Beaumont 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 attempt to reschedule missed visits to meet the frequency in the plan of care in 2 (P-2 and P-4) of 17 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #2 (P-2) was admitted to this home care agency on 7/2/25 with the diagnosis of hypertension (high blood pressure). During record review on 9/24/25, it was noted the plan of care (dated 7/2/25) ordered services from a home health aide 2 times a week for 4 weeks. Upon further review of the record, it was determined 9 of 9 scheduled home health aide visits were documented as missed visits for various reasons. However, there was no documentation of attempts made to reschedule the missed visits to meet the ordered visit frequency. Patient #4 (P-4) was admitted to this home care agency on 8/9/25 with the diagnoses of bilateral radius and ulna (wrist) fractures, hemiplegia following a cerebrovascular accident (weakness on half of the body following a stroke), and type II diabetes mellitus. During record review on 9/25/25, it was noted that skilled nursing services were ordered 1 time a week for 9 weeks and home health aide services were ordered 1 time a week for 2 weeks, 2 times a week for 1 week, and 1 time a week for 4 weeks. During review of the visit notes, it was determined that skilled nursing was unable to reach the patient on 9/3/25 for a visit and no visit was made that week. A missed visit was documented, however, there was no documentation of attempts made to reschedule the missed visits to meet the ordered visit frequency. Additionally, it was noted the home health aide documented a missed visit on 9/19/25 due to no answer at the door. However, there was no documentation of who was notified of the missed visit or of attempts made to reschedule the missed visit to meet the ordered frequency. A review of agency policy titled “Missed Visit Management” (last reviewed 9/20/22) revealed, “A missed visit is one in which all efforts have been exhausted to reschedule the patient under the current ordered frequency.” The administrator (Adm-1), regional vice president (RVP), and director of survey accreditation and support service (DSA) reviewed and acknowledged the findings during an interview on 9/26/25 at 8:35 AM.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on interview and record review, it was determined the agency failed to ensure skilled nursing (SN) prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions in 2 (Patient/P-7, P-8) of 2 records in which home health aide (HHa) services were ordered, from a total of 17 sampled records reviewed, resulting in an incomplete list of safety precautions concerning the provision of services and the potential for poor patient outcomes. Findings include: P-7: The patient’s start of care (SOC) was 4/6/25, with diagnoses that included hypertensive heart disease, congestive heart failure, and chronic respiratory failure with hypoxia. The plan of care (POC) effective 4/6/25, indicated the following safety precautions: “Ambulation safety, daily weights, emergency/evacuation plan, fall precautions, medication precautions, oxygen precautions, pet safety, and universal precautions.” However, review of the HHa POC (4/6/25) noted only two precautions: “Bleeding precautions (if shaving applicable--only with electric razor) and high fall risk.” The Administrator (ADM-1), Regional Vice President (RVP) and Director of Survey Accreditation and Support Service (DSA) reviewed and acknowledged during an interview on 9/26/25 at 11:43 AM., the HHa POC should include all the safety precautions listed on the main or 485/POC. P-8: The SOC to the home care agency was 3/3/25, with diagnoses that included hypertensive heart disease, congestive heart failure, atrial fibrillation, and long-term (current) use of anticoagulants. The plan of care (POC) effective 3/3/25, indicated the following safety precautions: “Adaptive equipment precautions, ambulation safety, anticoagulation precautions, clear pathways, daily weights, emergency/evacuation plan, fall precautions, medication precautions, transfer safety, and universal precautions.” However, review of the HHa POC (3/14/25) noted there were no listed safety precautions. The Administrator (ADM-1), Regional Vice President (RVP) and Director of Survey Accreditation and Support Service (DSA) reviewed and acknowledged during an interview on 9/26/25 at 12:12 PM., that the HHa POC should include all the safety precautions listed on the main or 485/POC.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received all services outlined in the plan of care for 2 (P-2 and P-16) of 17 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #16: (P-16)’s SOC was 4/14/25, with diagnoses of diabetes type 2, gastroparesis, and pancreatitis. The Plan of Care ordered Skilled Nursing, Physical Therapy, Occupational Therapy, and Medical Social Worker services. During record review on 9/24/25, it was discovered that medical social worker (MSW) services were ordered to start on 4/17/25. There were no documented MSW visits in the record. During an interview on 9/26/25 at 1:30 PM, the administrator (Adm-1) acknowledged the above findings and stated, “The MSW was never notified that services were ordered.” Patient #2 (P-2) was admitted to this home care agency on 7/2/25 with the diagnosis of hypertension (high blood pressure). During record review on 9/24/25, it was determined the plan of care (dated 7/2/25) ordered social work services 2 times a week for 4 weeks and home health aide services 2 times a week for 4 weeks. Upon further review of the record, it was determined P-2 was never seen by the social worker or the home health aide between 7/2/25 and 8/27/25 when the patient was receiving home health care from this agency. During review of the orders written for P-2, it was noted there were orders written on 7/7/25, 7/15/25, and 7/28/25 to move the social work evaluation due to “inability to coordinate care.” An order was written on 8/8/25 to void social work services due to “inability to coordinate care.” Additionally, review of home health aide documentation revealed 9 missed visits were documented for various reasons. No home health visits were actually made by the home health aide. The agency failed to ensure the patient received all services outlined in the plan of care. The administrator (Adm-1), regional vice president (RVP), and director of survey accreditation and support service (DSA) reviewed and acknowledged the findings during an interview on 9/26/25 at 8:35 AM.”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that 1 (Patient/P-6) of 4 patients reviewed with severe pain levels had an appropriate documented response in addressing the pain, from a total of 17 sampled patients resulting in unidentified health concerns, delay in treatment and unmet patient care needs. Findings include: P-6: The patient’s start of care (SOC) to the home care agency was 8/22/25, with diagnoses that included post-surgical laminectomy with discectomy, spinal stenosis, and hypertension. On 9/24/25, record review of the SOC comprehensive assessment performed by skilled nursing (SN) on 8/22/25, noted P-6’s pain level was “Excruciating” or a 9 out of 10 (10 being the worst possible), affecting P-6’s back and legs. The “Provider (physician) Notification” section within the SOC assessment was left blank. Further, no documentation was found that SN had attempted any pain-relieving measures that could provide relief or potentially resolve P-6’s pain at the time. The Administrator (ADM-1), Regional Vice President (RVP) and Director of Survey Accreditation and Support Service (DSA) reviewed and acknowledged the findings listed above in an interview on 9/26/25 at 11:22 AM. Administration above further acknowledged this did not meet agency expectations or its policy referenced below. Agency Policy: “Pain Assessment” ID: QA-014 HH (revised 9/21/22) stated, “All patients will receive an initial pain assessment. When pain is identified, a more comprehensive pain assessment will be completed. Pain assessments ...will be documented to facilitate regular reassessment and follow-up by clinicians.” The agency failed to document any follow-up actions/interventions to help resolve/lesson P-6’s “excruciating” pain experienced during the SOC assessment.”

“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 record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects, and failed to provided documented evidence that the physician was notified of identified drug interactions in 10 (Patient/P-6, P-9, P-10, P-11, P-12, P-13, P-14, P-15, P-16, P-17) of 17 records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this Agency. Findings include: Patient #14: (P-14)’s Start of Care (SOC) was 9/20/25, with diagnoses of fracture of vertebrae, hypertension and falls. The Plan of Care ordered Skilled Nursing, Physical Therapy, Occupational Therapy, and Home Health Aide services. During record review on 9/24/25, it was discovered that section M2001 (Medication review) of the Initial Comprehensive Assessment documented “No issues found during review.” The patient’s medications were reviewed on 9/24/25, in the agency’s electronic medical record and revealed 3 moderate drug-to-drug interactions. Patient #15: (P-15)’s SOC was 9/6/25, with diagnoses of Left femur fracture, falls, and pain. The Plan of Care ordered Skilled Nursing, Physical Therapy, Occupational Therapy, and Home Health Aide services. During record review on 9/25/25, it was discovered that section M2001 (Medication review) of the Initial Comprehensive Assessment documented “No issues found during review.” The patient’s medications were reviewed on 9/25/25, in the agency’s electronic medical record and revealed 4 moderate drug-to-drug interactions. Patient #16: (P-16)’s SOC was 4/14/25, with diagnoses of diabetes type 2, gastroparesis, and pancreatitis. The Plan of Care ordered Skilled Nursing, Physical Therapy, Occupational Therapy, and Medical Social Worker services. During record review on 9/24/25, it was discovered that section M2001 (Medication review) of the Initial Comprehensive Assessment documented “No issues found during review.” The patient’s medications were reviewed on 9/24/25, in the agency’s electronic medical record and revealed 11 moderate and 4 severe drug-to-drug interactions. The agency also failed to include oxygen on the medication profile. P-16 was on 3L of oxygen via nasal cannula. Patient #17: (P-17)’s SOC was 9/21/25, with diagnoses of diabetes type 2, joint replacement aftercare, and pain. The Plan of Care ordered Skilled Nursing and Physical Therapy services. During record review on 9/23/25, it was discovered that section M2001 (Medication review) of the Initial Comprehensive Assessment documented “No issues found during review.” The patient’s medications were reviewed on 9/23/25, in the agency’s electronic medical record and revealed 2 moderate drug-to-drug interactions. The administrator (Adm-1) reviewed and confirmed the above findings during an interview on 9/26/25 at 1:30 p.m. Patient #9’s (P-9) Start of Care (SOC) was dated 6/25/25. The Plan of Care (POC) identified diagnoses of Knee Replacement, Hypertension and Anemia. During record review on 9/25/25, it was noted that one “Medication Interaction” note was completed on 6/25/25 that stated, “MD (Medical Doctor) office notified.” The comprehensive assessment dated 6/25/25 stated, “Provider Notification: The provider below was contacted to report the following: Blank.” The medical record contains conflicting evidence of whether the physician was indeed contacted to report the medication interaction. Additionally, the med profile documented three medications, Hydrocodone, Naloxone and Nitroglycerin as “As Needed” frequency. There were no instructions as to the ordered frequency. Patient #10’s (P-10) Start of Care (SOC) was dated 7/16/25. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Atrial Fibrillation and Vascular Disorder of Intestine. During record review on 9/23/25, it was noted that the Registered Nurse completed an evaluation assessment on 7/24/25 and documented, “Respiratory: Indicate the oxygen flow rate: 2 LPM (Liters per minute). Frequency of oxygen: Continuous.” The medication profile updated on 7/24/25 failed to include Oxygen. Patient #11’s (P-11) Start of Care (SOC) was dated 9/20/25. The Plan of Care (POC) identified diagnoses of Post Laminectomy, Obesity and Hypertension. During record review on 9/24/25, it was noted that two “Medication Interaction” notes were completed on 9/20/25 that stated, “DR (Doctor) aware.” The comprehensive assessment dated 9/20/25 stated, “Provider Notification: The provider below was contacted to report the following: Blank.” The medical record contains conflicting evidence of whether the physician was indeed contacted to report the medication interactions. Additionally, the Electronic Medical Record (EMR) documented discrepancies from the Referral and medication profile. The missing medications from the referral were Aspirin, Acetaminophen, Senna, Ergocalciferol, Furosemide and Rosuvastatin. There is no documented medication reconciliation completed with the physician to determine an accurate home medication regimen. Patient #12’s (P-12) Start of Care (SOC) was dated 7/12/25. The Plan of Care (POC) identified diagnoses of Colon Cancer, Anemia, Ileostomy. During record review on 9/24/25, it was noted that five “Medication Interaction” notes were completed on 7/12/25 that stated, “MD (Medical Doctor) order.” The comprehensive assessment dated 7/12/25 stated, “Provider Notification: The provider below was contacted to report the following: Blank.” The medical record contains conflicting evidence of whether the physician was indeed contacted to report the medication interactions. Patient #13’s (P-13) Start of Care (SOC) was dated 6/26/25. The Plan of Care (POC) identified diagnoses of Hypocalcemia, Hypokalemia and Hypomagnesemia. During record review on 9/25/25, it was noted that nine “Medication Interaction” notes were completed on 6/26/25 that stated, “Physician aware.” The comprehensive assessment dated 6/26/25 stated, “Provider Notification: The provider below was contacted to report the following: Blank.” The medical record contains conflicting evidence of whether the physician was indeed contacted to report the medication interactions. A review of the agency policy occurred on 9/26/25 titled “Medication Profile” (Reviewed: 9/7/202). The policy states, “Purpose: To define the use of the medication profile in evaluating a patient’s current medication regimen…Policy: Patients receiving medications will have a current, accurate medication profile in the clinical record…3.3 Medication Interaction 3.3.2 All interactions require physician notification via a phone call and documentation in PointCare. 3.3.3 A higher severity interaction (2 or 3), should include a request of urgency when leaving a message for the physician.” The Administrator (ADM-1), Regional Vice President (RVP) and Director of Survey Accreditation and Support Service (DSA) reviewed and acknowledged the findings listed above in an interview on 9/26/25 at 9:45 am. P-5: This patient was admitted to the home care agency on 9/17/25, with diagnoses that included after care following right total knee replacement, diabetes-type 2, and chronic pain. During a joint home visit with physical therapy services on 9/23/25, the hospital discharge medication list for P-5 was compared to the medication list generated by home care’s skilled nursing (SN), which populated onto P-5’s plan of care (POC) on 9/17/25. During this review, the following medication discrepancies were found: The POC listed a total of 7 medications but failed to include medications that P-5 needed to take after hospital discharge on 9/16/25, which were: Aspirin 81 mg. twice a day; Voltaren (pain/inflammation relieving 1% gel to skin twice a day); Colace (stool softener) twice a day as needed; Norco 5-325 mg. 1-2 tablets every 6 hours as needed for pain relief; Zofran 1 tablet every 8 hours as needed for nausea/vomiting; and Ultram 1 tablet every 6 hours as needed for pain relief. The comprehensive assessment performed by SN, documented under “Medications” that “No issues were found during review.” Physician notification was not evidenced in the medical record concerning the medication discrepancies noted above which go against the agency’s policy titled “Medication Profile”. This policy stipulates all interactions require physician notification and a higher severity interaction (2 or 3), “should include a request of urgency when leaving a message for the physician.” No evidence was found indicating this was done, which included all the medications that P-5 was taking on 9/17/25. The Administrator (ADM-1), Regional Vice President (RVP) and Director of Survey Accreditation and Support Service (DSA) reviewed and acknowledged the above findings during an interview on 9/26/25 at 10:56 AM.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included patient specific parameters to meet the needs of the patient for 10 (P-1, P-2, P-3, P-4, P-6, P-9, P-14, P-15, P-16 and P-17) of 17 records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: Patient #14: (P-14)’s Start of Care (SOC) was 9/20/25, with diagnoses of fracture of vertebrae, hypertension and falls. The Plan of Care (POC) ordered Skilled Nursing, Physical Therapy, Occupational Therapy, and Home Health Aide services. During record review on 9/24/25, it was discovered that the POC failed to include pain parameters to notify the physician with P-14 having a diagnosis of fracture of vertebrae. Patient #15: (P-15)’s SOC was 9/6/25, with diagnoses of Left femur fracture, falls, and pain. The Plan of Care ordered Skilled Nursing, Physical Therapy, Occupational Therapy, and Home Health Aide services. During record review on 9/25/25, it was discovered that the POC failed to include pain parameters to notify the physician with P-15 having a diagnosis of femur fracture and pain. Patient #16: (P-16)’s SOC was 4/14/25, with diagnoses of diabetes type 2, gastroparesis, and pancreatitis. The Plan of Care ordered Skilled Nursing, Physical Therapy, Occupational Therapy, and Medical Social Worker services. During record review on 9/24/25, it was discovered that no blood sugar parameters were ordered on the POC with a primary diagnosis of type 2 diabetes mellitus. Patient #17: (P-17)’s SOC was 9/21/25, with diagnoses of diabetes type 2, joint replacement aftercare, and pain. The Plan of Care ordered Skilled Nursing and Physical Therapy services. During record review on 9/23/25, it was discovered that the POC failed to include pain parameters to notify the physician with P-17 having a diagnosis of joint replacement, and pain. The POC also failed to include blood sugar parameters with a diagnosis of diabetes mellitus. The administrator (Adm-1) reviewed and confirmed the above findings during an interview on 9/26/25 at 1:30 p.m. Patient #9’s (P-9) Start of Care (SOC) was dated 6/25/25. The Plan of Care (POC) identified diagnoses of Knee Replacement, Hypertension and Anemia. During record review on 9/25/25, it was noted that the POC stated, “Physical Therapist to monitor and provide instruction regarding pain control methodologies including pharmacologic and non-pharmacologic methods. Therapist will notify client’s physician, RN (Registered Nurse) case manager or a clinical liaison of uncontrolled pain…” The Physical Therapy Assistant (PTA) completed a visit on 6/27/25 and stated, “Pain: Indicate client’s level of pain: Standardized pain assessment: Excruciating (9-10) (Intervention required)…” The coordination note dated 6/27/25 stated, “Assessment: Patient reports 9/10 pain in L (Left) knee. Educated painted on pain management techniques including rest, ice, positioning, taking pain medication prior to arrival…” The POC failed to contain pain parameters to notify the physician. A review of the agency policy occurred on 9/26/25 titled “Ongoing Assessment” (Reviewed: 9/2/2022) The policy states, “1. During each home visit, plan of care review or comprehensive assessment, the appropriate clinician with support of clinical leadership if necessary, will re-evaluate the patient’s status according to the problems identified during the episode. 2. Using the standards of care identified by the organization and in collaboration with the patient/representative, the clinician will reassess the patient for: 2.3. Pain status when applicable.” The Administrator (ADM-1), Regional Vice President (RVP) and Director of Survey Accreditation and Support Service (DSA) reviewed and acknowledged the findings listed above in an interview on 9/26/25 at 9:55 am. P-6: The patient’s start of care (SOC) to the home care agency was 8/22/25, with diagnoses that included post-surgical laminectomy with discectomy, spinal stenosis, and hypertension. On 9/24/25, record review of P-6’s Plan of Care (POC) effective on 8/22/25, documented the following: “Skilled Nurse (SN) to intervene with increased pain level to minimize complications.” The POC failed to provide clear guidance of when to notify the physician for potential orders, including when a patient meets or exceeds severe pain thresholds. This was evident on 8/22/25, when the SOC comprehensive assessment performed by SN, documented P-6’s pain level was “Excruciating” or a 9 out of 10 (10 being the worst possible). Since the POC did not specific interventions or pain parameters to notify the physician, P-6 had no documented clinical support by SN when experiencing excruciating pain on 8/22/25. The Administrator (ADM-1), Regional Vice President (RVP) and Director of Survey Accreditation and Support Service (DSA) reviewed and acknowledged the findings listed above in an interview on 9/26/25 at 11:22 AM. Administration above further acknowledged this did not meet agency expectations or its policy referenced below. Patient #1 (P-1) was admitted to this home care agency on 9/2/25 with the diagnoses of spinal stenosis status post lumbar laminectomy with posterior spinal fusion (lower back surgery with hardware placement). During record review on 9/23/25, it was noted the start of care assessment performed by the physical therapist on 9/2/25 indicated P-1 had pain that was “Horrible (7-8) (Intervention Required).” Upon further review of the record, it was determined the plan of care failed to include pain parameters for when to notify the physician. Patient #2 (P-2) was admitted to this home care agency on 7/2/25 with the diagnosis of hypertension (high blood pressure). During record review on 9/24/25, it was noted the start of care assessment performed by the skilled nurse on 7/2/25 indicated P-2 had pain that was “Discomforting (3-4).” Upon further review of the record, it was determined the plan of care failed to include pain parameters for when to notify the physician. Patient #3 (P-3) was admitted to this home care agency on 8/15/25 with diagnoses of a thoracic aorta aneurysm and chronic kidney disease. During record review on 9/24/25, it was noted the start of care performed by the skilled nurse on 8/15/25 indicated P-3 had pain that was “Distressing (5-6) (Intervention Required).” Upon further review of the record, it was determined the plan of care failed to include pain parameters for when to notify the physician. Patient #4 (P-4) was admitted to this home care agency on 8/9/25 with the diagnoses of bilateral radius and ulna (wrist) fractures, hemiplegia following a cerebrovascular accident (weakness on half of the body after a stroke), and type II diabetes mellitus. During record review on 9/25/25, it was noted the start of care performed by the skilled nurse on 8/9/25 indicated P-4 had pain that was “Discomforting (3-4).” Upon further review of the record, it was determined the plan of care failed to include pain parameters for when to notify the physician. The administrator (Adm-1), regional vice president (RVP), and director of survey accreditation and support service (DSA) reviewed and acknowledged the findings during an interview on 9/26/25 at 8:35 AM.”

“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 record review and interview, the agency failed to ensure communication to integrate all services to ensure patient needs were met in 1 (P-2) of 17 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs Findings include: Patient #2 (P-2) was admitted to this home care agency on 7/2/25 with the diagnosis of hypertension (high blood pressure). During record review on 9/24/25, it was noted the plan of care (dated 7/2/25) ordered services from skilled nursing 1 time a week for 3 weeks and once every other week for 6 weeks, physical therapy 1 time a week for 6 weeks, occupational therapy 1 time a week for 7 weeks, home health aide services 2 times a week for 4 weeks, and social work for 2 times a week for 4 weeks. Upon further review of the record, it was determined there were no visits made by social work or a home health aide. Upon review of the orders, it was noted there were orders dated 7/7/25, 7/15/25 and 7/28/25 to move the social work evaluation due to “inability to coordinate care.” Ultimately, the order for social work was voided on 8/8/25 due to continued “inability to coordinate care.” There was no documentation to indicate the social worker attempted to coordinate care with skilled nursing (who completed 5 of 5 scheduled visits), physical therapy (who completed 5 of 8 scheduled visits), or occupational therapy (who completed 5 of 7 scheduled visits) during the time P-2 was receiving services from this agency. Upon review of the missed visits documented by the home health aide, it was determined the 9 of 9 scheduled visits were missed for various reasons. There was no documentation to indicate the home health aide attempted to coordinate care with skilled nursing, physical therapy, or occupational therapy as mentioned above. A review of agency policy titled “Coordination of Services” (last reviewed 9/7/22) revealed, “5. When the patient requires more than one (1) service from the organization, the agency is responsible for coordinating care planning in order to assure that goals, actions, and the interrelationship of services are not duplicated and to minimize the potential for missed or conflicting services.” There was no evidence of care coordination between disciplines to meet identified patient needs. The administrator (Adm-1), regional vice president (RVP), and director of survey accreditation and support service (DSA) reviewed and acknowledged the findings during an interview on 9/26/25 at 8:35 AM.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency’s skilled nursing (SN) services failed to coordinate and facilitate care as ordered by the physician in 1 (Patient/P-7) of 2 records reviewed with congestive heart failure, from a total sample of 17 records reviewed, resulting in the lack of cardiac monitoring and the potential for poor clinical outcomes. Findings include: P-7: The patient’s start of care (SOC) was 4/6/25, with diagnoses that included hypertensive heart disease, congestive heart failure (CHF), and chronic respiratory failure with hypoxia. On 9/24/25, record review of the referral for home care effective 4/5/25 noted P-7 was discharged from the hospital due to exacerbation (worsening) of CHF fluid overload. Hospital discharge records noted daily weights were warranted to monitor for the reoccurrence of fluid overload and subsequent hospital re-admission. The plan of care ordered the skilled services of nursing (SN): 2W1 (twice weekly visits times one week), followed by 1W8, physical therapy (PT: 1W8), and occupational therapy (OT: 1W9). The SOC assessment performed by SN on 4/6/25 documented P-7’s weight was 360 pounds. On 4/10/25, SN documented a weight of 360 pounds again. However, the day after on 4/11/25, PT services performed their evaluation and agency records noted P-7’s weight had increased to 373 pounds. Follow-up visits were made by SN and OT services on 4/17/25 with a recorded weight of 373 pounds. Up to this point, no documentation was found in the medical record that indicated any of the skilled disciplines assigned were aware of the significant weight increase potentially caused by fluid overload. On 4/24/25, SN and OT services again provided home visits and the recorded weight on that day had another increase to 380 pounds. No physician notification or coordination of care was found in the record concerning this SCIC (significant change in condition). Subsequent visits were provided by all 3 services through 5/6/25 with the last recorded weight being 380 pounds. The next day (5/7/25), P-7’s weight had decreased to 366 pounds with no further increases noted. The findings above were reviewed and acknowledged by the Administrator (ADM-1), Regional Vice President (RVP) and Director of Survey Accreditation and Support Service (DSA) during an interview on 9/26/25 at 12:13 PM. All further acknowledged this did not meet agency expectations or its policy referenced below. Agency Policy: “Coordination of Services” ID: OP-009 HH (revised 9/7/22) stated, “Timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient...The clinician/technician will be responsible for facilitating communications about changes in the patient’s status among the assigned personnel.””

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were provided with the name and contact information of the clinical manager in 1 (P-1) of 7 records reviewed, resulting in the potential for patients to be unaware of who to contact regarding concerns about the agency. Findings include: The agency’s admission booklet given to patients was reviewed on 9/23/25 at 11:30 AM. During review of the booklet, it was noted it included contact information for a clinical manager, however, the name of the clinical manager was not identified. Upon further review of the admission packet, it was noted the first page had a blank line next to the words “Clinical Manger” as well as blank spaces next to other disciplines to be filled out. During a joint home visit with Patient #1 (P-1) and the occupational therapist on 9/24/25 at 9:00 AM, it was noted there was no name listed next to the space for clinical manager in P-1’s admission booklet. During an interview with the administrator (Adm-1) on 9/25/25 at 1:49 PM, Adm-1 was queried regarding the above findings. Adm-1 stated the agency has 8 clinical managers and the staff should be writing the name of the clinical manager for each patient in the front of the booklet upon admission. Adm-1 acknowledged the findings at the time of interview.”

“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 interview, it was determined that the agency failed to ensure the professional staff provided ongoing reassessment in 7 (P-1, P-2, P-4, P-9, P-10, P-14, P-16) of 17 records, resulting in the potential for unidentified patient needs. Findings include: Patient #14: (P-14)’s Start of Care (SOC) was 9/20/25, with diagnoses of fracture of vertebrae, hypertension and falls. The Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health Aide (HHA) services. During record review on 9/25/25, it was discovered that the plan of care (POC) had oxygen saturations (O2 Saturation) ordered for each visit. SN failed to document an O2 saturation on 9/20/25, and OT failed to document an O2 saturation on 9/23/25. Patient #16: (P-16)’s SOC was 4/14/25, with diagnoses of diabetes type 2, gastroparesis, and pancreatitis. The Plan of Care ordered SN, PT, OT, and Medical Social Worker (MSW) services. During record review on 9/24/25, it was discovered that the plan of care (POC) had oxygen saturations (O2 Saturation) ordered for each visit. SN failed to document an O2 saturation on 4/14/25, OT failed to document an O2 saturation on 4/25/25, and PT failed to document O2 saturations for 4/16/25, 5/13/25, and 5/19/25. The administrator (Adm-1) reviewed and confirmed the above findings during an interview on 9/26/25 at 1:30 p.m. Patient #9’s (P-9) Start of Care (SOC) was dated 6/25/25. The Plan of Care (POC) identified diagnoses of Knee Replacement, Hypertension and Anemia. During record review on 9/25/25, it was noted that the Physical Therapist (PT) completed a comprehensive assessment on 6/25/25 with an ordered frequency of 2w2 (2 times a week for 2 weeks), 3w1. The POC stated, “Orders of Discipline and Treatments: …Therapist will perform temperature, blood pressure, oxygen saturation level, respiratory rate and heart rate at each visit.” The PT failed to document oxygen saturation level for 7 of 7 completed visits. Patient #10’s (P-10) Start of Care (SOC) was dated 7/16/25. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Atrial Fibrillation and Vascular Disorder of Intestine. During record review on 9/23/25, it was noted that the PT completed a comprehensive assessment on 7/16/25 with an ordered frequency of 1w8. The POC stated, “Orders of Discipline and Treatments: …Therapist will perform…oxygen saturation level…at each visit.” The PT failed to document oxygen saturation level for 8 of 8 completed visits. Additionally, the Occupational Therapist (OT) completed an evaluation on 7/17/25 with an ordered frequency of 1w2, 1q2w2 (1 time every two weeks for 2 weeks), 1w4. The OT POC stated, “…Occupational Therapist…Therapist will perform…oxygen saturation level…at each visit.” The OT failed to document oxygen saturation level for 3 of 6 completed visits: 7/17/25 (OT evaluation), 8/14/25 and 9/5/25 (OT discharge). Furthermore, Skilled Nursing (SN) completed an evaluation on 7/24/25 with an ordered frequency of 1w8. The SN POC stated, “Skilled Nurse…Nurse will perform…oxygen saturation level…at each visit.” The SN failed to document oxygen saturation level for 4 of 8 completed visits: 8/6/25, 8/13/25, 8/27/25, 9/3/25. A review of the agency policy occurred on 9/26/25 titled “Ongoing Assessment” (Reviewed: 9/2/2022) The policy states, “Policy: The scope and intensity of ongoing assessments will be determined by collaborating with the patient regarding the patient’s diagnoses, condition, desire for care, response to previous care, and the care setting. Overview: 1. During each home visit, plan of care review or comprehensive assessment, the appropriate clinician with support of clinical leadership if necessary, will re-evaluate the patient’s status according to the problems identified during the episode. The Administrator (ADM-1), Regional Vice President (RVP) and Director of Survey Accreditation and Support Service (DSA) reviewed and acknowledged the findings listed above in an interview on 9/26/25 at 10:05 am. Patient #1 (P-1) was admitted to this home care agency on 9/2/25 with the diagnoses of spinal stenosis following lumbar laminectomy with posterior spinal fusion (low back surgery with hardware placement). During record review on 9/23/25, it was noted the plan of care (dated 9/2/25) included an order for occupational therapy (OT) which stated, “Therapist will perform temperature, blood pressure, oxygen saturation level, respiratory rate, and heart rate at each visit.” Upon further review of the record, it was determined the OT notes dated 9/10/25 and 9/17/25 failed to record respiratory rate. Additionally, the OT note dated 9/24/25 failed to include respiratory rate and oxygen saturation level. Patient #2 (P-2) was admitted to this home care agency on 7/2/25 with the diagnosis of hypertension (high blood pressure). During record review on 9/24/25, it was noted the plan of care (dated 7/2/25) included an order for physical therapy (PT) which stated, “Therapist will perform temperature, blood pressure, oxygen saturation level, respiratory rate, and heart rate at each visit.” Upon further review of the record, it was determined the PT assistant (PTA) notes dated 7/17/25 and 8/18/25 failed to include oxygen saturation level. Patient #4 (P-4) was admitted to this home care agency on 8/9/25 with the diagnoses of bilateral radius and ulna (wrist) fractures, hemiplegia following a cerebrovascular accident (weakness on half of the body following a stroke), and type II diabetes mellitus. During record review on 9/25/25, it was noted the plan of care (dated 8/9/25) included an order for occupational therapy (OT) which stated, “Therapist will perform temperature, blood pressure, oxygen saturation level, respiratory rate, and heart rate at each visit.” Upon further review of the record, it was determined the OT assistant (COTA) notes dated 8/13/25, 8/18/25, 8/27/25, and 9/3/25 failed to include oxygen saturation level. The Administrator (Adm-1), Regional Vice President (RVP), and Director of Survey Accreditation and Support Service (DSA) reviewed and acknowledged the findings during an interview on 9/26/25 at 8:35 AM.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure clinical notes were accurate and individualized for 3 (Patient/P-6, P-9, P-10) of 17 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: Patient #9’s (P-9) Start of Care (SOC) was dated 6/25/25. The Plan of Care (POC) identified diagnoses of Knee Replacement, Hypertension and Anemia. During record review on 9/25/25, it was noted that the Electronic Medical Record (EMR) contained conflicting information for the frequency of visits to be completed by the Physical Therapist (PT). On 6/25/25, the PT completed a comprehensive assessment that stated, “Discipline and Frequency: 3w3 (3 times a week for 3 weeks).” The PT documented a “Coordination Note” on 6/25/25 stating, “Plan of care: Frequency & Duration: 1w8 (1 time a week for 8 weeks). The POC completed by the PT on 6/25/25 stated, “Frequency/Duration of Visits: PT 2w2, 3w1.” The PT failed to ensure documentation was accurate. Patient #10’s (P-10) Start of Care (SOC) was dated 7/16/25. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Atrial Fibrillation and Vascular Disorder of Intestine. During record review on 9/23/25, it was noted that the Occupational Therapist (OT) completed an evaluation on 7/17/25 with an ordered frequency of 1w2 (1 time a week for 2 weeks), 1q2w2 (1 time every two weeks for 2 weeks), 1w4. On 8/2/25 and 8/21/25, the OT documented, “Vital Signs: Oxygen Saturation Characteristics: On oxygen 2 L (Liters), on room air.” The OT failed to accurately document the patient’s oxygen status. A review of the agency policy occurred on 9/26/25 titled “Clinical Record Review” (Reviewed 9/7/2022). The policy states, “Overview: 1.0 As part of an ongoing clinical record review, the clinical record is reviewed by the Compliance and/or Quality Department for: …1.2 The completeness of clinical records. 1.3 The accuracy of clinical records...” The Administrator (ADM-1), Regional Vice President (RVP) and Director of Survey Accreditation and Support Service (DSA) reviewed and acknowledged the findings listed above in an interview on 9/26/25 at 10:15 am. P-6: The patient’s start of care (SOC) to the home care agency was on 8/22/25, with diagnoses that included post-surgical laminectomy with discectomy, spinal stenosis, and hypertension. On 9/24/25, record review of P-6’s skilled nursing visits notes on 8/29/25, 9/2/25, and 9/8/25 revealed documentation under “Wound Care Provided” by RN-1, that each wound care note had 4,020 identical characters written in auto populated, third person language. In addition, no documentation was evidenced that indicated wound care was performed and what P-6’s response was. Instead, the narrative concerning “Wound Care Provided” was based on interventions surrounding vital signs, falls risk, impacts of polypharmacy, teaching/reinforcement relating to cardiovascular status... etc. The Administrator (ADM-1), Regional Vice President (RVP) and Director of Survey Accreditation and Support Service (DSA) reviewed and acknowledged the clinical record regarding the documentation from the above SN visits were not appropriate during an interview on 9/26/25 at 11:28 AM. Administration above further acknowledged this did not meet agency expectations or its policy referenced below.”