Lutheran Home Health Agency

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on clinical record review, agency policy review, patient/caregiver interview and agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 1 of 5 sampled patients receiving home health aide services (Patient #6). The agency reported 13 patients received care provided by a home health aide. Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency’s home health aides for each patient increased the risk agency patients would receive inappropriate or inconsistent home health aide services. Findings include: According to the policy, titled Home Health Aide/Homemaker Visit Note, dated 7/11/25, the aide must follow the care plan exactly. Each task/activity on the care plan must be charted, either completed or refused, with every visit. Patient #6 had a start of care date of 3/28/25 and a discharge date of 4/25/25. Clinical record review revealed: a. Plan of Care, dated 3/28/25 to 5/26/25, included primary diagnosis of acute cystitis without hematuria and physician orders for skilled nursing and home health aide services. b. Aide care plan, dated 3/31/25, included tasks bath: bed per patient request and bath: shower bench. c. Aide visit notes, dated 4/4, 4/11, 4/18, 4/22 and 4/25/25, included documentation the task bath: bed per patient request was not applicable and the task bath: shower bench was done. d. Aide visit notes, dated 4/1, 4/8 and 4/15/25, included documentation the task bath: bed per patient request patient refused and the task bath: shower bench was done. During an interview on 1/7/25 at 2:11 PM, Staff B, Clinical Manager, reported the aide task bath: shower bench should be entered on the care plan with the task bath: shower. Staff B indicated the task bath: shower bench would indicate the patient used a shower bench when bathing from the aide but the task bath: shower was not an option for the aide to document. The aide care plan failed to include all necessary specific tasks for the aide to complete. The above stated findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.”

“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 clinical record review, policy review and agency staff interview, the agency failed to follow physician orders for 1 of 7 sampled patients (Patient #2). Failure to ensure staff follow physician orders placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Plan of Care, dated 7/11/25, the plan of care will be established and authorized in writing by the physician based on an evaluation of the patient’s immediate and long-term needs. The plan of care developed covering types of services and equipment required, frequency of visits, activities provided, medications and treatments, and any other appropriate items. Patient #2 had a start of care date of 11/17/25. Clinical record review revealed the following: a. Plan of Care, dated 11/17/25 to 1/15/26, included primary diagnosis of Type 2 Diabetes Mellitus and physician orders for skilled nurse to contact physician when weight gain of greater than 3 pounds in 24 hours or greater than 5 pounds in a week. b. Undated aide care plan, identified the task to assist patient with weighing on home scale, with a start date of 12/18/25. c. Aide visit note, dated 12/22/25, completed by Staff D, Home Health Aide (HHA), identified the task to assist patient with weighing on home scale was marked with a weight of 147.4 pounds. d. Aide visit note, dated 12/26/25, completed by Staff D, HHA, identified the task to assist patient with weighing on home scale was marked with a weight of 153 pounds, an increase of 5.6 pounds. e. Skilled nurse visit note, dated 12/29/25, completed by Staff B, Clinical Manager, failed to include documentation the physician was notified of the weight gain or a reason why the physician was not notified. During an interview on 1/7/26 at 3:34 PM, Staff B, Clinical Manager, reported the weight on 12/22/25 was inaccurate when looking at the weight flowsheet but she failed to include this information in the documentation on 12/29/25. The above stated findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on clinical record review, policy review and agency staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 1 of 5 sampled patients receiving home health aide services (Patient #2). The agency reported 13 patients received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients’ personal care needs were not adequately met. Findings include: According to the policy, titled Home Health Aide/Homemaker Visit Note, dated 7/11/25, the aide must follow the care plan exactly. Each task/activity on the care plan must be charted, either completed or refused, with every visit. Patient #2 had a start of care date of 11/17/25. Clinical record review revealed the following: a. Plan of Care, dated 11/17/25 to 1/15/26, included primary diagnosis of Type 2 Diabetes Mellitus and physician orders for skilled nurse and home health aide services. b. Undated aide care plan, identified the tasks bath: bed and bath: shower for the aide to complete. c. Aide visit note, dated 1/2/26, completed by Staff D, Home Health Aide, included documentation the tasks bath: bed and bath: shower were done. During an interview on 1/7/26 at 3:00 PM, Staff B, Clinical Manager reported she had reviewed the aide note and will contact the aide to annotate the correct bath type completed. The above stated findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.”