Wellness Home Health Care, Inc.

“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 the registered nurse (RN) provided care as ordered by the physician in the plan of care for 1 (P-2) of 7 records reviewed, from a total sample of 7 records reviewed, resulting in the potential for a poor outcome for the patient. Findings include: P-2: This patient was admitted to the Agency on 1/10/25, diagnoses included hypertensive heart disease with congestive heart failure, gout, and generalized weakness. Record review on 3/14/25 noted an order (effective 1/10/25) for SN (skilled nursing) to teach “disease process, EDEMA (swelling), HTN (elevated blood pressure) medication management, safety.” The POC ordered a SN visit frequency of 1W4 (once weekly x four weeks) and for “SN to assess O2 (oxygen) saturation on room air each visit. Report weight gain of 1 lb./1 day, 5 lb./1 week. (for potential fluid overload).” Additional record review noted the following deficiencies SN failed to perform as ordered on the POC. 1/17/25: No O2 readings or patient weight acquired, and no evidence of HTN medication management and safety education were found. 1/24/25: No O2 readings or patient weight acquired, and no evidence of HTN medication management and safety education were found. 1/31/25: Approved MV (missed visit). 2/7/25 (Discharge Visit): No O2 readings or patient weight acquired, and no evidence of HTN medication management and safety education were found. During an interview on 3/14/25, at 3:15 PM., the Administrator (Adm-1) and Clinical Manager (CM-1) acknowledged the above findings.”

“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 the transfer/discharge summaries were complete, provided the patient’s current health status at the time of transfer/discharge in 2 (P-2, P-7) of 2 records in which the patient was discharged/transferred from the Agency’s services, from a total of 7 sampled records reviewed, resulting in the potential for unidentified continuing health concerns and unmet care needs. Findings include: P-7: The patient’s start of care (SOC) was 5/31/24, with diagnoses of diabetes mellitus, and pain. During the record review on 3/13/25, it was noted that the patient received Physical Therapy (PT) services. The patient was discharged from PT services on 7/25/24. The discharge OASIS dated 7/25/24, failed to include a summary of the patient’s care including the patient’s medications at discharge. During an interview on 3/14/25, at 2: 45 p.m., the administrator (Adm-1) acknowledged the above findings. P-2: The patient was admitted to home care on 1/10/25, with diagnoses which included hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, and gout. On 3/13/25, record review revealed skilled nursing (SN) services had discharged the patient on 2/7/25. The discharge OASIS (Outcome and Assessment Information Set) dated 2/20/25, failed to include a summary of the patient’s care including the patient’s medications at discharge. In addition, a request was made on 3/14/25 at 10:20 AM., to review when the OASIS discharge summary was sent to the physician. The Agency was unable to identify a time when it was sent out to the physician. Also, no evidence that a discharge summary from the Agency was sent to the physician within the required 5 days after discharge. During an interview on 3/14/25, at 3:10 PM., the Administrator (Adm-1) and Clinical Manager (CM-1) acknowledged the above findings.”