Good Samaritan Society Home Care

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 3 of 5 sampled patients with orders for Physical Therapy services. (Patients #1, #4 and #5) Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient’s health care needs. Findings: According to the agency policy, titled Provider Orders and Notification, dated 5/27/25, the nurse or qualified practitioner responsible for furnishing/supervising the ordered services, must document orders in the patient’s medical record. Verbal orders must be authenticated by the provider. The provider must be notified of any missed visits. Documentation in the clinical record must reflect this notification. During an interview on 2/11/26 at 11:45 AM, Staff A, Administrator, reported missed visits are documented in a coordination note, the staff documenting the missed visit is responsible for notifying the physician of the missed visit and this should be documented in that coordination note. 1. Patient #1 had a start of care date of 12/26/25. Clinical record review revealed: a. Plan of Care, dated 12/26/25 to 2/23/26, included orders for skilled nursing, physical therapy and occupational therapy services. Physical therapy effective 12/28/25 for one time a week for one week. b. PT visit note, dated 1/4/26, completed by Staff E, PT, identified evaluation completed. One week after the order, dated 12/28/25. No documentation why evaluation visit not completed week of 12/28/25 as ordered. c. PT interim physician order, dated 2/11/26, completed by Staff A, Administrator, included documentation initial PT evaluation to be completed on 1/4/26. During an interview on 2/11/26 at 3:15 PM, Staff A, Administrator provided surveyor with a copy of Webex communication (electronic communication program used by agency staff) dated 1/2/26 by Staff E, PT, requesting evaluation be moved to 1/4/26. The agency failed to provide PT services as ordered. 2. Patient #5 had a start of care date of 1/6/26. Clinical record review revealed Plan of Care, dated 1/6/26 to 3/6/26, included orders for skilled nursing, physical therapy and occupational therapy services. Physical therapy effective 1/11/26 for one time a week for one week. The clinical record lacked documentation of a PT evaluation visit or documentation of a reason why PT evaluation was not completed. The agency failed to provide PT services as ordered. 3. Patient #4 had a start of care date of 10/29/25. Clinical record review revealed: a.Plan of Care (POC), dated 12/27/25 to 2/24/26, included the patient’s diagnosis of chronic obstructive pulmonary disease (COPD) and orders for Physical Therapy (PT) to evaluate the patient. b.Physical Therapy (PT) visit note, dated 12/23/25, completed by Staff E, Physical Therapist (PT), identified evaluation completed. No documentation why the Physical Therapy (PT) evaluation visit was not completed after 12/27/25 as ordered. c.The next Physical Therapy (PT) visit took place on 1/8/26 with Staff G, Physical Therapy Assistant (PTA). The agency failed to complete a Physical Therapy (PT) evaluation visit after 12/27/25 as ordered. d.Physical Therapy (PT) interim physician order, signed by Staff H, Nurse Practitioner, dated 12/23/25, included orders for Physical Therapy (PT) as follows: Physical Therapy (PT) effective 12/28/25 for 1 visit per week for 3 weeks and 2 visits per week for 1 week. e.Physical Therapy (PT) visit note, dated 12/23/25, completed by Staff E, Physical Therapist (PT), identified a visit completed. f.The next Physical Therapy (PT) visit took place on 1/8/26 with Staff G, Physical Therapy Assistant (PTA). No documentation of why a Physical Therapy (PT) visit was not completed the week of 12/28/25. The agency failed to complete a Physical Therapy (PT) visit the week of 12/28/25 as ordered. g.Physical Therapy (PT) interim physician order, signed by Staff H, Nurse Practitioner, dated 1/22/25, included orders for physical therapy as follows: Physical Therapy (PT) effective 1/25/25 for 1 visit per week for 1 week, 2 visits per week for 1 week, and 1 visit per week for 2 weeks. h.Physical Therapy (PT) visit notes, dated 1/14/26 and 1/22/26 completed by Staff E, Physical Therapist (PT), identified visits were completed. No documentation of why a second Physical Therapy (PT) visit was not completed the week of 1/18/26. The agency failed to complete a second Physical Therapy (PT) visit the week of 1/18/26. i.The Physical Therapy (PT) visit note, dated 1/22/26, completed by Staff E, Physical Therapist (PT) and the Physical Therapy (PT) visit note, dated 2/3/26, completed by Staff I Physical Therapy Assistance (PTA) identified visits were completed. No documentation of why a visit was not completed the week of 1/25/26. The agency failed to complete 1 Physical Therapy (PT) visit the week of 1/25/26. The agency failed to provide physical therapy (PT) services as ordered. The above findings were shared with the Administrator and the Senior Administrative Assistant. According to the agency policy, titled Provider Orders and Notification, dated 5/27/25, the nurse or qualified practitioner responsible for furnishing/supervising the ordered services, must document orders in the patient’s medical record. Verbal orders must be authenticated by the provider. The provider must be notified of any missed visits. Documentation in the clinical record must reflect this notification. During an interview on 2/11/26 at 11:45 AM, Staff A, Administrator, reported missed visits are documented in a coordination note. The staff documenting the missed visit is responsible for notifying the physician of the missed visit and this should be documented in the coordination note. 1. Patient #1 had a start of care date of 12/26/25. Clinical record review revealed: a. Plan of Care, dated 12/26/25 to 2/23/26, included orders for skilled nursing, physical therapy and occupational therapy services. Physical therapy (PT) effective 12/28/25 for one time a week for one week. b. PT visit note, dated 1/4/26, completed by Staff E, Physical therapist (PT), identified evaluation completed. One week after the order, dated 12/28/25. No documentation why evaluation visit not completed week of 12/28/25 as ordered. c. PT interim physician order, dated 2/11/26, completed by Staff A, Administrator, included documentation initial PT evaluation to be completed on 1/4/26. During an interview on 2/11/26 at 3:15 PM, Staff A, Administrator provided surveyor with a copy of communication by electronic communication program used by agency staff dated 1/2/26 by Staff E, PT, requesting evaluation be moved to 1/4/26. The agency failed to provide PT services as physician ordered. 2. Patient #5 had a start of care date of 1/6/26. Clinical record review revealed Plan of Care, dated 1/6/26 to 3/6/26, included orders for skilled nursing, physical therapy and occupational therapy services. Physical therapy effective 1/11/26 for one time a week for one week. The clinical record lacked documentation of a PT evaluation visit or documentation of a reason why PT evaluation was not completed. The agency failed to provide PT services as physician ordered. Patient #1 had a start of care date of 8/3/21. Clinical record review revealed: a. Plan of Care, dated 11/9/25 to 1/7/26, included primary diagnosis of mild intellectual disability and physician orders for skilled nursing services one time per week and home health aide services seven times per week. b. There was no home health aide visit note, dated 12/7/25, 12/13/25 or 12/14/25, or documentation notifying the physician why no visit was completed on 12/7/25. 12/13/25 or 12/14/25. c. There was no home health aide note, dated 1/3/26, or documentation notifying the physician why no visit was completed on 1/3/26. The agency failed to provide home health aide services as ordered in the plan of care or notify the physician why the services were not provided as ordered. 3. Patient #4 had a start of care date of 10/29/25. Clinical record review revealed: a. Plan of Care (POC), dated 12/27/25 to 2/24/26, included the patient’s diagnosis of chronic obstructive pulmonary disease (COPD) and orders for Physical Therapy (PT) to evaluate the patient. b. The agency failed to complete a Physical Therapy (PT) evaluation visit after 12/27/25 as ordered. c .Physical Therapy (PT) interim physician order, signed by Staff H, Nurse Practitioner, dated 12/23/25, included orders for Physical Therapy (PT) as follows: Physical Therapy (PT) effective 12/28/25 for 1 visit per week for 3 weeks and 2 visits per week for 1 week. d.The next Physical Therapy (PT) visit took place on 1/8/26 with Staff G, Physical Therapy Assistant (PTA). There was no physical therapy visit note, for the week of 12/28/25, or documentation notifying the physician why no visit was completed and No documentation of why a second Physical Therapy (PT) visit was not completed the week of 1/18/26. f.The next Physical Therapy (PT) visit took place on 1/8/26 with Staff G, Physical Therapy Assistant (PTA). No documentation of why a Physical Therapy (PT) visit was not completed the week of 12/28/25. The agency failed to complete a Physical Therapy (PT) visit the week of 12/28/25 as ordered. g.Physical Therapy (PT) interim physician order, signed by Staff H, Nurse Practitioner, dated 1/22/25, included orders for physical therapy as follows: Physical Therapy (PT) effective 1/25/25 for 1 visit per week for 1 week, 2 visits per week for 1 week, and 1 visit per week for 2 weeks. h.Physical Therapy (PT) visit notes, dated 1/14/26 and 1/22/26 completed by Staff E, Physical Therapist (PT), identified visits were completed. No documentation of why a second Physical Therapy (PT) visit was not completed the week of 1/18/26. The agency failed to complete a second Physical Therapy (PT) visit the week of 1/18/26. i.The Physical Therapy (PT) visit note, dated 1/22/26, completed by Staff E, Physical Therapist (PT) and the Physical Therapy (PT) visit note, dated 2/3/26, completed by Staff I Physical Therapy Assistance (PTA) identified visits were completed. No documentation of why a visit was not completed the week of 1/25/26. The agency failed to complete 1 Physical Therapy (PT) visit the week of 1/25/26. The agency failed to provide physical therapy (PT) services as ordered. The above findings were shared with the Administrator and the Senior Administrative Assistant.”

“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 patient interview, staff interview, agency policy, clinical record, and observation, the agency failed to include all supplies/equipment and medications in Plans of Care for 1 of 3 sampled patients with home visit observations, Patient #3. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services according to assessed needs and physician orders. Findings include: According to the agency policy, titled Care Planning and Care Coordination, Home Health and Therapy, dated 11/12/25, the plan of care should be patient-specific and include complete medication and treatment orders, equipment and supplies. In an interview on 2/11/26 at 10:30 AM, when asked if the Plan of Care (POC) should include all of the patient’s current medications, the Administrator reported that she will educate the nurse on medication reconciliation. Patient #3 had a start of care date of 11/26/25. Clinical record review, home visit observation, and patient interview revealed the following: a. The POC, dated 1/25/26 to 3/25/26, had a diagnosis of surgical aftercare following surgery of the digestive system and congestive heart failure (CHF, heart muscle is unable to pump blood efficiently, causing blood to back up and fluid to build up in the lungs, legs, and other tissues) and orders for skilled nursing services and the following medications: ferrous sulfate 325 mg 1 tablet daily, furosemide 20 mg 1 tablet daily and Nystop powder100,000 units one application per day when needed for skin rash. b. During home observation on 2/10/26 at 10:00 AM, Patient #3 reported they used the medications since before they started home health care with the agency and showed the surveyor the medication containers of ferrous sulfate, furosemide, and Nystop powder. The above findings were reported to the Administrator and Senior Administrative Assistant.”

“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, policy review, and clinical record review, the agency failed to comprehensively provide wound assessments for 1 of 2 sampled patients with wounds, Patient #3. Failure to accurately and thoroughly complete wound assessments placed patients at an increased risk of unidentified condition changes. Findings include: Review of the agency’ s policy, titled Wound Care, Home Health, Hospice, and Assisted Living, last revised 9/23/25, wounds will be measured in centimeters (length x width x depth) at least weekly unless covered with a non-removable dressing during the nurse visit. Wound and peri-wound appearance will be assessed each visit unless covered with a non-removable dressing. Wound assessment will include but is not limited to; color, odor, drainage, tunneling/undermining, and character of wound bed tissue. In an interview on 2/10/26 at 10:40 AM, when asked about frequency and content of wound assessment, the Administrator reported that wound assessment are performed the first visit of every week. The assessment would be documented in an area under the visit notes, to include length, width, and depth, and a general description of the wound, odor, drainage. Patient #3 had a start of care date of 11/26/25. Clinical record review revealed the following: a.The patient had a Plan of Care (POC), dated 1/25/26 to 3/25/26, and had a diagnosis of surgical aftercare following surgery of the digestive system. The patient had weekly skilled nursing visits. b.The skilled nursing visits completed by Staff B, Registered Nurse (RN) failed to include comprehensive wound assessments and wound measurements for the weeks of 12/12/25, 12/19/25, 12/24/25, and 12/31/25. c. The skilled nursing visit completed by Staff B, RN on 1/30/26 failed to include measurement of the wound. d.In an interview on 2/10/26 at 10:00 AM, Staff B, RN, reported that she measures the patient’s wound weekly unless the patient just had the dressing changed at the wound clinic. The agency failed to obtain weekly wound assessment including measurements. The above findings were shared with the Administrator and the Senior Administrative Assistant.”