Amedisys Home Health

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS system within 30 days of completion. Findings: Review of the agency’s OASIS Final Validation Report with a submission date of 11/07/2024 revealed 46 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 11/08/2024 revealed 28 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 12/02/2024 revealed 78 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 12/04/2024 revealed 32 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 12/11/2024 revealed 38 records were processed with 2 records receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 12/16/2024 revealed 52 records were processed with 2 records receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 12/18/2024 revealed 22 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 12/19/2024 revealed 17 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 01/06/2025 revealed 46 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 01/07/2025 revealed 7 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 01/20/2025 revealed 72 records were processed with 2 records receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S1DOO on 01/30/2025 at 2:27 p.m. He reviewed the above OASIS validation reports and confirmed 14 of the records were submitted late, more than 30 days after completion.”

“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 Plan of Care was followed as evidenced by a Skilled Nurse (SN) visit not conducted as ordered for 1 (#8) of 15 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #15, #16, and #17) sampled patient records reviewed with orders for SN services. Findings: Review of the agency’s policy titled, “Coordination of Care” with a revision date of 05/22/2024 revealed the following, in part: Procedure: 13.A missed visit note is completed and documented in the patient’s record when a visit is unable to be completed as ordered and not able to be rescheduled within the patient’s Medicare treatment week. The physician/allowed practitioner will be notified of the missed visit by: The visiting clinician phone call to the physician/allowed practitioner; or By way of faxing/mailing the missed visit communication note to physician’s/allowed practitioner’s office; or By the Clinical Manager/Director of Operations (DOO) or other clinical management representative. The clinician/Clinical Manager /DOO notifying the physician/allowed practitioner of the missed visit documents this communication in the clinical record utilizing appropriate note/communication form. There are no exceptions, in which the physician/allowed practitioner does not have to be notified of a missed visit. Review of Patient #8’s Clinical Record revealed he began receiving services from the Home Health Agency on 08/25/2024 and had a Certification Period of 08/25/2024 through 10/23/2024. Patient #8 had diagnoses, which included Pressure Ulcer of Left Heel Stage 4, Pressure Ulcer of Sacral Region Stage 3, Pressure Ulcer of Left Ankle Stage 3, Pressure Ulcer of Right Buttock Stage 2, Pressure Ulcer of Right Heel Stage 1, Chronic Systolic Congestive Heart Failure, End Stage Renal Disease, and Paraplegia. Review of the Plan of Care for Certification Period 08/25/2024 through 10/23/2024 revealed Patient #8 was ordered to receive Skilled Nursing Visits three times weekly for one week, then twice weekly for seven weeks, and once weekly for one week. Review of the Skilled Nurse (SN) electronic missed visit note, dated 10/18/2024 revealed the following: Reason: Blank Missed Visit Notification: Blank Review of Patient #8’s Coordination Notes for Certification Period 08/25/2024 through 10/23/2024 revealed no documented evidence or Physician notification of the SN missed visit on 10/18/2024. An interview was conducted with S1DOO on 01/30/2025 at 3:25 p.m. S1DOO reviewed Patient #8’s Clinical Record and SN missed visit note dated 10/18/2024. S1DOO confirmed the SN missed visit documentation was not completed and there was no documented evidence the Physician was notified of the SN missed visit and there should have been.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure the Registered Nurse provided home health agency services in accordance with current clinical practice guidelines and accepted professional standards for 1 (#8) of 2 (#8 and #9) patients reviewed for pressure ulcers. The agency failed to ensure the Registered Nurse assessed Patient #8’s pressure wounds, including size and stage on a weekly basis. Findings: Review of the Louisiana State Board of Nursing, Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management revealed, in part, the following: Registered nurses render care that is directed towards the prevention and the treatment of wounds. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The Registered Nurse initiates appropriate wound prevention measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by the authorized prescriber. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Review of the agency’s policy titled, “The Provision of Wound and Skin Care” with a revision date of 12/12/2024, revealed the following, in part: Measuring: In accordance with best practice and standard of care, wounds will be measured a minimum of one time a week… Patients who are seen at a frequency of one time a week should have the wound measured at that visit. Review of Patient #8’s Clinical Record revealed he began receiving services from the Home Health Agency on 08/25/2024. Patient #8 had diagnoses, which included Pressure Ulcer of Left Heel Stage 4, Pressure Ulcer of Sacral Region Stage 3, Pressure Ulcer of Left Ankle Stage 3, Pressure Ulcer of Right Buttock Stage 2, and Pressure Ulcer of Right Heel Stage 1. Review of Patient #8’s Plan of Care revealed he was certified to receive Skilled Nursing services from 08/25/2024 to 10/23/2024 three times weekly for one week, then twice weekly for seven weeks, and once weekly for one week. Further review of Patient #8’s Plan of Care revealed the following, in part: Wound care Pressure Injury to Left Heel Stage 3, Left Ankle Stage 3, Right Heel Stage 1, Sacrum Stage 3, and Right Buttock Stage 2. Change three times weekly, excluding wound care days. New order on 09/17/2024 – Skilled Nursing visits effective 09/15/2024 once weekly for six weeks. Review of Patient #8’s Skilled Nursing Visit notes for Certification Period 08/25/2024 to 10/23/2024 revealed Patient #8’s Pressure Ulcer Left Heel Stage 4, Pressure Ulcer of Sacral Region Stage 3, Pressure Ulcer of Left Ankle Stage 3, Pressure Ulcer of Right Buttock Stage 2, and Pressure Ulcer of Right Heel Stage 1 were not assessed by an RN, to include measurements the weeks of 09/08/2024, 09/22/2024, and 09/29/2024. Review of Patient #8’s Plan of Care dated 10/24/2024 to 12/22/2024 revealed he was certified to receive Skilled Nursing services once weekly for nine weeks. Further review of Patient #8’s Plan of Care revealed the following, in part: Frequency of dressing changes- Home Health to change dressings every Friday or Saturday. Review of Patient #8’s Skilled Nursing Visit notes for Certification Period 10/24/2024 to 12/22/2024 revealed Patient #8’s Pressure Ulcer Left Heel Stage 4, Pressure Ulcer of Left Ankle Stage 3, and Pressure Ulcer of Right Heel Stage 1 were not assessed by an RN, to include measurements the week of 12/01/2024. Review of Patient #8’s current Plan of Care dated 12/23/2024 to 02/20/2025 revealed he was certified to receive Skilled Nursing services once weekly for nine weeks. Further review of Patient #8’s Plan of Care revealed the following, in part: Frequency of dressing changes- Home Health to change dressings Friday or Saturday. Review of Patient #8’s Skilled Nursing Visit notes for Certification Period 12/23/2024 to 02/20/2025 revealed Patient #8’s Pressure Ulcer Left Heel Stage 4 and Pressure Ulcer of Right Heel Stage 1 were not assessed by an RN, to include measurements the weeks of 12/22/2024, 12/29/2024, 01/05/2025, 01/12/2025, and 01/19/2025. An interview was conducted with S1DOO on 01/30/2025 at 3:25 p.m. S1DOO verified pressure wounds should be assessed and measured by a Registered Nurse at least weekly. S1DOO reviewed Patient #8’s Clinical Record and confirmed a Registered Nurse had not assessed or measured Patient #8’s pressure wounds listed above weekly.”

“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, interviews, and record review, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure skilled nursing and therapy staff reconciled patients’ medications for 4 (#1, #2, #5 and #6) of 7 (#1, #2, #3, #4, #5, #6 and #7) patients reviewed with home visits. Findings: Review of the agency’s policy titled, “Drug Regimen Review” with a last review date of 12/09/2024 revealed the following, in part: Purpose: To identify appropriateness, inconsistencies, and/or significant drug interactions in the patient’s current medication regimen, as well as ensure the comprehensive list of medications are updated any time there is a medication change including dose changes, new medications, and any medications discontinued. Patient #1 Review of Patient #1’s Clinical Record revealed she began receiving services from the Home Health Agency on 01/08/2025 and had a current Certification Period of 01/08/2025 through 03/08/2025. Patient #1 had diagnoses, which included Spondylosis Without Myelopathy or Radiculopathy Lumbar Region, Atrial Fibrillation, Spondylosis Cervical Region, Long Term Use of Anticoagulants, and Long Term Use of Oral Steroids. Patient #1 was ordered to receive Skilled Nursing Visits, Physical Therapy Visits, and Occupational Therapy Visits once weekly for four weeks. A home visit was conducted with Patient #1 on 01/27/2025 at 12:15 p.m. with S3PT present in the home. Patient #1’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current Medication Profile provided by the agency: Prednisone 1 mg take two tablets by mouth daily was on the medication profile and not present in the home; Sennosides 8.6 mg/Docusate Sodium 50 mg take two tablets by mouth daily was on the medication profile and not present in the home; Warfarin 1mg take one tablet by mouth on Mondays and Fridays was on the medication profile, and the patient was receiving Warfarin 1.25 mg by mouth on Mondays and Fridays; and Ferrous Sulfate 324 mg take one tablet by mouth daily was on the medication profile, and the patient was receiving once weekly on Wednesdays. An interview was conducted with Patient #1’s husband during the home visit. Patient #1’s husband stated he managed Patient #1’s medications. Patient #1’s husband stated Patient #1 had been receiving Ferrous Sulfate once weekly on Wednesdays since she began services with the agency on 01/08/2025. Patient #1’s husband stated Patient #1 had not received Prednisone in three months, had not taken Sennosides 8.6/Docusate Sodium 50 mg since 01/10/2025, and had been receiving Coumadin 1.25 mg by mouth on Mondays and Fridays for months. Patient #2 Review of Patient #2’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/15/2025 and had a current Certification Period of 01/15/2025 through 03/15/2025. Patient #2 had a diagnosis, which included Encounter for Orthopedic Aftercare. Patient #2 was ordered to receive Skilled Nursing Visits twice weekly for two weeks then once weekly for two weeks, and Physical Therapy Visits twice weekly for three weeks then once weekly for one week. A home visit was conducted with Patient #2 on 01/27/2025 at 2:10 p.m. with S4LPN present in the home. Patient #2’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current Medication Profile provided by the agency: Biotin 10,000 mcg take one capsule by mouth daily was present in the home and not on the medication profile; Centrum Silver Men 50 plus take one tablet by mouth daily was present in the home and not on the medication profile; Zyrtec 10 mg take one tablet by mouth daily was present in the home and not on the medication profile; and Vitamin D3 25 mcg (1,000 IU) take one soft gel by mouth daily was present in the home and not on the medication profile. An interview was conducted with Patient #2 during the home visit. He stated he managed his own medications. He stated he had been taking Biotin, Centrum Silver, Zyrtec and Vitamin D3 daily for over 6 years. An interview was conducted with S4LPN on 01/27/2025 at 2:30 p.m. during the home visit. S4LPN confirmed the above medication discrepancies during the home visit. S4LPN stated medications should be reconciled during every home visit. Patient #5 Review of Patient #5’s Clinical Record revealed she began receiving services from the Home Health Agency on 01/23/2025 and had a current Certification Period of 01/23/2025 through 03/23/2025. Patient #5 had diagnoses, which included Encounter for Orthopedic Aftercare and Acute Pain due to Trauma. Patient #5 was ordered to receive Skilled Nursing Visits once weekly for one week, Physical Therapy Visits once weekly for nine weeks, Occupational Therapy Visits once weekly for three weeks then twice weekly for one week, and once weekly for four weeks and Home Health Aide Visits once weekly for four weeks. A home visit was conducted with Patient #5 on 01/28/2025 at 8:55 a.m. with S5CNA present in the home. Patient #5’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current Medication Profile provided by the agency: Amiodarone 200 mg take one tablet by mouth two times daily was on the medication profile and the patient was receiving once daily; Clonidine HCL 0.1 mg take one tablet two times daily was on the medication profile and the patient was receiving three times daily; Eliquis 5 mg take one tablet by mouth two times daily was on the medication profile, and the patient was receiving Eliquis 2.5 mg by mouth twice daily; Labetalol 200 mg take one tablet by mouth two times daily was on the medication profile and the patient was no longer taking; and Losartan 25 mg take two tablets by mouth two times daily and Losartan 50 mg take two tablets by mouth twice daily were on the medication profile, and the patient was receiving Losartan 100 mg by mouth twice daily. An interview was conducted with Patient #5’s grandson during the home visit. He stated he managed Patient #5’s medications and filled her pill planner weekly. He stated Patient #5’s Amiodarone was decreased to once daily on 01/03/2025. He stated Patient #5 received Losartan twice daily and he used both 25 mg and 50 mg tablets to equal 100 mg of Losartan and Patient #5 had been on that dose for a while. He stated Patient #5’s Clonidine was prescribed three times daily. He stated Patient #5 received Eliquis 2.5 mg one tablet twice daily and had never been prescribed Eliquis 5 mg. He stated Patient #5’s Labetalol was discontinued on 01/20/2025 when she was discharged from the hospital. Patient #6 Review of Patient #6’s Clinical Record revealed she began receiving services from the Home Health Agency on 12/23/2024 and had a current Certification Period of 12/23/2024 through 02/20/2025. Patient #6 had diagnoses, which included Acute Post-Hemorrhagic Anemia, Alzheimer’s Disease with Early Onset, Hypertensive Heart and Chronic Kidney Disease, and Personal History of Transient Ischemic Attack. Patient #6 was ordered to receive Skilled Nursing Visits once weekly for five weeks then once every two weeks for four weeks, Physical Therapy Visits once weekly for five weeks, and Occupational Therapy Visits once weekly for six weeks. A home visit was conducted with Patient #6 on 01/28/2025 at 11:30 a.m. with S2OT present in the home. Patient #6’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current Medication Profile provided by the agency: Donepezil 5 mg take one tablet by mouth daily was on the medication profile, and the patient was no longer taking; Pravastatin 20 mg take one tablet by mouth daily was on the medication profile, and the patient no longer taking; and Pantoprazole 40 mg by mouth daily was listed on the medication profile twice, and the patient was only taking once daily. An interview was conducted with Patient #6’s daughter during the home visit. Patient #6’s daughter stated she managed Patient #6’s medications. She stated Patient #6 had only been taking Pantoprazole once daily since before her start of care with the agency. She stated Patient #6 had not taken Donepezil and/or Pravastatin since before her start of care with the agency in December 2024. An interview was conducted with S1DOO on 01/30/2025 at 3:10 p.m. He stated medications should be reconciled during each home visit by the clinicians. He stated medication reconciliation should have been completed by comparing the medications in the home to the patient’s current medication profile. He stated if there was any discrepancy identified during the home visit, the clinician should have updated the medication profile. He was made aware of Patient #1, #2, #5 and #6’s medication discrepancies identified during their home visits. He confirmed the medications each patient was currently receiving should have matched the patient’s current medication profile.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure a comprehensive assessment was updated within 48 hours after a hospital admission of greater than 24 hours for 1 (#6) of 5 (#6, #9, #11, #15, and #16) patients reviewed for resumption of care. Findings: Review of the agency’s policy titled, “Patient Assessment/Reassessment” with a revision date of 10/10/2024 revealed the following, in part: Purpose: The comprehensive assessment will be completed, consistent with the patient’s immediate needs, in accordance with regulatory requirements. Procedure: 13. A patient reassessment for resumption of care following an inpatient admission of 24 hours or greater will be initiated within 48 hours of the patient’s return home from the facility or on physician/allowed practitioner ordered resumption of care date. Review of Patient #6’s Clinical Record revealed a start of care date of 12/23/2024, with a current certification period of 12/23/2024 through 02/20/2025, and diagnoses, which included Acute Post-Hemorrhagic Anemia, Alzheimer’s Disease with Early Onset, Hypertensive Heart and Chronic Kidney Disease, and Personal History of Transient Ischemic Attack. Further review of the Clinical Record revealed no Resumption of Care was completed. Review of Patient #6’s Hospital Paperwork from a local hospital revealed she was admitted to the hospital on 12/25/2024 and discharged on 12/28/2024. Review of Patient #6’s Visit Notes for certification period of 12/23/2024 through 02/20/2025 revealed discipline visits were resumed on 12/30/2024. Further review revealed no documentation a comprehensive resumption of care assessment was completed after Patient #6 was discharged from a three day hospitalization on 12/28/2024. An interview was conducted with S1DOO on 01/29/2025 at 10:35 a.m. He stated Patient #6 was admitted to the home health agency on 12/23/2024 and was admitted to the hospital on 12/25/2024. He stated Patient #6 was discharged from the hospital on 12/28/2024, and discipline visits were resumed on 12/30/2024 without a comprehensive assessment being completed. He stated a resumption of care assessment should have been completed within 48 hours of Patient #6’s discharge from the hospital.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interviews and record reviews, the agency failed to assure communication with all physicians involved in the Plan of Care. The agency failed to ensure: 1. The physician was notified Home Health Aide Services were not provided for 2 (#11 and #17) of 4 (#5, #11, #12, and #17) patients reviewed with orders for Home Health Aide Services; and 2. The physician was notified of a patient’s change in skin assessment for 1 (#13) of 17 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17) patient records reviewed. Findings: Review of the agency’s policy titled, “Coordination of Care” with a revision date of 05/22/2024 revealed the following, in part: (d.) Standard: Coordination of Care: The Home Health Agency must: 1.) Assure communication with all physicians or allowed practitioners involved in the plan of care. Procedure: 7. Agency staff involved in the patient’s plan of care (clinicians, clinical managers) provide patient related updates in a timely manner to the physician/allowed practitioner and include as appropriate: Changes in patient condition. 17. In the event Therapy Assistant (PTA/OTA) personnel identify a problem or a change in condition with a patient, the PTA/OTA will immediately notify the supervising therapist and/or Clinical Manager who will make a determination of the appropriate intervention: The Clinical Manager…will coordinate care with the appropriate patient’s physician/allowed practitioner. 1. Patient #11 Review of Patient #11’s Clinical Record revealed she began receiving services from the Home Health Agency on 11/30/2024 and had a current Certification Period of 11/30/2024 through 01/28/2025. Patient #11 had diagnoses, which included Hypertensive Heart and Chronic Kidney Disease with Heart Failure, and Combined Systolic and Diastolic Congestive Heart Failure. Further review revealed a physician’s order dated 11/27/2024 for admit to home health, which included Home Health Aide Services to evaluate and treat. Review of Patient #11’s Plan of Care (PoC) revealed no evidence the agency ordered Home Health Aide Services. Further review of the Clinical Record revealed no evidence the patient’s physician was notified the Home Health Aide Services were not provided. An interview was conducted with S1DOO on 01/29/2025 at 9:49 a.m. S1DOO reviewed Patient #11’s Clinical Record and Home Health referral dated 11/30/2024. S1DOO confirmed the physician ordered Home Health Aide services. S1DOO further confirmed there was no documented evidence the physician was notified Home Health Aide Services were not provided as ordered. Patient #17 Review of Patient #17’s Clinical Record revealed she began receiving services from the Home Health Agency on 03/06/2024, had a Certification Period of 03/06/2024 through 05/24/2024, and was discharged on 03/22/2024. Patient #17 had diagnoses, which included Type 2 Diabetes, Hypertensive Chronic Kidney Disease, History of Cerebral Infarction, and Dependence on Wheelchair. Further review revealed a physician’s order dated 03/05/2024 for admit to home health which included Home Health Aide Services. Review of Patient #17’s Plan of Care (PoC) revealed no evidence the agency ordered Home Health Aide Services. Further review of the Clinical Record revealed no evidence the patient’s physician was notified the Home Health Aide Services were not provided. An interview was conducted with S1DOO on 01/30/2025 at 11:30 a.m. S1DOO reviewed Patient #17’s Clinical Record and Home Health referral dated 03/05/2024. S1DOO confirmed the physician ordered Home Health Aide services. S1DOO further confirmed there was no documented evidence the physician was notified Home Health Aide Services were not provided as ordered. 2. Patient #13 Review of Patient #13’s Clinical Record revealed she began receiving services from the Home Health Agency on 03/10/2023, had a Certification Period of 03/10/2023 through 05/08/2023, and was discharged on 04/20/2023. Patient #13 had diagnoses, which included Hereditary and Idiopathic Neuropathy, Prediabetes, and Major Depressive Disorder. Patient #13 was ordered to receive Occupational Therapy Visits once weekly for nine weeks and Physical Therapy Visits once weekly for one week, then once every other week for two weeks, once weekly for two weeks and once every other week for two weeks. Review of Patient #13’s Physical Therapy Assistant’s (PTA) notes revealed the following, in part: 03/24/2023- Patient lifted shirt to show PTA open sores all over her back and trunk. PTA reported to Clinical Manager (CM). Care Coordination: Indicate if you communicated with physician or other disciplines involved in this case: Yes Indicate Name and title of person you spoke with: S8CM. Signed S7PTA. Review of Patient #13’s Coordination Notes dated 03/24/2023 through 04/10/2023 revealed the following, in part: 03/24/2023-Received report from S7PTA… Also noted that the patient showed sores to trunk area that appear to be from scratching… Signed S8CM. Further review revealed no documented evidence the Physician was notified of Patient #13’s change in skin assessment from 03/24/2023 to 04/10/2023. An interview was conducted with S8CM on 01/30/2025 at 4:05 p.m. S8CM reviewed Patient #13’s Clinical Record and stated on 03/24/2023, S7PTA reported to her the patient had sores on her trunk area which appeared to be from scratching. S8CM reviewed S7PTA’s visit dated 03/24/2023 and confirmed S7PTA documented the patient had open sores all over her back and trunk. S8CM confirmed there was no documented evidence in Patient #13’s Clinical Record the Physician was notified of the change in Patient #13’s skin assessment. An interview was conducted with S1DOO on 01/30/2025 at 3:15 p.m. S1DOO reviewed Patient #13’s Clinical Record and S7PTA’s visit dated 03/24/2023. S1DOO confirmed S7PTA documented Patient #13 had open sores on her back and trunk and notified S8CM. S1DOO reviewed the coordination note dated 03/24/2023 documented by S8CM and confirmed S8CM documented the patient had sores from scratching. S1DOO confirmed there was no documented evidence in the Clinical Record the Physician was notified of the change in Patient #13’s skin assessment.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on interviews and record review, the agency failed to ensure orders from the physician for Home Health Aide Services were integrated into the Plan of Care to ensure all services and interventions were provided to the patient for 2 (#11 and #17) of 4 (#5, #11, #12, and #17) patients reviewed with orders for Home Health Aide Services. Findings: Review of the agency’s policy titled, “Coordination of Care” with a revision date of 05/22/2024 revealed the following, in part: (d.) Standard: Coordination of Care: The Home Health Agency must: 2.) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. Patient #11 Review of Patient #11’s Clinical Record revealed she began receiving services from the Home Health Agency on 11/30/2024 and had a current Certification Period of 11/30/2024 through 01/28/2025. Patient #11 had diagnoses which included Hypertensive Heart and Chronic Kidney Disease with Heart Failure, and Combined Systolic and Diastolic Congestive Heart Failure. Further review revealed a physician’s order dated 11/27/2024 for admit to home health, which included Home Health Aide Services to evaluate and treat. Review of Patient #11’s Plan of Care (PoC) revealed no evidence the agency implemented Home Health Aide Services as ordered. Review of Patient #11’s Client Calendar Report revealed no documentation of a Home Health Aide visit for the Certification Period 11/30/2024 to 01/28/2025. An interview was conducted with S1DOO on 01/29/2025 at 9:49 a.m. S1DOO reviewed Patient #11’s clinical record and Home Health referral dated 11/30/2024. S1DOO confirmed the physician ordered Home Health Aide services. S1DOO further confirmed the agency did not integrate Home Health Aide Services into Patient #11’s Plan of Care. Patient #17 Review of Patient #17’s Clinical Record revealed she began services from the Home Health Agency on 03/06/2024, had a Certification Period of 03/06/2024 through 05/24/2024, and was discharged on 03/22/2024. Patient #17 had diagnoses which included Type 2 Diabetes, Hypertensive Chronic Kidney Disease, History of Cerebral Infarction, and Dependence on Wheelchair. Further review revealed Patient #17’s physician’s order dated 03/05/2024 for admit to home health which included Home Health Aide Services. Review of Patient #17’s Plan of Care (PoC) revealed no evidence the agency implemented Home Health Aide Services as ordered. Review of Patient #17’s Client Calendar Report revealed no documentation of a HHA visit for the Certification Period 03/06/2024 through 05/24/2024. An interview was conducted with S6CM on 1/30/2025 at 10:28 a.m. S6CM reviewed Patient #17’s Plan of Care and confirmed there was no documented evidence Home Health Aide Services were integrated into the Plan of Care. S6CM confirmed the agency made no attempts to implement the Home Health Aide Services for Patient #17 and should have. An interview was conducted with S1DOO on 01/30/2025 at 11:30 a.m. S1DOO reviewed Patient #17’s clinical record and Home Health referral dated 03/05/2024. S1DOO confirmed the physician ordered Home Health Aide services. S1DOO confirmed the agency did not integrate Home Health Aide Services into Patient #17’s Plan of Care, and Home Health Aide Services were not provided to Patient #17 as ordered.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interviews, the agency failed to provide services as ordered by the Practitioner in the Plan of Care for 1 (#8) of 17 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17) patient records reviewed. The agency failed to ensure: 1. The skilled nurse obtained a blood glucose reading for Patient #8 on each home visit; and 2. The skilled nurse provided wound care as ordered for Patient #8 the week of 09/15/2024. Findings: Review of the agency’s policy titled, “Physician Orders and Medical Supervision of the Plan of Care” with a revision date of 11/04/2024, revealed the following, in part: Procedure: 2. Each patient receives the Home Health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals… 4. All patient care orders from all physicians/allowed practitioners, must be recorded/integrated in the plan of care to assure coordination of all services and interventions provided. 1. Review of Patient #8’s Clinical Record revealed he began receiving services from the Home Health Agency on 08/25/2024. Patient #8 had diagnoses, which included Type 1 Diabetes Mellitus With Diabetic Chronic Kidney Disease, Pressure Ulcer of Left Heel Stage 4, Pressure Ulcer of Sacral Region Stage 3, Pressure Ulcer of Left Ankle Stage 3, Pressure Ulcer of Right Buttock Stage 2, and Pressure Ulcer of Right Heel Stage 1. Review of Patient #8’s Plan of Care for Certification Period 08/25/2024 to 10/23/2024 revealed he was to receive Skilled Nursing services three times weekly for one week, then twice weekly for seven weeks, and once weekly for one week. Further review of Patient #8’s Plan of Care revealed the following, in part: Diabetes Management: Blood glucose test every visit frequency. Registered Nurse/Licensed Practical Nurse to report to Physician blood glucose readings greater than 300 or less than 70. Review of Patient #8’s Skilled Nurse Visit notes for Certification Period 08/25/2024 to 10/23/2024 revealed no documented blood glucose reading. Review of Patient #8’s Vital Signs Report for Certification Period 08/25/2024 to 10/23/2024 revealed no documented blood glucose reading. 2. Review of Patient #8’s Plan of Care for Certification Period 08/25/2024 to 10/23/2024 revealed orders which included the following, in part: 09/17/2024- Wound cleaning and dressing orders. Frequency of dressing changes- Home Health to change dressings on Friday 09/20/2024 or Saturday 09/21/2024. Nurse Practitioner to see patient next Tuesday 09/24/2024. Review of Patient #8’s Complaint Report dated 09/26/2024 revealed the following, in part: Name/Relationship-Nurse Practitioner Description: Nurse Practitioner called to notify agency the Registered Nurse continues to see Patient #8 on Thursday’s when orders clearly states Friday/Saturday visits. Review of Patient #8’s Skilled Nurse Visit for Certification Period 08/25/2024 to 10/23/2024 revealed a Skilled Nurse visit was made on Thursday 09/19/2024 and wound care was performed. An interview was conducted with S1DOO on 01/30/2025 at 3:25 p.m. S1DOO reviewed Patient #8’s Plan of Care for Certification Period 08/25/2024 to 10/23/2024 and verified blood glucose testing was ordered every Skilled Nurse visit. S1DOO reviewed Patient #8’s Vital Signs Report and Skilled Nurses’ Notes for the episode. S1DOO confirmed there was no documented evidence of Patient #8’s blood glucose readings and there should have been. S1DOO reviewed the Complaint Report for Patient #8 and stated the Nurse Practitioner reported to the agency Patient #8’s wound care was not performed on the day it was ordered. S1DOO reviewed the Nurse Practitioner’s order dated 09/17/2024 and Skilled Nurse visits for Patient #8. S1DOO confirmed the Skilled Nurse made a visit on Thursday 09/19/2024, instead of Friday or Saturday per the Nurse Practitioner’s orders. S1DOO confirmed Patient #8 did not receive wound care as ordered and should have.”