Intensive Home Health Care, Inc.

“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 record review and interview, the agency failed to ensure the patient’s written POC (plan of care) was followed by failing to collect and document the patient’s weight or measure arm girth for 4 (#2, #4, #5, and #6) of 7 sampled patients. Findings: Review of the Agencies undated policy titled “Plan of Care/485 policy” read in part... Implementation of the plan of care: All services shall be delivered in accordance with the authorized plan of care. Patient #2 Review of Patient #2’s clinical record for the certification period of 12/20/2025- 02/17/2026 revealed the following diagnoses in part…Age related Fracture to Left Femur, Acute Embolism, Type 2 Diabetes Mellitus, and Anemia. Review of the Patient #2’s plan of care for the certification period of 12/20/2025- 02/17/2026 revealed an order for skilled nurse visits 1wk 9 (1 visit a week for 9 weeks). The POC revealed an order for weights every skilled nurse visit, and if unable to obtain weight to obtain arm girth in centimeters. Review of Patient #2’s vital sign log and nurse’s notes for the certification period of 12/20/2025- 02/17/2026 revealed no weights or arm girth documented. Patient #4 Review of Patient #4’s clinical record for the certification period of 11/27/2025-01/25/2026 revealed the following diagnoses, included in part…, Type 2 Diabetes Mellitus, Congestive Heart Failure, Hypertensive Heart Disease, and Depression. Review of the Patient #4’s plan of care for the certification period of 11/27/2025-01/25/2026 revealed an order for skilled nurse visits 1wk6 and 1wk2 (1 visit a week for 6 weeks and 1 visit a week for 2 weeks). The POC revealed an order for weights every skilled nurse visit and if unable to obtain weight to obtain arm girth in centimeters. Review of Patient #4’s vital sign log and nurse’s notes for the certification period of 11/27/2025-01/25/2026 revealed no weights or arm girth documented for the following nursing visits: 12/4/2025, 12/18/2025, and 01/02/2026. Patient #5 Review of Patient #5’s clinical record for the certification period of 11/29/2025-01/27/2025 revealed the following diagnoses included in part… Type 2 Diabetes Mellitus, Non Pressure Chronic Ulcer, Hypertensive Heart Disease, and Atrial Fibrillation. Review of the Patient #5’s plan of care for the certification period of 11/29/2025-01/27/2025 revealed an order for skilled nurse visits 1wk8 (1 visit a week for 8 weeks). The POC revealed an order for weights every skilled nurse visit and if unable to obtain weight to obtain arm girth in centimeters. Review of Patient 5’s vital sign log and nurse’s notes for the certification period of 11/29/2025-01/27/2026 revealed no weights or arm girth documented. Patient #6 Review of Patient #6’s clinical record for the certification period of 10/17/025-12/10/2025 revealed the following diagnoses included in part…Orthopedic Aftercare of Surgical Amputation to Right above the Knee Amputation, Peripheral Vascular Disease, and Hypertension. Review of the Patient #6’s plan of care for the certification period of 10/17/2025-12/10/2025 revealed an order for skilled nurse visits 1wk9 (1 visit a week for 9 weeks). The POC revealed an order for weights every skilled nurse visit and if unable to obtain weight to obtain arm girth in centimeters. Review of Patient #6’s vital sign log and nurse’s notes for the certification period of 10/17/2025-12/10/2025 revealed no weights or arm girth documented for the following nursing visits: 10/17/2025, 10/21/2025, 11/04/2025, 11/18/2025, 11/25/2025, and 12/02/2025. An interview on 01/21/2026 at 9:15 a.m. with S2LPN confirmed that she does not collect weight or arm girth every visit because at times she forgets. An interview on 01/22/2026 at 10:49 a.m. with S1DON confirmed the above weights/arm girth were not documented as collected in the patient’s charts, but should have been.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation and interview the agency failed to ensure the skilled nurse followed accepted standards of practice for infection control for 1 (#1) of 3 patients observed during home visits as evidenced by failing to ensure the skilled nurse changed gloves and perform hand hygiene appropriately during wound care. Findings: Review of the Agency’s undated policy titled, “Infection Control Policy” read in part…Standard Transmission: All personnel will use standard precautions at all times to prevent the spread of infectious agents; this includes not limited to, hand hygiene, use of personal protective equipment, and proper disposal of sharps. Review of Patient #1’s plan of care for certification period of 12/15/2025-2/12/2026 revealed Patient #1 had a pressure ulcer to right and left foot with the following orders in place: Wound #3 Left Medial distal foot-cleanse with wound cleanser, pat dry, apply moisturizer lotion to surrounding tissue, mix and apply topical antibiotics, apply alginate, cover with dry gauze, apply abdominal pad and wrap with kerlix. Wound #7- Right foot-cleanse with wound cleanser, pat dry, apply moisturizer lotion to surrounding tissue, mix and apply topical antibiotics, apply alginate, cover with dry gauze, apply abdominal pad and wrap with kerlix. An observation on 01/21/2026 at 9:15 a.m. of S2LPN performing wound care on Patient #1’s bilateral feet revealed that S2LPN applied gloves prior to wound care on the right foot wound. S2LPN was observed removing the right foot wound dressing, discarding the old dressing, reaching over in clean the field and removing 4x4 gauze from original packaging, cleaning the wound, discarding 4x4 gauze, reaching over into clean field, grabbing clean dressing, and then appling the clean dressing to the wound bed. S2LPN at this time removed the old gloves and discarded them. S2LPN then applied new gloves and provided wound care as above to the left foot wound. S2LPN failed to change out gloves and sanitize hands between each step during wound care for both wounds. At the end of wound care, S2LPN was observed wrapping the package of gauze that she reached into with soiled gloves and placed them back with the clean wound care supplies. An interview on 01/21/2026 at 9:35 a.m. S2LPN confirmed that she did not sanitized her hands in-between gloves changes and did not change gloves more than 1 time for each wound. S2LPN stated that she was unsure how many times her gloves needed to be changed. S2LPN confirmed that she did plan to use the 4x4 gauze that she placed in her bag after reaching into them with soiled gloves, but will now throw them out.”