Divinity Home Care

“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 plan of care included patient specific measurable outcomes and goals in 8 (P-4, P-5, P-6, P-7, P-8, P-9, P-10, and P-11) of 13 records reviewed resulting in the failure of the agency to determine the patient’s progress towards the goals of care. Findings include: Patient #7 (P-7) was admitted to this homecare agency on 5/24/25 with the diagnoses of hypertensive chronic kidney disease, anemia, and vascular dementia. During record review on 9/30/25, the following skilled nursing goals were noted on the plan of care: “Pt/Pcg will verbalize/demonstrate knowledge of and compliance with medication management: dose, route and schedule/actions, interactions, and contraindications/administration and compliance with prefilled medications/adherence to diet impacting medications/safe preparation and storage of medications/side effects and symptoms to report by _______ Achieve By Date: 06/07/2025 Start Effective Date: 05/24/2025.” [sic] “Patient /Caregiver will verbalize/demonstrate understanding of symptom management, resource utilization and medication management to reduce unplanned hospital or emergency department visits by: ____Achieve By Date: 06/06/2025 Start Effective Date: 05/24/2025.” [sic] Patient #8 (P-8) was admitted to this home care agency on 11/6/25 with diagnoses of lymphedema (swelling) of the right leg and idiopathic necrosis of the right femur (right leg pain). During record review, on 12/10/25, the following skilled nursing goals were noted on the plan of care: “Pt will demonstrate increased endurance by _____ Achieve By Date: 12/06/2025 Start Effective Date: 11/06/2025.” [sic] “Pt/Pcg will verbalize/demonstrate knowledge of and compliance with medication management: dose, route and schedule/actions, interactions, and contraindications/administration and compliance with prefilled medications/adherence to diet impacting medications/safe preparation and storage of medications/side effects and symptoms to report by _______ Achieve By Date: 12/06/2025 Start Effective Date: 11/06/2025.” [sic] Patient #9 (P-9) was admitted to the home care agency on 10/31/25 with the diagnoses of lumbar (low back) stenosis and cervical (neck) disc degeneration. During record review on 12/10/25, the following skilled nursing goals were noted on the plan of care: “Urinary elimination will be WNL for Pt by discharge Start Effective Date: 10/31/2025.” [sic] “Pt/Pcg will verbalize/demonstrate knowledge of and compliance with medication management: dose, route and schedule/actions, interactions, and contraindications/administration and compliance with prefilled medications/adherence to diet impacting medications/safe preparation and storage of medications/side effects and symptoms to report by discharge Start Effective Date: 10/31/2025.” [sic] Patient #10 (P-10) was admitted to this home care agency on 5/8/25 with the diagnoses of a stage 2 pressure ulcer of left buttock, hypertensive heart disease with heart failure, and type II diabetes mellitus. During record review on 12/9/25, the following skilled nursing goals were noted on the plan of care: “Pt/Pcg will verbalize understanding and demonstrate safe effective wound care: supply management/dressing change/disposal of soiled dressings/monitoring for infection and S/S to report by _____ Achieve By Date: 5/30/25 Start Effective Date: 05/08/2025.” [sic] “Pt/Pcg will verbalize/demonstrate measures to manage pain: medication management/alternative pain relief measures, behavior modification to avoid factors that increase pain/use of pain scale to identify intensity and determine comfort goal by ______ Achieve By Date: 05/30/2025 Start Effective Date: 05/08/2025.” [sic] Patient #11 (P-11) was admitted to this home care agency on 8/23/25 with the diagnoses of a pressure-induced deep tissue injury to the left heel and a urinary tract infection. During record review on 12/11/25, the following skilled nursing goals were noted on the plan of care: “Pt/Pcg will verbalize/demonstrate measures to manage pain: medication management/alternative pain relief measures, behavior modification to avoid factors that increase pain/use of pain scale to identify intensity and determine comfort goal by ______ Achieve By Date: 11/08/2025 Start Effective Date: 08/23/2025.” [sic] “Dyspnea will decrease by _____ Achieve By Date: 11/08/2025 Start Effective Date: 08/23/2025.” [sic] These goals lack measurable, patient-specific, quantifiable data to assess progress towards meeting them. Additionally, many of the goals are identical to goals set for other patients. The director of clinical services (DCS #1) and administrator (Adm #1) reviewed and acknowledged the findings during an interview on 12/12/25 at 1:50 PM. Patient #4 (P-4): This patient was admitted to the home care agency on 9/13/25 with diagnoses including hypovolemia (abnormally low fluid volume in the body); orthostatic hypotension (low blood pressure upon standing); and heart disease. The medical record was reviewed on 12/10/25. During review of the plan of care (POC) dated for the certification period of 9/13/25- 11/11/25, it was noted that the goals of care were not measurable. Examples of the goals documented for P-4 included the following: Cardiovascular Goals: blood pressure range will be within physician established parameters by discharge; patient will demonstrate increased endurance by discharge. It is unclear how the cardiovascular goals are specific for this patient with hypovolemia and orthostatic hypotension. It is unclear how these goals will be measured to determine P-4’s progress. Additionally, the comprehensive assessment completed on 9/13/25 identified this patient as using oxygen. The agency did not include any related respiratory measurable outcomes or goals of care in the POC. Patient #5 (P-5): This patient was admitted to the home care agency on 9/25/25 with diagnoses including aftercare following surgery; right artificial knee joint; and arthritis. The medical record was reviewed on 12/9/25. During review of the POC dated for the certification period of 9/25/25- 11/23/25, it was noted that the goals of care were not measurable. Examples of the goals documented for P-5 included the following: Patient/Caregiver will verbalize/demonstrate measures to manage pain: medication management/alterative pain relief measures, behavior modification to avoid factors that increase pain/use of pain scale to identify intensity and determine comfort goal by discharge; Incision will remain intact without signs of infections by discharge. It is unclear how these goals will be measured to determine P-5’s progress. Patient #6 (P-6): This patient was admitted to the home care agency on 12/4/25 with diagnoses including osteolysis (breakdown and gradual bone loss); kidney failure; and left breast cancer. The medical record was reviewed on 12/10/25. During review of the POC dated for the certification period of 12/4/25- 2/1/26, it was noted that the goals of care were not measurable. Examples of goals documented for P-6 included the following: Urinary elimination will be within normal limits for the patient by discharge; Patient/Caregiver will verbalize/demonstrate management of incontinence without skin breakdown by discharge. It is unclear how these goals are specific to P-6 and how they would be measured to determine progress. On 12/12/25 at 3:15 p.m., the above findings were reviewed and acknowledged during interview with the Director of Clinical Services (DCS #1) and the Administrator (Adm #1).”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure staff followed accepted standards of practice during 2 (P-6 and P-12) of 5 joint surveyor home visits potentially resulting in the transmission of infections or diseases. Findings included: An agency document named “Policy-Infection Control” (undated) was provided for surveyor review on 12/11/25. On page 8., it stated, “Equipment cleaning/care for Home Care: 1. Reusable items… will be cleaned with an EPA-registered disinfectant… after use on each patient, and when visibly soiled.” Patient #6 (P-6): This patient was admitted to the home care agency on 12/4/25 with diagnoses including osteolysis (breakdown and gradual bone loss); kidney failure; and left breast cancer. The medical record was reviewed on 12/10/25. On 12/9/25 at 12:30 p.m., a joint home visit was conducted with an agency occupational therapist (OT). During the visit, it was observed that the OT took a cloth gait belt out of her home care bag (agency bag brought to home visit with patient care supplies). The OT used the gait belt to provide transfer assist as P-6 walked to and from the restroom in the home. At the end of the visit, it was noted that the OT put the gait belt back into her home care bag. When asked how she (the OT) cleaned or disinfected the cloth gait belt, she stated that if it became soiled, she would clean it and she washed it once weekly even if not visibly soiled. On 12/10/25 at 11:40 a.m., the Director of Clinical Services (DCS #1) was asked what the policy is regarding cleaning/disinfecting cloth gait belts. DCS #1 stated that staff are expected to give the gait belt to the patient and not return the gait belt to their home care bag. DCS #1 also stated “I have a box of them” (speaking of gait belts for patients). On 12/12/25 at 3:15 p.m., this finding was reviewed and acknowledged during interview by both DCS #1 and the Administrator (Adm #1). Patient #12 (P-12): This patient was admitted to the home care agency on 11/18/25 with diagnoses including muscle wasting and atrophy; arthritis; and type 2 Diabetes. The medical record was reviewed on 12/12/25. On 12/11/25 at 10:45 a.m., a joint home visit was conducted with an agency registered nurse (RN). During the visit, it was observed that the RN put on a pair of clean gloves from the home care bag brought to the visit. The RN began an assessment of the patient, including both of P-12’s feet. After providing the foot assessment, the RN gathered vital sign monitoring equipment including blood pressure monitor; pulse oximeter; and thermometer. With the same gloves, the RN took the appropriate vital sign with each of the vital sign monitoring devices. It was observed that the RN placed the used pulse oximeter in the pocket of her shirt (scrub top). The RN also pulled a pen and paper out of her shirt pocket (and returned it when done), all while wearing the same gloves. After performing all the tasks, the RN used the same gloves to disinfect the vital sign monitoring equipment before removing the dirty gloves and performing hand hygiene. On 12/12/25 at 3:15 p.m., the above findings were reviewed during an interview with DCS #1 and Adm #1. When asked if staff should put (used) gloved hands or used vital sign equipment in their clothing pockets, DCS #1 stated, no, they have a bag for their items.”

“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 record review and interview, the agency failed to ensure the Skilled Nurse prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to the provision of care in 1 (P-13) of 2 records in which Home Health Aide services were ordered, from a total of 13 sampled records reviewed, resulting in the potential for the provision of unsafe care and poor patient outcomes. Findings include: Patient #13 (P-13)’s start of care was 11/22/25 with diagnoses that included Cellulitis Lower Left Extremity, Hematoma Left Knee and Atrial Fibrillation. The Plan of Care ordered Home Health Aide (HHa) services to be provided at a frequency of 1w1, 2w6 and revealed the patient had allergies to shellfish and Zyvox (Antibiotic). During the clinical record review on 12/11/25 at 10:25 a.m., it was noted that the Aide Care Plan was void of the above allergies. The Director of Clinical Services reviewed and acknowledged the above findings during an interview on 12/12/25 at 1:30 p.m. and responded, “I didn’t think about that.””

“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 the patient’s right to consent or refuse disciplines that would furnish care in advance of treatment, was completed in 2 (P-6 and P-12) of 13 records reviewed, resulting in the potential for caregiver burnout and unmet needs. Findings include: Patient #9 (P-9) was admitted to this home care agency on 10/31/25 with the diagnoses of lumbar (low back) stenosis and cervical (neck) disc degeneration. During record review on 12/10/25, it was noted the initial home care referral (dated 10/19/25) ordered services from skilled nursing, physical therapy, occupational therapy, and home health aide. Upon further review of the record, it was determined P-9 did not receive services from a home health aide. During an interview with the director of clinical services (DCS #1) on 12/12/25 at 1:50 PM, DCS #1 stated P-9’s family declined services from a home health aide. DCS #1 was asked where this was documented in the record. DCS #1 stated it should be marked on the consent form next to “Disciplines on referral that are refused,” however, DCS #1 confirmed it was not marked in this case. DCS #1 and the administrator (Adm #1), who was also present, acknowledged the findings at the time of interview. Patient #6 (P-6): This patient was admitted to the home care agency on 12/4/25 with diagnoses including osteolysis (breakdown and gradual bone loss); kidney failure; and left breast cancer. The medical record was reviewed on 12/10/25. During review, it was noted that the physician referral for home care dated 11/29/25 included orders for a home health aide. The comprehensive assessment was completed by the registered nurse (RN) on 12/4/25 and included documentation that P-6 needed partial/moderate assistance with toileting; transferring; walking; bathing; dressing; and grooming. The assessment included documentation that P-6 had a part-time caregiver in the home however, there was no evidence in the medical record that the agency offered home health aide services, or that service was refused by the patient. Patient #12 (P-12): This patient was admitted to the home care agency on 11/18/25 with diagnoses including muscle wasting and atrophy; arthritis; and type 2 Diabetes. The medical record was reviewed on 12/12/25. During review, it was noted that the physician referral for home care dated 12/14/25 included orders for a home health aide. The comprehensive assessment was completed by the RN on 11/18/25 and included documentation that P-12 needed assistance bathing; grooming; dressing; and maintain toileting hygiene. The assessment included documentation that P-12 lived in an assisted living center however, there was no evidence in the medical record that the agency offered home health aide services, or that the service was refused by the patient. On 12/12/25 at 3:15 p.m., the above findings were reviewed during interview with the Director of Clinical Services (DCS #1) and the Administrator (Adm #1). DCS #1 stated that the clinician completing the admission paperwork would mark on the “Patient Consent” form whether the patient “refused” services or whether services were “not needed”. P-6’s consent form home care did not have either “refused” or “not needed” marked. P-12’s consent form had “not needed” marked. When asked who made the decision that home health aide services were not needed (the clinician or P-12), DCS #1 was not able to determine that and acknowledged the findings.”

“Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This Element is not met as evidenced by: Based on record review and interview, the agency failed to have a system in place to record, track and investigate all complaints to prevent further potential violations for 3 (2023, 2024, and 2025) of 3 years reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: On 12/12/25 at 9:00 AM, the complaint log for the last 3 years was requested for review. Upon request, the director of clinical services (DCS #1) stated “I’ll be honest, we haven’t been keeping up on that.” DCS #1 stated the agency hasn’t had many complaints since she started about a year ago, however, the complaints they’ve had were dealt with within the patient record and not recorded in an official complaint log. At 9:30 AM, DCS #1 returned and provided a red binder labeled “Complaint Log Book” for review. DCS #1 stated she was not aware of this binder but wanted to provide it as requested. Upon review of the binder, it was noted the last complaint was dated 8/21/23. A review of agency policy titled “Patient/Client Complaints” (not dated) revealed, “1. Agency Professional Field Staff: a. Listens to and addresses patient concerns/complaints (if unresolved). b. Refers unresolved issues to the supervising nurse for discussion. c. Provides the “Client Concern Form” and assists in its completion and submission to the supervising nurse.” Following review of the policy above, DCS #1 was asked if a “Client Concern Form” had been filled out for this, or any, of the complaints logged in the binder. DCS #1 stated she was not aware of that form and did not think it had been filled out. DCS #1 stated the policy is likely old and outdated. At 11:00 AM, DCS #1 was asked to provide the name of a patient who filed a recent complaint so the current process could be reviewed. At 11:30 AM, DCS #1 provided a typed complaint dated 9/25/25 regarding a recent patient issue. DCS #1 stated she found it on the administrator’s (Adm #1) desk. Again, DCS #1 confirmed a “Client Concern Form” was not filled out for this complaint per agency policy. DCS #1 also confirmed the complaint was not entered on the log in the binder, therefore, there was no evidence of complaint tracking to prevent further potential violations. The agency failed to provide evidence of a system used to record, track, and investigate complaints and failed to follow their own policy regarding complaint investigation forms. DCS #1 and Adm #1 acknowledged the findings during an interview on 12/12/25 at 1:50 PM.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Registered Nurse conducted the initial assessment visit within 48 hours of referral to determine the immediate care and support needs of the patient, including homebound status and eligibility for the Medicare home health benefits for 1 (P-2) of 11 records in which nursing services was ordered, from a total sample of 13 sampled records reviewed, resulting in the delay of nursing services and the potential for decline in health status. Findings include: Patient #2 (P-2)’s start of care was 8/27/25 with diagnoses that included Rotator Cuff sprain, Cellulitis Bilateral Lower Extremity and Venous Statis Dermatitis. During the clinical record review on 12/9/25 at 10:30 a.m., it was noted that the referral for home care dated 8/25/25, ordered Physical Therapy (PT) and Skilled Nursing (SN) services to be provided. Upon further review, it was noted that PT conducted the initial assessment. The SN failed to conduct the initial assessment within 48 hours to ascertain the patient’s immediate care needs and establish homebound status as per this requirement. The Director of Clinical Services reviewed and confirmed these findings during an interview on 12/12/25 at 1:15 p.m.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s health status at the time of admission in 5 (P-1, P-2, P-4, P-10, and P-13) of 13 records reviewed, resulting in incomplete clinical information used to determine the needs of the patients. Findings include: Patient #10 (P-10) was admitted to this home care agency on 5/8/25 with the diagnoses of a stage 2 pressure ulcer of the left buttock, hypertensive heart disease with heart failure, and type II diabetes mellitus. During record review on 12/9/25, it was noted the comprehensive assessment listed “Type 2 diabetes mellitus without complications” as a diagnosis. Additionally, parameters were established on the plan of care to monitor and report blood glucose (sugar) levels “greater than 350 mg/dl or less than 60 mg/dl fasting/random.” [sic] However, below the section that listed the diagnoses on the comprehensive assessment, “No” was marked next to diabetes mellitus (DM) under “Comorbidities and Co-existing Conditions.” Additionally, the endocrine section did not indicate that P-10 was diabetic, and an initial blood glucose level was not obtained. The information is conflicting, therefore, does not show a clear picture of the patient’s current status and needs. The director of clinical services (DCS #1) and administrator (Adm #1) reviewed and acknowledged the findings during an interview on 12/12/25 at 1:50 PM. Patient #4 (P-4): This patient was admitted to the home care agency on 9/13/25 with diagnoses including hypovolemia (abnormally low fluid volume in the body); orthostatic hypotension (low blood pressure upon standing); and heart disease. The medical record was reviewed on 12/10/25. The comprehensive assessment was completed by the registered nurse (RN) on 9/13/25 and included 19 diagnoses listed for P-4. One of the diagnoses was “dependence on supplemental oxygen”. In the “Safety Measures” section of the assessment, O2 (oxygen) precautions was listed. The RN documented that equipment in the home included an oxygen concentrator. The RN did not have oxygen identified as in use (either as needed or continuous) in the “Respiratory Assessment” section and did not indicate the number of liters for the oxygen when or if used. There was no documentation indicating what P-4’s oxygen prescription was. Additionally, the RN selected “NA” (not applicable) for an oxygen emergency backup plan on P-4’s emergency preparedness plan. Other than identifying a pulse oximeter parameter to report to the physician, no other interventions, education, or goals were documented related to P-4’s use of oxygen. It was unclear what P-4’s oxygen use or needs were at the time of admission based on the comprehensive assessment. On 12/12/25 at 3:15 p.m., the above findings were reviewed and acknowledged during interview with the Director of Clinical Services (DCS #1) and the Administrator (Adm #1). Patient #1 (P-1)’s start of care (SOC) was 1/15/25 with diagnoses that included Syncope/Collapse, Bundle Branch Block and Bradycardia. The clinical record review was conducted on 9/30/25 at 12:25 p.m. Sections 1021/1023 of the Initial Comprehensive Assessment dated 1/15/25 completed by the Registered Nurse, listed the patient’s 11 diagnoses such as Hearing loss, Cataract, Hyperplasia and Chronic Kidney Disease as having an onset or exacerbation date of the same date of admission to the agency. The comprehensive assessment was inconsistent and failed to paint a clear clinical picture of the patient’s health status at the time of admission. The Director of Clinical Services (DCS #1) reviewed and acknowledged the above findings during an interview on 12/11/25 at 12:41 p.m. P-2’s SOC was 8/27/25 with diagnoses that included Strain Rotator Cuff Right shoulder, Cellulitis Bilateral Lower Extremity and Venous Statis Dermatitis. During the record review on 12/9/25 at 10:30 a.m., it was noted that sections 1021/1023 of the Initial Comprehensive Assessment dated 8/27/25, completed by the Physical Therapist, listed the patient’s 12 diagnoses such as Non-Hodgkin Lymphomas, Cardiac Murmur, Left bundle Branch Block and Generalized Osteoarthritis as having an onset or exacerbation date of the same date of admission to the agency. Additionally, various sections of the assessment had not been completed such as, primary caregiver, equipment currently in the home, Genitourinary/Gastrointestinal and Balance sitting/standing. The Physical Therapist failed to ensure the Comprehensive Assessment was complete and painted a clear clinical picture of the patient’s health status and needs at the time of admission. DCS #1 reviewed and acknowledged these findings during an interview on 12/12/25 at 1:15 p.m. P-13’s SOC was 11/22/25 with diagnoses that included Cellulitis Lower Left Extremity, Hematoma Left Knee and Atrial Fibrillation. During the clinical record review on 12/11/25 at 10:25 a.m., it was noted that sections 1021/1023 of the Initial Comprehensive Assessment completed by the Registered Nurse listed the patient’s 17 diagnoses such as Heart Failure, Hypotension, Osteoarthritis, Cardiomyopathy and Polyneuropathy as having an onset or exacerbation date as the same date of admission to the agency. The Comprehensive Assessment was inconsistent and failed to paint a clear clinical picture of the patient’s health status at the time of admission. DCS #1 reviewed and acknowledged the above findings during an interview on 12/12/25 at 1:30 p.m.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure activity of daily living needs were adequately met in the patient’s home for 1 (P-2) of 2 patients who required assistance with grooming, from a total of 13 sampled records reviewed, resulting in the potential for poor hygiene, low self-esteem and unmet care needs. Findings include: Patient #2 (P-2)’s start of care was 8/27/25 with diagnoses that included Rotator Cuff sprain, Cellulitis Bilateral Lower Extremities and Venous Statis Dermatitis. The Plan of Care ordered Skilled Nursing and Physical Therapy services to be provided. During the clinical record review on 12/9/25 at 10:30 a.m., it was noted that section M1800 of the Initial Comprehensive Assessment dated 8/27/25 documented someone must assist with grooming, dressing and toileting hygiene. Section M1100 documented, patient lives alone with occasional short-term assistance. Upon further review, there was no documented evidence of a willing caregiver who would be available to provide assistance with grooming. Further, there was no documented evidence that a home health aide was offered or provided. The Director of Clinical Services reviewed and acknowledged the above findings during an interview on 12/12/25 at 1:15 p.m.”

“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 perform a drug interaction review to identify potential adverse effects or drug interactions following the addition of new medications in 1 (P-10) of 13 records reviewed, resulting in the potential for poor patient outcomes. Findings include: Patient #10 (P-10) was admitted to this home care agency on 5/8/25 with the diagnoses of a stage 2 pressure ulcer of left buttock, hypertensive heart disease with heart failure, and type II diabetes mellitus. During record review on 12/9/25, it was noted a skilled nursing note dated 5/26/25 indicated the patient started “Cephalexin 500 mg 4 times a day x7 days” [sic] for a kidney infection. Additionally, a skilled nursing note dated 5/30/25 indicated “Patient started Benzonatate for cough this week and called in on 5/27/25.” [sic] Upon review of the medication interaction report, it was noted Cephalexin was added to the profile on 5/26/25 and Benzonatate was added to the profile on 5/27/25. However, upon further review of the medication interaction report, it was determined the interactions were only reviewed on 5/8/25 at the start of care and were not run again after the addition of 2 new medications. During an interview with the director of clinical services (DCS #1) on 12/12/25 at 1:50 PM, DCS #1 was asked about the agency expectation regarding a medication review following the addition of new medications. DCS #1 stated the expectation was that an interaction report would be run anytime a new medication was added to ensure no interactions. DCS #1 acknowledged the findings at the time of interview.”

“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 accurately reflected the needs of the patient for 5 (P-1, P-2, P-9, P-10, and P-11) records, from a total of 13 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: Patient #9 (P-9) was admitted to the home care agency on 10/31/25 with the diagnoses of lumbar (low back) stenosis and cervical (neck) disc degeneration. During record review on 12/10/25, it was noted the physical therapy evaluation dated 11/3/25 identified the patient had pain of a 6 out of 10 in her left knee. Upon further review of the record, it was determined the plan of care failed to include parameters to monitor pain levels for a patient with identified pain. Patient #10 (P-10) was admitted to this home care agency on 5/8/25 with the diagnoses of a stage 2 pressure ulcer of the left buttock, hypertensive heart disease with heart failure, and type II diabetes mellitus. During record review on 12/9/25, it was there was order dated 5/22/25 (following a hospital admission and resumption of care) for the patient to be on 2 liters of home oxygen during activity and listed an oxygen portable, oxygen concentrator, portable tank, and nasal cannula as equipment needed. During review of the plan of care following the resumption of care (dated 5/23/25), it was determined the updated plan of care failed to include safety precautions for oxygen use and failed to include the equipment needed for home oxygen use. Patient #11 (P-11) was admitted to this home care agency on 8/23/25 with the diagnoses of a pressure-induced deep tissue injury to the left heel and a urinary tract infection. During record review on 12/11/25, it was noted the plan of care included parameters to notify the physician of bowel movements and pain, however, these parameters failed to include any numbers to monitor as they were left blank. The director of clinical services (DCS #1) and administrator (Adm #1) reviewed and acknowledged the findings during an interview on 12/12/25 at 1:50 PM. Patient #1 (P-1)’s start of care (SOC) was 1/15/25 with diagnoses that included Syncope/Collapse, Bundle Branch Block and Bradycardia. The Plan of Care (POC) ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. On 9/30/25 at 12:25 p.m., during the clinical record review, it was noted that the POC listed the patient’s 11 diagnoses as having an onset/exacerbation date as the same date of admission to the agency (1/15/25). Additionally, there were no interventions, reportable parameters or associated goals to address the exacerbated diagnoses. The POC did not address the needs of the patient. The Director of Clinical Services (DCS #1) reviewed and acknowledged the above findings during an interview on 12/11/25 at 12:41 p.m. P-2’s SOC was 8/27/25 with diagnoses that included Sprain Rotator Cuff, Cellulitis Bilateral Lower Extremities and Venous Statis Dermatitis. The POC ordered SN and PT services to be provided. On 12/9/25 at 10:30 a.m., during the clinical record review, it was noted that the POC listed the patient’s 12 diagnoses as having an onset/exacerbation date as the same date of admission to the agency (8/27/25). There were no associated interventions to address the reportedly exacerbated diagnoses. Additionally, the POC listed weight parameters, however, there were no interventions to monitor the patient’s weight. The POC failed to address the individualized needs of the patient. DCS #1 reviewed and acknowledged these findings during an interview on 12/12/25 at 1:15 p.m.”

“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 services were provided in accordance with the Physician’s ordered frequency for 1 (P-1) of 1 patient discharged prior to completion of the ordered visits, from a total of 13 sampled records reviewed, resulting in the potential for untreated health concerns and unmet care needs. Findings include: Patient #1 (P-1)’s start of care was 1/15/25 with diagnoses that included Syncope/collapse, Bundle Branch Block and Bradycardia. The Plan of Care (POC) ordered Skilled Nursing (SN) services to be provided at a frequency of 1x/wk. x 3 wks. During the clinical record review on 9/30/25 at 12:25 p.m., it was noted that the patient was discharged from SN services on 1/22/25 prior to completion of the ordered visit frequency. Upon further review, there was no documented evidence that the Physician had been notified or approved of the discharge prior to completion of the ordered visits. The Director of Clinical Services reviewed and confirmed these findings during an interview on 12/11/25 at 12:41 p.m. and responded, “I don’t see that the Physician was notified either.””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was notified of relevant changes for 2 (P-10 and P-11) of 13 records reviewed, resulting in the potential for unmet care needs and poor patient outcomings. Findings include: Patient #10 (P-10) was admitted to this home care agency on 5/8/25 with the diagnoses of a stage 2 pressure ulcer of the left buttock, hypertensive heart disease with heart failure, and type II diabetes mellitus. During record review on 12/9/25, it was noted the comprehensive assessment documented a stage 2 pressure ulcer on P-10’s left buttock that measured 0.8 centimeters (cm) by 0.5 cm by 1 cm. The plan of care (dated 5/8/25) included wound care orders for “wound care 2 times a week; cleans with wound cleaner; apply triad cream; cover with boarder dressing secure with tape if needed.” [sic] Upon further review of the record, it was noted a skilled nursing note dated 5/23/25 (at the resumption of care visit) documented a new wound on P10’s coccyx that measured 0.5 cm by 1 cm. Upon review of the updated plan of care (dated 5/23/25), it was determined the wound care orders were written for the wound on the left buttock only. There were no additional orders for wound care to the coccyx, although subsequent skilled nursing daily notes indicated wound care was provided according to the orders for the left buttock wound. Additionally, a skilled nursing note dated 6/9/25 documented another new wound on P-10’s left posterior thigh that measured 1.5 cm by 1.5 cm by 0.1 cm. There was no evidence the physician was notified regarding the new wound to receive new orders for treatment. The same wound care orders were used to treat this wound as well. Patient #11 (P-11) was admitted to this home care agency on 8/23/25 with the diagnoses of a pressure-induced deep tissue injury to the left heel and a urinary tract infection. During record review on 12/11/25, it was noted the comprehensive assessment documented a closed left heel wound that measured 4.5 cm by 3.5 cm and a sacral wound that measured 0.1 cm by 0.1 cm. The sacral wound did not require treatment, however, review of the plan of care (dated 8/23/25) included orders for “Wound care to left heel, 2-3x a week; cleans with saline; pack with betadine soaked gauze; dress with abd; cover with krilix; secure with tape.” [sic] Upon further review of the record, it was noted a skilled nursing note dated 9/8/25 documented a new would on the left posterior heel that measured 0.5 cm by 0.3 cm. There was no evidence of physician notification regarding the change in status or to obtain wound care orders. Additionally, a skilled nursing note dated 10/14/25 documented a new pressure wound to the left superior heel that measured 0.7 cm by 0.7 cm. There was no evidence of physician notification regarding the change in status or to obtain wound care orders. The same wound care orders were used to treat all 3 wounds. During an interview with the director of clinical services (DCS #1) on 12/12/25 at 1:50 PM, DCS #1 was asked about the agency expectation regarding new wounds. DCS #1 stated the expectation was that the physician would be notified of any new wounds so orders to treat them could be obtained. DCS #1 and the administrator (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, the agency failed to ensure skilled professionals followed the orders indicated in the plan of care in 3 (P-4, P-8, and P-10) of 13 records reviewed, resulting in the potential for unmanaged symptoms and poor patient outcomes. Findings include: Patient #8 (P-8) was admitted to this home care agency on 11/6/25 with the diagnoses of lymphedema (swelling) of the right leg and idiopathic necrosis of the right femur (right leg pain). During record review, on 12/10/25, it was noted the plan of care orders included to notify the physician if “No BM (bowel movement) > 3 days” and “weigh gain of 3 lbs (pounds) in 24 hours or 5 lbs in 7 days.” [sic] Upon further review of the record, it was determined that 9 of 9 daily physical therapy notes dated between 11/11/25 and 12/9/25 failed to include a date of the last bowel movement or a weight to monitor the interventions ordered in the plan of care. Patient #10 (P-10) was admitted to this home care agency on 5/8/25 with the diagnoses of a stage 2 pressure ulcer of the left buttock, hypertensive heart disease with heart failure, and type II diabetes mellitus. During record review on 12/9/25, it was noted the plan of care orders included to notify the physician if “Blood Glucose is greater than 350 mg/dl or less than 60 mg/dl fasting/random” [sic] and “Weigh gain of 4 lbs in 24-48 hours.” [sic] Upon further review of the record, it was determined that 12 of 12 skilled nursing note dated between 5/12/25 and 6/30/25 failed to include a blood glucose reading or weight to monitor the interventions ordered in the plan of care. Additionally, it was noted the updated plan of care following a hospital admission (dated 5/23/25) ordered services from occupational therapy, social work, and speech therapy. During an interview with the director of clinical services (DCS #1) on 12/12/25 at 12:30 PM, DCS #1 was asked about the agency expectation for disciplines to complete evaluations after ordered. DCS #1 stated the expectation was that all orders are completed within 48 hours of being received. DCS #1 also stated it was expected that if any discipline was unable to complete the service ordered within 48 hours, it should be documented as to why it wasn’t done and a new order was to be obtained from the doctor. Upon further review of the record, it was determined occupational therapy evaluated the patient on 5/28/25 (5 days after it was ordered), social work evaluated the patient on 5/30/25 (7 day after it was ordered), and speech therapy evaluated the patient on 6/28/25 (36 days after it was ordered). There was no documentation by occupational therapy, social work, or speech therapy regarding a reason for the delay in care. There were also no orders from the doctor obtained regarding the delay. The director of clinical services (DCS #1) and administrator (Adm #1) reviewed and acknowledged the findings during an interview on 12/12/25 at 1:50 PM. Agency policy titled “Physician’s Plan of Care” (undated) was provided for surveyor review on 12/11/25. On the first page (noted as page 46), it stated “All clinical services are implemented ONLY in accordance with the physician’s Plan of Care as a written guide for the delivery of care.” Patient #4 (P-4): This patient was admitted to the home care agency on 9/13/25 with diagnoses including hypovolemia (abnormally low fluid volume in the body); orthostatic hypotension (low blood pressure upon standing); and heart disease. The medical record was reviewed on 12/10/25. During review of the plan of care (POC) for the certification period of 9/13/25- 11/11/25, it was noted that one of the physician-ordered vital sign parameters to report (to the physician) was a diastolic blood pressure (DBP) of less than 50 millimeters of mercury (mm Hg). The registered nurse (RN) made 8 visits between 9/13/25 and 10/29/25 and documented a DBP lower than 50 mm Hg during 4 of 8 visits with no notification to the physician indicated. The following DBP’s were entered by the RN: On 9/18/25- 48; On 10/22/25- 43; On 10/27/25- 42; On 10/29/25- 46. The physical therapist (PT) made 15 visits between 9/15/25 and 11/5/25 and documented a DBP lower than 50 mm Hg during 2 of 15 visits with no notification to the physician indicated. The following DBP’s were entered by the PT: On 10/10/25- 44; On 11/3/24- 44. Neither the RN nor the PT followed physician orders as indicated in the POC regarding the reporting of DBP below 50 mm Hg. On 12/12/25 at 3:15 p.m., the above findings were reviewed and acknowledged during interview with the Director of Clinical Services (DCS #1) and the Administrator (Adm #1).”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide was supervised every 14 days for 1 (P-7) of 2 records reviewed of patients receiving home health aide services, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #7 (P-7) was admitted to this homecare agency on 5/24/25 with the diagnoses of hypertensive chronic kidney disease, anemia, and dementia. During record review on 9/30/25, it was determined a home health aide was ordered 2 times a week for 4 weeks. Upon further review of the record, it was noted the skilled nurse performed a supervisory visit on 6/4/25 before skilled nursing services were discontinued. After that, the physical therapist performed supervisory notes on 6/5/25, 6/10/25, and 6/24/25, however, these notes failed to include the name of who was being supervised. The director of clinical services (DCS #1) and administrator (Adm #1) reviewed and acknowledged the findings during an interview on 12/12/25 at 1:50 PM.”

“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 completed, provided the patient’s current health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 6 (P-1, P-2, P-4, P-5, P-7, and P-10) of 6 records of patients discharged from the agency or an agency service, from a total of 13 sample records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Patient #7 (P-7) was admitted to this homecare agency on 5/24/25 with the diagnoses of hypertensive chronic kidney disease, anemia, and vascular dementia. During record review on 9/30/25, it was determined sections on the discharge summary were left blank, including “Services Provided” and “Condition at Discharge.” The “Condition at Discharge” section listed words under mental status and functional ability (“Forgetful,” “Oriented,” “Ambulation,” “Endurance,” and “Hearing”), however, they were all labeled with the start of care date (5/24/25) and contained no additional information. The discharge summary failed to include information regarding the patient’s course of treatment and status at the time of discharge. Additionally, it was noted the “Discharge From Agency Summary” dated 6/24/25 indicated by a check mark that the summary was sent to the referring physician, however, there was no documented evidence it was sent within 5 days of discharge. Patient #10 (P-10) was admitted to this home care agency on 5/8/25 with the diagnoses of a stage 2 pressure ulcer of the left buttock, hypertensive heart disease with heart failure, and type II diabetes mellitus. During record review on 12/9/25, it was determined sections on the discharge summary were left blank, including “Services Provided” and “Condition at Discharge.” The “Condition at Discharge” section listed words under mental status and functional ability (“Forgetful,” “Learning Barriers,” “Oriented,” “Ambulation,” “Endurance,” and “Hearing”), however, they were all labeled with the start of care date (5/8/25) and contained no additional information. The discharge summary failed to include information regarding the patient’s course of treatment and status at the time of discharge. Additionally, it was noted the “Discharge From Agency Summary” dated 6/30/25 did not indicate who the discharge summary had been sent to or when. The director of clinical services (DCS #1) and administrator (Adm #1) reviewed and acknowledged the findings during an interview on 12/12/25 at 1:50 PM. Patient #4 (P-4): This patient was admitted to the home care agency on 9/13/25 with diagnoses including hypovolemia (abnormally low fluid volume in the body); orthostatic hypotension (low blood pressure upon standing); and heart disease. The medical record was reviewed on 12/10/25. During review, it was noted that the physical therapist (PT) entered a discharge summary on 11/5/25 (as part of the Outcome and Assessment Information Set or OASIS discharge). It was noted that the PT completing the summary indicated who the referring physician was, however, failed to include details of the discharge summary being sent to the referring physician within 5 days of discharge (when and how). Patient #5 (P-5): This patient was admitted to the home care agency on 9/25/25 with diagnoses including aftercare following surgery; right artificial knee joint; and arthritis. The medical record was reviewed on 12/9/25. During review, it was noted that the PT entered a discharge summary on 10/10/25 (as part of the OASIS discharge). The PT did not select a referring physician that the summary would be sent to within 5 days and did not enter details (when and how) about sending a discharge summary. Additionally, when reviewing the section of the summary titled “Condition at Discharge”, it was unclear what the patient’s mental status and functional abilities were at discharge as the documentation only stated: Mental Status- Mental/Psychosocial/Cognitive Status: Oriented Start Effective Date: 9/25/25. Functional Ability- Functional Limitations: Ambulation Start Effective Date: 9/25/25; Endurance Start Effective Date:9/25/25; and Pain Start Effective Date: 9/25/25. On 12/12/25 at 3:15 p.m., the above findings were reviewed during interview with the Director of Clinical Services (DCS #1) and the Administrator (Adm #1). DCS #1 stated that no evidence was available to show discharge summaries were being sent to the physicians and acknowledged the finding. Patient #1 (P-1)’s start of care (SOC) was 1/15/25 with diagnoses that included Syncope/collapse, Bundle Branck Block and Bradycardia. The Plan of Care (POC) ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the clinical record review on 9/30/25 at 12:25 p.m. it was noted that P-1 was discharged from SN and OT services on 1/22/25 and was discharged from PT and the agency’s services on 2/13/25. Upon further review, the OT Discharge Summary dated 1/22/25 was void of a summary which detailed the course of care provided with responses and the patient’s overall status at the time of discharge. Additionally, there was no documented evidence that either of the above summaries (SN, PT, OT) had been forwarded to the Physician within 5 days of the date of discharge. The Director of Clinical Services (DCS #1) reviewed and acknowledged these findings during an interview on 12/11/25 at 12:41 p.m. P-2’s SOC was 8/27/25 with diagnoses that included Cellulitis Bilateral Lower Extremity and Venous Statis Dermatitis. The POC ordered SN and PT services to be provided. On 12/9/25 at 10:30 a.m., during the record review, it was noted that the patient was discharged from PT services on 10/24/25. The PT Discharge Summary dated 10/24/25 was void of a summary that detailed the course of care provided with responses, the patient’s overall status at the time of discharge and which, if any goals were met versus not met. Additionally, there was no documented evidence that the summary was forwarded to the Physician within 5 days of the date of discharge. DCS #1 reviewed and acknowledged the above findings during an interview on 12/12/25 at 1:15 p.m.”