Wesley Life Home Health

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency: 1) failed to comply and follow through with the policy set by the agency of addressing discharge for cause (G462): 2) failed to advise the patient and health care professional who would be responsible for providing care and services to the patient after discharge from the agency that a discharge for cause is being considered (G464): 3) failed to make efforts to resolve the problems presented by the patients behavior, the behavior of other persons in the patient’s home, or situation (G466) and 4) failed to document the problem and efforts made to resolve the problem and enter this documentation into its clinical records (G470). The cumulative effects of these systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care.”

“Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This Element is not met as evidenced by: Based on observations, family interviews, staff interviews, record review and policy review, the agency failed to document the patient’s behaviors and circumstances that warranted patient’s discharge for cause and the agency’s efforts to resolve the problems prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patient #5) Failure to completely document the patient’s behaviors and circumstances that warranted patient’s discharge, prevented the patient of the ability to attempt to correct the issue prior to the involuntary discharge. Findings include: According to the policy titled Discharge Criteria and Process, dated 5/2024, the decision to terminate or reduce services must be documented in the clinical record, citing the circumstances and notification to the client, the responsible family/caregiver or representative, and the client’s physician. Efforts to resolve problems prior to discharge will also be documented in the client’s record, to include identification of the problems encountered, assessment of the situation, communication with the program management and the physician responsible for the plan of care, a plan to resolve the issues, and results of the plan implementation. The client shall be provided contact information for other agencies and providers if continued care is needed. The program director or designee is accountable for the decision and the required docuemntation. Patient #5 had a start of care date of 10/13/22 and was discharged for cause on 9/9/25. a. The Plans of Care (POC), dated 5/30/25 to 7/28/25 and 7/29/25 to 9/26/25, included diagnoses of multiple sclerosis, neuromuscular dysfunction of the bladder, retention of urine and personal history of urinary tract infection. The POC included physician orders for a skilled nurse visit every other week to monitor the patient each visit for signs and symptoms of worsening depression and call physician if evident. The skilled nurse (SN) also to change the suprapubic tube with 20 French and 20 cubic centimeter balloon every 2 weeks and may irrigate suprapubic tube with 50 milliliters sterile normal saline as needed for blockage/leakage. The SN to assess for and instruct the patient/caregiver on catheter care, signs and symptoms of urinary tract infection and the 24 hours on-call service for catheter problems. The POC also included identification the patient had a history of multiple sclerosis and expresses frustration and anxiety related to catheter care and Demonstrates appropriate humor and social interaction during visit despite recent negative experiences with home health services. The POC identified no current plan for discharge as patient needs ongoing assistance for maintenance of suprapubic catheter. b. The physicians order, dated 9/9/25, includes the initial contact and verbal order to discharge from the agency. c. The recertification comprehensive assessment, completed by Staff G, Registered Nurse (RN), dated 5/27/25, revealed the patient’s mood anxious and behavior appropriate and within normal limits. The note idenitified there were no plans for discharge. d. The recertification comprehensive assessment, completed by Staff D, RN, dated 7/25/25, revealed the patient’s mood irritable and behavior appropriate and within normal limits. The note idenitified there were no plans for discharge. e. The skilled nurse notes, completed by Staff H, Licensed Practical Nurse (LPN), dated 6/5, 6/18/25, 8/26/25, and 9/9/25, revealed no concerns with disruptive, aggressive or threatening behavior by the patient. f. The skilled nurse notes, completed by Staff H, LPN, dated 9/2/25, the patient demonstrated agitation when awakened, telling staff to “back off” and “get away from me” and exhibited inappropriate threatening behavior. g. The skilled nurse note, completed by Staff I, RN, dated 6/28/85 at 4:11 AM, revealed a visit as needed for catheter needs completed. The patient stated he/she did not like the catheter being changed and gets anxious when it is. The patient raised his/her voice and stated he/she did not like the nurses attitude and to get the (explicite) out of the house and he/she will go to the Emergency room for a catheter change. h. The skilled nurse note, completed by Staff J, RN, dated 6/28/25 at 1:45 AM, revealed the patient used profane lanuage when describing a previous nurse. i. The skilled nurse note, completed by Staff J, RN, dated 6/29/25, revealed a visit as needed for catheter needs completed. The note included no concerns with disruptive, aggressive or threatening behavior by the patient. j. The communication note, dated 7/23/25, Staff C, RN Case Manager documented she received a call from the insurance to report the patient requested a skilled visit. Call made to the patient and the RN explained the allotted as needed skilled visits already used. k. The skilled nurse note, completed by Staff D, RN, dated 8/15/25, the patient using profanity and making inappropriate comments about previous healthcare staff. Staff D educated the patient on imprtance of using home health services for catheter changes rather than hospital visits and discussed the case manger’s concerns about proper use of home health services. l. The skilled nurse note, completed by Staff E, LPN, dated 8/21/25, patient has fluctuating moods and Pleasant with nurse. m. During an interview on 10/21/25, at 2:14 PM, Staff G, RN stated she had been scheduled a few times to change the patinet’s catheter and both times, he/she reported had went to the hospital emergency room and had the catheter changed there. She stated she had talked to the patient and caregiver and educated if a situation in which the catheter needed to be changed prior to the next visit, to call the agency office. Staff G aware there had been situations the patinet had been rude to nurses but not threatening. She stated she had not been involved in discussiona concerning the patient dischrge from the agency. n. During an interview on 10/21/25 at 2:33 PM, Staff A, Interim Adminstrator stated the nurses had been trying to work with the patient on an appropriate plan of care. The patinet had been going to the emergency room for catheter needs and not calling the ageny. The agency increased the scheduled nursing visits to attempt to not have the emergency visits and had as needed visits to use inbetween scheduled visits. Staff A also stated Staff C, RN had told her Staff E, LPN had reported the patient had been verbally assaultive and derogatory about another nurse during a visit. She reported it made her very uncomfortable. made the dicision to discharge. Staff C notified the personal care physician at that time. Several attempts were made to call the patient prior to speaking to him/her and a certified letter had been sent to the patient to notify of the discharge. At 4:40 PM Staff A stated she was on vacation at the time of the incident. Staff E, LPN reported the incident to Staff C, RN the day it occured (9/2/25) and Staff C reported it to Staff F, Clinical Manager. They waited to discharge until Staff A returned from vacation. At the time Staff A returned, Staff C went on vacation. Staff C reported the incident to the Staff A on 9/9/25 and the decision made to discharge the patient. She further stated the agency did not have a behavior contract signed with the patient. o. During an interview on 10/21/25 at 3:00 PM, Staff E, LPN stated she worked with the patient one time. The patient had been really grumpy that day and called another nurse a derogatory name. She stated she contacted Staff C, RN to report it right away. She further stated she felt uncomfortable but did not feel threatened. p. During an itnrview on 10/21/25 at 8:48 AM, Staff F, previous Clinical Manager (at the time of patient discharge) stated Staff C, RN reported to her that Staff E, LPN had reported to Staff C the patient called another nurse a derogatory name. There had also been other times the patient had been rude to staff and called staff names. Staff F reported to Staff C that they needed to wait for the Interim Administrator to return to the office because she wanted to have input involving a patient discharge for cause. Staff F further stated she believed the case manager educated the patient on changing behaviors, but not sure. The case manager definately educated the patient to flush the catheter per order. Staff F stated she did not contact the patient after Staff C, RN reported the incident since Staff A was gone. She did not want to give the patient misinformation or cause confusion. q. During an interview with Staff B, Clinical Manager on 10/22/25 at 9:38 AM she stated she had been the patient’s case manager a long time ago and she did provide teaching to the patient and caregivers on orders for catheter flushes. The patient had been inappropriate with nurses and some nurses refused to return to the home. The agency did talk about a possible behavior contract during meetings. Not sure if one completed. r. During an interview with Staff C, RN Case Manager on 10/22/25 at 10:01 AM she stated the patient had used the emergency room for catheter changes and not call the agency first. Staff C stated she had communication when he/she called requesting a visit. The as needed visits lready used and the insurance did not provide additional as needed visits. Education provided to flush the catheter. Staff C further stated Staff E, LPN reported the patinet had called a nurse a derogitory name and requested to not go back. Staff had provided multiple education about calling the agency and not go th=o the emergency room. Staff C brought the incident up to Staff F, Clinical Manager and she did not feel comfortable to make the dicision to discharge without Staff A. Staff C brought it up to Staff A in a case meeting and she stated to go ahead and discharge the patinet. The agency documented the patient displayed disruptive or aggressive behaviors and the use of emergency room visits prior to the agency on-call service and failed to document the agency’s efforts to resolve the issues prior to discharge for cause. The above findings were reviewed with the Interim Administrator and the Executive Director.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on agency staff interviews and caregiver interviews, clinical record review, and agency policy review, the agency failed to notify the patient prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patient #5) Failure to provide patients with notification that discharge for cause is being considered denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge and left the patient at risk for not receiving needed care. Findings include: See G462 The agency failed to notify patient #5 of discharge for cause prior to the discharge date. The above findings were reviewed with the Interim Administrator and Executive Director.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to initiate any efforts to resolve problems presented by the patient’s behavior or a situation prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patient #5) Failure to attempt to initiate any efforts to resolve problems denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge. Findings include: See G462 The agency failed to attempt to initiate efforts to resolve the problems before patient #5 was discharged for cause. The above findings were reviewed with the Interim Administrator and Executive Director.”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to document any efforts to resolve problems presented by the patient’s behavior or a situation prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patient #5) Failure to document efforts to resolve problems denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge for cause. Findings include: See G462 The Agency failed to document efforts made to resolve the problems prior to Patient #5’s discharge for cause. The above findings were reviewed with the Interim Administrator and Executive Director.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to provide an initial assessment visit within 48 hours of receipt of referral and/or known discharge date, or on the physician ordered start of care date for 4 of 6 sampled patients (Patients #2,#3 #4 & #6). At the time of the survey, the agency reported providing services to 480 patients. Failure to provide an initial assessment visit within 48 hours put agency patients at risk for not having immediate care needs met. Findings include: According to the agency’s policy titled, Initial and Comprehensive Assessment, dated 01/2025, an initial client assessment will be performed and documented in the client’s clinical record by a registered nurse, physical therapist, occupational therapist or speech therapist. The initial assessment visit must be performed either within 48 hours of the referral or physician ordered referral date, within 48 hours of the patient’s return home, o, on the start of care date ordered by the physician (or other authorized licensed independent practitioner), or at the patient/family request with the approval of the physician (or other authorized licensed independent practitioner). During an interview on 8/28/25 at 8:12 AM with Staff F, Intake Coordinator, reported referrals come to a fax box, Staff F is responsible for dividing the paperwork and giving it to the intake nurses for clinical review. 1. Patient #4 had a start of care date of 7/21/25. Clinical record review revealed the following: a. The physician’s initial referral order, dated 5/16/25 and sent to the agency by facsimile on 6/17/25, ordered skilled nursing home health, physical therapy, occupational therapy and home health aide services but did not identify a specific start of care date. b. Patient Notes/Messages, dated 6/23/25, identified Staff H, RN (registered nurse), arrived to patient’s home and patient requested start of care be done Tuesday (6/24/25) after 12:00 PM. c. Patient Notes/Messages, dated 6/24/25, identified Staff H, RN, went to patient’s home at agreed time and no answer to door. Staff H called patient’s daughter, daughter called patient to let them know Staff H was at door and could come in. The patient never came to door. Staff H called daughter again and daughter requested agency staff contact daughter to arrange visit time so daughter could be present at patient’s home to let staff in the house. Staff H called office to request this information be added to patient’s chart. During an interview on 8/28/25 at 8:54 AM with Staff H, RN, she reviewed electronic medical record and reported to surveyor visits were assigned in June. The first visit Staff H was unable to get in Patient #4’s home, second visit Staff H was unable to get in the patient’s home. Staff H unsure what happened after that, admit visit was assigned to Staff H for July 18, Staff H called patient’s daughter and was able to get in home to complete admit on July 21, 2025. d. Staff D, Intake Nurse, completed an interim physician order, dated 7/18/25, documenting a physician ordered start of care date for 7/21/25. During an interview on 8/27/25 at 3:44 PM, Staff D, Intake Nurse, reported initial referral was faxed on 6/18/25 and admit was set up for that day, Staff H, RN had gone out to do the admit but patient wanted to be admitted the following Tuesday (6/24/25). Staff D went on vacation that Friday and did not know what happened after that. The patient’s daughter called the office in July asking why home health had not started yet, Staff H went out and did the admit in July. e. The Plan of Care, dated 7/21/25 to 9/18/25, identified the start of care date for Patient #4’s services was 7/21/25. f. The clinical record lacked documentation of any skilled nursing visit prior to 7/21/25 and lacked documentation of any case communication notes or notes within the electronic medical record explaining the delay. g. The clinical record lacked documentation of any follow up with the referring physician to report the delay in initial visit prior to 7/21/25, 34 days after the referral was received. During an interview on 8/28/25 at 9:34 AM, Staff A, Executive Director, confirmed the agency did not follow through on the referral. 2. Patient #3 had a start of care date of 7/25/25. Clinical record review revealed the following: a. The physician’s initial referral order, dated 7/16/25 and sent to the agency by facsimile on 7/16/25, ordered physical therapy services for balance disorder but did not identify a specific start of care date. b. Staff D, Intake Nurse, completed an interim physician order, dated 7/24/25, documenting a physician ordered start of care date for 7/25/25. c. The Plan of Care, dated 7/25/25 to 9/22/25, identified the start of care date for Patient #3’s services was 7/25/25. d. The clinical record lacked documentation of any skilled nursing visit prior to 7/25/25 and lacked documentation of any case communication notes or notes within the electronic medical record explaining the delay. e. The clinical record lacked documentation of any follow up with the referring physician to report the delay in initial visit prior to 7/24/25, 8 days after the referral was received. 3. Patient #2 had a start of care date of 5/29/25. Clinical record review revealed the following: a. The physician’s initial referral order, dated 5/23/25 and sent to the agency by facsimile on 5/23/25, ordered skilled nursing home health services and physical therapy services for frequent falls and lower extremity weakness but did not identify a specific start of care date. b. Staff E, Intake Nurse, completed an interim physician order, dated 5/28/25, documenting a physician ordered start of care date for 5/29/25. c. The Plan of Care, dated 5/29/25 to 7/27/25, identified the start of care date for Patient #2’s services was 5/29/25. d. The clinical record lacked documentation of any skilled nursing visit prior to 5/29/25 and lacked documentation of any case communication notes or notes within the electronic medical record explaining the delay. e. The clinical record lacked documentation of any follow up with the referring physician to report the delay in initial visit prior to 5/28/25, 5 days after the referral was received. 4. Patient #6 had a start of care date of 6/3/25. Clinical record review revealed the following: a. The physician’s initial referral order, dated 5/30/25 and sent to the agency by facsimile on 5/30/25, ordered skilled nursing home health services twice a week for wound care but did not identify a specific start of care date. b. Staff D, Intake Nurse, completed an interim physician order, dated 6/2/25, documenting a physician ordered start of care date for 6/3/25. c. The Plan of Care, dated 6/3/25 to 8/1/25, identified the start of care date for Patient #6’s services was 6/3/25. d. The clinical record lacked documentation of any skilled nursing visit prior to 6/3/25 and lacked documentation of any case communication notes or notes within the electronic medical record explaining the delay. e. The clinical record lacked documentation of any follow up with the referring physician to report the delay in initial visit prior to 6/2/25, 3 days after the referral was received. The findings were reviewed with the Executive Director and Performance Improvement Partner.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This Element is not met as evidenced by: Based on patient interviews, agency staff interviews, clinical record reviews and policy reviews, the agency failed to communicate and/or document communication with the physician and patient in ongoing plans for discharge from the agency for 1 of 5 sampled patients (Patient #3). Failure to communicate and document communication with the patient and physician in the clinical record placed the patient at risk for not receiving needed care and services at the time discharge occurs. Findings include: According to the policy titled Discharge Planning, dated 9/2020, discharge planning will be initiated for every client upon admission to the agency. Clinicians will assist clients regarding their discharge by consulting with client and family regarding the need for discharge, serving as a referral source to obtain follow up services and consulting with the client and family regarding the provision of discharge information. All communication and information regarding discharge planning will be documented in the clinical record. During an interview on 4/9/25 at 9:49 AM, the agency Director of Quality stated discharge planning discussions occur throughout care and are expected to be documented in the clinical record. Patient #3 had a start of care date of 2/14/12. During an interview on 4/7/25 at 7:35 PM, Patient #3, reported his/her frustration with the lack of communication from the agency regarding his/her discharge plans. Patient #3 stated he/she was informed of the agency’s plan to discharge him/her by the end of April 2025 as agency can no longer meet patient’s needs; however, patient has not received a discharge date or any assistance in securing another agency’s services. Patient noted he/she was told a Social Worker from the agency would be contacting him/her to assist with the transition of care. Patient denied having any communication from agency Social Worker and denied any communication regarding definitive discharge plans. Clinical record review revealed the following: a. The Plans of Care (POC), dated 2/5/25 to 4/5/25 and 4/6/25 to 6/4/25, included orders for skilled nursing and home health aide services. The POCs identified the patient had diagnoses of encounter for attention to cystostomy and quadriplegia. b. POC included orders for skilled nurse to provide 1 visit every other day for 60 days for bowel program and catheter management and for home health aide to provide 1 visit per day for 60 days. c. Skilled nurse communication note, dated 3/4/25, completed by Staff F, Registered Nurse (RN), identified patient and patient’s care team, including patient’s physician, were informed of agency’s plan to discharge patient by the end of April 2025 as agency can no longer meet patient needs. An order was obtained for Social Worker to assist with transition of care to another agency. d. Skilled nurse visit note, dated 3/23/25, completed by Staff C, RN, identified patient’s frustration with not receiving any communication regarding a specific discharge date and with not receiving a phone call or visit from Social Worker to assist him/her with the transition of care to another agency. e. Social Worker missed visit note, dated 3/27/25, completed by Staff E, Social Worker (SW), identified SW visit not needed at this time. During an interview on 4/8/25 at 4:00 PM, Staff E, SW, stated she received an email from Staff G, Scheduler, stating Staff A, Executive Director, reported patient does not need to be seen by SW as his/her transfer needs have been met. f. Skilled nurse visit note, dated 3/29/25, completed by Staff C, RN, identified patient still has not heard from SW to assist with discharge planning. g. Email communication (not entered in patient’s clinical record) received from Staff B, Director of Quality, dated 3/20/25, completed by Staff H, Clinical Manager, identified Agency B agreed to take Patient #3 and would be in touch regarding an admission date. During an interview on 4/8/25, Staff A, Executive Director, stated Agency B agreed to take patient and will be in touch with an admission date. Staff A identified it is a “miss” on the agency’s part if the communication with the patient and Agency B was not documented in the medical record. The agency failed to communicate with the patient and patient’s physician regarding ongoing discharge plans and the agency failed to document patient’s discharge plans in his/her clinical record. The above findings were reviewed with the Director of Quality.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on agency staff interview, policy review and review of emergency preparedness training documentation, the agency failed to ensure training in emergency preparedness to all current staff annually. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: According to the agency policy titled Emergency Management Plan, dated 5/2024, staff training includes: initial training in emergency preparedness policies and procedures to all new and existing team members, individuals providing service under arrangement, and volunteers if applicable. The training is provided every 2 years and demonstrates team members knowledge of emergency procedures. The agency will provide training to all new hire for all team members and individuals under arrangement and volunteers, if applicable within 30 days of hire. Review of the agency’s emergency preparedness plan trainings, lacked documentation of training for contracted Staff L, Occupational Therapist (OT) and contracted Staff M, Physical Therapist (PT). During an interview on 1/29/25 at 11:00 AM, the Director of Quality stated no training for Staff L, OT or Staff M, PT had been completed for the emergency preparedness plan. The above findings were reviewed with the Agency Administrator and the Office Manager,”

“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 5 of 5 sampled patients with wounds (Patients #1, #6, #12, #16 and #17). 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 Skin Management, revised 5/2024, a comprehensive wound assessment will be completed at every admission visit, weekly and with every comprehensive assessment time point (start of care, resumption of care, follow-up, significant change in condition and discharge) to include assessment of wound bed, wound edges, peri-wound, drainage, odor, signs and symptoms of infection and measurements (length x width x depth) unless orders from a physician direct otherwise. During an interview on 1/29/25 at 12:40 PM, Staff G, Clinical Manager stated wound measurements are done weekly and include length, width and depth. Staff G also noted wound measurements prepopulate from the previous visit. 1.Patient #1 had a start of care date of 6/18/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 12/15/24 to 2/12/25, identified the patient had diagnoses of encounter for change or removal of nonsurgical wound dressing, lymphangitis and venous insufficiency and included orders for skilled nursing services three times a week. b. The recertification comprehensive assessment, dated 12/14/24, included the following documentation of wounds: 1) Left lower extremity medial proximal: wound described to be open with partial thickness, wound bed is 100% pink. The description included attached wound edges, large amount of serous drainage, no odor and surrounding tissue is erythema and excoriated. The wound measured 1 centimeter (cm) by 2 cm. The measurements lacked a depth measurement. 2) Left lower extremity medial distal: wound described to be open and wound bed is 100% red. The description included attached wound edges, large amount of serous drainage and surrounding tissues is erythema and excoriated. The wound measured 5 cm by 4 cm. The measurements lacked a depth measurement. c. Skilled nurse visit notes, dated 12/16/24, 12/23/24 and 12/30/24, included the following documentation of wounds: 1) Left lower extremity medial proximal: wound described to be open. The description included attached wound edges, large amount of serous drainage, no odor and surrounding tissue is intact. The wound measured 1 cm by 2 cm. The measurements lacked an accurate depth measurement and identified 0 cm depth. 2) Left lower extremity medial distal: wound described to be open. The description included attached wound edges, large amount of serous drainage, no odor and surrounding tissue intact. The wound measured 5 cm by 4 cm. The measurements lacked an accurate depth measurement and identified 0 cm depth. d. Skilled nurse visit note, dated 1/6/25, included the following documentation of wounds: 1) Left lower extremity medial proximal: wound described to be open and wound bed red. The description included attached wound edges, surrounding tissue fragile, large amount of serous drainage and no odor. The wound measured 1 cm by 2 cm. The measurements lacked an accurate depth measurement and identified 0 cm depth. 2) Left lower extremity medial distal: wound described to be open and wound bed red. The description included attached wound edges, surrounding tissue fragile, large amount of serous drainage and no odor. The wound measured 5 cm by 2.5 cm. The measurements lacked an accurate depth measurement and identified 0 cm depth. e. Skilled nurse visit note, dated 1/13/25, included the following documentation of wounds: 1) Left lower extremity medial proximal: wound described to be open and wound bed pink/red. The description included attached wound edges, surrounding tissue intact, erythema, large amount of serous drainage and no odor. The wound measured 1 cm by 2 cm. The measurements lacked an accurate depth measurement and identified 0 cm depth. 2) Left lower extremity medial distal: wound described to be open and wound bed pink/red. The description included attached wound edges, surrounding tissue intact, erythema, large amount of serous drainage and no odor. The wound measured 5 cm by 2.5 cm. The measurements lacked an accurate depth measurement and identified 0 cm depth. f. Skilled nurse visit note, dated 1/20/25, included the following documentation of wounds: 1) Left lower extremity medial proximal: wound described to be open and wound bed red. The description included attached wound edges, surrounding tissue erythema, large amount of serous drainage and no odor. The wound measured 0.8 cm by 0.8 cm. The measurements lacked an accurate depth measurement and identified 0 cm depth. 2) Left lower extremity medial distal: wound described to be open and wound bed red. The description included attached wound edges, surrounding tissue intact, erythema, large amount of serous drainage and no odor. The wound measured 4 cm by 1 cm. The measurements lacked an accurate depth measurement and identified 0 cm depth. 2. Patient #6 had a start of care date of 4/30/22. Clinical record review revealed the following: a. The POCs, dated 10/16/24 to 12/14/24 and 12/15/24 to 2/12/25, identified the patient had diagnoses of flaccid neuropathic bladder, displaced intertrochanteric fracture left femur and pressure ulcer of sacrum and included orders for skilled nursing services one time a week. b. The resumption of care comprehensive assessment, dated 12/4/24, included documentation of wound to the sacrum. Wound described as open and unstageable. The description included wound bed 50% pink/red and 50% slough. Wound edges are attached, surrounding tissue intact, erythema, and fragile. No drainage or odor. The wound measured 1 cm by 0.8 cm. The measurements lacked a depth measurement. c. The recertification comprehensive assessment, dated 12/11/24, included documentation of wound to sacrum. Wound described as open and stage 2. The description included wound bed 100% pink/red. Wound edges are attached and surrounding tissue intact, fragile. Small amount of serosanguineous drainage. The wound measured 2 cm by 1 cm. The measurements lacked a depth measurement. d. The skilled nurse visit note, dated 12/18/24, included documentation of wound to sacrum. Wound described as open and stage 1. The description included wound bed 100% pink/red. Wound edges are attached, surrounding tissue intact and no drainage. The wound measured 1.8 cm by 1 cm. The measurements lacked an accurate depth measurement and identified 0 cm depth. The agency failed to included accurate and complete comprehensive assessments of wound measurements. 3. Patient #12 had a start of care date of 8/21/24. Clinical record review revealed the following: a. The POC, dated 12/19/24 to 2/16/25, identified the patient had diagnoses of pressure ulcer to the left heel and included orders for skilled nursing services two times a week. b. The recertification comprehensive assessment, dated 12/18/24, included documentation of wound to the left heel. Staff J described the wound open, stage 2 with wound bed red and wound edges attached with a moderate amount serosanguineous drainage. The wound measured 1.5 cm by 1.3 cm. The measurements did not include depth. The assessment also included a wound to the left lateral upper thigh. The wound identified stage 3 and included measurements of 1.5 cm by 1.3 cm. The measurements lacked a depth measurement. d. The skilled nurse visit note, dated 11/18/24 and 11/22/24, included documentation of a wound to the left heel. Staff O, LPN described the wound as open and stage 2. The description included wound bed red and moderate amount of serosanguineous drainage. The wound measured 1.2 cm by 1.2 cm. The measurements lacked an accurate depth measurement and identified 0 cm depth. The agency failed to included accurate and complete comprehensive assessments of wound measurements. 4. Patient #12 had a start of care date of 5/23/23 and discharged from the agency on 11/26/24. Clinical record review revealed the following: a. The POC, dated 11/13/24 to 1/11/25, identified the patient had diagnoses of a pressure ulcer of sacrum region and included orders for skilled nursing services one time a week. b. The resumption of care comprehensive assessment, dated 11/8/24, included documentation of wound to the sacrum. The wound measured 2.6 cm by 0.2 cm and depth of 0.1 cm. c. The skilled nurse visit note, dated 11/15/24, lacked documentation of the sacral wound assessment. The agency failed to included accurate and complete assessments of the wound. 5. Patient #17 had a start of care date of 4/1/24 and discharged form the agency on 7/3/24. Clinical record review revealed the following: a. The POC, dated 5/31/24 to 7/29/24, identified the patient had diagnoses of heart failure and included orders for skilled nursing services one time a week with nursing discharge date of 5/24/24. Orders also included physical therapy (PT)1 time a week and occupational therapy (OT) 1 time a week with OT discharge date of 6/14/24. b. The recertification comprehensive assessment, dated 5/28/24, included documentation of wound to the great toe. Wound described as open and measured 1.6 cm by 1.4 cm by 0.2 cm. c. The PT visit notes, dated 6/5/24 and 7/27/24, Staff F, PT, failed to include documentation of an assessment of the patient’s wound. d. The OT visit note, dated 6/5/24, Staff R, OT, failed to include documentation of an assessment of the patient’s wound. e. The physical therapy assistant (PTA) visit note, dated 6/14/24, Staff P, PTA failed to include documentation of an assessment of the patient’s wound. f. The PTA visit note, dated 6/17/24, Staff Q, PTA failed to include documentation of an assessment of the patient’s wound The agency failed to included accurate and complete assessments of wound measurements. The above findings reviewed with the Administrator and Director of quality.”

“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 5 of 7 sampled patients with home observation visits (Patients #1, #3, #4, #6 and #7). 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 Medication Profile Policy, revised 10/2024, a drug regimen review (DRR) will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a client has been placed on hold and with the addition of new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicate drug therapy and noncompliance with drug therapy. During an interview on 1/29/25 at 12:40 PM, Staff G, Clinical Manager stated DRR’s are completed at all assessment time points and whenever a new medication is added. 1.Patient #1 had a start of care date of 6/18/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 12/15/24 to 2/12/25, identified the patient had a diagnosis of Encounter for change or removal of nonsurgical wound dressing and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 12/14/24, completed by Staff G, Clinical Manager, included documentation a DRR was completed and no discrepancies identified. c. During a home observation visit on 1/23/25 at 9:00 AM with Staff G, Clinical Manager, interview with the patient stated he/she sets up his/her own medication. The following medication discrepancies were identified: 1) The patient identified he/she takes Penicillin V Potassium 500 milligrams (mg) with instructions to take one tablet by mouth twice a day. Patient reported taking this medication for greater than one year. The POC lacked documentation of an order for Penicillin V Potassium. The Penicillin V Potassium was filled on 12/26/24. 2) The patient identified he/she takes Senokot 8.6 mg regular strength one tablet one time a day for greater than one year. The POC lacked documentation of an order for Senokot. 3) The POC identified the patient takes Vitamin D3 oral 125 micrograms (mcg) (5000 units) with instructions to take one capsule by mouth every day. The bottle in the home is Vitamin D3 25 mcg (1000 units). Patient reports taking one tablet daily for greater than one year. The DRR failed to include an accurate review of all medications taken by the patient. 2.Patient #4 had a start of care date of 12/24/24. Clinical record review revealed the following: a. The POC, dated 12/24/24 to 2/21/25, identified the patient had a diagnosis of Chronic obstructive pulmonary disease and included physician orders for medication and skilled nursing services. b. The start of care comprehensive assessment, dated 12/24/24, completed by Staff I, RN, included documentation a DRR was completed, severe interactions were noted and no other discrepancies identified. c. During a home observation visit on 1/27/25 at 3:30 PM, Staff C, RN, set up patient’s medications. The following medication discrepancies were identified: 1) The patient identified he/she takes Nitroglycerin 0.4 mg tablets as needed for about one year. The POC lacked documentation of an order for Nitroglycerin tablets. 2) The patient identified he/she uses Breztri 160 mcg/4.8 mcg inhaler. The patient stated he/she has used it for about two months. The POC lacked documentation of an order for Breztri inhaler. 3) The patient identified he/she uses Stiolto Respimat 2.5 mcg/25 mcg inhaler. The patient stated he/she has used it for about two months. The POC lacked documentation of an order for Stiolto Respimat inhaler. The DRR failed to include an accurate review of all medications taken by the patient. 3.Patient #6 had a start of care date of 4/30/22. Clinical record review revealed the following: a. The POC, dated 12/15/24 to 2/12/25, identified the patient had a diagnosis of Displaced intertrochanteric fracture left femur and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 12/11/24, completed by Staff J, RN, included documentation a DRR was completed and no discrepancies identified. Assisted living facility staff administer patient’s medications. c. During review of the current POC and assisted living medication list, the following medication discrepancies were identified: 1) The POC identified the patient is taking Ferrous Sulfate 325 mg tablets with instructions to take one tablet orally every other day. The Assisted Living Facility (ALF) medication list does not include this medication. 2) The POC identified the patient is taking PreserVision AREDS capsules with instructions to take one capsule orally twice daily for eye health. The ALF medication list identified the patient is taking one tablet by mouth one time a day. 3) The POC identified the patient is taking Aspirin 81 mg with instructions to take one tablet orally once daily for heart. The ALF medication list does not include this medication. 4) The POC identified the patient is taking Senna-Plus 8.6-50 mg tablets with instructions to take two tablets orally two times daily for constipation. The ALF medication list does not include this medication. 5) The POC identified the patient is taking Miralax 17 gram (gm)/scoop with instructions to take 17 g orally once nightly as needed for constipation. The ALF medication list does not include this medication. 6) The POC identified the patient is taking Acetaminophen 325 mg tablets with instructions to take two tablets every four hours as needed for moderate pain. The ALF medication list identified the patient is taking Tylenol Extra Strength (Acetaminophen) 500 mg with instructions to take one tablet by mouth three times a day. 7) The POC identified the patient is taking Norco Oral 5-325 mg tablets with instructions to take one tablet orally every six hours as needed for severe back pain. The ALF medication list identified the patient is taking Hydrocodone-Acetaminophen (Norco Oral) tablets with instructions to take one tablet orally every 12 hours as needed for pain. 8) The ALF medication list identified the patient is taking Dulcolax oral tablets delayed release 5 mg with instructions to take 1 tablet by mouth every 24 hours as needed for constipation. The POC lacked documentation of an order for Dulcolax. 9) The ALF medication list identified the patient is taking Buspirone Hydrochloride (HCL) 7.5 mg tablets with instructions to take one tablet by mouth two times a day for anxiety and depression. The POC lacked documentation of an order for Buspirone HCL. The DRR failed to include an accurate review of all medications taken by the patient. 4. Patient #3 had a start of care date of 1/6/25. Clinical record review revealed the following: a. The POC, dated 1/6/25 to 3/6/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for medication and physical therapy and occupational therapy services. b. The comprehensive assessment at start of care, dated 1/6/25, completed by Staff N, Physical Therapist, included documentation a DRR was completed and no discrepancies identified. c. During a home observation visit on 1/27/25 at 11:45 AM with Staff E, Occupational Therapist, the surveyor identified the following medication discrepancies. 1) Albuterol Sulfate 2.5 mg/3 milliliter (ml) solution via nebulizer. During the visit the patient stated he/she utilizes the nebulizer at least daily and had been doing the nebulizer treatment prior to home health admission on 1/6/25. The medication not listed on the POC. 2) Gluticasone Propianoate nasal spray bottle, 1 squirt in each nare every day, and identified the medication taken for the past 2 weeks. 3) Acetaminophen 500 mg 2 tablets, identified taken for the past month for pain. 4) Calcium 238 mg, magnesium 143 mg, chloride 416 mg, identified taken for the past couple weeks. The DRR failed to include an accurate review of all medications taken by the patient. The above findings shared with the Administrator and Director of .Quality.”

“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 interviews, clinical record reviews and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient for 7 of 17 sampled patients (Patients #1, #4, #5, #7, #8, #10 and #15). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, supplies and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy titled Care Planning Process, revised 5/2024, an individualized written plan of care will be initiated within five days of start of care and updated at least every 60 days or as client’s condition warrants. The plan of care includes but is not limited to the following: All pertinent diagnoses, frequency and duration of services, all medications and treatments, and types of services, supplies and equipment required. 1.Patient #1 had a start of care date of 6/18/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 12/15/24 to 2/12/25, identified the patient had a diagnosis of Encounter for change or removal of nonsurgical wound dressing. The POC included the following durable medical equipment (DME) used by the patient: cane, grab bars, exam gloves, walker, bipap (bilevel positive airway pressure), bed rail, hand held shower, wound care supplies, ted hose, lymphedema pump and sock aid. b. During a home observation visit on 1/23/25 at 9:00 AM with Staff G, Clinical Manager, the surveyor identified the following DME used by the patient: medication cassette. The patient stated during the same home visit that he/she had used the medication cassette for greater than one year. The agency failed to include all DME utilized by the patient on the POC. 2. Patient #4 had a start of care date of 12/24/24. Clinical record review revealed the following: a. The POC, dated 12/24/24 to 2/21/25, identified the patient had a diagnosis of Chronic obstructive pulmonary disease. The POC included the following DME used by the patient: cane, oxygen, tub/shower bench, incontinence supplies and oxygen tubing. b. During a home observation visit on 1/27/25 at 3:30 PM with Staff C, RN, the surveyor identified the following DME used by the patient: bipap machine. The patient stated during the same home visit that he/she had used the bipap machine every night since 1998. c. Skilled nurse visit note, dated 12/31/24, completed by Staff H, Licensed Practical Nurse (LPN), identified the patient uses his/her four wheeled walker appropriately. The agency failed to included all DME used by the patient on the POC. 3. Patient #5 had a start of care date of 3/6/24. Clinical record review revealed the following: a. The POC, dated 12/31/24 to 2/28/25, identified the patient had a diagnosis of Venous insufficiency. The POC included the following DME used by the patient: grab bars, exam gloves, tub/shower bench and walker. b. During a home observation visit on 1/28/25 at 9:15 AM with Staff D, RN, the surveyor identified the following DME used by the patient: life alert system. The patient stated during the same home visit that he/she had the life alert for about two years. The agency failed to include all DME utilized by the patient on the POC. 4. .Patient #7 had a start of care date of 6/18/24. Clinical record review revealed the following: a. The POCs, dated 10/21/24 to 12/19/24 and 12/20/24 to 2/17/25, identified the patient had a diagnosis of Parkinson’s Disease. The POC included the following DME used by the patient: cane, grab bars, exam gloves, tub/shower bench, grabber, med planner, sock aid and apple watch. b. The POCs also included orders for the nurse to check the patients weight and to notify the physician for weight greater than 150 pounds or less than 149 pounds. c. The home health aide care plan, dated 12/20/24, included the task the aide to remind the patient to weigh self every visit (per scale). The agency failed to include all DME utilized by the patient on the POC to include a scale. 5. Patient #8 had a start of care date of 12/26/24. Clinical record review revealed the following: a. The POC, dated 12/26/24 to 2/23/25, identified the patient had a diagnosis of hypertensive heart and kidney disease. The POC included the following DME used by the patient: cane, wheelchair, elevated toilet seat, grab bars, tub/shower bench, walker, chux/underpads, reacher, pill cutter and pill box. b. The comprehensive assessment at the start of care, dated 12/26/24, included documentation the patient had a ramp at the home entrance. The agency failed to include all DME utilized by the patient on the POC to include a ramp. 6. Patient #10 had a start of care date of 12/8/24. Clinical record review revealed the following: a. The POC, dated 12/8/24 to 2//25, identified the patient had a diagnosis of urinary tract infection. and diabetes mellitus. The POC included the following DME used by the patient: wheelchair, gloves and walker. The POC also included diabetic medications which included Novolog insulin mix 70/30 units administered per sliding scale (blood sugar readings). b. The comprehensive assessment at the start of care, dated 12/8/24, included documentation the patient had diabetic supplies and incontinent of urine.. The agency failed to include all DME utilized by the patient on the POC to include a diabetic and incontinent supplies. 7. Patient #15 had a start of care date of 12/18/24. Clinical record review revealed the following: a. The POC, dated 12/18/24 to 2/15/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease. The POC included the following DME used by the patient: wheelchair, dressing supplies, diabetic supplies, grab bars, tub/shower bench, electric wheelchair, transfer board removable shower head, libra testing supplies. b. The comprehensive assessment at start of care, dated 12/18/24, included documentation the patient had an electric wheelchair and had incontinence. c. The occupational therapy evaluation, dated 12/27/24, included documentation the patient had an electric wheelchair and had incontinence. The agency failed to include all DME utilized by the patient on the POC to include an electric wheelchair and incontinence products. The above information reviewed with the Administrator and Director of Qaulity.”

“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 agency staff interview, patient interview, clinical record review and agency policy review, the agency failed to follow physician orders for treatments for 7 of 17 sampled patients (Patients #1, #3, #5, #6, #7, #8 and #17). Failure to ensure staff obtain and follow physician orders for treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy titled Care Planning Process, revised 5/2024, the Plan of Care will be based on the physician’s orders and will encompass the equipment, supplies and services required to meet the client’s needs. 1.Patient #1 had a start of care date of 6/18/24. Clinical record review revealed the following: a. The Plans of Care (POC), dated 10/16/24 to 12/14/24 and 12/15/24 to 2/12/25, identified the patient had a diagnosis of Encounter for change or removal of nonsurgical wound dressing and included orders for skilled nursing visits three times a week. b. The POCs included physician orders for medications and treatments, which included orders to notify the physician of weight greater than 317 pounds or less than 297 pounds. c. The skilled nurse visit notes, dated 11/18/24, 11/22/24, 11/25/24, 11/27/24, 11/29/24, 12/2/24, 12/4/24, 12/6/24, 12/9/24, 12/16/24, 12/20/24, 12/23/24, 12/26/24, 12/28/24, 12/30/24, 1/1/25, 1/3/25, 1/6/25, 1/8/25, 1/10/25, 1/13/25, 1/15/25, 1/17/25 and 1/20/25 lacked documentation of the patient’s weight. d. The skilled nurse visit note, dated 1/23/25 included documentation the patient weighed 321 pounds but lacked documentation the physician was notified of the weight that fell outside parameters set. Agency staff failed to document the patient’s weight every visit and failed to notify physician of weight outside parameters set on POC. 2.Patient #5 had a start of care date of 3/6/24. Clinical record review revealed: a. The POCs, dated 11/1/24 to 12/30/24 and 12/31/24 to 2/28/25, identified the patient had a diagnosis of Venous insufficiency and included orders for skilled nursing visits one time a week. b. The POCs included physician orders for medications and treatments, which included orders for skilled nurse to assess oxygen saturation on room air every visit and notify physician of oxygen saturation less than 90% on room air. c. The skilled nurse visit note, dated 12/30/24, lacked documentation of the patients oxygen saturation on room air. The agency staff failed to document the patient’s oxygen saturation on room air each visit. 3. Patient #6 had a start of care date of 4/30/22. Clinical record review revealed the following: a. The POC, dated 12/15/24 to 2/12/25, identified the patient had a diagnosis of Displaced intertrochanteric fracture left femur and included orders for skilled nursing visits one time a week. b. The POC included physician orders for medications and treatments, which included orders to notify the physician of weight greater than 138 pounds or less than 128 pounds. c. The skilled nurse visit notes, dated 12/18/24, 12/24/24, 1/1/25, 1/8/25, 1/15/25 and 1/22/25 lacked documentation of the patient’s weight. Agency staff failed to document the patient’s weight every visit.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and agency staff interview, the agency failed to ensure skilled professional staff involved in the patient’s plan of care completed an ongoing interdisciplinary services as required by agency policy and expectation for 1 of 8 sampled patients (Patient #8), who received home health aide services. Failure to complete an ongoing interdisciplinary services placed patients at risk not receiving ongoing needs. Findings include: According to the agency policy, titled Home Health Timely Initiation of Therapy Services Policy, reviewed 12/2024, during the start of care a clinical comprehensive assessment will be performed. The patient’s overall clinical status and health care needs will be assessed by the admitting clinician. Initiating multi-disciplinary services indicated from referral documentation will be reviewed by the start of care clinician. Front loading various disciplines will be considered to meet the patient’s highest clinical need. During Interview on 1/29/25 at 1:30 PM, Staff A, Administrator, stated the agency does a daily huddle with staff every morning and afternoon. In the morning huddle the agency discusses what the patient needs are and what visits are scheduled or needed. We discuss admits and recertifications. In the afternoon huddle, we discuss any concerns for the day. During an interview on 1/29/25 at 11:00 AM, Staff B Director of Quality, stated the agencies process is for the skilled nurse or Physical Therapist (PT) to do a clinical assessment at start of care and identify the patients needs. She further stated the agency has a standard for the Occupational Therapy (OT) to go over the needs with the patient. We like OT to evaluate the patient, to build the plan if there is a natural support to provide education. Expectation will vary on the patient needs. If the patient needs a bath aide prior to OT evaluation, the agency would provide the bath aide. If need care as soon as the patient needs it. If I had impairment or moving needs. Any qualified provider could provide the service. We have had some staffing problems with start of aide services. We have had looks at other disciplines providing bathing. We have had internal conversation, we have looked at hire new staff and OT, PT staff to bathe the patients. Patient #8 had a start of care date of 12/26/24. Clinical record review revealed: a. The Plan of Care (POC), dated 12/26/24 to 2/23/25, identified the patient had a diagnosis of hypertensive heart and chronic kidney disease. Orders included skilled 1 time a week physical therapy 1 times a week and occupational therapy 1 time a week. a. The patient consent at admission, dated 12/26/24, identified services included physical therapy (PT) occupational therapy (OT) and home health aide (HHA) based on OT evaluation. b. The comprehensive assessment completed at start of care, dated 12/26/23, documented the patient required assistance with grooming and dressing of the upper and lower body and required the presence of another person in bathing for assistance or supervision. b. The missed visit note, dated 12/31/24, included documentation the visit missed due to the Patient unsure if wanted OT referral for services. c. The PT notes, dated 1/3/25 and 1/7/25, failed to include documentation the patient’s hygiene needs addressed. d. The OT noted dated 1/9/25, included documentation the patient required HHA service for hygiene needs. e. The HHA noted dated 1/17/25, included a visit made with hygiene services of provided (22 days following the start of care). The agency nurses failed to provided services required by the patient in a timely manner. The above findings were reviewed with the Administrator and Director of Quality.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on staff interviews, patient/caregiver interviews, policy review and clinical record review the agency Failed to ensure each patient received services that were established by a doctor of medicine, osteopathy or podiatry (G572); The cumulative effects of these systemic practices resulted in placing patients at risk of not receiving safe, individualized and consistent care designed to meet each patients health needs.”

“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 staff interviews, patient/caregiver interviews, policy review and clinical record review, the agency failed to follow a Plan of Care established and periodically reviewed by a physician and to notify the physician of the need to vary frequency of visits or inability to perform services as originally ordered on the Plan of Care for 1 out of 8 sampled patients. (Patient #3) 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 patients health needs. According to the policy, Care Planning Process, dated 5/2024, an individualized written plan of care will be initiated within five days of the start of care and updated at least every 60 days or as the clients condition warrants. The clinical plan of care will include the types of services, supplies and equipment required and the frequency and duration of visits to be made. The plan of care will be based upon the physicians orders. Clinicians will inform the client’s physician of any changes that suggest a need to alter the plan of care and changes must be written, dated, and signed by the professional making the changes. The organization will provide the client and caregiver a copy of written instructions, outlining a visit schedule, including frequency of visits by personnel acting on behalf of the organization. During an interview on 9/23/24 at 11:30 AM, Patient #3’s caregiver stated, that no home care services had been provided since 8/13/24, and stated the RN Case Manager told her it was because the authorization had not been approved. The caregiver reported she took over setting up Patient #3 medications, because there was no one else available for that task, but stated she did not feel comfortable with the medication set up and felt that a nurse should be completing that task. The caregiver for patient #3 reported she took patient #3 to see her physician on 9/9/24 and asked the physician why Patient #3 was no longer receiving home care services. The Caregiver indicated the physician stated in the appointment that Patient #3 should still be receiving services and the authorization should have been obtained by the agency before the last one had expired. The caregiver stated she had contacted the home health office at least twice during the time between 8/13/24 and 9/23/24, and stated the answer she was given, was the agency was waiting on prior authorization to be approved and that someone would look into why it had not been approved yet. The caregiver reported she never received an answer. Interview 9/23/24 at 11:00 AM with Staff B, Director of Quality, stated there is no stop gaps in the agency’s electronic medical record (EMR) to indicate when Patient #3 was inactive. All patient prior authorizations for services are completed by the contracted authorization company that does the home health agency’s prior authorizations. If a prior authorization doesn’t come in prior to the end date, and the recertification is due, and the home health agency is not alerted to the prior authorization coming through, the patient can fall off the census and become inactive. So with Patient #3, the agency didn’t have prior authorization to go out to see Patient #3 through her/his health care plan, the recertification was missed and there was not a fail stop in our EMR to alert us that Patient #3 was not on the schedule. During interview on 9/25/24 at 2:00 pm, with Staff A, Administrator and Staff B, Director of Quality, both acknowledged Patient #3 was not identified on the agency’s current census list nor was Patient #3 identified on the agency’s discharge list that the agency had provided to the surveyor. Staff B, Director of Quality stated Patient #3 had fallen to an inactive patient status, when the clinician failed to complete the comprehensive assessment for recertification due by 8/29/24 and Patient #3’s prior authorization (a process that requires the home health agency to contact a patient’s health plan and receive approval for the home health services before the services can be covered) had expired on 8/13/24. Staff B, Director of Quality, reported the assigned clinician did not complete the comprehensive assessment for Patient #3 because there was not a current approved prior authorization for Patient #3. Because there was not a current approved prior authorization for Patient #3 the system did not alert the management to request a non billable visit to complete that comprehensive assessment as would be the agency expectation. Staff A, Administrator and Staff B, Director of Quality both acknowledged they were not aware Patient #3 had not been receiving any of the physician ordered services since 8/13/24 until the Surveyor’s clinical record review brought it to their attention. Staff B, Director of Quality reported their electronic medical record, (EMR) does not have a trigger to alert staff when a new authorization has been approved if the patient is past the end of the recertification period. Staff B, Director of Quality, acknowledged if the Plan of Care (POC) is not followed and visits are missed, the physician needs to be contacted. Staff A, Agency Administrator and Staff B, Director of Quality together, acknowledged that Patient #3 had a lapse in services between 8/13/24 and the end of the certification period 8/29/24, and the agency failed to notify the physician of the missed visits. During interview on 9/23/24 at 4:00 PM, Staff C, Registered Nurse (RN), indicated skilled nursing visits could not be completed with Patient #3 after 8/13/24, because the prior authorization had expired and new authorization had not been approved. Staff C, RN stated, if the authorization can not be obtained prior to the end of the certification period, the expectation would be that the patient be discharged and then admitted again once the authorization was approved. The physician would be notified. Staff C, RN reported she did email the authorization team to request a new authorization for Patient #3, however she had not received confirmation it had been approved and stated she had been on vacation at the time the recertification comprehensive review should have been completed. During a staff interview on 9/23/24 at 1:55 pm, Staff D, Home Health Aide, revealed she was the the primary home care aide for Patient #3 and indicated she was instructed to stop going to provide services for Patient #3 by the RN Case Manager, Staff C, because there was no prior authorization approved after 8/13/24. Staff D stated if the patient doesn’t have approval from insurance, sometimes staff are instructed to stop providing visits until further instruction is given from the RN Case Manager. Staff D reported she attempted to get answers via email and phone calls from office staff, but stated she never received a response back and Patient #3 was no longer on her schedule. Patient #3 had a start of care date of 3/9/23. Clinical record review revealed the following. The Plan of Care (POC), dated 7/1/24 to 8/29/24, included physician orders for Skilled Nursing visits once ever other week for assessment, medication set up, compliance and Home Health aide visits home health aide visits, 2 time per week for bathing and personal cares. a. The clinical record lacked documentation of any skilled nurse visits between 8/7/24 and 8/29/24. b. The clinical record lacked documentation of any home health aide visits between 8/13 and 8/29. The clinical record lacked documentation of communication with the physician for missed visit notification. The clinical record lacked documentation of notification to the physician regarding the missed visit. The above findings were reviewed with Staff A, Administrator and Staff B, Director of Quality.”

“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 policy review, clinical record review and agency staff interviews, the agency failed to follow a Plan of Care (POC) established and periodically reviewed by a physician or notify the physician of missed visits for 3 of 5 sampled patients (Patients #1,#3 and #4). Failure to follow a POC 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: According to the agency policy, titled Care Planning Process and dated 5/2024, the Plan of Care (POC) will be based on the physician’s orders and will encompass the equipment, supplies, and services required to meet the client’s needs. Clinicians will inform the client’s physician of any changes that suggest a need to alter the plan of care. According to the agency policy, titled Missed Visits and dated 2/2022, missed visits will be communicated to the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. Clinical record review revealed the following: 1. Patient #1 had a start of care date of 5/23/23. a. The POC, dated 3/18/24 to 5/16/24, included physician orders for skilled nursing visits once week for 9 weeks, for skilled observation, assessment of diabetes and respiratory status. b. The clinical record lacked documentation of skilled nurse visits the week of 3/25/24 through 3/30/24. c. The clinical record lacked documentation of skilled nurse visits the week of 3/31/34 through 4/6/24. The clinical record lacked documentation of notification to the physician regarding the missed skilled nurse visits. 2. Patient #3 had a start of care date of 5/1/24 a. The clinical record lacked documentation a plan of care was developed at the time of admission. b. The clinical record lacked documentation a plan of care was developed at the time of recertification 6/26/24. The agency failed to develop and complete a plan of care with physician orders to provide appropriate care of the patient both at admission and on recertification. 3. Patient # 4 had a start of care date of 5/6/24. a. The POC, dated 5/6/24 to 7/4/24, included physician orders for skilled nursing visits once week for 9 weeks, for skilled observation, assessment. b. The clinical record lacked documentation of skilled nurse visits the week of 5/12/24-5/18/24. c. The clinical record lacked documentation of skilled nurse visits the week 5/19/24 - 5/25/24. d. The clinical record lacked documentation of skilled nurse visits the week of 5/26/24 - 6/1/24 e. The clinical record lacked documentation of skilled nurse visits the week of 6/2/24 - 6/8/24. f. The clinical record lacked documentation of skilled nurse visits the week of 6/9/24 - 6/15/24. g. The clinical record lacked documentation of skilled nurse visits the week of 6/16/24 - 6/22/24. h. The clinical record lacked documentation of skilled nurse visits the week of 6/23/24 - 6/29/24. i. The clinical record lacked documentation of skilled nurse visits the week of 6/30/24 - 7/4/24. The clinical record lacked documentation of notification to the physician regarding the missed skilled nurse visits. The above findings were reviewed with the Administrator and Director of Clinical Quality.”

“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 policy review, clinical record review and agency staff interviews, the agency failed to follow a Plan of Care (POC) established and periodically reviewed by a physician or notify the physician of missed visits for 4 of 5 sampled patients (Patients #1, #2, #3, and #4). Failure to follow a POC 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: According to the agency policy, titled Care Planning Process and dated 5/2024, the Plan of Care (POC) will be based on the physician’s orders and will encompass the equipment, supplies, and services required to meet the client’s needs. Clinicians will inform the client’s physician of any changes that suggest a need to alter the plan of care. According to the agency policy, titled Missed Visits and dated 2/2022, missed visits will be communicated to the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. During an agency staff interview on 5/13/24 at 4:08 PM, the Administrator reported anytime a POC is affected, the physician needs notified. 1.Patient #1 had a start of care date of 4/14/24. Clinical record review revealed the following: a. The POC, dated 4/14/24 to 6/12/24, included physician orders for skilled nursing visits once week for 9 weeks for skilled observation, assessment, and wound care for laceration of scalp, skin tear to left arm and elbow, and skin tear to left knee. The plan also included physician reporting parameters including: 1. Systolic blood pressure readings greater than 160 or less than 85. 2. Diastolic blood pressure readings greater than 100 or less than 60. b. The skilled nurse visit note, dated 4/25/24, identified the patient’s blood pressure reading was 110/50. The diastolic reading was below the physician ordered parameters on the POC. The clinical record lacked documentation the nurse contacted the physician to report the low diastolic blood pressure reading. 2. Patient #2 had a start of care date of 2/14/2012. Clinical record review revealed the following: a. The POCs, dated 2/11/24 to 4/10/24 and 4/11/24 to 6/9/24, included physician orders for home health aide services once daily for 60 days for personal cares. b. The clinical record lacked documentation of any home health aide visits on the following days: 3/10/24, 3/22, 3/23, 3/24, 4/6, 4/7, 4/20, 4/21, 5/4, and 5/5/24. The clinical record lacked documentation of notification to the physician regarding the missed visits. 3. Patient #3 had a start of care date of 1/17/24. a. The POC, dated 3/17/24 to 5/15/24, included physician orders for home health aide services once weekly effective 3/20/24. b. The clinical record lacked documentation of home health aide visits the week of 3/17/24 through 3/23/24. The clinical record lacked documentation of notification to the physician regarding the missed visit. 4. Patient #4 had a start of care date of 4/20/24. a. The POC, dated 4/20/24 to 6/18/24, included physician orders for home health aide services twice a week for 9 weeks. b. The clinical record identified a missed visit on 5/10/24 due to patient being out of town. The clinical record lacked documentation of notification to the physician regarding the missed visit. The above findings were reviewed with the Administrator and Director of Clinical Quality. The agency provided no additional information prior to the end of the survey.”