Health Wise Home Health Care

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain, review, or update the written emergency preparedness policies and procedures, resulting in the agency’s inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of all patients served by this agency. Findings include: On 3/13/25, the binder titled “Disaster Readiness and Emergency Management Plan,” was reviewed. During the review, it was noted that the emergency preparedness policies and procedures failed to indicate an initial or review date, or evidence the policies were reviewed and updated at least every two years. This finding was reviewed and acknowledged by the alternate clinical manager (Alt-CM) and intake/community relations staff (CR) during an interview on 3/14/25 at 0930.”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated and revised in 1 (P-6) of 10 records reviewed, resulting in the potential for unmet care needs. Findings include: P-6: This 85-year-old was admitted to home care on 1/8/25 with diagnoses of hypertensive heart disease with heart failure and osteoarthritis of the knee. During record review on 3/12/25, it was noted that the patient received skilled nursing and physical therapy services. The plan of care ordered skilled nursing once a week for two weeks. The patient was discharged from nursing services on 1/16/25 and the patient continued to receive physical therapy until discharge from the agency on 2/21/25. The medical record contained a physician order dated 1/24/25, stating, “RN for wound care.” A skilled nursing visit note from 1/27/25 indicated the patient had a 1.5cm x 1.5 cm “circular growth/bump protrusion” on the left calf. There was no evidence the comprehensive assessment was updated or revised. It was also noted there was no evidence of continued visits from the nurse. This finding was reviewed and acknowledged by the alternate clinical manager (Alt-CM) and intake/community relations staff (CR) during an interview on 3/14/25 at 0930.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the individuals who furnished Home Health Aide services on its behalf met the competency evaluation requirements of this section by ensuring the required skills were evaluated by a Registered Nurse, who observed the Aide’s performance of the required tasks for 1 of 2 aides (HHA#2) , resulting in the potential for the provision of substandard care and unmet care needs. Findings include: Policy: “Home Health Aide Services and Training Program 9.12.1”, (Reviewed 1/22/2021) states, “All Home Health Aides employed by the Agency shall satisfactorily complete a home health aide training program and/or competency evaluation program prior to performing patient care. Procedure: 10. Documentation is maintained to demonstrate that the competency evaluation, inservice, and performance review requirements are met.” During the home health aides’ personnel file review on 3/13/25, it was noted that HHA#2’s file did not contain any competency or training evaluation program documentation. CR (Community Relations) was questioned on 3/13/25 at 12:45 pm and stated, “I do not see a competency evaluation in her file.” The agency failed to ensure the home health aides’ were qualified and competent to provide patient focused personal care.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 2 (P-3 and P-6) of 3 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare covered services. Findings include: P-3: The Start of Care (SOC) was dated 12/12/24. The Plan of Care (POC) identified diagnoses of Parkinson’s, Ataxia and Falls. During record review on 3/12/25, it was noted the “Notice of Medicare Non-Coverage” was signed on 1/22/25, the date of the discharge. There was no documentation to indicate the patient was informed of the impending discharge within 2 days of discharge. This finding was reviewed with and acknowledged by the Alt-CM (Alternate Clinical Manager) during an interview on 3/14/25 at 8:55 am. P-6: This 85-year-old was admitted to home care on 1/8/25 with diagnoses of hypertensive heart disease with heart failure and osteoarthritis of the knee. The plan of care ordered skilled nursing and physical therapy. The patient was discharged from agency services on 2/21/25. During record review on 3/12/25, it was noted that the Notice of Medicare Non-Coverage was signed by the patient on 2/21/25, the same day as discharge. The agency failed to provide written notice in advance of terminating on-going care.”

“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 conduct the initial assessment visit within 48 hours of referral in 2 (P-8, P-9) of 7 records reviewed resulting in the patient not receiving the ordered home health services in a timely manner resulting in a delay of needed care as ordered by the physician. Findings included: P-8: The Start of Care was dated 2/17/2025. The Plan of Care for the Certification Period of 2/17/25 to 4/17/2025 identified diagnoses of Atrial Fibrillation, Atherosclerotic Heart Disease of the coronary artery, Rheumatoid Arthritis, Rheumatoid Arthritis, Hypertensive Heart Disease with Heart Failure, Cardiomyopathy, Heart Failure, History of falling, and Long-Term use of Anticoagulants. The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) Services. Upon review of the record, it was noted the referral was dated 2/13/2025. The Start of Care (SOC) comprehensive assessment was completed on 2/17/2025, 4 days after the referral date resulting in a delay of needed care. P-9: The Start of Care was dated 2/27/2025. The Plan of Care for the Certification Period of 2/27/2025 to 4/27/2025 identified diagnoses of Hypertensive Heart Disease with Heart Failure; Chronic diastolic Congestive Heart Failure; Diabetes Type 2; Chronic Obstructive Pulmonary Disease, Bilateral Primary Osteoarthritis of Knee; Diverticulosis of Large Intestine, Depression, Morbid Obesity, and Dependance on supplemental oxygen. The patient was receiving Skilled Nurse (SN) and Physical Therapy (PT) Services. Upon review of the record, it was noted the referral was dated 1-31-2025. The Start of Care comprehensive assessment was completed on 2/27/2025, 27 days after the referral date resulting in a delay of needed care. There was no evidence found in the record that the physician or patient had requested a delay in care. These findings were reviewed and acknowledged by the Administrator and Clinical Manager on 3/14/2025 at 2:30 p.m.”

“Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure the goals on the Plan of Care were objectively measurable to determine the patient’s progress towards obtaining the goals in three (P-8, P-9, P-10) of 10 records reviewed resulting in the inability to determine the patient’s progress towards obtaining the goals. Examples included: P-8: The Start of Care was dated 2/27/2025. The Plan of Care for the Certification Period of 2/27/25 to 4/17/2025 identified diagnoses of Atrial Fibrillation, Atherosclerotic Heart Disease of the coronary artery, Rheumatoid Arthritis, Rheumatoid Arthritis, Hypertensive Heart Disease with Heart Failure, Cardiomyopathy, Congestive Heart Failure, History of falling, and Long-Term use of Anticoagulants. The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) Services. Upon review of the record, it was noted the SN goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient will maintain optimal breathing patterns as evidenced by proper use of incentive spirometer and/or deep breathing and coughing exercises during episode of care, Patient/Caregiver will be able to state what each medication is indicated for.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. In addition, upon further review of the Plan of Care, there were no Physical Therapy interventions or goals on the Plan of Care to determine the interventions or goals the patient could achieve. P-9: The Start of Car was dated 2/27/2025. The Plan of Care for the Certification Period of 2/27/2025 to 4/27/2025 identified diagnoses of Hypertensive Heart Disease with Heart Failure; Chronic diastolic Congestive Heart Failure; Diabetes Type 2; Chronic Obstructive Pulmonary Disease, Bilateral Primary Osteoarthritis of Knee; Diverticulosis of Large Intestine, Depression, Morbid Obesity, and Dependance on supplemental oxygen. Upon review of the record, it was noted the Skilled Nursing (SN) and Physical Therapy (PT) goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards achieving the goals. Examples for SN included: “Patient will maintain optimal breathing patterns as evidenced by proper use of incentive spirometer and/or deep breathing and coughing exercises during episode of care{sic}”. Patient will verbalize understanding of healthy food choices to help with weight reduction.” These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples for PT included: “Patient will improve ability to safely transfer from chair to bed with independently {sic} to allow patient to decrease burden f care; Patient will improve standing dynamic balance to G {sic}; Patient will climb entrance steps independently with cane, rails {sic}. These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-10: The Start of Care was dated 1/18/2025. The Plan of Care for the Certification period 1/18/2025 to 3/18/2025 identified diagnoses of Cutaneous abscess of left lower limb; Diabetes Type 2 with diabetic neuropathy; Primary generalized osteoarthritis; Ulcerative Colitis; Hypertension; and long-term use of oral hypoglycemic drugs. The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) Services. Upon review of the Plan or Care, it was noted the goals on the Plan of Care for Skilled Nursing were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient will be able to state what each medication is indicated for by 1/22/25; Patient will be able to demonstrate how to perform daily foot care/inspection practices to maintain skin integrity by end of care. These goals are not objectively measurable to determine the patient’s progress towards obtaining the SN goals. Further review of the Plan of Care revealed there were no orders, interventions, or goals documented on the Plan of Care for Physical Therapy Services. The only PT interventions and orders were as follows: “Rehab potential: Good to achieve stated goals with skilled intervention and patient’s compliance with the plan of care. Discharge plans: Discharge patient to self-care.” These findings were reviewed and acknowledged by the Administrator and Clinical Manager on 3/14/2025 at 2:30 p.m.”

“Incorporate OASIS items CFR(s): 484.55(c)(8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. This Element is not met as evidenced by: Based on record review and interview, the agency failed to include documentation of needed supplies to address the patient’s diagnoses of Diabetes and Wound care in 1 of 7 medical (P-10) records reviewed in which the patient required supplies to treat the patient’s health conditions. Findings included: **Agency Policy: Billing Policy, reviewed 1/25/2021. The Policy states, “The Agency will assure accurate billing which reflects only the services, care, supplies, and equipment provided to each individual patient.” P-10: The Start of Care was dated 1/18/2025. The Plan of Care for the Certification period 1/18/2025 to 3/18/2025 identified diagnoses of Cutaneous abscess of left lower limb; Diabetes Type 2 with diabetic neuropathy; Primary generalized osteoarthritis; Ulcerative Colitis; Hypertension; and long-term use of oral hypoglycemic drugs. The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) Services. Upon review of the Start of Care OASIS on 3/12/25, it was noted under the category of Supplies, the only supply listed was, “Exam Gloves.” There were no supplies listed to address the patient’s Wound and Diabetic equipment needs such as needles, syringes, sharps containers for used needles, alcohol pads, gauze, bandages, medical tape, sponges, dressings, cotton balls. Also, there was no documentation of the name of the Durable Medical Equipment Supplier, that area of the Comprehensive Assessment was blank. These findings were reviewed and acknowledged by the Administrator and Clinical Manager on 3/14/2025 at 2:30 p.m.”

“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 observation, record review and interview, the agency failed to ensure safety precautions, individualized to the patient’s identified needs with reportable parameters, and all medications and treatments were included on the plan of care for 2 (P-2 and P-5) of 10 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-5: This 89-year-old patient was admitted to home care on 6/23/22 with diagnoses of lymphedema, venous insufficiency, and hypertensive heart and chronic kidney disease with heart failure. An oxygen concentrator and portable oxygen concentrator were observed in the patient’s home during the home visit observation with the registered nurse on 3/13/25. The plan of care failed to include oxygen therapy or safety measures related to oxygen use. The patient was queried on the oxygen and stated, “I am not using it right now but will be using it when I start walking more.” This finding was reviewed and acknowledged by the alternate clinical manager (Alt-CM) and intake/community relations staff (CR) during an interview on 3/14/25 at 0930. **Agency Policy: “Plan of Care – HCFA #485 and Physician Orders” (Reviewed 1/25/2021). The policy states, “The Plan of Care is established in consultation with the physician, Agency staff, the patient and members of the patient’s family. The Plan of Care includes: … Specific procedures deemed essential for the health and safety of the patient.” **Agency Policy: “Care Planning Process” (Reviewed 1/25/2021). The policy states, “Care will be coordinated initially and ongoing among staff providing care. Care planning for each patient will be individualized to include: Problems and needs… Specific care or services to be provided… Implementation of actions and interventions…” P-2: The Start of Care (SOC) was dated 1/17/25. The Plan of Care (POC) identified diagnoses of Sacral Pressure Ulcer Stage 2, Chronic Kidney Disease and Diabetes Type 2. During record review on 3/11/25, noted the comprehensive assessment was completed on 1/17/25 by Skilled Nursing (SN). A comment under the “Endocrine” section stated, “Is patient diabetic: Yes. Is caregiver independent with glucometer use: Yes. Comments: Checks BS (Blood Sugar) with Dexcom: cg (caregiver) draws up insulin, pt (patient) is able to inject herself and dispose properly in biohazard sharps container.” The POC documented two diabetic medications: Tresiba and Novolog. The POC documented interventions to monitor, “Vital sign parameters: Notify Physician of: Temperature greater than (>) 101 or less than () 100 or less than () 26 or less than () 160 or less than () 90 or less than ( This finding was reviewed with and acknowledged by the Alt-CM (Alternate Clinical Manager) during an interview on 3/14/25 at 9:35 am and stated, “I expect those parameters to be in the plan of care.”

“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 observation, record review and interview, the agency failed to ensure visit frequencies were provided only as ordered by the physician for 2 (P-2 and P-3) of 10 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: **Agency Policy: “Plan of Care – CMS #485 and Physician Orders” (Reviewed 1/25/2021). The policy states, “The Plan of Care is established in consultation with the physician, Agency staff, the patient and members of the patient’s family. The Plan of Care includes: … Frequency of visits...” P-2: The Start of Care (SOC) was dated 1/17/25. The Plan of Care (POC) identified diagnoses of Sacral Pressure Ulcer Stage 2, Chronic Kidney Disease and Diabetes Type 2. During record review on 3/11/25, it was noted that the POC ordered Physical Therapy (PT) at a frequency of 2w7 (2 visits a week for 7 weeks). The PT documented a missed visit on Thursday, 1/30/25 stating, “Comments: Received call from pt’s (patient’s) daughter cancelling todays PT visit because pt fell earlier and was not feeling well.” No further attempts were made to complete the ordered frequency. The PT failed to provide the services and frequency as ordered by the physician. P-3: The Start of Care (SOC) was dated 12/12/24. The Plan of Care (POC) identified diagnoses of Parkinson’s, Ataxia and Falls. During record review on 3/12/25, it was noted that Occupational Therapy (OT) completed an evaluation on 12/16/24 with an ordered frequency of 1w3. The OT documented a missed visit on Monday, 12/23/24 stating, “Comments: Patient’s daughter stated her mom was not feeling well and wanted to cancel OT visit on this date 12/23/24.” Additionally, the OT documented a missed visit discharge on Monday, 12/30/24 stating, “Comments: Pt (Patient) daughter spoke to OT via phone and asked if OT could come the following week (1/5/2025) due to her mother not feeling well.” The record contained no evidence of the OT attempting to visit the patient the week of 1/5/2025 or complete the ordered frequency. The OT failed to provide the services and frequency as ordered by the physician. These findings were reviewed with and acknowledged by the Alt-CM (Alternate Clinical Manager) during an interview on 3/14/25 at 8:50 am.”

“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 nursing provided services as ordered by the physician in the plan of care for 2 (P-2 and P-5) of 10 records reviewed, resulting in the potential for unmet care needs. Findings include: P-5: This 89-year-old patient was admitted to home care on 6/23/22 with diagnoses of lymphedema, venous insufficiency, and hypertensive heart and chronic kidney disease with heart failure. During record review on 3/11/25, it was noted that the plan of care ordered skilled nursing to remeasure wounds and update wound photo weekly on wound chart. On 2/24/25, 2/27/25, 3/10/25, and 3/13/25, there was no evidence of wound measurements or photos attached to the medical record. This finding was reviewed and acknowledged by the alternate clinical manager (Alt-CM) and intake/community relations staff (CR) during an interview on 3/14/25 at 0930. **Agency Policy: “Plan of Care – CMS #485 and Physician Orders” (Revised 1/25/2021). The policy states, “The Plan of Care is established in consultation with the physician, Agency staff, the patient and members of the patient’s family. 1. The Plan of Care includes: …Specific procedures deemed essential for the health and safety of the patient… 6. Care and services provided will be provided according to physician orders. Orders are current and updated. 7. Drugs and treatments are administered by staff only as ordered by physician…” P-2: The Start of Care (SOC) was dated 1/17/25. The Plan of Care (POC) identified diagnoses of Sacral Pressure Ulcer Stage 2, Chronic Kidney Disease and Diabetes Type 2. During record review on 3/11/25, it was noted that the Registered Nurse (RN) completed a comprehensive assessment on 1/17/25 and ordered RN at a frequency of 1w3 (1 visit a week for 3 weeks) with an additional order on 1/26/25 to extend RN services with a frequency of 1w4. The POC states, “Interventions: …SN (Skilled Nurse) to remeasure wounds and update wound photo weekly on wound chart…” The SN documented within the comprehensive assessment under the “Wound Care Worksheet”, “Comment: 1/17/25: Right buttock small opening (SN measured but forgot to write down, will record next visit) …” On 1/23/25 and 1/28/25, the SN documented the wound as “3cm x 2cm” with no depth indicated. Wound pictures for the dates of 1/17/25, 1/23/25 and 1/28/25 clearly indicate the wound had depth. The SN documented wound depths for the following visits: 2/4/25, 2/14/25, 2/18/25, 2/26/25, 3/4/25 and 3/11/25. The SN failed to accurately document the wound as ordered. This finding was reviewed with and acknowledged by the Alt-CM (Alternate Clinical Manager) during an interview on 3/14/25 at 8:45 am.”

“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 they adequately documented on-site supervisory visit to the patient’s home to supervise the services that were provided by the home health aide for 1 (P-3) of 3 records reviewed in which aide services had been provided, from a total sample of 10 records reviewed, resulting in a lack of oversight of aide care and services. Findings include: Agency Policy, “Home Health Aide Supervision” (Reviewed 1/22/2021) states, “Procedure: 1. Home Health Aides are closely supervised to ensure their competence in providing care. At least every 14 days the registered nurse (RN) makes an onsite home supervisory visit to assess relationships and determine whether goals are being met. This is done with or without the aide’s presence. 2. If the patient is not receiving skilled nursing care, but is receiving another skilled service (PT, OT, or SLP), supervision may be provided by the appropriate therapist. P-3: The Start of Care (SOC) was dated 12/12/24. The Plan of Care (POC) identified diagnoses of Parkinson’s, Ataxia and Falls. During record review on 3/12/25, it was noted that the Registered Nurse (RN) completed the comprehensive assessment on 12/12/24 with an ordered RN frequency of 1w2 (1 time a week for 2 weeks), PT (Physical Therapy)/OT (Occupational Therapy) eval and treat, Home Health Aide 1w6. PT completed an evaluation on 12/12/24 with an ordered frequency of 1w1, 2w6. OT completed an evaluation on 12/16/24 with an ordered frequency of 1w3. The medical record contained no evidence of an onsite Home Health Aide supervisory visit over the 6 weeks that aide services were provided. The agency failed to follow policy and complete onsite supervisory visits. This finding was reviewed with and acknowledged by the Alt-CM (Alternate Clinical Manager) during an interview on 3/14/25 at 8:25 am and stated, “I do not see that any supervisory visits have been completed.”

“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 record review and interview, the agency failed to ensure clinical notes were accurate for 1 (P-1) of 10 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: **Agency Procedure: “Timely Submission Agreement”. The procedure states, “This document represents the agreement between Agency and the employee, that the employee will submit documentation in a timely manner. The following is a guideline, for example purposes only, of the timeline for submissions: …Notes: Submitted weekly...” P-1: The Start of Care (SOC) was dated 2/14/25. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Anxiety and Osteoarthritis. During record review on 3/12/25, it was noted that Physical Therapy (PT) was ordered at a frequency of 2w6 (2 times a week for 6 weeks). The last two PT visit notes dated 3/4/25 and 3/6/25 state, “Not Started”. The agency failed to document visits timely. This finding was reviewed with and acknowledged by the Alt-CM (Alternate Clinical Manager) during an interview on 3/14/25 at 9:05 am.”

“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 detailed discharge summary was sent to the physician within 5 business days of discharge for 3 (P-3, P-6, and P-10) of 3 discharge records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: P-3: The Start of Care (SOC) was dated 12/12/24. The Plan of Care (POC) identified diagnoses of Parkinson’s, Ataxia and Falls. During record review on 3/12/25, it was noted that the Physical Therapist (PT) completed a discharge on 1/22/25. The Electronic Medical Record (EMR) contained a “Fax Cover Sheet” dated 2/3/25 stating, “Discharge Summary for your records…” The discharge summary was sent to the physician on the 8th business day, not within the 5 business days of the patient’s discharge per the policy. This finding was reviewed with and acknowledged by the Alt-CM (Alternate Clinical Manager) during an interview on 3/14/25 at 9:15 am. P-10: The Start of Care was dated 1/18/2025. The Plan of Care for the Certification period 1/18/2025 to 3/18/2025 identified diagnoses of Cutaneous abscess of left lower limb; Diabetes Type 2 with diabetic neuropathy; Primary generalized osteoarthritis; Ulcerative Colitis; Hypertension; and long-term use of oral hypoglycemic drugs. The patient was only receiving Skilled Nursing Services. Upon review of the record, it was noted that a Discharge Oasis was submitted by the Registered Nurse on February 1, 2025, However, there was no evidence found in the record that a Discharge Summary had been completed and submitted by the Registered Nurse. These findings were reviewed and acknowledged by the Administrator and Clinical Manager on 3/14/2025 at 2:30 p.m. P-6: This 85-year-old was admitted to home care on 1/8/25 with diagnoses of hypertensive heart disease with heart failure and osteoarthritis of the knee. During record review on 3/12/25, it was noted that the patient received skilled nursing services that were discontinued on 1/16/25 and resumed for one visit on 1/27/25. The patient also received physical therapy services twice a week until discharge from the agency on 2/21/25. A copy of the physical therapy discharge summary, which was sent to the physician, was noted in the chart. The discharge summary failed to include the nursing services provided or patient outcomes in meeting the nursing goals in the plan of care. This finding was reviewed and acknowledged by the alternate clinical manager (Alt-CM) and intake/community relations staff (CR) during an interview on 3/14/25 at 0930. The Alt-CM stated the discharge summary only includes a summary of the last service provided, not a summary of all care provided by the agency. *Agency Policy-Discharge Summary Policy (Reviewed 1/25/21). A discharge summary form will be completed by the Skilled Nurse, Medical Social Worker, and/or Therapist. The discharge summary will include, but is not limited to discharge date, reason for discharge, status of problems identified throughout the course of care, patient’s overall status, and a summary of care or services provided.”