Hegg Home Health Care

“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, including all medical supplies/equipment, all medications, treatments, and information related to advance directives for 3 of 7 sampled patients (Patients #2, #6 and #7). Failure to maintain complete and accurate Plans of Care 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 Care Planning and Coordination, dated 7/2026, an individualized Plan of Care (POC) is developed by the admitting registered nurse (RN) within 24 hours of the start of care that reflects the patients identified problems and needs, consistent with physician orders or prescriptions. Care planning is a collaborative process that takes into consideration the patient’s wishes with regards to medical intervention and treatment choices. The POC includes interventions to address identified patient needs, a list of all medical equipment and supplies used by the patient and measurable patient outcomes. 1.Patient #2 had a start of care date of 1/10/25. Clinical record review revealed: a. The POC, dated 7/4/26 to 9/1/26, identified the patient had a primary diagnosis of aftercare following joint replacement surgery and included physician orders for medications used by the patient. The POC included the following medications used by the patient: bisacodyl, bupropion, cyanocobalamin, docusate sodium, magnesium hydroxide, mirabegron, multivitamin, polyethylene glycol and ziprasidone. b. During a home observation visit on 8/25/26 at 9:15 AM with Staff C, RN, they surveyor identified the patient had icy hot pain relief roll on topical ointment and Flonase 50 microgram nasal spray on the table next to patient’s chair. An interview with the patient revealed, the patient has utilized the icy hot for a long time and he/she has used the nasal spray since 6/2026. The agency failed to include all medications the patient uses on the patient’s POC, including icy hot and nasal spray. 2. Patient #6 had a start of care date of 12/24/25 and a discharge date of 1/27/26. Clinical record review revealed: a. The POC, dated 12/24/25 to 2/21/26, identified the patient had a primary diagnosis of a right hip fracture and listed the patient’s advance directive as a full code (wants life saving measures to restart patient’s heart or breathing). b. The advance directives form in the patient’s clinical record, signed by the patient on 12/24/25, identified the patient does not want cardiopulmonary resuscitation (CPR) performed. The agency failed to include accurate advance directives on the patient’s POC. 3. Patient #7 had a start of care date of 3/16/26 and a discharge date of 5/14/26. Clinical record review revealed: a. The POC, dated 3/16/26 to 5/14/26, identified the patient had a primary diagnosis of congestive heart failure, included orders for interventions/treatments and listed the patient’s advance directive as a full code (wants life saving measures to restart patient’s heart or breathing). b. The advance directives form in the patient’s clinical record, signed by the patient on 3/16/26, identified the patient does not want cardiopulmonary resuscitation (CPR) performed. c. The physical therapist (PT) visit note, dated 5/12/26, completed by Staff G, PT, identified the patient had a Stage III pressure ulcer to the left buttock that has yellow, dry, fibrinous slough throughout the wound bed. The PT cleansed the wound with a wound cleanser, debrided the wound and applied a silicone bordered foam dressing. The agency failed to include accurate advance directives on the patient’s POC and failed to include physician orders for wound care on the POC. The above findings were reviewed with the Administrator, Clinical Manager and Staff C, RN.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on staff interview, clinical record review and agency policy review, the agency failed to notify the physician of changes in patient condition or needs that suggest an alteration to the Plan of Care for 4 of 7 sampled patients (Patients #2, #3, #4 and #5). Failure to report changes in patient condition or identified needs placed agency patients at risk for inadequate or inappropriate care. Findings include: According to the agency policy titled Care Planning and Coordination, dated 7/2026, an individualized Plan of Care (POC) is developed by the admitting registered nurse (RN) within 24 hours of the start of care that reflects the patients identified problems and needs, consistent with physician orders or prescriptions. Care planning is a collaborative process that takes into consideration the patient’s wishes with regards to medical intervention and treatment choices. The physician is contacted as necessary and appropriate with reports of changes in the patient’s clinical status and/or needs. During an interview on 8/25/26 at 2:30 PM, Staff B, Clinical Manager, identified the electronic medical record (EMR) system has vital sign parameters set up in the system and it highlights if the patient’s vital signs fall outside of those parameters. Staff B stated the provider is not always contacted when this happens, it depends on the patient. During an interview on 8/26/26 at 9:46 AM, the Administrator stated she is unsure what the vital sign parameters are set up as in the EMR. The Administrator said she would expect the doctor be notified if the vital signs are flagged as abnormal in the system. 1.Patient #2 had a start of care date of 1/10/25. Clinical record review revealed: a. The POC, dated 7/4/26 to 9/1/26, identified the patient had a primary diagnosis of Aftercare following joint replacement surgery and included orders for skilled nurse visits 1 time every 2 weeks. b. The skilled nurse visit note, dated 7/14/26, completed by Staff C, Registered Nurse (RN), identified the patient’s blood pressure of 140 systolic and 66 diastolic as abnormal. c. The skilled nurse visit note, dated 8/11/26, completed by Staff C, RN, identified the patient’s blood pressure of 142 systolic and 76 diastolic as abnormal. The clinical record lacked documentation of communication to the physician regarding the abnormal blood pressure. 2. Patient #3 had a start of care date of 8/17/26. Clinical record review revealed: a. The POC, dated 8/17/26 to 10/15/26, identified the patient had a primary diagnosis of intertrochanteric fracture and included orders for skilled nurse visits 1 time every week. b. The skilled nurse visit note, dated 8/17/26, completed by Staff B, Clinical Manager, identified the patient’s blood pressure of 140 systolic and 42 diastolic as abnormal. c. The skilled nurse visit note, dated 8/24/26, completed by Staff B, Clinical Manager, identified the patient’s blood pressure of 112 systolic and 53 diastolic as abnormal. The clinical record lacked documentation of communication to the physician regarding the abnormal blood pressure. 3. Patient #4 had a start of care date of 7/31/26. Clinical record review revealed: a. The POC, dated 7/31/26 to 9/28/26, identified the patient had a primary diagnosis of Type II Diabetes and included orders for skilled nurse visits 2 times every 60 days. b. The skilled nurse visit note, dated 7/31/26, completed by Staff B, Clinical Manager, identified the patient’s blood pressure of 116 systolic and 50 diastolic as abnormal and also identified the patients oxygen saturation level of 91 percent as abnormal. The clinical record lacked documentation of communication to the physician regarding the abnormal blood pressure and abnormal oxygen saturation level. 4. Patient #5 had a start of care date of 8/13/26. Clinical record review revealed: a. The POC, dated 8/13/26 to 10/11/26, identified the patient had a primary diagnosis of limb girdle muscular dystrophy and included orders for skilled nurse visits 1 time every week. b. The skilled nurse visit note, dated 8/13/26, completed by Staff C, RN, identified the patient’s blood pressure of 100 systolic and 58 diastolic as abnormal and also identified the pulse (number of heart beats per minute) of 56 as abnormal. The clinical record lacked documentation of communication to the physician regarding the abnormal blood pressure and abnormal pulse. The above findings were reviewed with the Administrator, Clinical Manager and Staff C, RN.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; 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 wound assessment on a weekly basis per agency policy for 1 of 3 sampled patients with a wound (Patient #7). Failure to accurately and thoroughly complete wound assessments put patients at an increased risk of unidentified condition changes. Findings include: According to the agency’s policy titled Skin and Wound Assessment, dated 7/2026, wounds will be measured at the time of discovery. A comprehensive assessment will be completed and documented to identify skin, wound or pressure ulcer concerns. A wound assessment should take into account duration of the wound, location of the wound, measurements (length, width and depth), description of wound margins, clinical appearance, odor, pain and general condition surrounding the skin. During an interview on 8/25/26 at 2:30 PM, Staff B, Clinical Manager stated wound documentation can be found in the electronic medical record and wounds are measured each week unless a doctor has specified other instructions. Patient #7 had a start of care date of 3/16/26 and a discharge date of 5/14/26. Clinical record review revealed: a. The POC, dated 3/16/26 to 5/14/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nursing and physical therapy services. b. The skilled nurse visit note, dated 3/26/26, completed by Staff C, Registered Nurse (RN), identified the patient had a Stage II pressure ulcer to the left buttock that measured 2.5 centimeters (length in cm) by 0.7 (width in centimeters) but failed to include a depth. c. The skilled nurse visit note, dated 3/30/26, completed by Staff C, RN failed to include documentation of an assessment/measurements to patient’s Stage II pressure ulcer on the left buttock. d. The skilled nurse visit note, dated 5/5/26, completed by Staff A, Administrator, identified the patient had an open area to the buttock but failed to include an assessment or measurements. e. The physical therapist (PT) visit note, dated 5/12/26, completed by Staff G, identified the patient had a Stage III pressure ulcer to the left buttock that has yellow, dry, fibrinous slough throughout the wound bed. The PT cleansed the wound with a wound cleanser and debrided the wound. The PT identified the wound measured 0.7 cm X 0.9cm but failed to include a depth. The agency staff failed to obtain weekly wound assessments and measurements per agency policy. The above findings were review with the Administrator, Clinical Manager and Staff C, RN.”