United Home Health Care LLC

“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 record review and interview, the home health agency failed to ensure the POC included all required information regarding wound care treatment for 3 of 4 active patient records reviewed of patients with wounds (Patient #1, 2, 4). Findings include: 1. The Patient Assessment/Plan of Care policy, indicated “… A physician’s plan of treatment… must include… The types of services… The frequency, and duration, of visits to be made… Patient-specific interventions and education…” 4. A home visit observation of RN 3 providing care for Patient #4 was conducted on 4/22/26 at 10:58 AM. Observed no grab bars in Patient #4’s bathroom. When asked about grab bars, Patient #4 reported they did not have grab bars in the home. Patient #4’s POC for certification period 4/02/26 to 5/31/26 included grab bars in the durable medical equipment and supplies section. The agency failed to exclude equipment Patient #4 did not have from the POC. The POC also failed to include information regarding the patient receiving services from a wound center and failed to include wound care frequency and who was to perform wound care. The record included written wound care orders which included “before each dressing change, place gauze soaked Vashe [a wound cleanser] onto wound for 5-10 minutes.” The POC indicated “Cleanse wound with vashe.” The POC failed to include the patient-specific instructions for Vashe use. During an interview on 4/22/26 at 1:31 PM, the CM relayed if the patient needed DME it should be listed in the POC, but the clinician should specify in the POC that it is needed rather than just listing it. During an interview on 4/23/26 at 11:42 AM, the CM relayed Patient #4’s POC wound orders did not include wound care frequency, who was to perform the wound care, or the specific instructions regarding Vashe use. 2. Patient #1’s clinical record included a POC for the certification period 3/08/26 to 5/06/26. The POC indicated the agency would provide SN services two times per week to perform wound care. The POC failed to include information regarding the patient receiving services from a wound center and failed to include wound care frequency and who was to perform wound care. During an interview on 4/23/26 at 11:29 AM, the CM relayed the POC should have indicated who was to perform wound care when the SN is not present. 3. Patient #2’s clinical record included a POC for the certification period 3/09/26 to 5/07/26. The POC indicated the agency would provide SN services two times per week to perform wound care. The POC failed to include information regarding the patient receiving services from a wound center and failed to include wound care frequency and who was to perform wound care. During an interview on 4/22/26 at 12:55 PM, the CM relayed the POC should have indicated who was to perform wound care when the SN is not present. 5. A home visit observation was conducted with Patient #9 and HHA 1 on 4/27/26. DME was reviewed in the home with Patient #9 and comparison of the home health agency’s DME list on the POC and the DME noted during the home visit observation evidenced the following discrepancies: a) Motorized scooter was used in the home by Patient #9. The POC DME list failed to evidence the motorized scooter. b) Hoyer lift was found in the home. The POC DME list failed to evidence the hoyer lift. Patient #9’s clinical record included a POC for the certification period 3/25/26 to 5/23/26. The recertification POC failed to include all DME used by the patient. During an interview on 4/28/26 at 12:00 PM, the CM relayed motorized scooter and hoyer lift should have been listed on the POC.”

“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 record review and interview, the agency failed to provide wound care as ordered by a physician for 2 of 4 active patient records reviewed with wounds (Patient #1 and 3). 2. Patient #3’s clinical record included a POC for the recertification period 2/03/26 to 4/03/26 which was returned signed by the provider on 3/06/26. Patient #3’s clinical record failed to evidence an order for the agency to perform wound care was obtained prior to 3/06/26. The record evidenced the SN performed wound care during visits on 2/23/26, 2/25/26, 2/27/26, and 3/2/26. The record included a POC for the recertification period 4/04/26 to 6/02/26 which was not returned signed by the provider as of 4/23/26. Patient #3’s clinical record failed to evidence an order for the agency to perform wound care was obtained prior to the date of record review. The record evidenced the SN performed wound care during visits on 4/06/26, 4/10/26, 4/13/26, and 4/17/26. The agency failed to ensure provider orders were received prior to providing wound care for Patient #3. During an interview on 4/23/26 at 10:37 AM, Admin 4 relayed Patient #3’s POC for certification period 4/04/26 to 6/02/26 had not yet been returned signed by the provider. During an interview on 4/28/26 at 12:10 PM, RN 4 relayed she probably had to leave a message when she called the provider about Patient #3’s POC for certification period 4/04/26 to 6/02/26. RN 4 relayed she did not document the date and time or who she spoke with at the provider’s office nor what was discussed. During an interview on 4/28/26 at 1:36 PM, the CM relayed Patient #3’s POC for certification period 2/03/26 to 4/03/26 indicated the physician was contacted, but the POC was not signed by the clinician who would have made the phone call. 1. Patient #1’s clinical record evidenced a SOC on 1/07/26 and included an OASIS comprehensive assessment which evidenced RN 1 performed wound care to Patient #1’ s wounds on 1/07/26. The clinical record failed to evidence the nurse obtained wound care orders prior to performing wound care treatment on 1/07/26. The record also included a POC for certification period 3/08/26 to 6/06/26. Patient #1’s clinical record failed to evidence a verbal order for SN frequency and wound care. The record included SN visits in which wound care was performed on 3/09/26 and 3/11/26. The agency failed to ensure provider orders were received prior to providing wound care services for Patient #1. During an interview on 4/27/26 at 3:59 PM, RN 1 verified wound care was performed during the 1/07/26 SOC visit and stated she developed the wound care orders prior to verifying with the physician. During an interview on 4/23/26 at 11:29 AM, the CM verified she created Patient #1’s recertification POC and she thought RN 1 obtained the recertification POC orders. Findings include: 1. Patient #1’s clinical record evidenced a SOC on 1/07/26 and included an OASIS comprehensive assessment which evidenced RN 1 performed wound care to Patient #1’ s wounds on 1/07/26. The clinical record failed to evidence the nurse obtained wound care orders prior to performing wound care treatment on 1/07/26. The record also included a POC for certification period 3/08/26 to 6/06/26. Patient #1’s clinical record failed to evidence a verbal order for SN frequency and wound care. The record included SN visits in which wound care was performed on 3/09/26 and 3/11/26. The agency failed to ensure provider orders were received prior to providing wound care services for Patient #1. During an interview on 4/27/26 at 3:59 PM, RN 1 verified wound care was performed during the 1/07/26 SOC visit and stated she developed the wound care orders prior to verifying with the physician. During an interview on 4/23/26 at 11:29 AM, the CM verified she created Patient #1’s recertification POC and she thought RN 1 obtained the recertification POC orders. 2. Patient #3’s clinical record included a POC for the recertification period 2/03/26 to 4/03/26 which was returned signed by the provider on 3/06/26. Patient #3’s clinical record failed to evidence an order for the agency to perform wound care was obtained prior to 3/06/26. The record evidenced the SN performed wound care during visits on 2/23/26, 2/25/26, 2/27/26, and 3/2/26. The record included a POC for the recertification period 4/04/26 to 6/02/26 which was not returned signed by the provider as of 4/23/26. Patient #3’s clinical record failed to evidence an order for the agency to perform wound care was obtained prior to the date of record review. The record evidenced the SN performed wound care during visits on 4/06/26, 4/10/26, 4/13/26, and 4/17/26. The agency failed to ensure provider orders were received prior to providing wound care for Patient #3. During an interview on 4/23/26 at 10:37 AM, Admin 4 relayed Patient #3’s POC for certification period 4/04/26 to 6/02/26 had not yet been returned signed by the provider. During an interview on 4/28/26 at 12:10 PM, RN 4 relayed she probably had to leave a message when she called the provider about Patient #3’s POC for certification period 4/04/26 to 6/02/26. RN 4 relayed she did not document the date and time or who she spoke with at the provider’s office nor what was discussed.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the provider was notified of wound measurement increases for 1 of 4 active records reviewed of patients with wounds (Patient #3). Findings include: 1. The Patient Assessment/ Plan of Care policy indicated “… In addition to required reports, the physician is immediately notified when… Any significant adverse change in the patient’s condition…” 2. Patient #3’s clinical record included nurse notes with Wound 1 measurements of 1.2 x 0.4 x 0.4 centimeters (cm) on 2/23/26, 1.5 x 0.5 x 0.4 cm on 3/02/26, 2 x 0.5 x 0.4 cm on 3/09/26 and 3/16/26, 1.5 x 0.5 by 0.4 cm on 3/23/26, 2 x 0.5 x 0.4 on 4/02/26. The record also included nurse notes with Wound 3 measurements 0.5 by 0.5 by 0 cm on 2/23/26, 1 x 1 x 0 cm on 3/2/26, 0.3 x 0.3 x zero cm on 3/09/26, 2 x 0.7 x 0 cm on 3/16/26, 4.5 x 0.1 x 0.1 cm on 3/23/26, and 5.5 x 4 by 0 cm on 4/02/26. The record failed to evidence the physician was notified of the increase in wound size. 3. During an interview on 4/28/26 at 12:15 PM, RN 4 relayed she had not notified the physician of Patient #3’s wound size increases on 3/02/26, 3/09/26, 3/16/26, 3/23/26, and 4/02/26. RN 4 indicated Entity A, a wound center, followed the patient so she thought they were aware of the patient’s measurements.”