Sanford Home Health and Hospice Sheldon

“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, recertifications, resumption of care and discharge assessments for 1 of 1 sampled patient with wounds (Patient #3). 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 Documentation of Wound Care, reviewed 9/23/25, wounds will be measured in centimeters (length by width by depth) at least weekly unless covered with a non-removable dressing during the nurse visit. During Interview on 1/22/25 at 10:30 AM, the Administrator concured the documentation failed to include measurement of the wounds depth. Patient #3 had a start of care date of 12/19/25. Clinical record review revealed: a. The Plan of Care (POC), dated 12/19/25 to 2/16/26, identified the patient had a diagnosis of infection of a surgical site. Orders included skilled nurse services 2 times a week. b. The skilled nurse comprehensive visit note at start of care, dated 12/19/25, Staff D, Resgistered Nurse (RN) identified the patient had an open wound on the left dorsal foot. The wound measured 3.1 centimeters (cm) (length) by 1.9 cm (width). The assessment failed to include documentation of measurements of wound depth. c. The skilled nurse assessment, dated 12/24/25, Staff D, RN documented the patient had an open wound of the left dorsal foot. The wound measured 3.1 cm by 1.9 cm. The assessment failed to include documentation of measurements of wound depth. d. The skilled nurse assessments, dated 12/29/25, 1/7, 1/12, and 1/20/26, Staff D, RN documented the patient had an open wound of the left dorsal foot. The wound measured 3.3 cm by 2.3 cm at each visit. The assessments failed to include documentation of measurements of wound depth. The agency nurses failed to provided complete skilled nurse services. The above findings were reviewed with the Administrator and Clinical Manager.”

“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 1 of 3 sampled patients with home observation visits (Patient #1). 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: According to the agency policy titled Medication Management, dated 11/12/25,a drug regimen review in post-acute care is generally considered to include medication reconcilliation, a review of all medications and a review of the drug regimen to identify and prevent potential medicataion issues. During an interview on 1/22/26 at 10:10 AM the Clinical Manager stated the Registered Nurse (RN) responsible to complete the Drug Regimen Review (DRR) at admission, recertification and discharge. Patient #1 had a start of care date of 8/12/2020. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/13/25 to 3/13/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney discease with heart failure and included physician orders for medications and skilled nursing services. b. The comprehensive assessment at recertification, dated 1/12/25, completed by Staff C, RN, included documentation a DRR was completed. c. During a home observation visit on 1/20/26 at 10:00 AM with Staff D, RN, the patient interview revealed the following medication discrepancies orders and patient stated medication schedule: 1) Anoro/Ellipta 62.5-25 microgram inhaler, 1 puff daily. The patient identified the medication not used in over 6 months. 2) Triamcinolone 0.1% cream. Apply 3 times a week to arms and legs. The patient stated the medication not utilized in over 1 year. The DRR failed to include an accurate review of all current medications taken by the patient. The above 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 agency policy review, clinical record review and agency staff interview, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency’s knowledge of return home from an inpatient facility for 1 of 1 sampled patients requiring a resumption of care assessment (Patient #6). The agency performed 5 resumption of care assessments in the previous 6 months. Failure to complete 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 policy, titled OASIS (Outcome and Assessment Information Set), dated 7/30/25, at the resumption of care (ROC), the comprehensive assessment must be completed within 48 hours of returning home after discharge from an inpatinet facility or a physician ordered resumption of care. Patient #6 had a start of care date of 8/29/25. Clinical record review revealed the following: a. The OASIS transfer document, dated 9/19/25, Staff C, Registered Nurse (RN) documented the patient transfered to the hospital. b. The Communication note, dated 9/27/25, Staff E, RN documented the patient discharge to home on 9/26/25 and a visit made to the home. The documentation lacked an assessment of the patient. c. The updateded comprehensive assessment at resumption of care, dated 10/1/25, completed by Staff C, RN, 5 days following discharge from the hospital and 3 days late. The agency failed to complete the update to the comprehensive assessment completed at resumption of care within 48 hours of the patient’s discharge from the hospital. The above findings were reviewed with the Administrator and Clinical Manager.”