Fv at Home By Friendship Village

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on review of personnel files and interview, the home health provider failed to ensure emergency preparedness (EP) training was completed on hire and/or annually in five of five personnel records reviewed (Employees #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: EMPLOYEE #1: Review of Employee #1’s personnel file showed in part: - The employee’s position was physical therapy assistant; - Orientation in-service training took place on 07/12/2021; and - The personnel file failed to contain evidence that EP training was completed upon hire and every two years. EMPLOYEE #2: Review of Employee #2’s personnel file showed in part: - The employee’s position was occupational therapist; - Orientation in-service training took place on 10/04/2021; and - The personnel file failed to contain evidence that EP training was completed upon hire and every two years. EMPLOYEE #3: Review of Employee #3’s personnel file showed in part: - The employee’s position was registered nurse; - Orientation in-service training took place on 02/08/2024; and - The personnel file failed to contain evidence that EP training was completed upon hire. EMPLOYEE #4: Review of Employee #4’s personnel file showed in part: - The employee’s position was licensed practical nurse; - Orientation in-service training took place on 10/03/2024; and - The personnel file failed to contain evidence that EP training was completed upon hire. EMPLOYEE #5: Review of Employee #5’s personnel file showed in part: - The employee’s position was medical social worker; - Orientation in-service training took place on 10/02/2025; and - The personnel file failed to contain evidence that EP training was completed upon hire. During an interview on 12/03/2025 at 3:20 PM, the business office manager stated that: - They did not have a policy specifically stating that staff would receive EP training upon hire and every two years; - They had an orientation itinerary that contained an EP module; -They expected employees to receive EP training upon hire and every two years; and - They were unable to provide evidence that Employee #1, #2, #3, #4, and #5 had received EP training upon hire or every two years.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the OASIS (Outcome and Assessment Information Set) data accurately reflected the patient’s status at the time of assessment in one of five records reviewed (Record/Patient #3). This deficient practice has the potential to affect the reporting of OASIS data for all the provider’s patients. Findings included: Review of the provider’s policy titled, “OASIS Data Transmission,” revised 06/2022, showed in part, that the encoded OASIS data must accurately reflect the patient’s status at the time of assessment. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of laceration (cut) of the right hand. The patient had a history of urinary tract infections (UTIs). Review of the OASIS Start of Care comprehensive assessment documentation, dated 11/18/2025, showed in part that: - The clinician completed OASIS items that showed: * Item M1400: When is the patient dyspneic (short of breath) or noticeably short of breath: This was marked as 2 (two) – with moderate exertion; and * Item M1600: Has this patient been treated for a UTI in the past 14 days? This was marked as no; - The visit note failed to contain documentation of a respiratory assessment that included assessment of the patient’s dyspnea; and - The patient had taken Macrobid (an antibiotic) for UTI prophylaxis (prevention) since 08/02/2025. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that: - The clinician reported to him/her that the patient was short of breath during ambulation but had not documented the assessment; and - They had understood question M1600 to be focused on the patient having a UTI at the time of assessment, and had not considered the Macrobid as a prophylactic (preventative) when providing an answer; and - The OASIS answers for M1600 and M1400 were inaccurate.”

“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 personnel file review and interview, the home health provider failed to ensure infection control training was completed on hire and annually in two of five employee records reviewed (Employees #2 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: EMPLOYEE #2: Review of Employee #2’s personnel file showed in part that: - The employee’s position was physical therapy assistant; - Orientation in-service training took place on 07/12/2021; and - The personnel file failed to contain evidence that infection control training was completed upon hire or annually. EMPLOYEE #3: Review of Employee #3’s personnel file showed in part that: - The employee’s position was occupational therapist; - Orientation in-service training took place on 10/04/2021; and - The personnel file failed to contain evidence that infection control training was completed upon hire or annually. During an interview on 12/03/2025 at 3:20 PM, the business office manager stated that: - They did not have a policy specifically stating that staff would receive infection control training upon hire and annually; - They had an orientation itinerary that contained an infection control for home-based care providers; -They expected employees to receive initial and annual training on infection control; and - They were unable to provide evidence that Employee #2 and #3 had received initial and annual training on infection control.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on job description review, record review, and interview, the home health provider failed to ensure the staff documented clearly and completely in two of five full records reviewed (Records/Patients #1, and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the “LPN (licensed practical nurse) Job Description,” showed in part, the nurse will accurately and timely complete required documentation. Review of the “RN (registered nurse) Case Manager (job description),” showed in part, the nurse will accurately and timely document patients/residents progress toward goals and other observations. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 (two) diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the registered nurse (RN) start of care (SOC) assessment, dated 11/17/2025, showed the RN documented the patient had an active diagnosis of DM in the Outcome and Assessment Information Set (OASIS- a data collection tool) section (M1028) and documented no DM in the endocrine assessment section. The rest of the endocrine DM section was not completed since the nurse documented the patient did not have DM. (The nurse’s documentation was unclear and incomplete since the patient had a diagnosis of type 2 DM.) RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/21/2025 with a primary diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and secondary diagnoses that included pneumonia (infection that involves one or both lungs) and end stage renal disease (kidneys no longer function on their own). The patient lived at home alone, but his/her daughter in law was staying temporarily to assist the patient. Review of the LPN visit note, dated 10/28/2025, showed a comment in the medication change since last visit section; “Daughter in law sets up medications in planner. Lexapro (an antidepressant) decreased. Renee (this should be Remeron (an antidepressant)) on start for weight loss”. This unclear note carried over to the LPN visits on 10/30/2025, 11/04/2025, and 11/06/2025. During an interview on 12/03/2025 at 9:20 AM, the clinical manager stated that he/she was unsure why the endocrine section was completed incorrectly, or why the medication note carried over to multiple visits.”

“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 assessments accurately reflected the patient’s current health, psychosocial, functional, and cognitive status in one of five 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 policy titled, “Initial and Comprehensive Assessment,” revised 06/2022, showed in part, that the initial and comprehensive patient assessment would include a physical assessment, including blood pressure, temperature, pulse, respiration, skin, pain, height/weight, allergies, nutritional status, and other relevant data related to pertinent physical findings. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of laceration (cut) of the right hand. The patient had secondary diagnoses of diabetes (a chronic disease that affects how the body uses sugar for energy), generalized anxiety disorder, hyperlipidemia (elevated fats in the blood), and hypertension (high blood pressure). The patient resided in his/her own home with the assistance of his/her spouse, family members, and private pay caregivers for four hours each morning and four hours each evening. Review of the healthcare practitioner’s progress note, dated 11/12/2025, showed in part that the patient was to start using hydrocortisone cream (a cream used to treat itching) to treat his/her itching; and the patient’s last HGB A1C (glycated hemoglobin, a blood test that measures an individual’s average blood sugar levels over the past two to three months) was abnormal. Review of the referring facility’s profile and face sheet, dated 11/13/2025, showed in part that that profile contained orders for: - Monitoring of the patient’s blood sugar reading two times per day; - The use of Vitamin A & D ointment to perineal area three times per day as needed to prevent skin irritation; - Eucerin itch relief lotion twice daily to rash area; - A wound on his/her right shin with dressing changes ordered every three days; and - A wound on his/her coccyx (tail bone) with wound care ordered two times per day. Review of the comprehensive, initial nursing visit documentation, dated 11/18/2025, showed in part that the documentation failed to contain an assessment of: - The patient/caregiver’s competence in performing blood glucose monitoring; and - The patient’s perineal area, rash, or the shin wound. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that the comprehensive assessment failed to include an assessment of the patient’s diabetes management, including glucometer use, and failed to include an assessment of the patient’s perineal area, the rash, and the shin wound. He/she would expect the comprehensive assessment to accurately reflect the patient’s condition.”

“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, observation, and interview, the home health provider failed to ensure staff performed a review of all medications the patient was currently taking 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. Findings included: Review of the provider’s policy titled, “Medication Profile,” revised 06/2022, showed in part the following: - Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record; and - Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of laceration (cut) of the right hand. The patient had secondary diagnoses of diabetes (a chronic disease that affects how the body uses sugar for energy), generalized anxiety disorder, hyperlipidemia (elevated fats in the blood), and hypertension (high blood pressure). The patient resided in his/her own home with the assistance of his/her spouse, family members, and private pay caregivers for four hours each morning and four hours each evening. Review of the healthcare practitioner’s progress note dated 11/12/2025, showed in part that the patient was to start using hydrocortisone cream (a cream used to treat itching skin) to treat his/her itching skin. Review of the facility profile and face sheet, dated 11/13/2025, showed in part that that profile contained an order for hydrocortisone cream with a start date of 11/13/2025. Review of the providers home health certification and plan of care, dated 11/18/2025, showed in part that the document failed to contain an order for hydrocortisone cream. Review of the provider’s updated medication profile, dated 11/18/2025, showed that the document failed to contain an order for hydrocortisone cream. Observation and interview on 11/12/2025 at 10:45 AM, showed that the patient had hydrocortisone cream in his/her home. The spouse stated that the patient had started using hydrocortisone cream for itch relief before his/her return to their private residence on 11/18/2025. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that: - They would expect the patient’s medication profile to contain all the medications used by the patient; and - They were unable to find an order for hydrocortisone cream on the patient’s medication list. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the skilled nursing facility (SNF) discharge medication list dated 11/14/2025 showed: - Hydrochlorothiazide (used to treat high blood pressure and fluid retention) 12.5 milligrams (mg) every Monday, Wednesday, and Friday; - Cholecalciferol (vitamin D3) (used to treat low vitamin D3 levels and supports healthy bones, muscles and nerves) 50,000 international units (IU) every month; - Ferrous sulfate (iron supplement) 325 mg one table daily; - Probiotic (helps restore good bacteria to the digestive system) one capsule daily; - Zofran (used to treat nausea and vomiting) 4 mg tablet every 6 hours PRN (as needed); and - Docusate sodium (stool softener laxative used to treat constipation) 100 mg capsule once daily. Observation and interview on 12/02/2025 at 10:25 AM showed the following discrepancies between the provider’s medication profile and the patient’s home medications: - The provider’s profile showed hydrochlorothiazide 12.5 mg daily (should be Monday, Wednesday and Friday). The patient stated that he/she took 12.5 mg Monday through Friday and did not take it on Saturday or Sunday; - The provider’s profile showed cholecalciferol 50,000 “UT” (should be IU) every month. The patient stated that he/she took calcium 1200 mg with D3 1000 IU daily; - The provider’s profile showed ferrous sulfate 325 mg one table daily. The patient stated that he/she took one tablet on Monday, Wednesday and Friday; - The provider’s profile showed probiotic one capsule daily. The patient stated that he/she took one capsule twice a day; - The provider’s profile showed Zofran 4 mg every 6 hours PRN (as needed). The patient stated that he/she did not have that medication and did not use it; and - The provider’s profile showed docusate sodium 100 mg one capsule daily. The patient stated that he/she took two capsules daily. The patient had all his/her medications in a basket, used a list that he/she created, and stated that he/she independently took medications and did not use a medication planner. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the skilled nursing facility (SNF) discharge medication list, dated 11/14/2025, showed: - Hydrochlorothiazide (used to treat high blood pressure and fluid retention) 12.5 milligrams (mg) every Monday, Wednesday, and Friday; - Cholecalciferol (vitamin D3) (used to treat low vitamin D3 levels and supports healthy bones, muscles and nerves) 50,000 international units (IU) every month; - Ferrous sulfate (iron supplement) 325 mg one table daily; - Probiotic (helps restore good bacteria to the digestive system) one capsule daily; - Zofran (used to treat nausea and vomiting) 4 mg tablet every 6 hours PRN (as needed); and - Docusate sodium (stool softener laxative used to treat constipation) 100 mg capsule once daily. Observation and interview on 12/02/2025 at 10:25 AM showed the following discrepancies between the provider’s medication profile and the patient’s home medications: - The provider’s profile showed hydrochlorothiazide 12.5 mg daily (should be Monday, Wednesday and Friday). The patient stated that he/she took 12.5 mg Monday through Friday and did not take it on Saturday or Sunday; - The provider’s profile showed cholecalciferol 50,000 “UT” (should be IU) every month. The patient stated that he/she took calcium 1200 mg with D3 1000 IU daily; - The provider’s profile showed ferrous sulfate 325 mg one table daily. The patient stated that he/she took one tablet on Monday, Wednesday and Friday; - The provider’s profile showed probiotic one capsule daily. The patient stated that he/she took one capsule twice a day; - The provider’s profile showed Zofran 4 mg every 6 hours PRN (as needed). The patient stated that he/she did not have that medication and did not use it; and - The provider’s profile showed docusate sodium 100 mg one capsule daily. The patient stated that he/she took two capsules daily. The patient had all his/her medications in a basket, used a list that he/she created, and stated that he/she independently took medications and did not use a medication planner. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 06/01/2025 with a primary diagnosis of chronic peripheral venous insufficiency (a condition in which veins have problems moving blood back to the heart). The patient resided in an assisted living facility (ALF). Observation and interview on 12/02/2025 at 11:00 AM showed the following discrepancies between the provider’s medication profile and the ALF’s medication profile: -The provider’s profile showed the patient took lisinopril (used to treat high blood pressure) 20 milligrams (mg) take one tablet by mouth once daily. The ALF’s profile showed lisinopril 10 mg take one tablet by mouth once daily; -The ALF’s profile showed the patient took cilostazol (used to improve the flow of blood through the vessels) 50 mg take one tablet by mouth two times daily. The provider’s medication profile failed to contain this medication; and -The ALF’s profile showed the patient took gabapentin (used to treat nerve pain) 300 mg capsules, take one capsule by mouth three times a day. The provider’s medication profile failed to contain this medication. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that the cilostazol was a 30-day order and came off the medication profile after the 30 days. He/she also stated that they would expect the medication profile to match what the patient is taking. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of laceration (cut) of the right hand. The patient had secondary diagnoses of diabetes (a chronic disease that affects how the body uses sugar for energy), generalized anxiety disorder, hyperlipidemia (elevated fats in the blood), and hypertension (high blood pressure). The patient resided in his/her own home with the assistance of his/her spouse, family members, and private pay caregivers for four hours each morning and four hours each evening. Review of the healthcare practitioner’s progress note, dated 11/12/2025, showed, in part, that the patient was to start using hydrocortisone cream (a cream used to treat itching) to treat his/her itching skin. Review of the facility profile and face sheet, dated 11/13/2025, showed, in part, that that profile contained an order for hydrocortisone cream with a start date of 11/13/2025. Review of the providers home health certification and plan of care, dated 11/18/2025, showed, in part, that the document failed to contain an order for hydrocortisone cream. Review of the provider’s updated medication profile, dated 11/18/2025, showed that the document failed to contain an order for hydrocortisone cream. Observation and interview on 11/12/2025 at 10:45 AM, showed that the patient had hydrocortisone cream in his/her home. The spouse stated that the patient had started using hydrocortisone cream for itch relief before his/her return to their private residence on 11/18/2025. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that: - They would expect the patient’s medication profile to contain all the medications used by the patient; and - They were unable to find an order for hydrocortisone cream on the patient’s medication list.”

“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, observation, and interview, the provider failed to ensure the plan of care (POC) included all required treatment orders, and complete/accurate interventions in three of five full records reviewed (Records/Patients #1, #3, and #4). This deficient practice has the potential to affect the provision of care for all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning Process,” revised 06/2022, showed in part, based on the assessment and conclusions, the plan of care will include, but will not be limited to; patient specific interventions and education; and specific services and treatments to be provided. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of laceration (cut) of the right hand. The patient had secondary diagnoses of diabetes (a chronic disease that affects how the body uses sugar for energy), generalized anxiety disorder, hyperlipidemia (elevated fats in the blood), and hypertension (high blood pressure). The patient resided in his/her own home with the assistance of his/her spouse, family members, and private pay caregivers for four hours each morning and four hours each evening. Review of the comprehensive, initial nursing visit documentation, dated 11/18/2025, showed in part that the: - The patient had diabetes and was to be on a no concentrated sweets diet; and - Nurse had prefilled the patient’s medication planner during his/her visit. Review of the home health providers certification and plan of care dated 11/18/2025, showed in part that: - The document failed to contain interventions for the nurse to monitor the patient’s diabetes and prefill his/her medication planner; - The document contained and order to treat pain hot/cold packs; and - The document failed to contain individualized instructions for the use of hot/cold packs including, but not limited to, length and frequency of use. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that they would expect the plan of care to: - Contain all medications, interventions, and goals related to the care of the patient; and - He/she was unable to locate orders related to the monitoring of the patient’s diabetes, prefilling of the medication planner, or length and frequency of use for the hot/cold packs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the POC dated 11/17/2025 showed the following: - “Instruct patient nonpharmacologic pain relief measures: hot/cold packs”. The order failed to include the location, frequency, and duration for the use of hot or cold therapy; - “Skilled nurse (SN) to (teach) patient to wear compression therapy to edematous extremity/area”. The order failed to include the location, type, or duration for the application of compression therapy; and - The POC contained blood sugar parameters for fasting and random blood sugar readings for notification to the physician. The POC failed to include orders for the patient or staff to monitor or not to monitor the patient’s blood sugar. Observation and interview on 12/02/2025 at 9:40 AM showed the patient did not take any medications to control blood sugar and the patient stated that his/her hemoglobin A1C (a lab test that monitors control of blood sugar over a period of time) was always good, so he/she did not check his/her blood sugars. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/21/2025 with a primary diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and secondary diagnoses that included pneumonia (infection that involves one or both lungs) and end stage renal disease (kidneys no longer function on their own). The patient lived at home alone, but his/her daughter in law was staying temporarily to assist the patient. Review of the SN start of care assessment dated 10/21/2025 showed the patient received dialysis and had a right central venous catheter ((CVC) a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided into a large vein above the right side of the heart). Review of the POC dated 10/21/2025 showed the following: - “Instruct patient nonpharmacologic pain relief measures: hot/cold packs”. The order failed to include the location, frequency, and duration for the use of hot or cold therapy; - “SN to (teach) patient to wear compression therapy to edematous extremity/area”. The order failed to include the location, type, or duration for the application of compression therapy; and - The POC failed to include orders or instructions related to the right CVC that was used when patient received dialysis. During an interview on 12/03/2025 at 9:20 AM, the clinical manager stated that the hot/cold and compression interventions are already written and they could not be changed, but staff could write other interventions. The POC should include instructions related to the CVC and who managed it. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the POC, dated 11/17/2025, showed the following: - “Instruct patient nonpharmacologic pain relief measures: hot/cold packs”. The order failed to include the location, frequency, and duration for the use of hot or cold therapy; - “Skilled nurse (SN) to (teach) patient to wear compression therapy to edematous extremity/area”. The order failed to include the location, type, or duration for the application of compression therapy; and - The POC contained blood sugar parameters for fasting and random blood sugar readings for notification to the physician. The POC failed to include orders for the patient or staff to monitor or not to monitor the patient’s blood sugar. Observation and interview on 12/02/2025 at 9:40 AM showed the patient did not take any medications to control blood sugar and the patient stated that his/her hemoglobin A1C (a lab test that monitors control of blood sugar over a period of time) was always good, so he/she did not check his/her blood sugars. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of laceration (cut) of the right hand. The patient had secondary diagnoses of diabetes (a chronic disease that affects how the body uses sugar for energy), generalized anxiety disorder, hyperlipidemia (elevated fats in the blood), and hypertension (high blood pressure). The patient resided in his/her own home with the assistance of his/her spouse, family members, and private pay caregivers for four hours each morning and four hours each evening. Review of the comprehensive, initial nursing visit documentation, dated 11/18/2025, showed, in part, that the: - The patient had diabetes and was to be on a no concentrated sweets diet; and - Nurse had prefilled the patient’s medication planner during his/her visit. Review of the home health providers certification and plan of care, dated 11/18/2025, showed, in part, that: - The document failed to contain interventions for the nurse to monitor the patient’s diabetes and prefill his/her medication planner; - The document contained and order to treat pain hot/cold packs; and - The document failed to contain individualized instructions for the use of hot/cold packs including, but not limited to, length and frequency of use. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that they would expect the POC to: - Contain all medications, interventions, and goals related to the care of the patient; and - He/she was unable to locate orders related to the monitoring of the patient’s diabetes, prefilling of the medication planner, or length and frequency of use for the hot/cold packs. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/21/2025 with a primary diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and secondary diagnoses that included pneumonia (infection that involves one or both lungs) and end stage renal disease (kidneys no longer function on their own). The patient lived at home alone, but his/her daughter in law was staying temporarily to assist the patient. Review of the SN start of care assessment, dated 10/21/2025, showed the patient received dialysis and had a right central venous catheter ((CVC) a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided into a large vein above the right side of the heart). Review of the POC dated 10/21/2025 showed the following: - “Instruct patient nonpharmacologic pain relief measures: hot/cold packs”. The order failed to include the location, frequency, and duration for the use of hot or cold therapy; - “SN to (teach) patient to wear compression therapy to edematous extremity/area”. The order failed to include the location, type, or duration for the application of compression therapy; and - The POC failed to include orders or instructions related to the right CVC that was used when patient received dialysis. During an interview on 12/03/2025 at 9:20 AM, the clinical manager stated that the hot/cold and compression interventions are already written and they could not be changed, but staff could write other interventions. The POC should include instructions related to the CVC and who managed it. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 09/08/2025 with a primary diagnosis of dementia with other behavioral disturbances (decline in mental capacity with agitation such as verbal and physical aggression, wandering, and hoarding) and a secondary diagnosis of chronic pain. The patient resided in an assisted living facility (ALF). Review of the plan of care (POC) showed the patient was admitted with a referral for physical therapy and occupational therapy. The POC failed to contain interventions and goals related to the patient’s diagnosis of chronic pain. During an interview on 12/03/2025 at 12:30 PM, the home health clinical manager stated that he/she would expect the POC to contain interventions relating to the patient’s diagnosis and needs.”

“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 job description review, record review, and interview, the home health provider failed to report symptoms to the physician in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated job description titled, “Home Health RN (Registered Nurse) Case Manager,” showed in part, the RN case manager was to report patient/resident changes, needs, and/or requirements to the appropriate staff. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 06/01/2025 with a primary diagnosis of chronic peripheral venous insufficiency (a condition in which veins have problems moving blood back to the heart). The patient resided in an assisted living facility (ALF). Review of the plan of care (POC) dated 09/29/2025 to 11/27/2025 and the POC dated 11/28/2025 to 01/06/2026 showed an intervention for the skilled nurse (SN) to report to physician if patient experiences pain level not acceptable to patient, pain level greater than 5 (five) (numeric pain scale rating where 0 (zero) is no pain and 10 is the worst pain), or pain affecting ability to perform patient’s normal daily activities. Review of the RN skilled nursing visit notes dated 10/21/2025, 10/24/2025,10/28/2025, 11/11/2025, and 11/14/2025, showed a pain rating of a 7 (seven) out of 10. The provider failed to document communication to the physician regarding the high pain level. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that the clinician did contact the physician on 10/28/2025 and the physician chose not to change the medication order for pain, but the clinician did not document this conversation. He/she then stated that they would expect all physician contact to be documented.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure complete pain assessments were completed on clinician visits in three of five full records reviewed (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Initial and Comprehensive Assessment,” dated 06/2022, showed in part, during the comprehensive assessment, all data and other relevant information will be documented in the patient’s clinical record, including a physical assessment, including blood pressure, temperature, pulse, respiration, skin, pain status, height/weight, allergies, nutritional status, and other relevant data related to pertinent physical findings of common symptoms. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the plan of care (POC) dated 11/17/2025 showed a goal for patient to report effective pain control: will report pain less than 3 (numeric pain scale rating where 0 is no pain and 10 is the worst pain). Review of the physical therapy assistant (PTA) note dated 11/24/2025 showed the PTA documented that the patient had bilateral knee pain and back pain that was increased by “chronic pain, walking”, relieved by “sitting”, and interferes with “comfort”. The PTA failed to document a pre-therapy and post-therapy rating of the pain. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/21/2025 with a primary diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and secondarydiagnoses that included pneumonia (infection that involves one or both lungs) and end stage renal disease (kidneys no longer function on their own). The patient lived at home alone, but his/her daughter in law was staying temporarily to assist the patient. Review of the plan of care (POC) dated 10/21/2025 showed a goal for patient to report effective pain control: will report pain less than 3 (numeric pain scale rating where 0 is no pain and 10 is the worst pain). Review of the physical therapy notes showed the physical therapist (PT) or PTA failed to document a complete pain assessment in the following notes: - The PTA noted dated 11/06/2025 showed the patient had left hip/groin pain that was increased by “activity- aware but not painful”, relieved by “avoidance, lying down and resting”, and interferes with “comfort”. The PTA failed to document a pre-therapy and post-therapy rating of the pain; - The PTA noted dated 11/13/2025 showed the patient had left hip/groin pain that was increased by “activity- aware but not painful weather change”, relieved by “avoidance, lying down and resting”, and interferes with “comfort”. The PTA failed to document a pre-therapy and post-therapy rating of the pain; - The PT re-evaluation note dated 11/18/2025 showed the patient had left hip pain that was increased by “activity”, relieved by “avoidance”, and interferes with “upright activity”. The PT failed to document a pre-therapy and post-therapy rating of the pain; - The PTA note dated 11/20/2025 showed the patient had left hip pain that was increased by “activity”, relieved by “avoidance”, and interferes with “upright activity”. The PTA failed to document a pre-therapy and post-therapy rating of the pain; and - The PTA note dated 11/24/2025 showed the patient had left hip/groin pain that was increased by “initially standing and taking the first few steps”, relieved by “avoidance”, and interferes with “upright activity”. The PTA failed to document a pre-therapy and post-therapy rating of the pain. Review of the occupational therapy (OT) visit notes showed OT failed to document a complete pain assessment in the following notes: - The OT note dated 11/13/2025, showed the patient had left knee pain that was increased by “baseline”, relieved by was not completed, and interferes with was not completed. The OT failed to document a pre-therapy and post-therapy rating of the pain; - The OT note dated 11/18/2025, showed the patient had left knee pain that was increased by “increases with prolonged activity”, relieved by was not completed, and interferes with was not completed. The OT failed to document a pre-therapy and post-therapy rating of the pain; and - The OT note dated 11/24/2025, showed the patient had left knee pain that was increased by “baseline – patient reports increased pain when ambulating/standing”, relieved by “Tylenol” (pain reliever), and interferes with was not completed. The OT failed to document a pre-therapy and post-therapy rating of the pain. During an interview on 12/03/2025 at 9:40 AM, the clinical manager stated that the staff should document the patient’s report of pain before and after treatment and if patient has high levels of pain, they should recommend medication before treatments. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the plan of care (POC) dated 11/17/2025 showed a goal for patient to report effective pain control: will report pain less than 3 (numeric pain scale rating where 0 is no pain and 10 is the worst pain). Review of the physical therapy assistant (PTA) note dated 11/24/2025 showed the PTA documented that the patient had bilateral knee pain and back pain that was increased by “chronic pain, walking”, relieved by “sitting”, and interferes with “comfort”. The PTA failed to document a pre-therapy and post-therapy rating of the pain. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 06/01/2025 with a primary diagnosis of chronic peripheral venous insufficiency (a condition in which veins have problems moving blood back to the heart). The patient resided in an assisted living facility (ALF). Review of the PTA visit, dated 11/21/2025, showed patient had pain to the left leg that was “increased by walking”, “relieved by elevation and rest”, and “interferes with walking speed. The clinician failed to document a pain level pre therapy and post therapy. Review of the PTA visit, dated 11/26/2025, showed patient had pain to the left leg that was increased by walking, relieved by elevation and rest, and interferes with walking speed. The clinician failed to document a pain level pre therapy and post therapy. During an interview on 12/03/2025 at 12:30 PM, the home health clinical manager stated that he/she expected full pain assessments to be completed on every visit. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/21/2025 with a primary diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and secondary diagnoses that included pneumonia (infection that involves one or both lungs) and end stage renal disease (kidneys no longer function on their own). The patient lived at home alone, but his/her daughter in law was staying temporarily to assist the patient. Review of the POC, dated 10/21/2025, showed a goal for patient to report effective pain control: will report pain less than 3 (numeric pain scale rating where 0 is no pain and 10 is the worst pain). Review of the physical therapy notes showed the physical therapist (PT) or PTA failed to document a complete pain assessment in the following notes: - The PTA note, dated 11/06/2025, showed the patient had left hip/groin pain that was increased by “activity- aware but not painful”, relieved by “avoidance, lying down and resting”, and interferes with “comfort”. The PTA failed to document a pre-therapy and post-therapy rating of the pain; - The PTA note, dated 11/13/2025, showed the patient had left hip/groin pain that was increased by “activity- aware but not painful weather change”, relieved by “avoidance, lying down and resting”, and interferes with “comfort”. The PTA failed to document a pre-therapy and post-therapy rating of the pain; - The PT re-evaluation note, dated 11/18/2025, showed the patient had left hip pain that was increased by “activity”, relieved by “avoidance”, and interferes with “upright activity”. The PT failed to document a pre-therapy and post-therapy rating of the pain; - The PTA note, dated 11/20/2025, showed the patient had left hip pain that was increased by “activity”, relieved by “avoidance”, and interferes with “upright activity”. The PTA failed to document a pre-therapy and post-therapy rating of the pain; and - The PTA note, dated 11/24/2025, showed the patient had left hip/groin pain that was increased by “initially standing and taking the first few steps”, relieved by “avoidance”, and interferes with “upright activity”. The PTA failed to document a pre-therapy and post-therapy rating of the pain. Review of the occupational therapy (OT) visit notes showed OT failed to document a complete pain assessment in the following notes: - The OT note, dated 11/13/2025, showed the patient had left knee pain that was increased by “baseline”, relieved by was not completed, and interferes with was not completed. The OT failed to document a pre-therapy and post-therapy rating of the pain; - The OT note, dated 11/18/2025, showed the patient had left knee pain that was increased by “increases with prolonged activity”, relieved by was not completed, and interferes with was not completed. The OT failed to document a pre-therapy and post-therapy rating of the pain; and - The OT note, dated 11/24/2025, showed the patient had left knee pain that was increased by “baseline – patient reports increased pain when ambulating/standing”, relieved by “Tylenol” (pain reliever), and interferes with was not completed. The OT failed to document a pre-therapy and post-therapy rating of the pain. During an interview on 12/03/2025 at 9:40 AM, the clinical manager stated that the staff should document the patient’s report of pain before and after treatment and if patient has high levels of pain, they should recommend medication before treatments.”