Renewcare Home Health

“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, it was determined the agency failed to include safety precautions on the aide’s care plan, in 1 of 3 records in which Home Health Aide (HHa) services were provided (P-5) resulting in the potential for the provision of unsafe care and negative patient outcomes. Findings included: Policy: Patient Care Policy page 12, section 4 (Undated) stated, “The POC must contain all pertinent diagnoses, including: “Safety measures to protect against injury.” Patient #5 (P-5) had a start of care date of 11/25/24. The Plan of Care (POC) dated 11/25/24, documented the following diagnoses, “Diabetes mellitus, COVID-19, and urinary tract infection.” During record review on 7/25/25, it was discovered that the aide POC dated 11/25/24, failed to document diabetic precautions for a patient with a diagnosis of diabetes and nail care ordered. The agency failed to follow their policy and ensure the aide plan of care included “Safety measures to protect against injury,” to ensure the patient’s safety and prevent potential negative outcomes. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 7/25/25, at 12:35 p.m.”

“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 give consent for or refuse Speech Language Pathology services in advance of treatment in 1 (P-7) of 10 records reviewed resulting in lack of a Speech Therapy assessment and potentially resulting in unmet care needs for this patient. Findings include: Patient #7 (P-7): This 55-year-old was admitted to the home care agency on 7/5/25 with diagnoses including critical illness myopathy (generalized weakness from being critically ill); gastrostomy (artificial opening in abdomen for nutritional support); and Cholecystostomy drain (tube from gallbladder to outside of body to drain fluids). The medical record was reviewed on 7/22/25. During review, it was noted that the physician referral for home health services dated 7/1/25 included orders for the following disciplines: Registered Nurse (RN); Physical Therapy (PT); and Speech Language Pathology (SLP). The referral also included a diagnosis of dysphagia (difficulty with swallowing). The RN completed the comprehensive assessment on 7/5/25 and documented that the following services were offered: RN, PT, Occupational Therapy and home health aide services. There was no evidence in the medical record that SLP services were ever offered to P-7 by the home care agency or that P-7 refused SLP services. On 7/25/25 during interview at 10:20 a.m., the Administrator (Adm-1) reviewed and acknowledged the above finding. Adm-1 stated that she thought the service was requested by the hospital case manager in error and did not realize the physician requested SLP services.”

“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 for immediate care and support needs within 48 hours of referral in 1 (P-6) of 10 records reviewed, and failed to ensure the registered nurse completed the initial assessment when both nursing and therapy services were ordered in 1 (P-10) of 10 records reviewed potentially resulting in a delay in services to maintain the patient’s health and safety. Findings include: Patient #6 (P-6): This 75-year-old was admitted to the home care agency on 2/25/25 with diagnoses including type 2 Diabetes and a chronic non-pressure wound to the lower right leg. The medical record was reviewed on 7/22/25. During review, it was noted that the physician referral for home health services was received by the agency on 2/17/25. The initial visit (comprehensive assessment) was completed by the Registered Nurse (RN) on 2/25/25 (8 days after receipt of referral). There was no evidence in the medical record indicating that the physician ordered a delay in the start of care or that P-6 requested a delay in the start of care. Patient #10 (P-10): This 63-year-old was admitted to the home care agency on 7/8/25 with diagnoses including Parkinson’s disease (progressive nerve disease affecting movement) and left sided weakness following a stroke. The medical record was reviewed on 7/25/25. During review, it was noted that the physician referral dated 7/3/25 included orders for the following home health services: RN; Physical Therapy (PT); Occupational Therapy; and Home Health Aide services. The initial (comprehensive assessment) was completed on 7/8/25 by PT services even though the referral order included RN services. On 7/25/25 during interview at 10:20 a.m., the Administrator (Adm-1) reviewed and acknowledged the above findings.”

“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 conduct a patient-specific, start of care (SOC) comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included baseline patient information in 5 (P-1, P-3, P-4, P-8, and P-9) of 10 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient. Findings include: Patient #8 (P-8): This 59-year-old was admitted to the home care agency on 7/10/25 with diagnoses including recent left knee replacement and type 2 Diabetes. The medical record was reviewed on 7/23/25. During review, it was noted that the comprehensive assessment was completed by the registered nurse (RN) on 7/10/25 and included the active diagnosis of Diabetes Mellites. Additionally, the RN documented under “Endocrine” assessment and checked the box indicating that P-8’s endocrine assessment was “WNL (Within Normal Limits)”, and marked “No” to the question “Is patient diabetic?” There was no further assessment regarding P-8’s diagnosis of Diabetes. Patient #9 (P-9): This 61-year-old was admitted to the home care agency on 7/18/25 with diagnoses including Chronic Obstructive Pulmonary Disease (progressive lung disease affecting breathing) and pneumonia. The medical record was reviewed on 7/25/25. During review, it was noted that the comprehensive assessment was completed by the RN on 7/18/25 and included documentation under “Fire Assessment for Patients with Oxygen” that P-9 did not use oxygen. Additionally, the RN documented under “DME” (or, Durable Medical Equipment) that P-9 had oxygen equipment in the home; and under “Respiratory” documented that P-9 was using oxygen at 2 liters via nasal cannula as needed. On 7/25/25 during interview at 10:20 a.m., the Administrator (Adm-1) reviewed and acknowledged the discrepancies in the patient’s current health status which were noted on the above comprehensive assessments. Patient #1 (P-1) had a start of care date of 11/21/24, with diagnoses that included hypertension, chronic kidney disease, and congestive heart failure. During record review on 7/22/25, it was discovered that the SOC comprehensive assessment dated 11/21/24, failed to document an actual baseline weight, rather than a stated weight, and also failed to document baseline edema measurements, with a diagnosis of congestive heart failure. Patient #3 (P-3) had a start of care date of 5/24/25, with diagnoses that included diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure. During record review on 7/23/25, it was discovered that the SOC comprehensive assessment dated 5/24/25, failed to document baseline edema measurements, for a patient with a diagnosis of congestive heart failure. Patient #4 (P-4) had a start of care date of 7/16/25, with diagnoses that included surgical aftercare, chronic kidney disease, and congestive heart failure. During record review on 7/24/25, it was discovered that the SOC comprehensive assessment dated 7/16/25, failed to document an actual baseline weight, rather than a stated weight, and also failed to document baseline edema measurements, with a diagnosis of congestive heart failure. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 7/25/25, at 12:35 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 interview, the agency failed to ensure the comprehensive assessment identified patient goals and home health interventions needed to result in measurable outcomes in 1 (P-9) of 10 records reviewed potentially resulting in failure to measure changes in health status and identify ongoing patient progress or decline. Findings include: Patient #9 (P-9): This 61-year-old was admitted to the home care agency on 7/18/25 with diagnoses including Chronic Obstructive Pulmonary Disease (progressive lung disease affecting breathing) and pneumonia. The medical record was reviewed on 7/25/25. During review of the comprehensive assessment dated 7/18/25, it was noted that the registered nurse (RN) documented the following assessments: Under “Respiratory” assessment, the RN documented that P-9 was using oxygen at 2 liters via nasal cannula as needed. There were no interventions or goals entered regarding P-9’s use of oxygen or respiratory status. Under “Pain” assessment, the RN documented that P-9 had pain with an intensity of 4 on a 0-10 scale (0 is no pain and 10 is the worst pain) during the assessment. Additionally, the RN documented that P-9’s pain “Occasionally” interfered with sleep and “Occasionally” interfered with day-to-day activities. There were no goals entered regarding P-9’s pain. Under “GU” (genitourinary) assessment, the RN documented that P-9 had burning, frequency, urgency, and dysuria (discomfort) with urination, and that P-9’s urine was cloudy and odorous. There were no interventions or goals regarding P-9’s GU status. On 7/25/25 during interview at 10:20 a.m., the Administrator (Adm-1) reviewed and acknowledged the above findings.”

“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 ensure the comprehensive assessment included a review of the patients medications to identify any potential drug interactions and duplicate therapies in 2 (P-6, and P-10) of 10 records reviewed, and failed to ensure follow-up with the physician for medication reconciliation concerns for 3 (P-1, P-2, and P-5) of 10 records reviewed resulting in the potential for negative patient outcomes. Findings include: *Policy: Medications (Medication Screening) section 4 page 16 states, “Any potential interactions and/or sensitivities identified are immediately brought to the attention of the physician. Changes, additions, or new medications that are added after the start of care (SOC) assessment are entered into the profiling system as soon as the clinician becomes aware of the change/addition.” Patient #1 (P-1) had a SOC date of 11/21/24, with diagnoses that included hypertension, chronic kidney disease, and congestive heart failure. During record review on 7/22/25, it was discovered that the SOC comprehensive assessment under section M2001 documented, “Issues found during drug review, physician notified.” Review of the patient’s medication reconciliation showed 8 drug/alcohol and 8 drug/drug reactions. There was no documented evidence in the record that the agency followed up with the physician regarding what was done about the issues found during the medication drug review. Patient #2 (P-2) had a SOC date of 7/18/25, with diagnoses that included hypertension, chronic kidney disease, and anemia. During record review on 7/22/25, it was discovered that the SOC comprehensive assessment under section M2001 documented, “Issues found during drug review, physician notified.” Review of the patient’s medication reconciliation showed 4 drug-food/alcohol and 1 drug/drug reactions. There was no documented evidence in the record that the agency followed up with the physician regarding what was done about the issues found during the medication drug review. Patient #5 (P-5) had a SOC date of 11/25/24, with diagnoses that included diabetes mellitus, COVID-19, and urinary tract infection. During record review on 7/25/25, it was discovered that the SOC comprehensive assessment under section M2001 documented, “Issues found during drug review, physician notified.” Review of the patient’s medication reconciliation showed 7 drug-food/alcohol and 2 drug/drug reactions. There was no documented evidence in the record that the agency followed up with the physician regarding what was done about the issues found during the medication drug review. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 7/25/25, at 12:35 p.m. Patient #6 (P-6): This 75-year-old was admitted to the home care agency on 2/25/25 with diagnoses including type 2 Diabetes and a chronic non-pressure wound to the lower right leg. The medical record was reviewed on 7/22/25. During review of the comprehensive assessment completed by the registered nurse (RN) on 2/25/25, documentation reflected that no issues were found when the RN completed the drug regimen review of P-6’s medications. On 7/25/25, a “Medications Interactions” report (for P-6’s medication) was generated by the home care agency’s electronic medical record (EMR) system for surveyor review. It was noted that P-6’s “Medications Interactions” report showed duplicate drug therapy between 3 medications and 1 potential drug to drug interaction. There was no evidence that the drugs with duplicate therapy and the potential interaction were immediately reported to the physician per agency policy. Patient #10 (P-10): This 63-year-old was admitted to the home care agency on 7/8/25 with diagnoses including Parkinson’s disease (progressive nerve disease affecting movement) and left sided weakness following a stroke. The medical record was reviewed on 7/25/25. During review of the comprehensive assessment completed by the Physical Therapist (PT) on 7/8/25, documentation reflected that no issues were found when the PT completed the drug regimen review of P-10’s medications. On 7/25/25, a “Medications Interactions” report (for P-10’s medication) was generated by the home care agency’s EMR system for surveyor review. It was noted that P-10’s “Medications Interactions” report showed duplicate drug therapy between 2 medications and 1 potential drug to drug interaction. There was no evidence that the drugs with duplicate therapy and the potential interaction were immediately reported to the physician per agency policy. On 7/25/25 during interview at 10:20 a.m., the Administrator (Adm-1) reviewed and acknowledged the above findings.”

“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 (POC) included safety precautions and parameters in 2 of 7 records (P-3, 5) reviewed, resulting in the potential for poor patient outcomes. Findings include: Policy: Patient Care Policy page 12, section 4 (Undated) stated, “The POC must contain all pertinent diagnoses, including: “Safety measures to protect against injury.” Patient #3 (P-3) had a start of care date of 5/24/25, with diagnoses that included diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure. During record review on 7/23/25, it was discovered that the POC dated 5/24/25, failed to include diabetic safety precautions for a patient with a diagnosis of diabetes. Patient #5 (P-5) had a start of care date of 11/25/24, with diagnoses that included diabetes mellitus, COVID-19, and urinary tract infection. During record review on 7/25/25, it was discovered that the POC dated 11/25/24, failed to include diabetic safety precautions and blood sugar parameters for a patient with a diagnosis of diabetes. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 7/25/25, at 12:35 p.m.”

“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 physical therapy (PT) and occupational therapy (OT) services were provided as ordered by the physician in the plan of care for 1 of 2 (P-4) records reviewed with PT and OT services ordered, from a total of 10 records reviewed, resulting in the potential for physical decline and negative patient outcomes. Findings include: Patient 4 (P-4): The SOC was dated 7/16/25. The POC identified diagnoses of surgical aftercare, chronic kidney disease, and congestive heart failure. During record review on 7/24/25, it was discovered that PT services were ordered at a frequency of 2 times a week for 3 to 4 weeks, and OT services were ordered at a frequency of 1 to 2 times a week for 3 to 4 weeks. No visits from PT or OT were documented in the record. There was no documentation in the record to indicate the patient had declined PT or OT services. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 7/25/25 at 12:35 p.m.”