Clayview Home Health Services, Inc.

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the registered nurse (RN) completed the initial assessment within 48 hours of the patient’s referral or return home in, but not limited to, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Initial/Comprehensive Assessment,” dated reviewed/revised 09/2025, showed in part, an RN, physical therapist (PT), or speech/language pathologist (SLP) must conduct the initial assessment within 48 hours of referral, within 48 hours of the patient’s return home, or on the physician-ordered start of care (SOC) date. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/27/2026 with a primary diagnosis of arthritis (a common, often chronic condition, characterized by inflammation, pain, and stiffness in one or more joints) of multiple sites. The patient lived alone in an apartment building. Review of the clinical record showed: -A referral dated 04/24/2026 for PT to evaluate and treat. - An OASIS (Outcome and Assessment Information Set; a standardized data collection tool) SOC assessment dated 04/27/2026 (72 hours later); and - A communication noted dated 04/27/2026 (72 hours after the referral was received) that showed: “This is to notify you that your referred patient to our agency (provider) refused to be seen within 48 hours of receiving the referral order. The patient declined the scheduled Friday visit and refused weekend visit availability. (There failed to be any documentation of the date that the patient was contacted to schedule the initial visit.) During an interview on 05/19/2026 at 4:20 PM the administrator stated that initial assessments were completed within 48 hours of the referral unless the patient requested a later date and, if so, the request would be documented, and the physician would be notified. During an interview on 05/20/2026 at 2:43 PM the administrator stated that: - When they entered the patient in the electronic medical record (EMR), that was the date that showed on the note and the EMR would not let them change the date; and - He/she would have to work on the “glitch” in the EMR, dating the documentation so it would be correct when a patient requested a late SOC.”

“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 that all medications the patient was taking were current in one of two home visit observation 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, “Drug Regimen Teaching,” dated reviewed/revised 09/2025, showed in part: -Policy: To ensure that clinicians instructed/reviewed with the patient/caregiver about how to manage medication effectively and safely; and - A drug review was to be completed at the time of admission. It would include all medications, prescribed and over the counter, the patient was currently taking and was to be included on the plan of care (POC). Review of the provider’s undated policy titled, “Medication Teaching,” showed in part: - A complete medication reconciliation would be performed at admission, resumption of care, recertification, and whenever changes occur; and - Discrepancies shall be clarified with physician and documented in the clinical record. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/27/2026 with a primary diagnosis of arthritis (a common, often chronic condition, characterized by inflammation, pain, and stiffness in one or more joints) of multiple sites. The patient lived alone in an apartment building. Review of a referral with a fax cover sheet dated 04/24/2026, showed under medications: Not taking amiodarone hydrochloride (HCl) 200 milligram (mg) one tablet daily (used for heart rhythm abnormalities). Linzess (used to treat irritable bowel syndrome) failed to be listed. Review of an OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care (SOC) assessment dated 04/27/2026, showed: - Item M2001 marked 0 = no medication issues found during review; and - Page 32 of 35 listed amiodarone HCl 200 mg one tablet daily, and it failed to show Linzess 290 microgram (mcg) daily. Review of the initial POC, dated 04/27/2026 to 06/25/2026, showed Amiodarone HCl 200 mg one tablet daily listed and it failed to show Linzess 290 mcg. Observation and interview on 05/19/2026 at 1:48 PM showed the following discrepancies between the provider’s current medication profile and the patient’s home medication bottles: - The provider’s current medication profile showed amiodarone HCl 200mg one tablet daily. The patient stated that he/she did not take this medication and had not since admission to home health, “Maybe since back in January”; and - The provider’s current medication profile failed to show Linzess 290 mcg daily. The patient stated that he/she did take the Linzess daily and “had for a long time.” (The fill date on the bottle showed 02/02/2026.) During an interview on 05/20/2026 at 2:43 PM, the administrator stated that: - The patient should have been taking what the medication profile showed; and - Sometimes the patient did not tell the provider of changes.”

“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, and interview, the provider failed to ensure that each patient’s written individualized plan of care included the frequency and duration of visits to be made, patient-specific interventions and education, measurable outcomes and goals identified in the comprehensive assessment, and all safety measures regarding high-risk medications in, but not limited to, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Review of the provider’s undated policy titled, “Plan of Care (POC),” showed in part: - “Named provider” would establish, implement, and maintain an individualized written POC for each patient receiving home health services. The POC would be developed in collaboration with the physician or allowed practitioner and reflect patient-specific needs to ensure safe and effective care; - The POC would be developed based on the comprehensive assessment; and - The POC would include diagnoses, mental and functional status, medications and treatments, measurable goals, frequency and duration of services, rehabilitation potential if applicable, and discharge planning. Review of the provider’s undated policy titled, “Medication Teaching,” showed in part: - “Named Provider” would provide medication education to patients and caregivers to promote safe medication administration, prevent adverse drug effects, and ensure compliance with physician orders and regulatory requirements; and - Medication education would include drug name, purpose, dosage, route, frequency, potential side effects, adverse reactions, drug interactions, storage requirements, and when to notify the physician. High-risk medications would receive additional focused teaching; special attention would be given to anticoagulants (medication that prevents blood from clotting too easily), insulin (injectable medication used to lower blood sugar), opioids (medication used for moderate to severe pain), cardiac (heart) medications, and other high-risk drugs. Patients would be educated to monitor parameters and signs of complications. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/27/2026 with a primary diagnosis of arthritis (a common, often chronic condition, characterized by inflammation, pain, and stiffness in one or more joints) of multiple sites. The patient lived alone in an apartment building. Review of an OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care (SOC) assessment dated 04/27/2026 showed item M2010 (Has the patient/caregiver received instructions on special precautions for all high-risk medications such as hypoglycemics (medication that lowers blood sugar levels), anticoagulants (medication that thins the blood), and how and when to report problems that may occur? Coded as one- yes. Review of the physical therapy (PT) evaluation note that was sent to the physician for signature, dated 04/28/2026, showed: visit frequency and duration was one time a week for one week, then two times a week for three weeks. Planned intervention: therapeutic exercises, neuromuscular reeducation, gait training, balance training, and home exercise program. (This information failed to be included on the initial POC). Review of the initial POC, dated 04/27/2026 to 06/25/2026 showed: - Xarelto 20mg (milligrams) one tablet daily (medication that thins the blood); - Case Summary: Patient admitted to home health services with diagnosis including arthritis, generalized pain, and weakness resulting in decreased mobility, reduced endurance, impaired balance, and increased fall risk within the home environment. Patients were referred for PT services to address strength deficits, gait instability, functional mobility limitations, pain management, and safety with daily activities; - “Therapy would follow through with patient. Order was for therapy care only. PT to evaluate and treat”; - PT goals: Patient would demonstrate ability to follow home exercise program by evaluation; - See therapy care plan for care goals; and - The initial POC failed to include patient-specific PT interventions and education, measurable outcomes and goals, and the PT visit frequency and duration; and - The POC failed to include specific safety measures regarding high-risk medications (Xarelto). During an interview on 05/19/2026 at 4:20 PM, the administrator stated that PT’s evaluation is their POC and the physician signs it. During an interview on 05/20/2026 at 10:23 AM, the administrator stated that: - It (high risk medication teaching) was marked on the OASIS SOC note, but did not pull over to the POC like it was supposed to; - He/she was going to call the electronic medical record (EMR) and find out why; - He/she always taught about high-risk medications, but it did not show on the POC; and - It may have been time to change EMRs. During an interview on 05/20/2026 at 2:43 PM, the administrator stated that he/she: - Thought the signed PT evaluation was the POC; and - Already started to fix the high-risk medication issue on the POC.”

“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, record review, and interview, the home health provider failed to ensure skilled professional services were provided in an acceptable manner and as ordered by the physician in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients on service with the home health provider. Review of the provider’s policy titled, “Coordination of Patient Care,” revised 09/2025, showed in part: - The provider must integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines; and - Coordination of providers internal resources includes assuring all involved staff members are aware of patient’s plan of care (POC). Findings included: RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 03/17/2026 with a primary diagnosis of hypertensive urgency (occurs when blood pressure is severely elevated but there is no evidence of acute organ damage), adult failure to thrive (unexplained loss of appetite, weight loss, cognitive and functional decline, and social isolation, complicated by multiple medical comorbidities and psychiatric factors), and dementia without behavioral disturbance (decline in mental capacity). The patient lived with his/her spouse. Review of the hospital discharge orders dated 03/15/2026, showed occupational therapy (OT) for evaluation and treat for safety with ADLs (activities of daily living) /IADLs (instrumental activities of daily living). Review of an OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care (SOC) assessment dated 03/17/2026 showed: - Fall injuries in the past six months, interventions planned: physical therapy (PT) box checked yes, OT box checked yes; - Orders for discipline and treatments: OT frequency per evaluation; and - Goals/Rehabilitation potential/discharge plans: OT - to demonstrate ability to follow home exercise program by (date) per evaluation inserted. Review of the initial POC, dated 03/17/2026 to 05/15/2026 showed: Orders for disciplines and treatments – OT per evaluation. Review of the communication note dated 03/18/2026 showed this is to inform you that there will be a delay in initiating OT services for the patient referred to the provider on 03/15/2026 and OT services are now scheduled to begin on 03/25/2026. Review of the record failed to show an OT evaluation. Review of the home health change of care notice showed: - Your home health care is changing. Starting on 03/26/2026 your home health provider will change the items/services listed below; - What items/services are changing? All home health services; - Reason for change – Insurance denies; and - Mailed to the patient 03/27/2026. During an interview on 05/20/2026 at 3:00 PM, the administrator stated that, when an order for an evaluation is received, the evaluation should be completed as ordered.”