Covenant at Home

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were informed of any factors that could impact treatment effectiveness for 1 (P-1) of 3 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #1 (P-1) was admitted to this home health agency on 1/8/26 with the diagnoses of venous insufficiency, bilateral lower leg cellulitis (with open wounds), and lymphedema. He was referred to this agency for wound care. During record review on 3/25/26, it was determined an initial order for wound care dated 1/8/26 stated, “Bilateral lower extremities: cleanse with wound cleanser, apply hydrofera blue to open areas, cover with ABD and wrap with ace wrap.” [sic] Additionally, it was determined alternative wound care orders were written later on 1/8/26 that stated, “Cleanse with saline, pat dry, saline moistened wet to dry dressing, wrap with kerlix or ace” until the other supplies could be obtained. Upon further review of the record, it was determined P-1 got upset with the agency on multiple occasions for not obtaining the supplies noted in the original wound care order. This was documented in skilled nursing notes dated 1/13/26 and 1/17/26, as well as in communication notes dated 1/17/26 and 1/19/26. It was determined the agency provided the hydrofera blue dressing on 1/17/26 (9 days after the initial order and start of care) and there was no evidence the agency provided ABD (abdominal, used for increased drainage) pads prior to P-1’s discharge from the agency on 1/19/26. During an interview with the clinical manager (Staff A) on 3/25/26 at 3:40 PM, Staff A was asked about the delay in obtaining the supplies noted on the original wound care order. Staff A stated this was due to P-1’s insurance and him not having a DME (durable medical equipment) company set up. Staff A stated this process can sometimes take a while. When asked if P-1 was informed that this could potentially cause a long delay in obtaining the ordered wound care supplies upon admission, Staff A stated it was often a verbal conversation that was had with the patient and acknowledged that it was not documented in the record for P-1. Additionally, it was noted the consent form signed by P-1 on 1/8/26 indicated, “I understand Medicare approved patient supplies are routinely provided by [the agency] at no cost to me during my home care stay.” When queried about this statement, Staff A stated Medicare was marked in error as P-1 did not have Medicare. However, Staff A acknowledged the wording indicated supplies would be provided for the patient. The agency failed to ensure P-1 was informed of any factors that could impact treatment effectiveness prior to care. Staff A acknowledged the findings at the time of interview.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on record review and interview, the agency failed to make efforts to resolve problems with patient behavior prior to discharge for cause in 1 (P-1) of 1 patient reviewed that was discharged for cause due to behavioral issues, resulting in the potential for unmet care needs. Findings include: A review of agency policy titled “Acceptance, Continuation, and Discharge from Services” (reviewed 6/2025) revealed under the “Procedure” section for discharge for cause (page 4) that: “1. [Agency] will advise the patient, patient representative (if applicable), the physician signing the plan of care, the practitioner responsible for providing care and services to the patient after discharge that a discharge for cause is being considered. 2. Documentation of the agency’s attempt to assure behaviors necessary to avoid discharge will be clearly documented in the clinical record. 3. When at all possible, the agency will make efforts to resolve problems present by the patient’s behavior, the behavior of other persons in the home or situation. If unresolved, the patient will be given three (3) weeks advanced notice of intent to discharge from services. All available resources to ensure the safety of the patient during the period prior to discharge will be utilized….. 4. Written notification of the discharge intent, reason, and effective date will be given to the patient….” [sic] Patient #1 (P-1): During record review on 3/25/26, it was noted P-1 was on the list of patients who were discharged for cause during the last 2 years. Upon review of a communication note dated 1/19/26 written by the nursing coordinator (Staff C), it was determined P-1 was informed by Staff C that the agency would no longer be coming to his home following an angry phone call during which P-1 yelled at the staff. Upon further review of the record, it was noted there was no documentation that the agency attempted to resolve the identified behavior problems prior to discharge for cause. Additionally, it was noted there was no documented evidence the steps were followed according to the agency policy above. When asked for documentation that the above steps for a discharge for cause had been followed during an interview with Staff A on 3/26/26 at 9:26 AM, Staff A was unable to provide evidence. When asked to provide another patient for review who was also discharged for cause due to behavior issues, Staff A stated that upon review of the discharge for cause list the night before, she determined no other patients had been discharged due to behavior. She also stated it was determined the rest of the list had been labeled incorrectly as a result. During further interview with Staff A on 3/26/26 at 10:27 AM regarding the discharge for cause documentation, Staff A stated she did not feel that P-1 should have been on the list either after review of the situation. Staff A stated she remembered reviewing the case with Staff C, who stated P-1 refused services from the agency and wanted to be discharged from the agency following the phone call on 1/19/26. However, Staff A acknowledged that this was not reflected in the documentation and the documentation showed he was discharged for cause without following the appropriate steps. Staff A acknowledged the findings at the time of this interview.”