Life Fountain Health Care, Inc.

“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, clinical record review, and interview, the home health provider failed to ensure the accuracy of the Outcome and Assessment Information Set (OASIS- Outcome and Assessment Information Set; a standardized data collection tool) data in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect accurate OASIS data collection for all the provider’s patients. Findings included: Review of the provider’s policy titled, “Assessment, Comprehensive,” revised “10/2018”, showed, in part: - “Named provider” will ensure timely (timeliness) and accuracy of the OASIS data; and - The Director of Patient Services and/or designee will consult the qualified clinician who conducted and completed the comprehensive assessment for purposes of collaboration, clarification or to complete missing OASIS data items. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 09/13/2025 with a primary diagnosis of alcoholic cirrhosis of the liver with ascites (a chronic liver disease caused by excessive alcohol consumption, leading to scarring (fibrosis) of the liver and the accumulation of fluid in the abdominal cavity (ascites). The patient resided at home with their spouse. Review of the OASIS Start of Care (SOC) initial assessment, dated 09/13/2025, showed: - Item M1306: Does this patient have at least one unhealed pressure ulcer injury at stage 2 (two) (a partial thickness loss of the skin caused by pressure) or higher (worse) or designated unstageable (the depth of the wound cannot be determined because it is covered)? This was marked as no; - Item M1324: Stage of most problematic unhealed pressure ulcer/injury that is stageable: This was marked as N/A (not applicable)– “Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries”; and - Under the wound care worksheet portion: wound 1- location: coccyx, status: open, present on admission, type: left blank, wound bed: pink, drainage: none, odor: left blank, surrounding tissue: intact, treatment: apply barrier cream. (There failed to be any measurements of the coccyx wound). During an interview on 09/18/2025 at 9:40 AM the clinical manager stated that the OASIS data entry was inaccurate, and they should have marked Item M1306: yes.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on clinical practice guidelines, clinical record review, and interview, the home health provider failed to maintain professional standards when wound measurements were not obtained/documented according to the clinical practice guidelines and interview, in one of two records with wounds (Record/Patient #3). This deficient practice has the potential to affect all the patients with wounds served by the provider. Findings included: Review of the provider’s policies showed the provider failed to have a wound care/management policy. Review of the article by Karen S. Clay, RN, BSN, CWCN Copyright 2008 titled, “Evidence-Based Pressure Ulcer Prevention: A Study Guide for Nurses,” showed the following: “The standard of practice requires at least weekly measurement of the wound. In addition, every time you change the dressing, assess peri-wound skin, wound margins, wound tissue, drainage, odor, pain, and any other relevant issues. On a weekly basis, assess those macroscopic (i.e., visible to the naked eye) indices, measure the wound, assess the effectiveness of the treatment, and determine any treatment plan changes.” (http://www.hcpro.com/content/76944.pdf Chapter 9-Wound Healing-Page 95) RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 08/22/2025 with a primary diagnosis of stage two (2) pressure ulcer (an injury with partial-thickness skin loss caused by unrelieved pressure) of the left ankle, type 2 diabetes mellitus (DM- a chronic disease that affects how the body uses sugar for energy) with foot ulcer (discontinuity or break in a bodily membrane that impedes normal function of the affected organ), non-pressure chronic (condition that persists over a long time, generally at least a year, or recurs frequently) ulcer on parts of left foot and right foot. The patient lived at home with his/her adult children. Review of the OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care (SOC) skilled nurse (SN) initial assessment, dated 08/22/2025, showed the following wound measurements: - Wound 1 (one), right heel - 6-centimeters (cm) x 3.4-cm x 0-cm; - Wound 2, posterior left lower leg – 4.5-cm x 1.5-cm x 0.3-cm; and - Wound 3 (three), anterior left foot – 2.0-cm x 2.9-cm x 0-cm. Review of the plan of care (POC), dated 08/22/2025 to 10/20/2025, showed in part: - The patient’s primary diagnosis was a pressure ulcer of the left ankle, stage 2; - SN visit frequency of one time a week for one week, then starting on 08/25/2025, three times a week for six weeks; and - Interventions included SN assessment of patient with stage 2 pressure ulcer of left ankle, type 2 DM with foot ulcer, and non-pressure chronic ulcer of other parts of left and right foot. Review of clinical record showed the skilled nurses failed to measure the patient’s wound the week of 08/24/2025 to 08/30/2025 and from 09/07/025 to 09/16/2025. During an interview on 09/18/2025, beginning at 10:57 AM, the clinical manager stated that he/she would expect that wounds were measured weekly.”

“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, clinical record review, and interview, the home health provider failed to complete the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient’s return home, or on the physician ordered start of care date in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect the immediate needs of all the provider’s patients. Findings included: Review of the provider’s policy titled, “Assessment, Comprehensive,” revised “10/2018”, showed, in part, a registered nurse, or qualifying clinician, must conduct an initial assessment within 48 hours of referral or patient’s return to home, or on the physician ordered start of care date. RECORD/PATIENT #1: Review of the patient profile sheet showed, under the comments section, the following: “9/9/2025: Received completed referral and report from “named employee”, marketer, that patient contact made for verification and referral is now ready for staffing. “Named clinical manager” 9/9/2025: Call made to verify “named physician” (PCP) (primary care physician) will follow for home care orders. Return call received, “named physician” to follow for home care orders. ” named clinical manager””. Review of the start of care (SOC) OASIS (Outcome and Assessment Information Set; a standardized data collection tool) initial assessment, and the first skilled nurse (SN) visit to the patient showed, in part: - The assessment was dated 09/13/2025 (ninety-six hours after the referral and 120 hours after inpatient discharge); - Item M0102 (Physician ordered start of care date), was answered with N/A- No specific SOC/ROC (resumption of care) date ordered by the physician; - Item M0104 (Date of Referral), was answered with 09/08/2025; and – Item M1005 (Inpatient discharge date) was answered with 09/08/2025. Further review of the clinical record failed to show physician orders for a specific SOC date. During an interview on 09/18/2025 at 9:40 AM, the clinical manager stated, “there should have been an order put in for a late SOC, but it wasn’t put in, so that was one that was missed”.”

“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, clinical record review, and interview, the home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s current health status 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, “Assessment, Comprehensive,” revised “10/2018”, showed, in part: - The comprehensive assessment must accurately reflect the patient’s status and serve as a purpose to provide the home health agency with a complete picture of the patient’s status to assist the home health agency in developing the patient’s plan of care; and - The comprehensive assessment must include at a minimum the following patient information: assessment of the patient’s current health status includes relevant past medical history as well as all active health and medical problems. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 09/13/2025 with a primary diagnosis of alcoholic cirrhosis of the liver with ascites (a chronic liver disease caused by excessive alcohol consumption, leading to scarring (fibrosis) of the liver and the accumulation of fluid in the abdominal cavity (ascites). The patient resided at home with their spouse. Review of the OASIS (Outcome and Assessment Information Set; a standardized data collection tool) Start of Care initial assessment, dated 09/13/2025, showed: - Under the wound care worksheet portion: wound 1- location: coccyx, status: open, present on admission, type: left blank, wound bed: pink, drainage: none, odor: left blank, surrounding tissue: intact, treatment: apply barrier cream; and - The initial assessment documentation failed to show any measurements of the coccyx wound. During an interview on 09/18/2025 at 9:40 AM, the clinical manager stated that there were no coccyx wound measurements, but they usually did measure the wounds on admission (if present) and weekly.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to provide skilled nursing services as ordered by the physician on the plan of care (POC) in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect the quality of nursing care to all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Plan of Care”, showed, in part, the following: - The initial POC must include, at a minimum, these patient specific items; * The frequency and duration of visits to be made by all disciplines; - The POC will serve as physician’s orders for patient care and all staff providing services will be in compliance with the orders; and - The patient’s physician orders for treatments and services are the foundation of the POC. If the agency (provider) misses a visit or treatment or service as required by the POC, which results in any potential for clinical impact upon the patient, then the agency will notify the responsible physician of such missed treatment or service. The physician will decide whether the treatment or service may be skipped or whether additional intervention is required by the home health agency due to the clinical impact on the patient. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 08/22/2025 with a primary diagnosis of stage two (2) pressure ulcer (an injury with partial-thickness skin loss caused by unrelieved pressure) of the left ankle, type 2 diabetes mellitus (a chronic disease that affects how the body uses sugar for energy) with foot ulcer (discontinuity or break in a bodily membrane that impedes normal function of the affected organ), non-pressure chronic (condition that persists over a long time, generally at least a year, or recurs frequently) ulcer on parts of left foot and right foot. The patient lived at home with his/her adult children. Review of the POC, dated 08/22/2025 to 10/20/2025, showed in part: - The patient’s primary diagnosis was a pressure ulcer of the left ankle, stage 2; - Type 2 diabetes mellitus with foot ulcer; - Non-pressure chronic ulcer on parts of left foot and right foot; - Skilled nurse (SN) visit frequency of one time a week for one week, then starting on 08/25/2025 three times a week for six weeks; and - Interventions included SN assessment of patient with stage 2 pressure ulcer of left ankle, Type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer on parts of left foot and right foot. Review of the clinical record showed nurses notes dated 08/25/2025, 08/28/2025, 09/02/2025, and 09/05/2025. Review of clinical record showed the skilled nurse failed to make three visits a week the weeks of 08/24/2025 to 08/30/2025 and from 08/31/025 to 09/06/2025. Review of the SN missed visit form, dated 08/27/2025, showed the patient’s adult child contacted the provider to cancel SN visit for that day and wanted to reschedule SN visit for the following day (Thursday 08/28/2025). The adult child stated he/she would be going to work today (08/27/2025). Fax sent to the physician. (the provider failed to make up the missed visit on other days during the week) Review of the SN visit, dated 08/28/2025, showed: - Treatment goals and plan audits comments – Adult child was in during the visit and requested SN visit next Tuesday (09/02/2025) as they were having family event over next few days. Review of the SN missed visit form dated 09/01/2025 showed the patient and adult child stated that they preferred the SN visit on Tuesday (09/02/2025) as they were having extended family over for that day. A fax was sent to the physician (the provider failed to make up the missed visit on other days during the week). During an interview on 09/18/2025, beginning at 10:57 AM, the clinical manager stated that he/she would expect the POC to be followed.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to provide a clinical record that was accurate and included completed nursing visits in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect the complete and accurate records of all the provider’s patients. Findings included: Review of the provider’s policy titled, “Contents of Clinical Records,” revised 10/2018, showed patient records must be kept current and confidential. Review of the provider’s policy titled, “Description of Services Policy, Skilled Nursing,” revised 10/2018, showed duties of the registered nurse are to keep current and adequate documentation showing assessment of the patient’s current status. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 08/22/2025 with a primary diagnosis of stage two (2) pressure ulcer (an injury with partial-thickness skin loss caused by unrelieved pressure) of the left ankle, type 2 diabetes mellitus (DM - a chronic disease that affects how the body uses sugar for energy) with foot ulcer (discontinuity or break in a bodily membrane that impedes normal function of the affected organ), non-pressure chronic (condition that persists over a long time, generally at least a year, or recurs frequently) ulcer on parts of left foot and right foot. The patient lived at home with his/her adult children. Review of the OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care (SOC) skilled nurse (SN) initial assessment showed the assessment was completed on 08/22/2025. Review of the plan of care (POC) dated 08/22/2025 to 10/20/2025, showed in part: - The patient’s primary diagnosis was a pressure ulcer of the left ankle, stage 2; -SN visit frequency of one time a week for one week, then starting on 08/25/2025 three times a week for 6 weeks; and - Interventions included SN assessment of patient with stage 2 pressure ulcer of left ankle, type 2 DM with foot ulcer, and non-pressure chronic ulcer of other parts of left and right foot. Review of clinical record showed visit verification signatures signed by the patient for 9/5/2025, 9/8/2025, 9/10/2025, 9/12/2025, and 9/15/2025 and failed to show visit notes and assessments documented for the visits. During an interview on 09/18/2025, beginning at 10:55 AM, the clinical manager stated that clinical record documentation should be completed within 48 hours as per Medicare, but staffing problems made her get behind.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to ensure a completed comprehensive discharge summary was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the home health provider/services within five business days of the patient’s discharge in two of two discharge records reviewed (Records/Patients #5 and #6). This deficient practice has the potential to affect the post-discharge care of all patients served by the home health provider. Findings included: Review of the provider’s policy titled, “Discharge/Transfer, Patient,” dated 10/2018, showed, in part: -The assigned staff member will document physician notification and as needed obtain a discharge/transfer order; -A completed discharge summary will be sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the home health agency (if any) within five (5) business days of the patient’s discharge; and -The discharge summary will be placed in the patient’s clinical record. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 03/29/2025, with a primary diagnosis of hemiplegia (paralysis affecting one side of the body) following cerebral infarction (stroke) affecting the right dominant side and functional quadriplegia (paralysis that affects all the person’s limbs). The patient resided at home with his/her spouse. Review of the patient’s discharge “Outcome and Assessment Information Set” (OASIS, a standardized data collection tool), dated 04/19/2025, showed, in part: -Reason for discharge: hospice; -Discharge from home health services; -All services notified and discontinued; -Physician notified of discharge prior to discharge date, per agency policy; and -Physician notified of discharge summary availability. Review of the clinical record failed to show the discharge summary was completed and sent to the primary care physician or to the receiving hospice provider. During an interview on 09/18/2025 at 09:41 AM, the clinical manager stated that: - There was not a discharge summary completed; therefore, no summary was sent to the patient’s primary care physician; and - He/she only had the order for the patient’s discharge. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to home health services on 06/07/2025 with a primary diagnosis of severe dementia (decline in mental capacity), thyrotoxicosis (a rare and life-threatening condition that occurs when the thyroid gland releases a large amount of thyroid hormones), and bilateral cortical age-related cataract (develops in the outer layers of the eye’s lens causing clouding of the lens, leading to blurred vision). The patient resided in the home with his/her adult children. Review of the OASIS discharge, dated 06/27/2025, showed in part: - The physician was notified of discharge prior to discharge date; and - The OASIS discharge was completed by the registered nurse. Review of the clinical record failed to show the discharge summary was sent to the primary care physician. During an interview on 09/17/2025 at 11:28 AM, the clinical director stated that: - The discharge summary was not sent; and - The order was sent to the physician for the patient to be discharged and the physician signed the order.”