Atrio Home Health

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure pain parameters ordered by the physician were followed in 1 (P-2) of 3 total sampled records reviewed, resulting in the potential to negatively affect all 307 patients currently serviced by this agency. Findings include: Patient #2 (P-2) was admitted to the agency on 5/10/25 with diagnoses that included venous insufficiency, chronic non-pressure ulcers of bilateral lower extremities, chronic heart and kidney disease. On 6/20/25, record review of P-2’s Plan of Care (POC) effective 5/10/25 noted the following order: “Educate to report to CM (case manager)/provider pain rating greater than (7/10-10 being highest possible) that is not relieved by current pain measures.” The POC further ordered skilled nursing visits at a frequency of 1W1 (once a week time one week), 3W3 with one PRN (as needed) for medical concerns. Further review of the SN home visits performed concerning wound care noted no objective pain measurements were documented on: 5/16/25 with “Client reports pain with the wound care...”, 5/19/25 with “Client has very bad pain with wound care. At one point she indicated she thought she was going to pass out.” In addition, the 5/19/25 visit by SN documented “Abnormal assessment findings reported to provider and provider response” as being N/A (not applicable). SN was noted to have documented a voice mail being left with the physician for the addition of lidocaine spray for added pain management. The SN home visits of 5/21/25, 5/28/25, 6/2/25, and 6/4/25 all failed to incorporate and document P-2’s pain in measurable terms as directed on the POC orders. The Administrator and Clinical Manager reviewed and acknowledged the findings above during an interview on 6/20/25 at 12:59 PM. Both further acknowledged this did not meet agency expectations.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary was complete, provided the patient’s current health status at the time of discharge, progress toward goals, and the reason(s) for discharge in 1 (P-2) of 1 closed records, from a total of 3 sampled records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Patient #2 (P-2) was admitted to the agency on 5/10/25 with diagnoses that included venous insufficiency, chronic non-pressure ulcers of bilateral lower extremities, chronic heart and kidney disease. On 6/20/25, record review noted P-2 was discharged from the agency on 6/8/25, with skilled nursing providing the last visit among all services provided (Occupational Therapy and Home Health Aide) on 6/4/25. Review of the discharge (DC) summary noted documentation deficiencies in the following categories: “Discharge Condition”, “Patient/Family Discharge Instructions”, “Post Discharge Goals”, and “Treatment Preferences”. All were documented as being “N/A (not applicable)” with no additional details noted. Further, the DC summary failed to list any progress made or lack of concerning “Goals/Outcomes” experienced throughout admission. No explanation was found which detailed the reason(s) why P-2 was “going to be trying a different homecare agency.” Due to the lack of information noted above within the DC summary, the agency failed to appropriately notify the physician regarding clinical care and relevant information leading up to the unplanned discharge from the agency. The Administrator and Clinical Manager reviewed and acknowledged the findings above during an interview on 6/20/25 at 12:52 PM. Both further acknowledged this did not meet agency expectations.”