Cgm Home Health Care

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical notes were complete and accurate for 4 (P-2, P-5, P-6, P-7) of 7 records reviewed (See G1012); failed to ensure a discharge summary was completed, provided the patient’s current health status at the time of discharge, progress toward goals in 2 (P-2, P-5) of 7 closed records, and failed to ensure a discharge summary was forwarded to the physician within 5 days of discharge in 7 (P-1, P-2, P-3, P-4, P-5, P-6, P-7) of 7 closed records (See G1022). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR§484.110 Clinical Records.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to provide documented evidence of infection control education for 4 of 7 sampled staff members including those employed through an arranged contract, which has the potential to negatively impact the safety and well-being of all 3 patients serviced by the agency in the past 12 months. Findings include: On 9/4/25, 7 personnel files for varied skilled staff, including 5 employed directly by the agency and 2 employed through arranged contracts, were reviewed. During review, it was noted that no orientation Infection Control (IC) education and no ongoing annual IC education were found in the contracted personnel files reviewed, Office Manager (OM-1) and Administrator Assistant (ADM AST-1). A review of the agency policy on 9/4/25 titled “Infection Control Training: Employee” (undated). The policy states, “Employees will receive education and training during orientation and at least annually.” A review of the agency policy on 9/4/25 titled “Contractors Services” (undated). The policy states, “5. The Agency will monitor, evaluate and annually audit all written agreements/contracts to ascertain if care services are being provided according to the terms of the contract, home care accreditation standards and level of safety and quality that Agency expects...” The Clinical Manager (CM-1) reviewed and acknowledged the findings listed above in an interview on 9/5/25 at 11:50 am.”

“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 patient’s clinical record documented all medications for 4 (P-1, P-3, P-4, P-5) of 7 records reviewed. This deficient practice results in the potential for inaccurate medication profile, unrecognized side effects and drug interactions that could affect all patients serviced by the agency. Findings included: Patient #1’s (P-1) Start of Care (SOC) was dated 8/19/22. The Plan of Care (POC) identified diagnoses of Bilateral Primary Osteoarthritis, Spondylosis, Obesity and Diabetes Type 2. During record review on 9/3/25, it was noted that there were discrepancies from the medication profile provided to the patient and the medication profile in the Electronic Medical Record (EMR). The missing medications from the EMR were Fluphenazine, Quetiapine, Docusate Sodium, Glipizide, Metformin, Atenolol, Metolazone and Potassium Chloride. The agency failed to maintain an accurate medication profile within the EMR. Patient #3’s (P-3) Start of Care (SOC) was dated 9/11/24. The Plan of Care (POC) identified diagnoses of Bilateral Osteoarthritis, Diabetes Type 2 and Low Back Pain. During record review on 9/4/25, it was noted that the EMR documented discrepancies from the “Office Visit” dated 9/10/24 and the medication profile. The missing medications from the “Office Visit” were Acyclovir, Betamethasone Valerate External Cream, Clotrimazole External Cream, Erythromycin Ophthalmic Ointment, Fluticasone Nasal Suspension, Metronidazole Gel, Semaglutide Pen-injector and Terbinafine HCl. There is no documented medication reconciliation completed with the physician to determine an accurate home medication regimen. Patient #4’s (P-4) Start of Care (SOC) was dated 9/17/24. The Plan of Care (POC) identified diagnoses of Primary Generalized Osteoarthritis, Muscle Weakness and Pain in Right Leg. During record review on 9/5/25, it was noted that the EMR documented discrepancies from the referral and medication profile. The missing medications from the referral were Lisinopril and Meloxicam. Furthermore, the medication profile contained Pantoprazole and Naproxen, which were not on the referral. There is no documented medication reconciliation completed with the physician to determine an accurate home medication regimen. Patient #5’s (P-5) Start of Care (SOC) was dated 10/3/24. The Plan of Care (POC) identified diagnoses of Bilateral Primary Osteoarthritis, Hypertension and Lupus. During record review on 9/10/25, it was noted that the Registered Nurse completed a comprehensive assessment on 10/3/24 and documented, “Respiratory Status: O2 (Oxygen) LPM (Liters per minute): 2 via N/C (Nasal Cannula).” The medication profile completed on 10/3/24 failed to include Oxygen. A review of the agency policy occurred on 9/5/25 titled “Medication Reconciliation” (Undated) The policy states, “The Agency will reconcile patient’s medications at time of admission and on an ongoing basis. Standards and Guidelines: 1. At time of admission, the admitting RN, PT, OT or SLP will create and document a complete list of medications that patient is taking at home, including dose, route, frequency, OTC creams and ointments. A RN will reconcile any discrepancies with the patient’s physician. Discrepancies include duplications, omissions, changes, contraindications and/or unclear information.” The Clinical Manager (CM-1) reviewed and acknowledged the findings listed above in an interview on 9/5/25 at 11:50 am and 9/11/25 at 12:15 pm.”

“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 visit frequencies were provided only as ordered by the physician for 3 (P-2, P-3, P-5) of 7 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: Patient #2’s (P-2) Start of Care (SOC) was dated 4/28/24. The Plan of Care (POC) identified diagnoses of Pneumonia, Chronic Obstructive Pulmonary Disease and Weakness. During record review on 9/4/25, it was noted that Skilled Nursing (SN) completed a comprehensive assessment on 4/28/24 with an ordered frequency of 2w4 (2 times a week for 4 weeks), Physical Therapy (PT): Eval/Treat. The SN only completed the SOC visit, and no further visits or documentation was noted within the Electronic Medical Record (EMR). Furthermore, the PT completed an evaluation on 5/1/24 with an ordered frequency of, “Care Plan: Frequency: Blank.” The PT then completed a visit on 5/2/24 and a discharge summary on 5/7/24 stating, “Refused Further Care.” The PT completed 3 visits without a physician’s ordered frequency. The agency failed to complete the SN visits as ordered and obtain physician orders for the PT services. Patient #3’s (P-3) Start of Care (SOC) was dated 9/11/24. The Plan of Care (POC) identified diagnoses of Bilateral Osteoarthritis, Diabetes Type 2 and Low Back Pain. During record review on 9/4/25, it was noted that Physical Therapy (PT) completed a comprehensive assessment on 9/11/24 with an ordered frequency of 2w6 (2 times a week for 6 weeks). During week 5 of service, the PT completed 1 (10/11/24) of 2 scheduled visits. The Electronic Medical Record (EMR) contained no documentation of a completed visit or missed visit. The PT failed to provide the services and frequency as ordered by the physician. Patient #5’s (P-5) Start of Care (SOC) was dated 10/3/24. The Plan of Care (POC) identified diagnoses of Bilateral Primary Osteoarthritis, Hypertension and Lupus. During record review on 9/10/25, it was noted that Skilled Nursing (SN) completed a comprehensive assessment on 10/3/24 with an ordered frequency of 1w1 (1 time a week for 1 week), 2w4 (2 times a week for 4 weeks). The SN completed visits on 10/3/24, 10/8/24, 10/10/24, 10/15/24 and 10/17/24. The SN then did not complete a visit until 11/23/24, 37 days from the last visit. Then completed a discharge visit on 11/25/24. The EMR contained no documentation as to the delay in ordered frequency and not completing the visits as ordered. A review of the agency policy occurred on 9/5/25 titled “Plan of Care (485) and Physician/NP Orders” (Undated). The policy states, “1. The Plan of Care is established in writing by the physician or NP, Agency staff, the patient and members of the patient’s family based on an evaluation of the patient’s immediate and long-term needs. The Plan of Care is developed with the patient’s participation and includes: …Frequency of visits and duration.” The Clinical Manager (CM-1) reviewed and acknowledged the findings listed above in an interview on 9/5/25 at 11:50 am and 9/11/25 at 12:15 pm.”

“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 complete and accurate for 4 (P-2, P-5, P-6, P-7) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: Patient #2’s (P-2) Start of Care (SOC) was dated 4/28/24. The Plan of Care (POC) identified diagnoses of Pneumonia, Chronic Obstructive Pulmonary Disease and Weakness. During record review on 9/4/25, it was noted that Physical Therapy (PT) completed an evaluation on 5/1/24. The following sections were blank on the evaluation: Muscle Strength/Functional ROM (Range of Motion) Evaluation, Functional Mobility/Balance Evaluation, Gait, Plan, Care and Discharge Planning, Care Plan, Short Term and Long Term Outcomes and Goals. The agency failed to complete and maintain an accurate patient record. Patient #5’s (P-5) Start of Care (SOC) was dated 10/3/24. The Plan of Care (POC) identified diagnoses of Bilateral Primary Osteoarthritis, Hypertension and Lupus. During record review on 9/10/25, it was noted that the Skilled Nurse (SN) completed two missed visit notes on 11/19/24 and 11/21/24 that stated, “Remarks: Blank.” The following SN visits were blank: 10/8/24, 10/10/24, 10/15/24, 10/17/24 and 11/25/24 (DC OASIS). The agency failed to complete and maintain an accurate patient record. Patient #6’s (P-6) Start of Care (SOC) was dated 2/1/24. The Plan of Care (POC) identified diagnoses of Noninfective Gastroenteritis and Colitis. During record review on 9/11/25, it was noted that the following SN visits were blank: 2/5/24, 2/6/24, 2/14/24, 2/16/24, 3/4/24, 3/6/24, 3/8/24, 3/11/24, 3/13/24, 3/15/24, 3/18/24, 3/20/24, 3/22/24, 3/25/24, 3/29/24, 4/1/24, 4/5/24, 4/8/24, 4/15/24, 4/19/24, 4/22/24, 4/26/24, 4/29/24 and 5/3/24 (DC OASIS). The agency failed to complete and maintain an accurate patient record. Patient #7’s (P-7) Start of Care (SOC) was dated 8/8/22. The Plan of Care (POC) identified diagnoses of Spondylosis, Chronic Obstructive Pulmonary Disease, Obesity and Hypertension. During record review on 9/11/25, it was noted that the SN completed a DC OASIS on 8/31/22, but the Electronic Medical Record (EMR) contained no evidence of a completed Discharge Summary. The agency failed to follow policy and complete a Discharge Summary. A review of the agency policy occurred on 9/5/25 titled “Entries into Medical Record Criteria” (Undated). The policy states, “…By authenticating entries in the patient’s record, staff is validating the correctness of the information.” A review of the agency policy occurred on 9/5/25 titled “Discharge Summary” (Undated). The policy states, “Policy: A Discharge Summary will be completed for all patients discharged from the Agency. Standards and Guidelines: 1. Skilled Nurse, Medical Social Worker and/or Therapist will complete Discharge Summary form.” The Clinical Manager (CM-1) reviewed and acknowledged the findings listed above in an interview on 9/5/25 at 11:50 am and 9/11/25 at 12:15 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 in 2 (P-2, P-5) of 7 closed records, and the agency failed to ensure a discharge summary was forwarded to the physician within 5 days of discharge in 7 (P-1, P-2, P-3, P-4, P-5, P-6, P-7) of 7 closed records resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 8/19/22. The Plan of Care (POC) identified diagnoses of Bilateral Primary Osteoarthritis, Spondylosis, Obesity and Diabetes Type 2. During record review on 9/3/25, it was noted that Physical Therapy (PT) completed a discharge on 9/30/22. The Electronic Medical Record (EMR) contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. Patient #2’s (P-2) Start of Care (SOC) was dated 4/28/24. The Plan of Care (POC) identified diagnoses of Pneumonia, Chronic Obstructive Pulmonary Disease and Weakness. During record review on 9/4/25, it was noted that PT completed a discharge on 5/7/24. The EMR contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. Additionally, it was noted that the PT discharge summary stated, “Discharge/Transfer Summary: Summary of Care: Blank.” The discharge summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient’s health status at the time of discharge in measurable terms. Patient #3’s (P-3) Start of Care (SOC) was dated 9/11/24. The Plan of Care (POC) identified diagnoses of Bilateral Osteoarthritis, Diabetes Type 2 and Low Back Pain. During record review on 9/4/25, it was noted that PT completed a discharge on 10/16/24. The Electronic Medical Record (EMR) contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. Patient #4’s (P-4) Start of Care (SOC) was dated 9/17/24. The Plan of Care (POC) identified diagnoses of Primary Generalized Osteoarthritis, Muscle Weakness and Pain in Right Leg. During record review on 9/5/25, it was noted that PT completed a discharge on 10/25/24. The Electronic Medical Record (EMR) contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. Patient #5’s (P-5) Start of Care (SOC) was dated 10/3/24. The Plan of Care (POC) identified diagnoses of Bilateral Primary Osteoarthritis, Hypertension and Lupus. During record review on 9/10/25, it was noted that the Skilled Nurse (SN) completed a discharge on 10/17/24. The EMR contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. Additionally, it was noted that the SN discharge summary stated, “Discharge/Transfer Summary: Summary of Care: Evaluation, nursing education and teaching about diet, nutrition and management of blood pressure and medication compliance.” The discharge summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient’s health status at the time of discharge in measurable terms. Patient #6’s (P-6) Start of Care (SOC) was dated 2/1/24. The Plan of Care (POC) identified diagnoses of Noninfective Gastroenteritis and Colitis. During record review on 9/11/25, it was noted that the SN completed a discharge on 5/3/24. The EMR contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. Patient #7’s (P-7) Start of Care (SOC) was dated 8/8/22. The Plan of Care (POC) identified diagnoses of Spondylosis, Chronic Obstructive Pulmonary Disease, Obesity and Hypertension. During record review on 9/11/25, it was noted that the SN completed a discharge on 8/31/22. The EMR contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. A review of the agency policy occurred on 9/5/25 titled “Discharge Summary” (Undated). The policy states, “Policy: A Discharge Summary will be completed for all patients discharged from the Agency. Standards and Guidelines: 1. Skilled Nurse, Medical Social Worker and/or Therapist will complete Discharge Summary form. 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. – Summary of care and services provided. 2. …a copy of the Discharge Summary will be sent to the physician within 5 business days of discharge.” The Clinical Manager (CM-1) reviewed and acknowledged the findings listed above in an interview on 9/5/25 at 11:50 am and 9/11/25 at 12:15 pm.”