Brockton Home Health Care Agency

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for 4 patients (#2, #6, #3, and #4), out of a total sample of 7 patients. 3. Patient #3 was admitted to the agency in November 2025 with a diagnosis of essential (primary) hypertension and required skilled services. Review of the physician ordered POC for certification period 11/23/25 through 1/21/26 indicated a physician’s signature dated 12/29/25. The POC was not signed within 30 days as required. Further review of the clinical record indicated a physician’s order for Resumption of Care (ROC-when a patient returns to home health after being admitted to an inpatient facility) dated 12/15/25 with a physician’s signature dated 1/28/26. The physician ordered ROC care was not signed within 30 days as required. During an interview on 2/19/26 at 12:45 P.M., the DON, after reviewing the clinical record, said the POC and ROC were not signed within 30 days by the physician as required. 4. Patient #4 was admitted to the agency in August 2025 with a diagnosis of bilateral Meralgia paresthetica (a condition that results in tingling, numbness and burning on the outer thigh) and required skilled services. Review of the physician ordered POC for certification period 8/6/25 through 10/4/25 indicated a physician’s signature dated 9/10/25. The POC was not signed within 30 days as required. During an interview on 2/19/26 at 12:02 P.M., the DON, after reviewing the clinical record, said the POC was not signed within 30 days by the physician as required. Review of the clinical record indicated a communication note, dated 10/4/25, indicating a transfer summary was faxed to the PCP (primary care physician). Further review of the communication note indicated that it had not been signed or dated by the clinician. During an interview on 2/19/26 at 12:45 P.M. the DON said that the communication note was not completed as required with the clinician’s signature and date. Findings include: Review of the agency’s policy titled Timeliness and Accuracy of Entries in the Clinical Record, revised 2024, indicated but was not limited to the following: *Each entry into the patient record must be current, accurate, signed, legible, and dated with the date of the entry by the individual making the entry. The record must include all services whether furnished directly or under arrangement. *All clinicians have a professional and legal duty of care and therefore record keeping should be able to evidence: -Complete clinical progress notes on the date service are rendered. Review of the agency’s policy titled Patient Record Documentation Policy, revised 2024, indicated but was not limited to the following: -All visit notes for all patients are documented within 24-48 hours in the EMR (Electronic Medical Record) Review of the agency’s policy titled Patient Care Audit, revised 2024, indicated but was not limited to the following: *Medical records contents to include but are not limited to the following: -POC signed within 30 days 1. Patient #2 was admitted to the agency in December 2025 with a diagnosis of major depressive disorder and required skilled services. Review of the Physician ordered Plan of Care (POC) for certification period 12/2/25 through 1/30/26, indicated the following: *Skilled Nurse (SN) Visits twice a week for 9 weeks and 3 as needed (PRN) visits. Review of the clinical record indicated Patient #2 continued to receive SN services into the subsequent certification period beginning 1/31/26. Review of the clinical record indicated the 2/5/26 and 2/11/26 SN Visit notes were not completed and submitted within 24-48 hours of the visit. During an interview on 2/18/26 at 3:33 P.M., the Director of Nursing (DON), after reviewing the clinical record, said the visit notes had not been completed and submitted within 24-48 hours as required. 2. Patient #6 was admitted to the agency in April 2025 and had a diagnosis of chronic obstructive pulmonary disease (COPD- group of lung diseases that make it hard to breathe) and required skilled services. Review of the physician ordered POC for certification period 8/2/25 through 9/30/25 indicated a physician’s signature dated 10/8/25. The POC was not signed within 30 days as required. During an interview on 2/19/26 at 12:02 P.M., the DON, after reviewing the clinical record, said the POC was not signed within 30 days by the physician as required.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated the last five days of every 60 days beginning with the start of care date for one patient (#2), out of a total sample of 7 patients. Findings include: Review of the agency’s policy titled Assessment and Reassessment Policy, revised 2024, indicated but was not limited to the following: *The comprehensive assessment is updated and revised (including administration of the Outcome and Assessment Information Set [OASIS-data collection tool to assess patient conditions, determine treatment plans, improve care quality, and calculate Medicare reimbursement]) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but no less frequently than the following: -The last 5 days of every 60 days beginning with the start of care, unless there is a patient-elected transfer -A significant change in condition, or a discharge and return to the same home health agency within the 60-day episode -Within 48 hours of the patient’s return home from a hospital admission of 24 hours or more for any reason other than diagnostic tests or the patient has a physician’s or allowed practitioner’s ordered resumption date -At discharge Patient #2 was admitted to the agency in December 2025 with a diagnosis of major depressive disorder, requiring skilled services. Review of the clinical record indicated a physician ordered Plan of Care (POC) for certification period 12/2/25 through 1/30/26. Patient #2 remained on service into a subsequent certification period beginning 1/31/26. Further review of the clinical record indicated an OASIS Recertification assessment for Patient #2, dated 1/29/26. The assessment was incomplete. A comprehensive assessment (including OASIS data elements) to reflect the patient’s current health status was not updated or revised in the last 5 days of every 60 days by a skilled nurse until discharged as required. During an interview on 2/18/26 at 3:33 P.M., the Director of Nursing, after reviewing Patient #2’s clinical record, said an updated comprehensive assessment was not completed within the required timeframe.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure nursing services were provided under the supervision of a registered nurse (RN) for 1 patient (#7), out of 3 patients, who received nursing services from a licensed practical nurse (LPN). Findings include: Review of the agency’s policy titled Administrative Patient Record Audit, updated 2024, included but was not limited to the following: *According to a time frame well defined, Brockton Home Health Care AGENCY, LLC reviews its patients’ records to confirm that the required information is present, accurate, legible, authenticated, and completed on time. *Brockton Home Health Care Agency, LLC, reviews a sample of active and closed medical records for completeness and accuracy in accordance with Federal and State laws and regulation and Brockton Home Health Care Agency, LLC policy. *Medical record content to include but not limited to the following: -LPN supervision completed every 30 days -Supervisory visits by RN completed timely Patient #7 was admitted to the agency in August 2025 with a diagnosis of bipolar disorder and required skilled home care services. Review of the physician ordered Home Health Certification and Plan of Care (POC) for certification period 10/27/25 through 12/25/25 indicated the following: -Skilled Nursing (SN) frequency: daily for 60 days and 3 visits as needed (PRN). Review of the physician ordered Home Health Certification and POC for certification period 12/26/25 through 2/23/26 indicated the following: -SN frequency: daily for 60 days and 3 visits PRN. Review of the clinical record for dates of services between 12/21/25 through 2/17/26 indicated LPN visits were conducted on 12/22/25, 1/2/26, 1/9/26, 1/19/26, 1/30/26 and 2/9/26. Further review of these dates of service failed to include any documented RN supervisory visits. During an interview on 2/19/26 at 1:01 P.M., the Director of Nurses (DON) and surveyor reviewed the clinical record for the dates of services between 12/21/25 through 2/17/26. The DON said she did not believe RN supervision of the LPN was necessary as the primary visits were being conducted by the RN and asked the scheduler to cancel the RN supervisory visits, so no supervision was provided. The DON and the surveyor reviewed the regulations and the agency policy and procedure. The DON said the RN should have documented supervision to the LPN every 30 days per regulation.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record included all interventions, including medication administration, treatments, and services, and responses to those interventions for one patient (#2), out of a total sample of 7 patients. Findings include: Review of the agency’s policy titled Timeliness and Accuracy of Entries in the Clinical Record, revised 2024, indicated but was not limited to the following: *All clinicians have a professional and legal duty of care and therefore record keeping should be able to evidence: -Full account of the assessment and care planned by the clinician. -Relevant information about the condition of the patient at any given time and measures taken to respond to their needs. Review of the agency’s policy titled Patient Record Audit, revised 2024, indicated but was not limited to the following: *Medical records contents to include but are not limited to the following: -Notes consistent with physician orders -Evidence of skilled services provided in each note -Treatment/services provided are consistent with physician orders and care plan -Notes reflect progress toward goals -Medication profile updated with changed medications Patient #2 was admitted to the agency in December 2025 with a diagnosis of major depressive disorder, requiring skilled services. Review of a Physician’s Order, dated 1/16/26, indicated the following: -New medication: Nystatin 100000 Unit/GM (gram) External Powder as directed/apply to the affected area two times a day topical (TOP) fungal rash Review of a Skilled Nurse (SN) Visit note, dated 1/16/26, indicated but was not limited to the following: -Patient reports being seen by PCP (primary care physician) on 1/13 and prescribed nystatin powder. RN (registered nurse) contacted pharmacy; nystatin powder refill requested to be filled today. Patient was reminded to be on the lookout for medication delivery. Patient stated he/she has an older bottle at home that he/she has been using. RN requested to review the medication bottle and expiration date; the bottle was found to be expired as of April 2025. Further review of SN Visit notes dated 1/21/26, 1/23/26, 1/24/26, 1/31/26, 2/5/26, 2/11/26, and 2/14/26 did not indicate whether the Nystatin powder medication was received by Patient #2 from the pharmacy, any relevant information regarding the patient’s condition, or services and responses to the interventions related to the fungal rash. Review of the clinical record indicated Patient #2 remained on service into a subsequent certification period beginning 1/31/26. The record did not, however, indicate an updated physician ordered Plan of Care (POC) to include an updated medication profile. During an interview on 2/18/26 at 3:33 P.M., the Director of Nurses (DON) said the physician ordered Nystatin powder was not documented in the clinical record as having been received, its use assessed, or documentation of whether the patient’s rash had improved. She said the POC was not updated to reflect the new medication or the patient’s specific measurable goals and outcomes related to the patient’s fungal rash.”