Complete Home Health, 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 individualized POC (Plan of Care) was followed as evidenced by: 1. the SN (Skilled Nurse) failed to change the patient’s trach (tracheostomy) ties every day as ordered which resulted in the patient sustaining a wound to the left side of her neck; and 2. the SN failed to provide extended care nursing services for the patient as ordered per the POC for 1 (#5) out of 10 sampled patients. Findings: 1. Patient #5. Review of the patient’s clinical records revealed the start of care date was 07/27/2006. The patient’s diagnoses included lennox-gastaut syndrome and tracheostomy. The certification period reviewed was 04/12/2026 to 6/10/2026. Review of the patient’s POC for certification period 04/12/2026 to 06/10/2026 revealed an order for 56 hours of extended nursing care per week which was 8 hours of SN services a day. Further review of the patient’s POC revealed an order “…Change trach ties qd (every day)…” Review of Patient #5’s extended care nursing assessment progress notes dated 04/13/2026 to 04/28/2026 revealed no evidence the SN changed the patient’s trach ties. Review of the patient’s Incident Report dated 04/29/2026 revealed: “Nature of incident (Detailed Description): (caregiver) reported via text message that Patient #5 was admitted to (the hospital)… Caregiver reports area on neck open due to oxygen string was rubbing against her skin and she got a break down.” Review of Patient #5’s ED (emergency department) note dated 04/28/2026 at 23:03 (11:03 p.m.) revealed: “19 year-old female with a history of cerebral palsy, mental impairment, epilepsy, tracheostomy in place on 1.5 L (liters) at baseline presents emergency department for fever, productive sputum output through tracheostomy as well as a wound to her left neck from the trach collar. Mother noted a fever today. Gave 300 mg of Tylenol 4 hours ago… Physical Exam: Vitals & Measurements: T: 38.4 C Rectal (101.12 F); HR 123; RR: 34; BP: 110/51; Sp02: 95%; O2 flow rate: 8; O2 therapy: Trach collar. Alert, mildly distressed, resting in bed. Tracheostomy in place, abrasion/wound to left neck which is rather deep…it is foul-smelling… tachycardic. Assessment Plan: PA (physician assistant) recommends ICU… 3. Tracheostomy dependent 4. Wound, open, neck 5. Sepsis.” On 05/12/2026 at 11:26 a.m., a telephone interview was conducted with S2LPN. S2LPN stated she was the primary nurse providing extended nurse services for Patient #5. S2LPN stated she did not change the patient’s trach ties daily. S2LPN stated that she changed the patient’s trach ties once a week and that she last changed them on 04/22/2026. S2LPN stated she did not know there was an order to change the trach ties daily. S2LPN stated on 04/28/2026, after her shift ended with the patient, the patient’s caregiver had face timed her to inform her that the patient developed an open wound on the left side of her neck which was caused from friction from the trach ties. S2LPN stated she was not aware the patient had developed an open wound on her neck because the trach ties covered the open wound. S2LPN stated Patient #5’s caregiver sent the patient to the hospital because of the open wound on her neck. On 05/12/2026 at 12:23 p.m., an interview was conducted with S1DEHC (Director of Extended Home Care). S1DEHC stated the patient’s aunt called her early on the morning of 04/29/2026. She stated the patient’s aunt told her Patient #5 had a fever and that she noticed the patient had an open wound on the side of her neck. S1DEHC stated S2LPN did not observe and assess the open wound on the patient’s neck. S1DEHC stated she spoke to S2LPN and asked her if she assessed the patient’s neck. S1DEHC stated that she told S2LPN that the patient’s aunt reported to her that she noticed an open wound on the side of the patient’s neck. S1DEHC stated S2LPN responded, “I missed it”. S1DEHC stated that she did not directly ask S2LPN if she changed Patient #5’s trach ties nor did she know if S2LPN was changing the patient’s trach ties daily. S1DEHC confirmed there was an order to change the patient’s trach ties daily and she confirmed that S2LPN should have been changing Patient #5’s trach ties daily as ordered. 2. Review of Patient #5’s clinical records revealed no evidence the patient received SN services on the dates of 04/12/2026 and 04/26/2026. Review of Patient #5’s weekly calendar for the month of April 2026 revealed that on the dates of 04/12/2026 and 04/26/2026 that there was no SN assigned to provide services for those two dates. On 05/11/2026 at 4:00 p.m., an interview was conducted with S1DEHC. S1DEHC reviewed Patient #5’s weekly calendar for the month of April 2026 and stated that the dates where unassigned was written were the dates the patient did not receive SN services. S1DEHC confirmed that no SN services were provided on the dates of 04/12/2026 and 04/26/2026.”

“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 agency failed to ensure the SN (skilled nurse) notified the RN/Physician of changes in the patient’s respiratory status for 1 (#5) out of 10 sampled patients. Findings: Review of S2LPN’s Mandatory Required Reporting form that was signed and dated on 09/18/2025 revealed: “The following items are MANDATORY to report to the office! Failure to report may result in written reprimand and/or termination! *You must report any: … *Plan of Care changes/updates/change in patient condition: (New diagnosis, decrease urinary output, vital signs out of parameters, signs & symptoms of UTI & respiratory distress, seizure activity, equipment, etc) Review of Patient #5’s clinical records revealed the start of care date was 07/27/2006. The patient’s diagnoses included lennox-gastaut syndrome and tracheostomy. The certification period reviewed was 04/12/2026 to 6/10/2026. Review of the patient’s POC (Plan of Care) for certification period 04/12/2026 to 06/10/2026 revealed an order for 56 hours of extended nursing care per week, which was 8 hours of SN services a day. Review of Patient #5’s extended care nursing assessment progress note dated 04/16/2026 revealed the SN suctioned thick, yellow, green phlegm from trach (tracheostomy). There was no evidence the SN notified the RN/MD. Review of Patient #5’s extended care nursing assessment progress note dated 04/18/2026 revealed the SN suctioned thick, yellow, green phlegm from trach. There was no evidence the SN notified the RN/MD. Review of Patient #5’s extended care nursing assessment progress note dated 04/24/2026 revealed the SN suctioned thick, yellow, green phlegm from trach. There was no evidence the SN notified the RN/MD. Review of Patient #5’s extended care nursing assessment progress note dated 04/27/2026 revealed the SN suctioned thick, yellow, green phlegm from trach. There was no evidence the SN notified the RN/MD. Review of the patient’s ED (emergency department) note dated 04/28/2026 at 23:03 (11:03 p.m.) revealed: “19-year-old female with a history of cerebral palsy, mental impairment, epilepsy, tracheostomy in place on 1.5 L (liter) at baseline presents emergency department for fever, productive sputum output through tracheostomy… Mother noted a fever today. Gave 300 mg of Tylenol 4 hours ago. She is concerned about pneumonia. Physical Exam: Vitals & Measurements: T: 38.4 C Rectal (101.1 F); HR 123; RR: 34; BP: 110/51; Sp02: 95%; O2 flow rate: 8; O2 therapy: Trach collar, Alert, mildly distressed, resting in bed. Tracheostomy in place… Purulent sputum from tracheostomy. Rhonchi to all lung fields… tachycardic. Assessment Plan: PA (physician assistant) recommends ICU 1. Pneumonia, Pseudomonas 2. Rhinovirus Infection 3. Tracheostomy dependent 4. Wound, open, neck 5. Sepsis.” On 05/12/2026 at 11:26 a.m., a telephone interview was conducted with S2LPN. S2LPN stated she was the primary nurse providing extended nurse services for Patient #5. S2LPN stated she suctioned the patient’s trach and that sometimes the mucus was thick, yellow, and green. S2LPN confirmed she did not inform the RN or the physician concerning the changes in the patient’s mucus. On 05/12/2026 at 12:50 p.m., an interview was conducted with S1DEHC (Director of Extended Home Care). S1DEHC stated S2LPN did not notify her of the changes in the patient’s mucus and that she should have notified her because that was a change in the patient’s status.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s injury of unknown source was investigated for 1(#3) out of 3 (#1, #2, and #3) sampled patients. On 04/15/2024, a review of the agency’s policy titled “9.08.1 Identifying and Reporting Possible Victims of Alleged or Suspected Abuse, Neglect, or Exploitation” with a date of 11/03/2017 revealed…..Purpose: To define the process for identifying and reporting possible victims of alleged/suspected abuse, neglect, or exploitation…. Procedure: 2. Criteria to identify abuse include… unexplained injuries or multiple hematomas....6. Staff will immediately report an assessment of patient’s condition and a supervisor will be assigned to assess…. 7. All findings and communication will be documented in the patients’ medical record. Review of the patient’s clinical records revealed the start of care date was 05/16/2016. The patient’s diagnoses included Cerebral Palsy, other abnormal involuntary movements, and Profound Intellectual Disability. The certification period reviewed was 02/04/2024 to 04/03/2024, and 04/04/2024 to 06/02/2024. Review of the patient’s Plan of Care (POC) for certification periods revealed an order for Skilled Nurse Extended Care Services for 72-84 hours per week. Patient’s POC revealed the skilled nurse was to monitor the status of patient’s skin integrity. Patient #3’s was dependent on others for all transfers and activities of daily living and had functional limitation of speech with aphasia. Review of daily extended care progress notes revealed the following: 02/03/2024 at 8:00 a.m. S3LPN (Licensed Practical Nurse) assessed Patient #3’s left eye being red and swollen. There was no documentation that the injury was reported. 02/04/2024 at 2:40 p.m. S4RN (Registered Nurse) assessed Patient #3’s redness to left side of face and around left eye. There was no documentation that the injury was reported. On 04/15/2024 at 1:45 p.m. a home visit was conducted with Patient #3. She was unable to verbalize any details regarding her redness and swelling that occurred to her left eye and face. On 04/15/2024 at 3:20 p.m., a telephone interview was conducted with S3LPN. She confirmed she assessed Patient #3 for redness and swelling to her left eye on 02/03/2024. She acknowledged that she did not notify anyone until she contacted S4RN the following day to assess. On 04/15/2024 at 3:30 p.m., a telephone interview was conducted with S4RN. She confirmed she received notice from S3LPN about Patient #3’s left eye being red and swollen. She was unable to recall if she notified anyone about the incident on that day. On 04/15/2024 at 3:50 p.m., an interview was conducted with S1ECS (Extended Care Supervisor). She confirmed Patient #3 had redness and swelling to her left eye and left side of face that occurred around 02/03/2024. She stated S4RN had notified her about it either over that weekend or possibly on the Monday. She confirmed she was unable to provide evidence that an investigation had been conducted for patient’s injury of unknown source.”