Essentia Health Home Care West

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation: G570 at 42 CFR 484.60, Care Planning, Coordination, Quality of Care. The agency failed to ensure code status was correctly identified on patient’s plan of care and/or transfer summary for 4 of 17 patients (P4, P12, P13, P14) whose medical records were reviewed. Findings include: Refer to G574: Based on interview and record review the home health agency (HHA) failed to ensure the plan of care (POC) included all required components accurately for 4 of 17 patients (P4, P12, P17, P13) whose records were reviewed for code status.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on documentation and interview, the facility failed to report all Outcome and Assessment Information Sets (OASIS) data collected in accordance with federal regulations for timely submission. The total number of records submitted beyond the 30 days after completion of M0090 (the date the assessment was completed) was 25 for the period of 1/1/25 through 12/31/25, with 15/25 being submitted late for reasons other than payor change. Findings include: On the HHA Error Summary by Agency report period of 1/1/25-12/31/25, the agency had an error code of -3330: record submitted late. The description included the submission was more than 30 days after completion on the new record. The total number of records submitted beyond the 30 days within that period was 25. During interview on 3/12/26 at 11:00 a.m., with director of nursing (DON) and clinical supervisor (CS)-B, OASIS oversight, DON stated the OASIS submission was completed daily, Monday through Friday. A review was completed of the identified late submissions as compiled by agency. Upon reviewing the information, it was noted 15/25 late submissions were for reasons outside of change of payor source. DON stated the OASIS guidance indicated the guidance for completion of the discharged patient must be completed by the last clinician, and at times there is miscommunication as to who is the last person providing services was, which had caused delays or errors in completion. CS-B stated all OASIS came to a work queue, and were assigned to staff by supervisors for the staff. A discussion was held at the Interdisciplinary Team (IDT) meetings to determine the last person who had seen the patient to determine who was to complete the OASIS and to review errors identified. IDT meetings were held weekly in some offices, and every two weeks in others. The facility policy, Home Care Certified Programs Comprehensive Assessment, last reviewed 6/15/23, and identified the OASIS data set requires timely completion and must be completed by the fifth day after the start of care. The policy identified the OASIS must be submitted through the iQIES system within 30 days.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and document review, the agency failed to complete a comprehensive reassessment the last 5 days of each 60-day certification period, beginning with the start of care (SOC), for 1 of 1 patient (P4) who received skilled home care services. P4’s plan of care (POC) 1/9/26 to 3/9/26, identified a start of care (SOC) date 1/9/26. Orders included for skilled nurse visits (SNV) one time per week for nine weeks for various assessments and medication administration. Diagnoses included peritoneal abscess (a localized collection of pus in the abdominal cavity) with infection, emphysema (a chronic lung condition), history of bariatric surgery and dependence on oxygen. Review of P4’s clinical record lacked any reassessments completed since the SOC on 1/9/26. A skilled nurse visit was on P4’s visit schedule to complete a SNV for an Outcome and Assessment Information Set (oasis) recertification, however, a visit had not been completed. During interview on 3/11/26, at 12:08 p.m. the director of nursing (DON) stated she was aware P4 did not receive her scheduled nurse visit. P4’s primary nurse was on vacation and P4 would not allow another nurse to make the visit. The DON stated normally she would expect a skilled nurse visit (SNV) within the five days required time frame for recertification a patient for continued home care services. A visit would be made when P4’s primary nurse returns from her vacation, and the agency would submit a late oasis. It was not the agency’s practice to discharge the patient and do a new SOC when a SNV could not be made to recertify the patient for home care services, they just submitted the oasis late. The agency policy Assessment, Reassessment and Coordination of Patient Services Home Care dated 4/26/24, identified patient assessments were completed by all professional staff within the home health care department. A comprehensive assessment was completed on patients every 55 to 60 days when the plan of care was reviewed and updated or on a resumption of care.”

“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, interview and document review, the agency failed to ensure the plan of care (POC) included all required components for 5 of 17 patients (P4, P12, P17,P13, and P8) whose records were reviewed. P8 P8’s plan of care (POC) 3/4/26 to 5/2/26, identified a start of care date 2/27/26. Services included skilled nurse visits (SNV) one time every two weeks for nine weeks for assessment and education. Additionally, the plan of care identified P8 was to receive home health aide (HHA) visits, one time per week for one week and two times per week for eight weeks to aid with personal needs. The diagnoses included trigeminal neuralgia (a chronic pain disorder which causes intense pain attacks to one side of the face), hypertension (high blood pressure), age-related osteoporosis (bone disease with weak or fragile bones) without current fracture, and bilateral hip replacements. P8’s POC listed durable medical equipment (DME- medically necessary devices and equipment designed for long-term use at home to help manage medical conditions) used for P8 as a walker, wheelchair, and grab bars. During observation on 3/10/26, at 2:30 p.m., HHA-B was observed as she assisted P8 to set up and complete her shower. HHA-B stated the plan of care identified P8’s personal needs. The plan of care was accessed online with the use of an agency telephone. P8 was noted to have a wheeled walker in place, as well as a wheelchair. During observation of shower, it was noted P8 had grab bars in the shower. P8 was also noted to have a removable raised toilet seat with arm rests in place, as well as a shower chair, and handheld shower in the shower enclosure. During interview on 3/12/26 at 9:00 a.m., the director of nursing (DON) stated the DME information included on the POC was to include all equipment used in the home. DON stated this was important to alert staff what was currently being used, and stated it was also important to have accurate information in the event a transfer was indicated so the appropriate equipment was available for P8. The facility policy, Home Care Clinical Record Closure and Retention, last reviewed 11/25/25, identified “when care was provided to the client (patient), documentation in the clinical record as a whole shall reflect the client’s physical condition, psychosocial status, safety measures to protect the client from injury, and medical care provided, as applicable, from admission to discharge.” Findings include: P4 P4’s plan of care (POC) dated 1/9/26 to 3/9/26, identified a start of care (SOC) date 1/9/26. Orders included skilled nurse visit (SNV) one time per week for nine weeks for various assessments and medication administration. Diagnoses included peritoneal abscess (a localized collection of pus in the abdominal cavity) with infection, emphysema (a chronic lung condition), history of bariatric surgery and dependence on oxygen. The POC identified P4’s code status (a medical instruction that identified to healthcare providers what emergency interventions a patient would want if their breathing and heart stopped) as prior. A code status history was listed for three previous code status orders. The first, with inactive date 12/27/25, as full code (the patient wants all life saving measures, including cardiopulmonary resuscitation). The second, with inactive date 11/24/25, as full code. A third code status was listed DNR (the patient does not want CPR or life saving measures initiated) inactive date 10/9/25. P4’s Service Plan dated 1/9/26, identified P4 had not completed a Provider Orders for Life-Sustaining Treatment form (POLST) but wished to be DNR. P4’s POLST signed by P4 and dated 1/9/26, identified P4’s wished to be DNR with physician signature 1/20/26. During interview on 3/11/26 at 8:56 a.m., the director of nursing (DON) stated P4’s code status identified her as a full code and that was not correct. There was a DNR POLST and order in P4’s medical record. There would be a potential for the staff to attempt to resuscitate P4 if P4’s heart were to stop when they were conducting a SNV. During telephone interview on 3/11/25 at 10:09 a.m., registered nurse (RN)-C stated there was a blank POLST form in the patient admission packet. The admitting nurse assisted the patient to fill out and then the nurse brought the form back to the office to be signed by the patient’s provider. If the POLST indicated DNR, it would be returned to the patient after the physician had signed and it had been scanned in the medical record. The POC identified the patient’s current code status. If the POC identified, “prior,” as code status, that meant in the orders their previous choice would show up and would be the chosen code status. RN-C was not P4’s primary nurse but he could potentially see her when he filled in for other nurses. RN-C reviewed P4’s POC and medical record. RN-C stated P4 was listed as a full code and had orders that identified a full code. If RN-C were conducting a SNV with P4 and her heart were to stop, he would call 911 and start CPR. During telephone interview on 3/11/26 at 11:15 a.m., P4 stated she had DNR ordered in her medical record. P4 did not have a POLST form in her home or on her refrigerator that directed health care providers she was DNR, but she wanted to be DNR and had signed something which indicated DNR in her health record on file at the agency. P4 stated she would not want CPR done for her at all. P12 P12’s POC 2/1/26 to 4/1/26, identified a SOC 8/5/25. Orders included SNV one every two weeks for eight weeks for various assessments and medication management. Diagnoses included hypertension (high blood pressure), heart disease, depression, chronic obstructive lung disease (COPD) and dependence on oxygen. The POC identified P12’s code status as full code. P12’s Service Plan dated 8/7/25, identified P12 had a completed POLST form. P12’s POLST, signed by P12 and dated 6/10/25, identified P12’s wishes were to be DNR with physician signature 6/19/25. During a home visit on 3/10/26 at 12:00 p.m., P12 stated he wished he, “could just die.” P12 stated he was tired of living the way he was, unable to do anything he used to do and just wished it would be over. During interview on 3/11/26 at 10:30 a.m., the DON stated therapy had admitted P12 to home care services in June of 2025 and at that time P12 was DNR. When nursing admitted P12 on 8/5/25, he wanted to be full code. The DON could not find documentation in the medical record to indicate code status had been discussed with P12 or that P12 had indicated he wanted to change his code status from DNR to full code. The DON stated a blank POLST form was always in the admission packet and should always be completed with admissions. One had not been completed when the agency nurse had admitted P12 on 8/5/25, and the only advanced directive was the POLST completed on 6/10/25. During telephone interview on 3/11/26 at 11:20 a.m., P12 stated he had a signed POLST on file that indicated he was DNR. P12 did not remember if he had signed a POLST form with the home care agency but he knew he was DNR on his medical records. P12 stated he had been exposed to agent orange during his service and had a lot of health problems. He would never want anything done to resuscitate him. P12 stated he did not have a POLST form in his home or on his fridge which showed he did not want CPR done but he knew it was listed in his medical records. P17 P17’s POC 12/19/25 to 2/16/26, identified a SOC date 12/19/25. Orders included SNV one time per week for nine weeks for various assessments and medication management. Physical therapy visits were ordered one time per week for one week, one time every two weeks for two weeks then one time per week for two weeks for treatment with gait, transfers, mobility and balance. Occupational therapy was ordered one time per week for six weeks to increase P17’s independence with activities of daily living (ADLs). Diagnoses included polymyalgia rheumatica (an inflammatory condition that causes pain in joints and muscles), low back pain, hypertension, cellulitis and depression. P17’s POC listed code status as DNR. P17’s Service Plan dated 12/19/25, identified P17 did have a completed POLST form. P17’s POLST, signed by P17 and dated 12/19/25, identified P17’s wishes were to be a full code with physician signature 12/23/25. P17’s Transfer Summary dated 1/12/26, identified P17 was being transferred to an inpatient facility with code status listed as DNR. During interview on 3/12/26 at 1:15 p.m., the DON stated P17 had a signed POLST dated 12/19/25, on file that identified her wishes were to be a full code. P17’s POC dated 12/19/25 identified P17 was a DNR. They were direct opposite of the other. DON was not sure why they were different and felt maybe the nurses were trying to get through their paperwork too quickly and made an error. During telephone interview on 3/12/26 at 1:30 p.m., RN-E stated she completed the admission visit for P17. When she admitted a patient to home care services, she would have the patient sign all the loose papers in the admission packet, which would include the blank POLST form. RN-E would explain what the POLST was and what each choice on the POLST meant. If the patient chose to fill it out, she would review their choices with them, have them sign and she would sign the back of the form. RN-E brought all the signed paperwork back to the office and the POLST would get sent to the physician for signature and scanned in to the patient’s electronic health record (EHR). RN-E would get the form back on her desk to return to the patient at her next visit. RN-E reviewed P17’s POC and stated the code status identified DNR and that was the direct opposite of the POLST P17 had signed. RN-E could not think of how the DNR code status had been entered on P17’s POC and was sure she had not entered DNR as P17’s code status. RN-E was unsure why the POC was not matching the POLST and felt it was a serious matter. RN-E then reviewed all her patient charts to check each had a correct code status listed on the POC and stated all her other patient’s POC code status were correct. RN-E planned to try to find out how P17’s POC identified the incorrect code status. P13 P13’s POC 11/11/25 to 1/9/26, identified a SOC date 11/11/25. Orders included SNV one time per week for nine weeks for various assessments and diabetes management. Physical therapy visits were ordered one time per week for three weeks for treatment with gait, transfers, mobility and balance. Diagnoses included diabetes, Parkinson’s disease and dementia. Code status was listed as, “prior.” A code status history was listed for three previous code status orders. The first, with inactive date 8/13/25, was for full code. The second, with inactive order date 8/11/25, was for full code and the third, with inactive order date 8/11/25, was for full code. P13’s Service Plan dated 11/11/25, identified P13 had not completed a POLST but had the information if needed. P13’s Provider Order dated 11/13/25, identified an order for P13 to be a full code with physician signature dated 11/21/25, however P13’s POC with code status, “prior,” was not updated to reflect her current code status ordered. During interview on 3/11/26 at 8:56 a.m., the DON stated the computer program EPIC that was used by the agency would wipe out patient code status any time they had an encounter in the emergency room, clinic or hospital. The system automatically input, “prior,” as the patient’s code status and so the agency nurses would have to go into the patient’s chart and enter in the patient’s code status each time. The agency nurses were supposed to look for a patient’s POLST, write an order to reflect the patient’s code status. If the physician had not signed the code status order, the POC would identify code status as, “prior,” until it was signed by the physician. The POLST should be returned to the patient after the first visit and put on the patient’s refrigerator. Until a POLST was signed, that identified DNR, every patient was considered a full code. The agency nurses were supposed to put the correct code status in the POC as soon as they were able. Several times, patients would have the POLST on their refrigerator. The nurses would bring the POLST back to the office and get it signed again and then an order would be generated and would reflect in the POC. The nurses would go by the POLST in the home, but DON was not able to ensure every patient would have their current POLST on their refrigerator. It was potentially possible, a nurse would do a full code on a patient that had a DNR POLST if the POC identified, “prior,” for code status. The nurses were able to see a patient’s code status during any of their visits by checking the patient’s EHR notes in the home. The agency nurses were well aware the code status was not pulling forward correctly. During telephone interview on 3/11/26, at 10:25 a.m. RN-B stated the nurses put patient code status in the orders tab and generally ask each patient to put their POLST on the refrigerator. Patients did not always keep them there. Nurses could quickly look up a patient’s code status in the home by looking in the EHR, under the, “orders,” tab during visits. The orders would either indicate full code or DNR. The nurses discussed code status with patients yearly. Sometimes a POC would list code status as, “prior.” RN-B was not sure why that was but would then just have to do a new order for the code status. If a code status was identified as, “prior,” RN-B would look in the medical record for an advanced directive or POLST. Keeping code status updated and accurate was very important. If a POLST or advanced directive could not be found and the POC listed, “prior,” as code status, RN-B stated she would likely initiate CPR. The agency policy Uniform Code Level Directive for CPR dated 2/24/25, identified every patient had the right to appropriate medical treatment that would maximize the opportunity of the prolongation of life in a meaningful way. In recognition of this fact that every individual also had the right to death with dignity. All patients of the agency would be presumptively coded as level one (full code) unless a specific order was written by a physician. Code level 2 (DNR) would be ordered on the attached form or on the POC. If a patient was code level 2 (DNR) they would be provided a photocopy of the form and the original copy of the form would be retained on the patient’s medical record. Staff were directed to review with the patient and family uniform code level directives and to make sure a copy of the directive form was in sight at all times.”

“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 interview and document review, the agency failed to provide home health aide, occupational and physical therapy services as ordered on referral or notify physician when the services were not needed for 1of 17 patients (P4) reviewed for referrals. The agency failed to ensure visits were conducted in accordance with physician orders for 1 of 17 patients (P4) and failed to notify the physician when the visits were not conducted according to the plan of care (POC). In addition, the facility failed to assure orders for frequency of skilled nurse visits and wound care orders appropriately reflected what was currently in place for 1 of 1 patients (P7) observed for wound care. P7 P7’s plan of care (POC) 3/6/26 to 5/4/26, identified a start of care date 1/5/26. P7’s diagnoses included hypertensive heart disease with heart failure (a condition caused to the heart from years of unmanaged or undermanaged high blood pressure), paroxysmal atrial fibrillation (irregular heart rhythm), atherosclerotic heart disease (narrowing or blockage of the arteries), venous insufficiency (decreased blood flow to the extremities), chronic obstructive pulmonary disease (COPD-an ongoing lung condition), and encounter for change or removal of nonsurgical wound dressing. P7 was to receive skilled nurse visits (SNV) one time every two weeks for eight weeks for INR (International Normalized Ratio) (a standardized blood test to measure of how long blood takes to clot) management and assessment. Although not identified in the SNV order, the narrative under Current Status, identified the orders were for “Medication, education, management and assessment of effectiveness, Disease education, management, and assessment, Pain management-instruct on pain relief measures and assess pain levels each visit and Wound management.” The POC outlined the following treatments to bilateral lower legs: Ammonium lactate 12% lotion to affected areas two times a week with wrap/dressing changes for venous dermatitis.Eucerin Cream apply to affected area (legs and feet) for skin irritation. The SNV POC identified under the heading of Goal the following entry: SNV to perform dressing change to left and right stasis ulcers twice weekly. The nurse was to remove old dressing, soaking with saline as needed to remove dressing. Nurse was directed to cleanse area with soap and water, and to apply Vaseline and triple layer short stretch compression. This intervention did not list a start date. The duration for this was six weeks. Under the intervention, identified as having started 1/20/26, staff were to cleanse lower legs with soap and water and cleanse off slough (dead tissue). The nurse was then to apply zinc barrier cream to lower legs, apply Mepilex to weeping areas, and wrap with calamine wrap, covered with compression wrap two times weekly. Although the directions for wound care were outlined in two different fashions under both goal and intervention in care plan, the medication listing and listing for durable medical equipment lacked any of this information and lacked clarification as to which was to be completed, or at what frequency as the frequency for nurse visits in the POC effective 3/6/26 to 5/4/26 indicated frequency of SNV to be completed every 2 weeks. A review of the physician orders dated 1/20/26, identified the treatment above in a modified fashion. The order identified the nurse was to cleanse the right and left lower leg with soap and water and cleanse off slough. The order then directed the nurse to apply hydrofera (a type of dressing) to the open area on the right leg. Zinc barrier cream was to be applied to lower legs, followed by compression wraps. The order directed the registered nurse (RN) to change the dressings weekly, and P7 was to go into the clinic for a second weekly change. On 3/9/26 at 1:30 p.m., a home care visit observation was completed with RN-B in P7’s home. Upon arrival, P7 was sitting in recliner, with legs unwrapped, and towel laid on the floor. RN-B assembled supplies for wound care. Once set up, RN-B initiated wound care implementing hand hygiene and glove usage appropriately throughout process. Lower legs were cleansed and slough removed. RN-B applied ammonium lactate to bilateral lower legs. Calamine wrap was then applied and subsequently secured with compression wrap. Following visit, RN-B confirmed the current process was different than what was identified on the POC, which was completed on 3/2/26. A review of subsequent orders entered on 3/9/26, at 2:45 p.m. indicated wound care was to be completed each visit, effective 1/20/26, as followed: RN was to cleanse lower legs with soap and water and cleanse off slough. Ammonia lactade [sic] was to be applied to lower legs. Wrap with calamine wrap covered with compression wrap twice weekly by RN or Physical Therapy (PT). A subsequent order was entered on 3/10/26, at 1:16 p.m, which added one SNV every week for 8 weeks from 3/8/26 to 5/2/26. P7’s prior POC from 1/5/26-3/5/26 identified orders for SNV one time every week for nine weeks. Orders were changed to twice weekly for six weeks from 1/25/26 to 3/5/26. The orders also reflected five visits as needed from 1/11/26 to 3/5/26. A review of the weekly schedules identified the visits were completed at a frequency of twice weekly during this time frame. The POC was updated with date of assessment being 3/2/26. At that time the frequency changed to once every two weeks for the period of 3/6/26 to 5/4/26. P7 was seen with a SNV on 3/2/26 and 3/4/26 within the last certification period. SNV was again completed on 3/9/26. During interview on 3/10/26 at 9:15 a.m., RN-B acknowledged orders were changed on 3/9/26, after observation had been completed and orders had been noted to vary from POC. On 3/10/26 at 10:49 a.m., the director of nursing (DON) stated the POC information was to reflect the most current orders at the time of the assessment. DON stated if there were changes to the treatment, the current orders were to reflect this and were to be documented/transcribed as orders and integrated into the plan of care. A review of the facility policy, Home Care-Provider’s Orders, las reviewed 6/25/25, identified “Interim Orders” were to be generated and sent for provider signature for any change in the plan of care for changes in orders that include care of disciplines, orders, and changes of frequencies. Findings include: Referral P4’s plan of care (POC) 1/9/26 to 3/9/26, identified a start of care (SOC) date 1/9/26. Orders included skilled nurse visits (SNV) one time per week for nine weeks for various assessments and medication administration. Diagnoses included peritoneal abscess (a localized collection of pus in the abdominal cavity) with infection, emphysema (a chronic lung condition), history of bariatric surgery and dependence on oxygen. P4’s Referral for Home Care Services, dated 1/7/26, identified the reasons for the referral included home health nursing, physical therapy, occupational therapy and home health aide. P4’s SOC skilled nurse visit (SNV) note dated 1/9/26, identified an assessment visit was made for a SOC with further visits planned. P4’s rehabilitation potential was listed as good to remain in her home with the assistance of home health. P4 had functional limitations of endurance, ambulation, shortness of breath with exertion and was oxygen dependent. P4’s goals were to regain strength and prevent hospitalizations. The visit note lacked documentation if therapies or the need for home health aide services had been assessed, discussed and/or offered to P4. Review of P4’s medical record lacked documentation why therapy or home health aide services had not been discussed or offered to P4 or if the need for the services had been assessed. The record also lacked documentation if the physician had been notified physical therapy, occupational therapy and home health aide services were not initiated for P4 as ordered on the referral. During interview on 3/11/26 at 11:59 a.m., the director of nursing (DON) stated when a patient had a referral for therapies and/or home health aid and the service was not started, the nurse would generate an order to discontinue the service. The agency did consider a referral as initial orders for services. The agency policy Home Health Admission Process dated 7/26/23, identified a referral was communicated to the home health agency for new SOC, resuming care for client on services or changing or increasing services. Patient needs would be reviewed and verification of staff availability. The agency policy Assessment, Reassessment and Coordination of Patient Services Home Care dated 4/26/24, identified the initial assessment was generally for the purpose of determining the patient’s need for care and the type of services required. The initial referral for additional services (therapy, speech or social worker) would be received via provider order. A referral order must be confirmed by completing a written or electronic order that would be signed by the provider. Missed Visits P4’s plan of care (POC) 1/9/26 to 3/9/26, identified a start of care (SOC) date 1/9/26. Orders included for skilled nurse visits (SNV) one time per week for nine weeks for various assessments and medication administration. Diagnoses included peritoneal abscess (a localized collection of pus in the abdominal cavity) with infection, emphysema (a chronic lung condition), history of bariatric surgery and dependence on oxygen. Review of P4’s electronic health record (EHR) indicated SNVs were completed weekly from SOC 1/9/26 to 2/28/26, however no visits had been completed 3/1/26 to 3/12/26. P4 was due for a SNV recertification for home care services that would need to be completed within the last five days of her 60-day certification period 3/5/25 to 3/9/26, however no visit was completed. This had a potential for discharge of the patient from home care services as P4 would not have the required physician orders for services when her certification period ended on 3/9/26. Review of P4’s EHR failed to include documentation to P4’s physician to notify a SNV for recertification for home care services had been missed. During interview on 3/11/26 at 12:08 p.m., the director of nursing (DON) stated she was aware P4 did not receive her scheduled nurse visit. P4’s primary nurse was on vacation and P4 would not allow another nurse to make the visit. DON stated normally she expected a skilled nurse visit (SNV) within the five days required time frame for recertification for continued home care services. A visit was planned when P4’s primary nurse returned from vacation. P4’s medical record lacked documentation the physician had been notified of the missed visit and there should have been notification to P4’s physician the visit had not been completed. The agency policy Missed Visit Documentation dated 9/11/24, identified notification was required to be sent to the ordering provider when visits were not performed per order. Notification of the visit must include the clinical impact of the missed services or treatment.”

“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 interview and document review, the agency failed to maintain a clinical record that contained current information for every patient receiving home health services for 2 of 17 patients (P6, P14) whose records were reviewed. Findings include: P6 P6’s plan of care (POC) 3/3/26 to 5/1/26, identified a start of care date 3/3/26. Services included skilled nurse visits (SNV) two times per week for one week, one time per week for one week and two times per week for seven weeks for various assessments, teaching and health care coordination. Diagnoses included hypertension (high blood pressure), encounter for attention to colostomy, and chronic obstructive pulmonary disease. P6’s POC listed P6’s code status (a medical instruction that identified to healthcare providers what emergency interventions a patient would want if their breathing and heart stopped) as a full code (the patient wants all life saving measures, including cardiopulmonary resuscitation (CPR). P6’s Service Plan dated 3/27/26, identified P6 had completed a POLST form to identify his wishes for code status. P6’s POLST was not located during record review. During interview on 3/11/26 at 9:00 a.m., the director of nursing (DON) stated she was unable to locate a completed POLST form scanned into P6’s medical record but would continue looking. On 3/11/26 at 10:30 a.m. a copy of P6’s POLST was provided. The POLST identified P6 wanted a full code (CPR) and was signed by P6 on 3/27/26. During interview on 3/11/26 at 10:33 a.m., the DON stated she had found the POLST P6 had completed on admission. It was in a pile of paperwork in one of the branch offices. The form should have been scanned into P6’s medical record and she had instructed the branch office they needed to scan in the document as soon as possible. P14 P14’s POC 1/14/26 to 3/14/26, identified a SOC date 1/14/26. Services included SNV one time per week for eight weeks for various assessments, medication management and teaching. Physical therapy was ordered one time per week for six weeks for for treatment with gait, transfers, mobility and balance. Occupational therapy was ordered one time per week for one week to increase P14’s independence with activities of daily living (ADLs). Diagnoses included fracture of left femur, bipolar disorder, anxiety disorder, malnutrition and history of falls. The POC identified P14’s code status was a DNR (the patient does not want CPR or life saving measures initiated). P14’s Service Plan dated 1/14/26, identified P14 had completed a POLST form to identify his wishes for code status. P14’s POLST was not located during record review. During interview on 3/11/26 at 2:30 p.m., the DON stated she was unable to locate P14’s POLST form in his medical record. There was no POLST on file that she could find or any documentation of which code status P14 had identified. The DON expected, when a patient identified they had a POLST, the agency staff would obtain that POLST for the patient’s medical record or have them complete a new one. The DON stated P14’s Service Plan on admission identified a POLST was on file at another health care facility but upon review of the indicated chart, DON was unable to find one. The admission nurse should have asked P14 to complete a new POLST on admission. On 3/11/26 at 2:30 p.m., a copy of P14’s POLST was provided. The POLST identified P14 wanted a DNR and was signed by P14 on 1/14/26. During interview on 3/11/26 at 2:33 p.m., the DON stated she had found the POLST P14 had completed on admission. It should have been scanned into his home health medical record, and it had not been. It was important the patient’s POLST was scanned into the medical record as soon as possible to show it was addressed with the patient and correctly identified the patient wishes for code status. The agency policy Uniform Code Level Directive for CPR dated 2/24/25, directed staff if a patient chose a code level 2 (DNR) code status, staff would provide a photocopy of the advanced directives to the patient. The original copy of the form would be retained on the patient’s medical record at the clinic or the hospital. If no copy was available from the client, the clinic or hospital would be requested to send a copy.”