Bjc Home Care Services

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on policy review, clinical record review, hospital record review, and interviews, the home health provider failed to promptly alert the physician of changes in the patient’s condition that suggested the plan of care may need to be altered in, one of three patients sampled (Record/Patient #1). This deficient practice had the potential to affect all patients receiving services from the provider who experienced significant changes in condition. Findings included: Review of the provider’s policy titled, “Care Planning Process-Provision of Care Treatment and Service/Home Health,” revised November 2020, showed in part, clinicians were required to inform the physician of changes suggesting a need to alter the plan of care. Review of the provider’s policy titled, “Reassessments/Recertification-Provision of Care Treatment and Service/Home Health,” revised April 2019, showed in part, the physician was to be notified when the patient’s condition deteriorated, or a significant change occurred. RECORD/PATIENT #1: Review of the clinical record showed the patient required management of an indwelling urethral Foley catheter (a sterile tube placed in the bladder to drain urine). Physician orders directed staff to change the catheter monthly and as needed for leakage, obstruction, or dislodgement using a 16 French (thickness of the catheter) catheter with a 5-10 milliliter balloon. The catheter could be irrigated with 60-120 milliliters of sterile saline as needed for obstruction or sediment. Review of the skilled nursing visit dated 10/29/2025 at 9:50 AM showed a registered nurse changed the urinary catheter using sterile technique. The nurse documented that the patient tolerated the procedure without observed pain and that yellow urine returned to the drainage bag. Review of a telephone encounter dated 10/29/2025 at 5:36 PM, showed the patient’s caregiver reported that the catheter had been changed that day and that there was “a lot of blood” in the patient’s urine. The caregiver asked whether the patient’s blood-thinning medications should be withheld. The telephone record showed a nurse returned the call on 10/29/2025 at 5:41 PM and instructed the caregiver to contact the patient’s physician to obtain an order regarding the blood-thinning medications. The caregiver stated that he/she would contact the patient’s cardiologist. The charge nurse was notified by e-mail. The clinical record contained no evidence that the provider staff: - Promptly notify the physician of the significant hematuria (presence of blood in the urine) following the catheter change; or - Obtained physician-directed instructions regarding evaluation or management of the hematuria. The clinical record contained no physician order directing that the blood thinning medications be withheld and no documentation showing whether the medications were withheld. Review of telephone documentation dated 11/07/2025 at 5:07 PM showed the caregiver reported that the Foley catheter was leaking urine, stated something was wrong with it, and reported the caregiver had previously requested a nursing visit but had not received information regarding the plan. Review of an unscheduled licensed practical nurse (LPN) visit dated 11/07/2025 at 5:35 PM showed the Foley catheter was replaced. The record documented yellow urine with sediment and “stones” and described the catheter as draining, intact, and patent following the intervention. The clinical record contained no evidence that the physician was notified of the recurrent catheter complication or catheter replacement on 11/07/2025. Review of the telephone documentation dated 11/15/2025 at 3:28 PM showed the caregiver reported decreased urinary output, concern that the Foley catheter was blocked, and several blood clots following irrigation. Review of the on-call nursing visit dated 11/15/2025 at 4:04 PM, showed the Foley catheter was not draining. The nurse removed the catheter and observed bleeding from the penis. Following placement of a new catheter, the nurse observed bright red urine and blood clots. The nurse notified the physician and called 911 when the bleeding did not completely stop. The patient was transported to the emergency department. Review of the emergency department documentation dated 11/15/2025 and 11/16/2025, showed the patient presented with gross hematuria, blood clots, and decreased urinary output and required hospital admission. During an interview on 07/15/2026 at 11:53 AM, the RN case manager stated that the physician was not notified of the catheter complication on 11/07/2025. The RN case manager further stated that, based on the reported catheter leakage and concern that something was wrong with the catheter, the patient should have been referred to emergency evaluation. During an interview on 07/15/2026 at 12:08 PM, the clinical manager stated that the clinical record contained no documentation showing that the physician was notified of the significant hematuria reported on 10/29/2025 or that an order was obtained to hold or discontinue the patient’s blood-thinning medications. The clinical manager stated that the caregiver had called the provider to report that the patient was bleeding and to ask whether the blood-thinning medications should be withheld. The clinical manager confirmed the provider’s staff did not notify the physician.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to ensure the individualized plan of care was reviewed and revised to reflect significant and recurring catheter-related changes in condition in, one of three sampled patients (Record/Patient #1). This deficient practice had the potential to affect patients receiving services from the provider whose changes in condition or care needs were not reflected in the individualized plan of care. Findings included: Review of the provider’s policy titled, “Care Planning Process-Provision of Care Treatment and Service/Home Health,” revised November 2020, showed in part: - The plan of care was to be revised as frequently as necessary based on ongoing assessments; - Care planning decisions were to be reflected in the specific services and actions implemented to meet the patient’s individualized problems and goals; and - Problems and needs related to the patient’s condition were to be included in the plan of care. Review of the provider’s policy titled, “Reassessments/Recertification-Provision of Care Treatment and Service/Home Health,” revised April 2019, showed in part, patients were to be reassessed when they were not responding to care, when their condition deteriorated, or when a significant change occurred. The policy required the clinical record and plan of care to be updated to reflect assessment findings and actions taken. RECORD/PATIENT #1: Review of the clinical record showed the patient required management of an indwelling urinary urethral Foley catheter (a sterile tube placed in the bladder to drain urine) due to urinary retention and neurogenic bladder (lower urinary tract dysfunction). The physician orders directed provider staff to change the catheter monthly and as needed for leakage, obstruction, or dislodgement using a 16 French (thickness of the catheter) catheter with a 5-10 milliliter balloon. The catheter could be irrigated with 60-120 milliliters of sterile saline as needed for obstruction or sediment. Review of the skilled nursing visit dated 10/29/2025 at 9:50 AM, showed a registered nurse (RN) changed the Foley catheter. The nurse documented that the patient tolerated the procedure without observed pain and that yellow urine returned to the drainage bag. Review of a telephone encounter dated 10/29/2025 at 5:36 PM, showed the caregiver reported that the catheter had been changed that day and that there was “a lot of blood” in the patient’s urine. Review of telephone records dated 11/07/2025 at 5:07 PM, showed the caregiver reported that the catheter was leaking urine, stated that something was wrong with it, and reported that he/she had previously requested a nursing visit. Review of an unscheduled licensed practical nurse (LPN) visit dated 11/07/2025 at 5:35 PM, showed the Foley catheter was replaced. The record documented yellow urine with sediment and “stones” and described the catheter as draining, intact, and patent following the intervention. Review of a skilled nursing visit dated 11/13/2025 at 10:34 AM, showed the catheter placed on 11/07/2025 was documented as draining, intact, and patent, with yellow urine. Review of the telephone documentation dated 11/15/2025 at 3:28 PM, showed the caregiver reported decreased urine output, concern that the patient did not appear to be producing urine, and that the Foley catheter might be blocked. The caregiver reported he/she had irrigated the catheter, the irrigation amount returned, and several blood clots were expelled. Review of the on-call nursing visit dated 11/15/2025 at 4:04 PM, showed the Foley catheter was not draining. The nurse removed the catheter and observed bleeding from the penis. Following placement of a new catheter, the nurse observed bright-red urine and blood clots. The patient was transported to the emergency department and subsequently admitted to the hospital. Despite the catheter-related changes in condition documented on 10/29/2025 and 11/07/2025, the clinical record contained no evidence that provider staff reviewed and revised the individualized plan of care to reflect: - Significant hematuria (blood in the urine) following a catheter change; - Recurrent catheter leakage; - The need for an unscheduled catheter replacement; - Increased risk for catheter obstruction, bleeding, or catheter-related trauma; - Whether additional monitoring or follow-up was needed; - Whether instructions concerning emergency evaluation needed to be revised; or - Whether physician direction was needed to revise the catheter-management approach. The plan of care continued to contain the existing routine and as-needed catheter-change and irrigation instructions without revisions addressing the recurring catheter complications. During an interview on 07/15/2026 at 12:08 PM, the clinical manager stated that the plan of care was not updated following the catheter-related changes in condition.”

“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 policy review, record review, and interview, the home health provider failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, in but not limited to, one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: RECORD/PATIENT #2: Review of the referral information, showed, in part: - Referral for home health services was sent to the home health provider on 03/13/2025; - Date to start labs: 03/14/2025; - Requested 24-48 hours; - Disciplines: Skilled nurse (SN), Physical therapy (PT), and Occupational therapy (OT); and - Skilled interventions: disease and medication management, and labs. Review of the clinical record showed, in part: - SOC (start of care) was dated 03/16/2025; - OASIS (Outcome and Assessment Information Set- is a standardized data set that measures quality and outcomes) question M0102 (Physician ordered start of care date), was answered with N/A- No specific SOC/ROC (resumption of care) date ordered by the physician; - OASIS question M0104 (Date of Referral), was answered with 03/13/2025; and - The clinical record failed to show documentation of the reason the SOC was late and no documentation of verbal order being received for late SOC within 48 (forty-eight) hours of the referral and/or the patient returning home. During an interview on 04/17/2025, at 12:43 PM, the administrator stated that she would expect the SOC to be done within 48 hours of the referral. Findings included: Review of the provider’s policy titled, “Admission And Comprehensive Assessment – Provision of Care Treatment And Service,” last revised April 2021, showed in part an initial patient assessment will be performed and documented in the patient’s clinical record by a registered nurse, physical therapist, or speech therapist on all patients referred. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patients return home, on the start of care (SOC) date ordered by the physician, or at the patient/family request with the approval of the physician.”

“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 policy review, record review, and interview, the home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s current health status including relevant past medical history in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Admission and Comprehensive Assessment- Provision of Care Treatment and Service/Home Health,” revised April 2021, showed in part: - During the initial and comprehensive patient assessments, all baseline data to be used in measuring the patient’s progress towards goals and other relevant information will be documented in the patient’s clinical record, including at least the following information, if applicable: * The patient’s medical and psychosocial history, including pertinent diagnosis and prognosis * Equipment presently in the home and potentially needed by a patient; and - Information gathered during the initial and comprehensive assessments will be used by the physician and developing and authorizing the plan of care. RECORD/PATIENT #1: Review of the inpatient hospital discharge summary, dated 02/01/2025, showed in part: - The pt (patient) had a fall in November of 2024 that resulted in a cervical fracture (broken neck) and (he/she) was placed in a cervical collar (c-collar - a neck brace); - The patient was admitted to the hospital on 01/22/2025 with “uncontrolled pain and an inability to wear (his/her) CPAP (continuous positive airway pressure- is a machine that delivers continuous air through the mouth and nose to keep the airway open while sleeping) while wearing the collar resulting in increased sleepiness”; - The past medical history (PMH) included a diagnosis of obstructive sleep apnea (a condition where breathing repeatedly stops and starts during sleep due to a blockage in the upper airway) that required the use of a CPAP and a history of deep vein thrombosis (DVT, a blood clot in a deep vein) of the lower extremity; - “Previously on Eliquis (a medication used to prevent blood clots) as OP which was d/c during recent admission”; - “Pt is not taking aspirin”; - “Cervical collar no longer required, but because of disuse and MSK injury/tightness, pain was ongoing while it was off. OK to wear the brace as needed especially when OOB and upright, but take off at night so (he/she) can use (his/her) CPAP”; and - Aspirin and Eliquis were not listed on the discharge medication list. Review of the clinical record, showed in part: - The patient was admitted to home health services on 02/02/2025 with primary diagnosis of stable burst fracture of first cervical vertebra (occurs when a vertebra breaks in multiple directions); and - The patient resided at home alone. Review of the OASIS (Outcome and Assessment Information Set; a standardized data collection tool) SOC (start of care) visit note dated 02/02/2025, showed in part: - The high-risk medication assessment section showed, in part: Anticoagulant use was answered with “Yes;” (The referral record showed that the Eliquis was discontinued during a recent admission and was not listed on the hospital discharge medication list); - The comprehensive assessment failed to show documentation of the patient’s health status related to the discontinuation of Eliquis; - Special treatments, procedures, and programs section showed, in part: CPAP use was answered with “No” (The referral record showed that the patient was to take the cervical collar off at night to wear his/her CPAP machine while sleeping); and - The comprehensive assessment failed to show documentation of the patient’s health/functional status with sleepiness and taking off the cervical collar at night to wear CPAP machine. During an interview on 04/16/2025 that began at 2:30 PM, the administrator stated that: - The patient had a BiPAP (Bilevel Positive Airway Pressure- is a machine that pushes air into the lungs through a mask) but couldn’t use it with the c-collar; - During the patient’s hospitalization the patient was cleared to take the c-collar off at night to wear the BiPAP while sleeping; - The patient continued to wear the c-collar at all times and not take it off at night to wear the BiPap; and - The patient wanted to wear the c-collar at all times and reported that (he/she) did not need the BiPAP.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the comprehensive assessment included the names of other agencies and persons involved in the past and present care of the patient in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Admission and Comprehensive Assessment,” showed that the comprehensive assessment would include the name of the hospital, other agencies, and persons involved in the past and present care of the patient. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/03/2023. The patient was recertified on 02/21/2025 with a primary diagnosis of pressure ulcer (skin injury caused by unrelieved pressure) of the left ankle. The patient had secondary diagnoses of paraplegia (paralysis in the lower limbs and trunk), emphysema (a lung disease that blocks airflow and makes it difficult to breathe), peripheral vascular disease (a condition where blood flow to the limbs is reduced due to narrowed or blocked veins), and neuromuscular dysfunction of the bladder (a disorder of the bladder caused by nerve damage which limits urine flow). The patient resided in his/her own home with the assistance of family. Review of the nursing recertification, comprehensive visit documentation, dated 02/19/2025, showed in part that the patient had a suprapubic catheter (a catheter surgically inserted through the wall of the abdomen into the bladder) that was inserted on 01/31/2025. The catheter was due to be changed on 02/25/2025. Review of the document titled, “Home Health Recertification,” dated 02/21/2025, showed in part that the suprapubic catheter was changed every month at the urologist’s office and PRN (as needed) if leaking, clogged or dislodged. During an interview on 04/16/2025 at 4:15 PM, the administrator stated that: - The comprehensive assessment did not identify that a urologist routinely changed the patient’s catheter; - The plan of care contained information that the catheter was changed at the urologist’s office; and - Neither document identified the name nor contact information of the urologist involved in the patient’s care.”

“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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure staff performed a complete medication review in three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 03/20/2025 with a primary diagnosis of cellulitis (a bacterial infection of the skin) of the right lower limb. The patient had a secondary diagnosis of chronic venous insufficiency (a condition where blood flow to the limbs was reduced due to narrowed or blocked veins). The patient resided in a private residence with the assistance of his/her spouse and adult child. Review of the nursing visit notes showed the patient had received nursing visits on, but not limited to, 04/08/2025 and 04/11/2025. Observation and interview on 04/15/2025 at 11:00 AM showed the patient was taking trimethoprim/sulfamethoxazole ((Tri/Sulfa) an antibiotic used to treat bacterial infections). During the medication review, the patient stated that he/she: - Was prescribed Tri/Sulfa following his/her physician appointment on 04/07/2025; - Began taking the medication the morning of 04/08/2025; - Had taken a dose of the new medication prior to his/her nursing visit on 04/08/2025; and - Had been taking the medication two times per day since 04/08/2025. Review of the provider’s current medication profile provided to the state agent (SA) prior to the home visit observation showed the document failed to include Tri/Sulfa. Review of the document titled, “Home Health Initial Plan of Care,” with effective dates of 03/20/2025 to 05/18/2025, showed the document failed to contain orders for Tri/Sulfa. During an interview on 04/16/2025 at 1:10 PM, the administrator stated that: - There were nursing visits on 04/08/2025 and 04/11/2025; - The nurse did enter Tri/Sulfa to the patient’s medication profile after the observation visit with the surveyor on 04/15/2025; and - They would have expected the medication Tri/Sulfa to be placed on the patient’s medication profile at the nursing visits dated 04/08/2025 or 04/11/2025. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the home health provider on 3/16/2025 after an inpatient hospital stay for primary diagnosis of subarachnoid hemorrhage (a life-threatening type of stroke where bleeding occurs in the space between the brain and the thin tissues covering it) and the patient resided at home alone with a caregiver checking on him/her. The patient received skilled nursing, physical therapy, and occupational therapy services. Observation on 4/15/2025 at 11:03 AM, during the patient’s home visit, showed the following: - The skilled nurse asked the patient if there had been any medication changes. The patient verbalized there had been no changes; - The state surveyor reviewed the provider’s Medication Profile form with the skilled nurse, along with the patient present, with the following discrepancies; * Cetirizine (antihistamine) 10 milligrams (mg) take 5 mg by mouth daily as needed. The medication bottle showed to take daily. The patient stated he/she takes one daily; * Cholecalciferol (Vitamin D-3) 2000 unit capsule take one capsule by mouth daily. The patient stated he/she is not taking because he/she never got it; * Glucagon (hyperglycemic agent to treat severe low blood sugar) 1 mg kit inject 1 mg into the muscle once as directed for low blood sugar. The medication failed to be available in the patient’s home. He/she does not know where it is and drinks milk or eats candy if blood sugar is low; * Insulin aspart niacinamide (FIASP) (rapid-acting insulin) 100 unit/3 milliliters (ml) pen for injection inject 2 units under the skin three times a day before meals. The patient stated he/she is not taking and uses Novolog insulin; * Insulin glargine (Lantus semglee) (long-acting insulin) 100 unit/ml vial for injection inject 5 units under the skin nightly. The patient stated he/she injects 6 units nightly; * NovoLog (rapid-acting insulin) 5 units three times a day. The medication failed to be on the provider’s list. The patient stated he/she has been taking for about one month and on his/her second pen; * Levothyroxine (used to treat hypothyroidism) 88 micrograms (mcg) one daily. The medication failed to be on the provider’s list. The bottle was filled on 3/28/2025); * Hair, Skin & Nails vitamins (gummies) two daily. The medication failed to be on the provider’s list. The patient stated he/she had been taking them for a couple weeks; and * CBD gummies (used for sleep and pain) nightly. The medication failed to be on the provider’s list. The patient stated he/she had been taking for a couple weeks since his/her last hospital stay. (The SN made a call to the physician for medication clarifications during the home visit) During an interview on 04/15/2025 at 1:05 PM, RN A stated medications are to be reviewed at each visit. During an interview on 04/17/2025 at 12:45 PM, the administrator stated she expects the case manager or designee to reconcile medications at each visit. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 02/02/2025 with primary diagnosis of stable burst fracture of first cervical vertebra (occurs when a vertebra breaks in multiple directions); and - The patient resided at home alone. Review of the referral record, dated 02/01/2025, showed the discharge medication list that included Naloxone (Commonly known as Narcan- a medication that rapidly reverses an opioid overdose) 4mg/actuation spray, non-aersol, administer 1 spray into affected nostril(s) as needed for opioid reversal or respiratory depression. Call 911. Administer a single spray in one nostril. Repeat every 3 minutes as needed if no or minimal response. Review of the plan of care medication profile dated 02/02/2025 to 04/02/2025, failed to show Naloxone listed. Review of the clinical record failed to show documentation of the medication discrepancy being reported to the physician. Review of an office visit summary with the patient’s physician on 04/08/2025, showed, in part: - A list of the patient’s current outpatient medications; and - Naloxone, 1 spray, nasal, PRN (as needed) was listed. Review of the clinical record failed to show the plan of care/medication profile were updated to include the Naloxone. During an interview on 04/16/2025 that began at 2:30 PM, the administrator stated that: - The Naloxone was not on the patient’s medication profile because the patient did not have the medication in the home; - The Naloxone was ordered during the previous hospital admission; - When the patient was discharged from the hospital the medication was not discontinued when the discharge orders were being entered; - It was possible that the hospital physician did not complete the discharge medication reconciliation correctly and that resulted in the Naloxone being listed on the patient’s discharge medication list; - There was no documentation that the patient’s physician was notified of the medication being listed and the patient not having it in the home; and - He/she would notify the physician about the medication and report that the patient does not have it.”

“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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure the individualized plan of care (POC) included all pertinent interventions and treatment orders, in two of five full records reviewed (Record/Patient #1 and #2). This deficient practice has the potential to affect the coordination of care and services for all the patients on service with the provider. Findings included: Review of the provider’s policy titled, “Care Planning Process – Provision of Care Treatment And Service,” last revised November 2020, showed in part: - The plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient; - The care planning process will be documented on the plan of care; - At the initial assessment, the clinician along with the physician and other involved disciplines, will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family or caregiver; - All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including, but not limited to: * Individualized patient needs, and resultant problems related to care functional status and family caregiver support systems; * Changes in patient’s condition; * Clinical drug monitoring; - Based on the assessment and conclusions, the plan of care will include, but not be limited to: * Patient specific interventions and education; * All patient care orders from all physicians involved in the plan of care including verbal orders; * Identified patient problems and needs, including functional limitations, activities permitted, nutritional requirements; * Specific services and treatments to be provided; * Actions to be taken to meet the patient’s goals; * Equipment and supplies; * Patient and caregiver education and training to facilitate timely discharge; and - The plan of care will be revised as frequently as deemed necessary by the clinician, based on the ongoing assessments of the patient. RECORD/PATIENT #1: RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 03/16/2025 with primary diagnosis of subarachnoid hemorrhage (a life-threatening type of stroke where bleeding occurs in the space between the brain and the thin tissues covering it); and - The patient resided at home alone and a caregiver checking on him/her. Review of the skilled nurse (SN) OASIS (Outcome and Assessment Information Set; a standardized data collection tool) resumption of care dated 04/07/205, showed in part: - Immobilized digits 2 and 3 of right hand since recent diagnosis of phalanx fracture 2nd digit; - Surgery scheduled April 17,2025; - OT educated patient on new precautions for right hand after new diagnosis of 2nd digit fracture; and - Index finger fracture right February (mid-February) 2025. Review of the occupational therapy (OT) reassessment dated 04/08/205, showed in part: - Immobilized digits 2 and 3 of right hand since recent diagnosis of phalanx fracture 2nd digit; - Surgery scheduled April 17, 2025; - OT educated patient on new precautions for right hand after new diagnosis of 2nd digit fracture; and - Index finger fracture right February (mid-February) 2025. Review of the physical therapy (PT) reassessment dated 04/09/205, showed in part: - The patient reported increased difficulty transferring from lower surfaces due to unable to use right hand; - PT instructed patient to have assist with mobility due to decreased use of right upper extremity (UE); and - The patient has an appointment with orthopedic for right finger fracture 04/17/2025. Review of the home health resumption plan of care dated 04/07/2025 to 04/14/2025, last updated 04/14/2025, failed to show the right-hand fracture. Observation and interview on 04/15/2025 at 11:03 AM, with Registered Nurse (RN) A, showed: - The patient had an ace wrap bandage wrapped around the hand, fingers and wrist area of his/her right hand; - The patient reported he/she had a fractured right finger and an appointment with the orthopedic doctor on 04/17/2025; and - The POC failed to show documentation of the fractured right-hand finger. During an interview on 04/17/2025 at 12:47 PM, the Administrator stated that: - The provider was not providing treatment directly for the fractured right hand digit so it was just in the notes and not on the POC; and - She would expect to see it on the POC. Findings included: Review of the provider’s policy titled, “Care Planning Process- Provision of Care Treatment and Service/Home Health,” revised November 2020, showed in part: - Based on the assessment and conclusions, the plan of care will include, but not be limited to: * Patient specific interventions and education * Equipment and supplies; and - The plan of care will be based upon the physician’s (or authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 02/02/2025 with primary diagnosis of stable burst fracture of first cervical vertebra (occurs when a vertebra breaks in multiple directions); and - The patient resided at home alone. Review of the inpatient discharge summary, dated 02/01/2025, showed in part: - The pt (patient) had a fall in November of 2024 that resulted in a cervical fracture (broken neck) and (he/she) was placed in a cervical collar (neck brace); - The patient was admitted to the hospital on 01/22/2025 with “uncontrolled pain and an inability to wear (his/her) CPAP (continuous positive airway pressure- is a machine that delivers continuous air through the mouth and nose to keep the airway open while sleeping) while wearing the collar resulting in increased sleepiness;” - The PMH (past medical history) included a diagnosis of obstructive sleep apnea (a condition where breathing repeatedly stops and starts during sleep due to a blockage in the upper airway) that required the use of a CPAP and a history of DVT (deep vein thrombosis- is a blood clot in a deep vein) of the lower extremity; - “Previously on Eliquis as OP which was d/c during recent admission;” - “Pt is not taking aspirin;” - “Cervical collar no longer required, but because of disuse and MSK injury/tightness, pain was ongoing while it was off. OK to wear the brace as needed especially when OOB and upright, but take off at night so (he/she) can use (his/her) CPAP;” - Ambulatory referral to home health showed a primary reason of: Pt (patient) with neck fracture, freq (frequent) fall history, BLE (bilateral lower extremity) edema and disciplines to evaluate and treat showed PT (physical therapy) and OT (occupational therapy); and - The discharge Medication list failed show Eliquis (an anticoagulant medication that helps prevent blood clots) and Aspirin (a nonsteroid anti-inflammatory medication used to treat pain, fever, or inflammation. It can also be used to treat or prevent heart attacks, strokes, and chest pain). Review of the POC dated 02/02/2025 to 04/02/2025, showed in part: - The DME (durable medical equipment) failed to show a CPAP machine listed - The POC failed to show CPAP orders/interventions; - BLE edema was listed as a problem on the referral record and the POC failed to show interventions for edema; - Impaired UE (upper extremity) function and/or fine motor skills: Intervention of splint/brace; OT to instruct patient/caregiver in wearing schedule of splint/brace on neck, ensure proper fit to decrease skin breakdown in 6 (six) weeks. (The interventions failed to show what the brace schedule was); - Impaired functional mobility/balance transfer training: PT to instruct patient/caregiver and perform transfer training (The intervention failed to show how the patient/caregiver was to perform transfers); - The POC medication section showed Eliquis and Aspirin listed but failed to show interventions/instructions for anticoagulant use; - Fall precautions/safety concerns: Fall precautions and general safety; Skilled disciplines to instruct patient to use proper lighting in all areas, stand/sit up slowly, use appropriate footwear when walking, use proper assistive devices, and to keep pathways clear of cords and clutter to prevent falls. Remove secure throw regs. Educate patient on medications and disease processes that increase fall risk, using corrective lenses as prescribed, placing hard to reach items within reach, what to do in the event of a fall and to report any falls to the home health agency; and - The POC failed to show what medications increased the risk for falls and/or what patient-specific education was to be provided. During an interview on 04/16/2025 that began at 2:30 PM, the administrator stated that: - The patient had a BiPap (Bilevel Positive Airway Pressure- is a machine that pushes air into the lungs through a mask) but couldn’t use it with the c-collar (cervical collar); - During the patient’s hospitalization the patient was cleared to take the c-collar off at night to wear the Bipap while sleeping but the patient chose to continue to wear the c-collar at all times; - Therapy used a gait belt for fall precautions when the patient ambulated; and - The patient’s mother walked behind the patient with the wheelchair for fall precautions when the patient ambulated.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the physician was promptly notified of changes in the patient’s condition or needs that suggest that the plan of care should be altered in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Care Planning Process,” showed in part that clinicians would inform the patient’s physician of any changes that suggest a need to alter the plan of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 03/20/2025 with a primary diagnosis of cellulitis (a bacterial skin infection) of the right lower limb. The patient had a secondary diagnosis of chronic venous insufficiency (a condition where blood flow to the limbs is reduced due to narrowed or blocked veins). The patient resided in a private residence with the assistance of his/her spouse and adult child. Review of the document titled, “Home Health Initial Plan of Care,” dated 03/20/2025, showed in part that the patient was to use alcohol wipes between his/her toes daily. Review of nursing visit documentation showed that: - On 03/20/2025, the patient and spouse were instructed to use alcohol wipes between his/her toes daily; and - On 03/24/2025, 03/27/2025, 04/04/2025, 04/08/2025, and 04/11/2025, the intervention note showed the clinician observed or performed wound care per physician’s order, dated 03/20/2025. Per interview conducted during a home visit observation on 04/15/2025 beginning at 11:00 AM, the patient stated that he/she had not been using alcohol wipes between his/her toes since he/she was discharged from the hospital. He/she stated that the alcohol wipes caused stinging and pain when applied between his/her toes. During an interview on 04/16/2025 at 1:10 PM, the administrator stated that: - There was no documentation prior to 04/15/2025 showing that the patient was experiencing pain with his/her wound care; - On 04/15/2025, the nurse notified the physician that the patient was not using alcohol pads between his/her toes during the wound care procedure; and - They would have expected the clinicians to notify the physician of the patient’s report of discomfort during the wound care procedure prior to the nursing visit performed 04/15/2025.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to assure coordination of care to meet the needs of the patient when the provider failed to verify discrepancies and/or orders in the referral record in, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Admission and Comprehensive Assessment- Provision of Care Treatment and Service/Home Health,” revised April 2021, showed in part: - Coordinate communication with all physicians involved in the plan of care; - Integrate orders from all physicians involved in the plan of care so that all services and interventions are coordinated; and - Coordination of care delivery to meet the patient’s needs, and involve the patient, representative, and caregivers, as appropriate, in the coordination of care activities. Review of the provider’s policy titled, “Verification of Physician Orders - Provision of Care Treatment and Service/Home Health,” revised November 2020, showed all orders and prescriptions will be reviewed for appropriateness and accuracy before providing care, treatment, or services. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 02/02/2025 with primary diagnosis of stable burst fracture of first cervical vertebra (occurs when a vertebra breaks in multiple directions); and - The patient resided at home alone. Review of the referral record dated 02/01/2025, showed in part: - The past medical history (PMH) included a diagnosis of obstructive sleep apnea (a condition where breathing repeatedly stops and starts during sleep due to a blockage in the upper airway) that required the use of a continuous positive airway pressure (CPAP, a machine that delivers continuous air through the mouth and nose to keep the airway open while sleeping) and a history of deep vein thrombosis DVT, a blood clot in a deep vein) of the lower extremity; - “Previously on Eliquis (an anticoagulant medication used to prevent blood clots) as OP which was d/c during recent admission”; - “Pt is not taking aspirin”; and - Eliquis and aspirin (a non-steroid anti-inflammatory medication used to treat pain, fever, or inflammation. It can also be used to treat or prevent heart attacks, strokes, and chest pain) were not listed on the discharge medication list. Review of the plan of care (POC) dated 02/02/2025 to 04/02/2025, showed in part: - Aspirin 81 milligrams (mg) enteric coated tablet, take one by mouth daily and the start and end dates were left blank (The clinical record failed to show documentation and/or orders that the physician was notified that this was not on the discharge medication list and orders received to restart the aspirin after the hospitalization); - Apixaban (Eliquis) 5mg tablet, take one tablet by mouth two times a day and the start and end dates were left blank; and - The clinical record failed to show documentation of coordination of care with the physician regarding the Eliquis and aspirin not being on the discharge medication list. The inpatient discharge summary showed the patient was not taking aspirin, the Eliquis was discontinued during the recent hospitalization, and clarification/confirmation was not received for the patient to take the medications. Review of an office visit summary with the patient’s physician on 04/08/2025, showed, in part: - A diagnosis of nocturnal hypoxia (a condition where blood oxygen levels drop during sleep) and the treatment plan was “on overnight O2 (oxygen)”; - “Needs home O2. Unable to wear BIPAP (BiPAP - bi-level positive airway pressure, a device that pushes air into the lungs through a mask)”; and - Naloxone (a medication that rapidly reverses an opioid overdose), one spray nasal, as needed (PRN) was listed for current outpatient medications (The clinical record failed to show the naloxone listed on the patient’s medication profile and/or coordination of care with the physician to clarify/confirm if the patient was to have the naloxone PRN). Review of the clinical record failed to show documentation that the patient received the oxygen and/or a follow-up to ensure that the patient was wearing oxygen at night as ordered by the physician. During an interview on 04/16/2025 that began at 2:30 PM, the administrator stated that: - The naloxone was not on the patient’s medication profile because the patient did not have the medication in the home; - There was no documentation that the patient’s physician was notified of the medication being listed and the patient not having it in the home; - He/she would notify the physician about the medication and report that the patient did not have it; - He/she was unaware that the physician ordered oxygen for the patient; - The patient had a BiPAP but couldn’t use it with the cervical collar (c-collar, a neck brace); - During the patient’s hospitalization the patient was cleared to take the c-collar off at night to wear the BiPAP while sleeping; - The patient wanted to wear the c-collar at all times and reported that (he/she) did not need the BiPAP; and - There was no documentation of the physician being notified that the patient was not wearing the BiPAP or the oxygen at night.”