Southern Home Health

“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 the PT (Physical Therapist) failing to record/monitor blood sugar readings for 2 (#7, #16) out of 17 sampled patients. Findings: 1. Patient #7. Review of the patient’s electronic clinical record revealed the start of care date was 12/20/2025. The patient’s diagnoses included diabetes, hypertensive heart disease with heart Failure and hemiplegia following cerebral infarction. The certification period reviewed was 02/18/2026 to 04/18/2026. Review of the patient’s POC (Plan of Care) for certification period 02/18/2026 to 04/18/2026 revealed an order for “PT effective 02/22/2026 1wk8wk, (physical therapy effective the week of 02/22/2026 visit one time a week for eight weeks). Further review of the POC revealed orders for, “…report falling outside the following established parameters… FBS (fasting blood sugar) (greater than) 200 RBS (random blood sugar) 300.” There were no orders for skilled nurse visits. Review of the patient’s PT visit notes dated 02/25/2026, 03/04/2026, and 03/11/2026 revealed there was no evidence the PT recorded or monitored the patient’s blood sugar readings. On 03/17/2026 at 1:10 p.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed the patient’s electronic clinical record and confirmed there was no evidence the PT recorded or monitored the patient’s blood sugar readings and should have. 2. Patient #16. Review of the patient’s electronic clinical record revealed the start of care date was 11/14/2025. The patient’s diagnosis included diabetes. The certification period reviewed was 01/13/2026 to 03/13/2026. Review of the patient’s POC (Plan of Care) for certification period 01/13/2026 to 03/13/2026 revealed an order for “PT 1wk8wk, (physical therapy visit one time a week for eight weeks). Further review of the POC revealed orders for, “…report falling outside the following established parameters… FBS 200 RBS 300.” There were no orders for skilled nurse visits. Review of the patient’s PT visit notes dated 01/15/2026, 01/23/2026, 01/30/2026, 02/06/2026, 02/10/2026, 02/19/2026, 02/27/2026, and 03/04/2026 revealed there was no evidence the PT recorded or monitored the patient’s blood sugar readings. On 03/17/2026 at 9:23 a.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed the patient’s electronic clinical record and confirmed there was no evidence the PT recorded or monitored the patient’s blood sugar readings and should have.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency staff failed to demonstrate that effective coordination of care occurred when the HHA (Home Health Aide) failed to inform the nursing staff of Patient #7’s complaint of exhaustion after straining to have a bowel movement for an hour for 1 (#7) out of 7 patients (#1-#7) seen for home visits out of a total sample of 17 patients. Findings: Review of the agency policy titled, “Coordination of Care, From Admit through Discharge” with a revision date of 12/01/2025 read in part, Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Procedure: Coordination of Care among disciplines and between in-person and virtual clinicians: Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge. This includes: c. Appropriate, timely communication with the patient, caregivers, and staff involved in the patient’s care regarding patient needs, goals, and care as well as changes in these… Significant changes in the patient’s condition (i.e. new or worsening symptoms…) i.e. (in other words). Patient #7. Review of the patient’s electronic clinical record revealed the start of care date was 12/20/2025. The patient’s diagnoses included hypertensive heart disease with heart failure and hemiplegia following cerebral infarction. The certification period reviewed was 02/18/2026 to 04/18/2026. Review of the patient’s POC (Plan of Care) for certification period 02/18/2026 to 04/18/2026 revealed an order for “HHA effective 02/22/2026 1wk4wk, (home health aide effective the week of 02/22/2026 visit one time a week for four weeks). On 03/17/2026 at 11:05 a.m., a home visit was made to Patient #7’s home and S3HHA was present. The patient was observed sitting up in his recliner during the home visit. During the home visit, the patient refused his shower. The patient stated that he was so exhausted from straining to have a bowel movement (BM) prior to S3HHA arrival to his home. The patient stated that he had to manually remove the BM which took an hour. The patient stated that 4 days had passed since his last BM and that it was hard. He stated the stool softeners and Miralax (laxative) did not work. S3HHA stated she would bathe him in the recliner in place of the shower. The patient did not complain of pain during the home visit, but S3HHA was still present with the patient when the surveyor left the home. Review of the patient’s HHA note dated 03/17/2026 at 12:11 p.m. revealed S3HHA documented, “Chair bath. Pt complained of hurting too much.” Review of the patient’s coordination note dated 03/17/2026 with no time and documented by S2PCM (Program Case Manager) revealed, “Received call from (S3HHA) stating patient was having increased generalized pain and didn’t want to get in shower during her visit.” There was no evidence that S3HHA informed S2PCM about the patient not having a BM for 4 days and straining for an hour to have a BM, which exhausted him along with the pain that he was experiencing during his bath. On 03/17/2026 at 3:22 p.m., an interview was conducted with S2PCM. S2PCM stated that S3HHA did call and informed her that Patient #7 was having pain all over when she was changing his position to bathe him in the chair. S2PCM stated that S3HHA did not report the patient was straining to have a bowel movement and had to manually remove it and was too exhausted to get up out of his chair to shower. S2PCM confirmed that S3HHA should have reported it.”