18 French catheter. c. Review of the clinical record lacked documentation of a verbal order for the change in catheter size to 18 French catheter. During an interview on 2/24/26 at 4:10 PM the Administrator verified unable to locate an order for the suprapubic catheter size change to 18 French. The agency failed to include verbal orders for all supplies and treatments required by the patient including catheter size. The findings reviewed with the Administrator and Clinical Manager.”