On Call Care Services Inc.

“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 policy review, record review, observation, and interview, the home health provider failed to ensure the accuracy of documentation in two of five full records reviewed (Records/Patients #1 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 03/10/2026 with a primary diagnosis of change or removal of surgical dressing, cutaneous abscess of groin (pus-filled lump under the skin caused by bacterial infections), necrotizing fasciitis (rapidly progressing, life-threatening bacterial infection) and type two diabetes mellitus (a chronic disease that affects how the body uses sugar for energy). The patient lived at an assisted living facility. Review of the clinician visit notes showed: -On 03/14/2026, the registered nurse (RN) documented the patient was alert and the skin had been washed. When the wound vac was discontinued, the skilled nurse (SN) was informed that the patient had schizoaffective disorder. After being educated on the removal of wound vac, wound is to be packed with Vashe dressing, the patient began to giggle indicating that he/she was responding to internal stimuli. He/she was encouraged to maintain the areas dry and intact, and he/she replied that he/she had no open areas on his/her buttocks and does not want them dressed right now. The surgeon was notified that the patient is unable to keep the wound vac on. New orders to pack the wound with Vashe soaked gauze, place ABD pad (absorbant dressing) and tape in place using tape using clean technique. Dressing was performed in the treatment room; -On 03/15/2026, (RN) documented the patient was alert and the skin had been washed. When the wound vac was discontinued, the skilled nurse (SN) was informed that the patient had schizoaffective disorder. After being educated on the removal of wound vac, wound is to be packed with Vashe dressing, the patient began to giggle indicating that he/she was responding to internal stimuli. He/she was encouraged to maintain the areas dry and intact, and he/she replied that he/she had no open areas on his/her buttocks and does not want them dressed right now. The surgeon was notified that the patient is unable to keep the wound vac on. New orders to pack the wound with Vashe soaked gauze, place ABD pad (absorbant dressing) and tape in place using tape using clean technique. Dressing was performed in the treatment room (same entry as 03/14/2026); -On 03/16/2026, (RN) documented the patient was alert and the skin had been washed. When the wound vac was discontinued, the skilled nurse (SN) was informed that the patient had schizoaffective disorder. After being educated on the removal of wound vac, wound is to be packed with Vashe dressing, the patient began to giggle indicating that he/she was responding to internal stimuli. He/she was encouraged to maintain the areas dry and intact, and he/she replied that he/she had no open areas on his/her buttocks and does not want them dressed right now. The surgeon was notified that the patient is unable to keep the wound vac on. New orders to pack the wound with Vashe soaked gauze, place ABD pad (absorbant dressing) and tape in place using tape using clean technique. Dressing was performed in the treatment room (same entry as 03/15/2026); -On 03/18/2026, the RN documented the patient’s skin had been cleaned and the patient was conscious. The SN was notified that the patient had schizoaffective disorder after the wound vacuum was stopped. The patient started reacting to him/herself after being instructed on how to remove wound packing using Vashe dressing, suggesting that he/she was reacting to internal sensations. He/she responded that he/she had no exposed regions on his/her buttocks when asked to keep the areas dry and intact. They are being seen every day for minimum drainage. Take note that he/she removes his/her dressing because his/her mind won’t let him/her wear it all day; and -On 03/19/2026, the RN documented the patient’s skin had been cleaned and the patient was conscious. The SN was notified that the patient had schizoaffective disorder after the wound vacuum was stopped. The patient started reacting to him/herself after being instructed on how to remove wound packing using Vashe dressing, suggesting that he/she was reacting to internal sensations. He/she responded that he/she had no exposed regions on his/her buttocks when asked to keep the areas dry and intact. They are being seen every day for minimum drainage. Take note that he/she removes his/her dressing because his/her mind won’t let him/her wear it all day (same entry as 03/18/2026). During an interview on 03/31/2026 at 11:35 AM, the predesignated administrator backup stated that he/she would not expect staff to carry forward previous visit notes. Findings included: Review of the provider’s policy titled, “Clinical Records,” dated 10/2017, showed in part: - The clinical record documentation provides patients information specific to care and services provided (not provided), current patient status, and progress towards goals and outcomes of care; - Documentation standards include: * All entries that are legible, clear, complete, concise, appropriately authenticated must include a signature and title, or a secured computer entry by a unique identifier or a primary author who has reviewed and approved the entry * Dates/times, types of intervention, assessments and coordination of care - Clinical records are accurate and adhere to current clinical record documentation standards of practice; and - All entries into the clinical record for services rendered will be written within 24 hours (by the pervert person providing the service) and shall be incorporated into the patient’s clinical record within seven days of the delivery of service. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted for home health services on 03/17/2026 with a primary diagnosis of non-pressure chronic ulcer to the left ankle and the patient resided at home. Review of the hospital discharge records showed that the patient was admitted to the hospital on 03/01/2026 and discharge home on 03/14/2026 with orders for home health services. Review of the skilled nursing (SN) start of care visit on 03/17/2026, showed: - Ethnicity: patient unable to respond; - Race: patient unable to respond; - Sensory status: impaired hearing (no documentation of speech impairment); - Neurological status: oriented to person, place, and time; - The documentation was unclear why the patient was unable to respond but was alert and oriented to person, place, and time; and - Inpatient discharge within the past 14 days: patient was not discharged from an inpatient facility (the patient was discharged from the hospital three days prior). During an interview on 04/01/2026, at 11:10 AM, the predesignated administrator backup stated that he/she would expect the documentation to be complete and accurately reflect the patient’s status.”

“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 home health provider failed to ensure the plan of care (POC) included all interventions and orders to address patient needs, safety measures, and all physicians that were providing orders, in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect the provision of care for 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 03/10/2026 with a primary diagnosis of change or removal of surgical dressing, cutaneous abscess of groin (pus-filled lump under the skin caused by bacterial infections, necrotizing fasciitis (rapidly progressing, life-threatening bacterial infection) and type two diabetes mellitus (a chronic disease that affects how the body uses sugar for energy). The patient lived at an assisted living facility. Review of the POC, dated 03/10/2026-05/08/2026, showed, in part: -The patient was prescribed lovenox (a blood thinner); -The patient was prescribed novolog insulin (injectable medication used to lower blood sugar) 13 units subcutaneous (under the skin) three times a day with meals; -The patient was prescribed novolog insulin sliding scale 0-199: 0 units, 200-250: 2 units, 251-299: 4 units, 300-349: 6 units, 350-399: 8 units, 400-449: 10 units, 450 and greater: 12 units SQ for elevated blood sugar; and -The skilled nurse (SN) to provide negative pressure wound therapy (a vacuum dressing system to promote healing in acute or chronic wounds by applying subatmospheric pressure) to right periwound area using aseptic technique. SN to clean/irrigate the wound with Vashe (saline-based wound cleanser), dry the wound with gauze, prepare the skin around the wound with skin prep, fill the wound cavity with black foam, cover and secure area with drape and apply tubing. Apply negative pressure device at 125 (millimeters of mercury) mm Hg continuously. SN may use wet-to-dry dressing as an alternative as needed or until the machine is available. Instruct patient/caregiver on application of wet-to-dry dressing as needed for device malfunction. Review of the patient’s physician order, dated 03/17/2026, showed to cleanse the wound with wound cleanser, apply Vashe soaked gauze packing in wound bed, cover and secure with abdominal dressing or 4x4 gauze and tape, using aseptic technique. Dressing to be changed daily. Observation on 03/31/2026 at 09:30 AM, showed registered nurse (RN) A provided wound care to the patient’s right groin area as per the 03/17/2026 order. The patient no longer had the negative pressure wound therapy. The POC failed to show a safety measures for bleeding precautions, diabetes symptom management, and the updated wound care orders. During an interview on 03/31/2026 at 11:35 AM, the predesignated administrator backup stated that he/she would expect bleeding precautions, diabetes symptom management and updated wound orders to included on the POC. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 10/2017, showed in part: - The plan of care is a written plan that specifies the care and services necessary to meet the patient-specific needs identified in the comprehensive assessment, and the measurable outcomes that the agency anticipates would occur as a result of implementing and coordinating the plan of care; - The plan of care is required to include all medications and treatments; - The planning care is required to include in the individualized plan of care all appropriate interventions that are necessary to address and mitigate identified risk factors that contribute to the agencies establishment of a particular risk level for a patient to be re-hospitalized or revisit the emergency room; - Agency professional staff will revise the plan of care, as necessary, to reflect current information from the patients updated comprehensive assessment, and to record the patient’s progress towards meeting the patient specific measurable outcomes and goals selected by the agency and patient, as specified in the plan of care; and - The plan of care is updated/revised as new orders are received and when a significant change in condition occurs. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted for home health services on 03/17/2026 with a primary diagnosis of non-pressure chronic ulcer to the left ankle and the patient resided at home. Review of the hospital discharge records showed: - The patient was discharged home on intravenous (IV) antibiotics (ABT) via a tunneled central catheter line for treatment of osteomyelitis (infection in the bone); - Ceftazidime (ABT) 1 gram (g) in 50 milliliters (ml), 2 g IV every Monday, Wednesday, and Friday; - Vancomycin (ABT) 500mg IV every Monday, Wednesday, and Friday; - Weekly labs: complete blood count (CBC) with differential, complete metabolic panel (CMP), and c-reactive protein (CRP). Fax results to infectious disease (named provider and fax number); - Central line care per protocol; - Hydralazine 25 mg tablet, one (1) tablet every eight hours for high blood pressure (hold prior to hemodialysis on Monday, Wednesday and Friday, and hold for systolic blood pressure below 110); - Oxygen 3 liters (L) nightly as needed; - Diet: hemodialysis (renal diet) and a 1200 ml fluid restriction; and - The patient was to follow up with (named) wound care clinic, (named) vascular clinic, and (named) infectious disease clinic. Review of the POC showed: - Ceftazidime 2 g IV every Monday, Wednesday, and Friday through central venous catheter (the POC failed to include interventions or orders regarding who was responsible for administering the IV antibiotic); - Vancomycin 500 mg IV via central venous catheter every Monday, Wednesday, and Friday during dialysis (the POC failed to include interventions or orders regarding who was responsible for administering the antibiotic and who was responsible for obtaining the weekly labs); - The POC failed to include weekly labs orders, the name of the infectious disease clinic, contact information, and fax number for the lab results to be sent to); - The POC failed to include interventions or orders for central line care; - Hydralazine 25 mg tablet, three times a day by mouth. If blood pressure is not over 89/40, hold this medication along with the other blood pressure medications except for Coreg (the hospital discharge orders showed the patient was to hold the medication on Monday, Wednesday and Friday, and to hold for systolic blood pressure below 110); - Oxygen 2-4 L via nasal cannula as needed (the hospital discharge orders showed 3L of oxygen); - Diet: 2000 ml fluid restriction (the hospital discharge showed 1200 ml); and - The POC failed to show the patient was to follow up with (named) wound care clinic, (named) vascular clinic, and (named) infectious disease clinic. The POC failed to include all relevant physicians that were providing orders for the POC. During an interview on 04/01/2026, at 11:10 AM, the predesignated administrator backup stated that all of the patient’s interventions, orders, and physicians should be listed on the POC.”

“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, record review, and interview, the home health provider failed to provide a completed discharge summary to the health care provider care within five (5) days of discharge in one of two discharge records reviewed (Record/Patient #6). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Discharge/Reduction in Services,” dated 10/2017, showed in part: - All discharge paperwork will be due in the office within 72 hours of the discharge date; and - A completed discharge summary will be sent to the primary medical doctor (MD) within five (5) business days of discharge. RECORD/PATIENT #6: Review of the clinical record showed that the patient was admitted for home health services on 12/09/2025 with a primary diagnosis of an unspecified open wound to the right lower leg and resided at home. Review of the discharge summary showed: - The discharge date was 01/30/2026; and - The discharge summary was not completed until 02/07/2026 (eight days after the patient was discharged). During an interview on 04/01/2026, at 11:10 AM, the predesignated administrator backup stated that he/she would expect the discharge summary to be completed and sent to the primary care provider within 5 days.”