Piggott Health System Southeast Missouri Home Health

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to: -Ensure individualized plan of care included patient-specific interventions and education were included in the plan of care (G0574); -Ensure a copy of the visit schedule, including frequency of visits, was provided to the patient (G0614); -Ensure a current copy of the patient’s medication schedule/instructions, was provided to the patient (G0616); -Ensure a copy of pertinent instructions related to the patient’s care and treatments was provided to the patient (G0620); and -Ensure the name and contact information of the clinical manager was provided to the patient (G0622). The cumulative effects of these deficient practices have the potential to affect all the patients served by the provider.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the provider’s staff failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in one of three home visit observations conducted (Record/Patient #2). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: Review of the provider’s policy titled, “Exposure Control Plan,” dated February 2024, showed in part, before entering the home, make sure the bag is stocked with bacteriostatic foam/fluid/gel and plastic trash bags (preferable in a side pocket). Upon entering the home, place the bag on a clean surface; paper towels or plastic bag may be used to create a clean area if indicated. Open the bag near the care area and, if possible, near the water supply: - Wash hands thoroughly with bacteriostatic foam/liquid/gel; - Remove all items which will be needed for the visit; * Place items on one of the paper towels. Close the bag and give the patient care; * If additional items are needed after care has started, wash hands before re-entering the bag; * Clean any visibly soiled items which will be returned to the bag; * Wash hands and return equipment to the bag; close the bag; and * Tidy up the work area disposing of wastes. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses that included pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. Observation on 06/10/2025 at 11:45 AM, showed the registered nurse (RN) assembled the equipment used for vital sign assessment on a single barrier along with his/her nursing bag (placed in the middle of the barrier). The RN completed the vital sign assessment and placed the dirty equipment on the right side of the barrier (now the dirty side). The RN applied hand gel, then applied gloves and began cleaning the equipment, placed some of the clean equipment on the left side of the barrier (clean side) and the patient asked a question. The RN walked over to the patient while he/she was still cleaning the equipment, answered the question and walked back to the barrier. The RN finished cleaning his/her stethoscope, and the blood pressure cuff and then placed it back on the right side (dirty side) of the barrier beside the black bag that holds the blood pressure cuff. The RN did not clean the black bag. The RN removed his/her gloves, failed to clean his/her hands, picked up the blood pressure cuff and placed it into the black bag, placed the black bag and the rest of his/her equipment into the nursing bag and then applied hand gel to his/her hands. The computer tablet used by the RN to document the visit was handed to the patient and the patient signed the tablet. The RN failed to wipe the tablet prior to leaving the patient’s home and failed to clean it in his/her car. After leaving the patient’s home, the observed process was discussed with the RN related to the failure to observe the clean and dirty side of the barrier, the failure to clean his/her hands after removing gloves, the failure to clean the tablet, and he/she agreed the process was incorrect. During an interview on 06/10/2025 at 1:40 PM, the administrator stated that the tablet (computer) should be wiped down and the staff should follow their policy (infection control).”

“Eligible training/competency evaluation orgs. CFR(s): 484.80(f) A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years: (1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; or (2) Permitted an individual who does not meet the definition of a “qualified home health aide” as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or (3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or (4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or (5) Was found to have compliance deficiencies that endangered the health and safety of the HHA’s patients, and had temporary management appointed to oversee the management of the HHA; or (6) Had all or part of its Medicare payments suspended; or (7) Was found under any federal or state law to have: (i) Had its participation in the Medicare program terminated; or (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA’s patients; or (v) Been closed, or had its patients transferred by the state; or (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program. This Standard is not met as evidenced by: Based on the results of this extended level survey resulting in noncompliance with one Condition of Participation: Care Planning, Coordination of Services, and Quality of Care, the provider may not train, or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 06/11/2027.”

“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, and interview, the home health provider failed to ensure the timeliness of documentation in one of five full records reviewed (Record/Patient #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, “Timely Submission of Patient Documentation,” dated February 2024, showed in part that itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding three business days. All patient visit reports from contract personnel must be submitted within three business days from the date of the visit. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/16/2024 with a primary diagnosis of a urinary tract infection (an infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra (UTI)). Review of the clinical record showed the following: -A certified occupational therapy assistant (COTA) visit was made on 05/28/2025 and signed/completed by the clinician on 06/03/2025 (six days later); -A COTA visit was made on 05/30/2025 and signed/completed by the clinician on 06/04/2025 (five days later); -A COTA visit was made on 06/02/2025 and signed/completed by the clinician on 06/10/2025 (eight days later); and -A COTA visit was made on 06/06/2025 and signed/completed by the clinician on 06/10/2025 (four days later). During an interview on 06/10/2025 at 2:00 PM, the administrator stated that he/she would expect the clinicians to have documentation completed within 24 hours of the visit during the week or up to 72 hours over the weekend.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to ensure staff performed a complete medication review in three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Reconciliation,” dated February 2024, showed in part: - At the time of admission, the admitting registered nurse, physical therapist, or speech-language pathologist will create and document a complete list of medications that the patient is taking at home, including dose, strength, route, and frequency: * Any concerns or discrepancies will be reconciled by a registered nurse with the patient’s physician/practitioner; * Discrepancies include duplications, omissions, changes, contraindications and/or unclear information; * The provider provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route, and frequency as well as which medications will be administered by the provider’s staff and staff acting on behalf of the provider; * In therapy only cases, the therapist submits a list of medications collected during the comprehensive assessment to the registered nurse for review, who contacts the physician/practitioner if indicated; and - Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medications. The patient’s medication list in the home will also be updated. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/16/2024 with a primary diagnosis of a urinary tract infection (an infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra (UTI)). Observation and interview on 06/09/2025 at 12:30 PM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile: -The provider’s profile showed the patient took duloxetine hydrochloride (HCl) (used to treat depression and anxiety) 60 milligrams (mg) by mouth daily. The patient stated he/she no longer took this medication; -The provider’s profile showed the patient took lyrica (used to treat nerve pain) 50 mg by mouth once daily. The patient stated he/she no longer took this medication; and -The patient took acetaminophen 1000 mg by mouth as needed for pain. The provider’s profile failed to include this medication. During an interview on 06/10/2025 at 2:00 PM, the home health administrator stated that he/she would expect the medications that the patient was taking to match the provider’s medication list. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health service on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses including pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. Review of the patient’s hospital discharge medication list, dated 06/02/2025, compared to the provider’s admission medication list showed two additional medications listed on the provider’s medication list; cetirizine hydrochloride (used to treat allergies) 10 milligram (mg) one tablet daily as needed for allergies, and Tylenol Extra Strength (used to treat mild to moderate pain or fever) 500 mg one or two tablets every six hours as needed for pain. Review of the document titled, “OASIS-E1 (Outcome and Assessment Information Set) Start of Care”, dated 06/04/2025, showed the document failed to include communication with the patient’s attending provider to clarify if the patient should use these additional medications. Observation and interview on 06/10/2025 at 11:45 AM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile. The provider’s profile showed the patient took Tylenol (acetaminophen) Extra Strength 500 mg one or two tablets every six hours as needed for pain. The patient had a bottle of acetaminophen 650 mg in the home and stated that he/she was using this medication. During an interview on 06/10/2025 at 1:40 PM, the home health administrator stated he/she expected communication about the meds (medications) found in the home if different than the hospital discharge list, and a request for orders from the physician (attending provider). The administrator was unable to find additional information in the clinical record to clarify the discrepancies. ECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/29/2025 with a primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of diabetes (a group of diseases that results in too much sugar in the blood), chronic kidney disease (a condition where the kidneys are damaged and can’t filter blood effectively, leading to a buildup of waste and fluid in the body), traumatic subarachnoid hematoma (a condition where bleeding occurs in the space between the brain and the tissue covering it), fractures of the second cervical (neck), first lumbar (lower back), and fourth thoracic (chest) vertebrae, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), atherosclerotic heart disease (ASHD; thickening of the arterial wall that results in decreased supply of blood flow), and convulsions. The patient resided in his/her own home with the assistance of his/her spouse. Observation and interview on 06/10/2025 at 9:30 AM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile: - Ferrous sulfate (an iron supplement) one tablet daily. The patient stated he/she had been taking for several years; and - Folic acid (a vitamin supplement) one tablet daily. The patient stated he/she had been taking since his/her return from the hospital. During an interview on 06/11/2025 at 10:00 AM, the administrator and clinical manager stated that they would expect the clinicians to reconcile the medications at each visit.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the provider failed to ensure the plan of care (POC) included all required treatments and interventions in three of five records reviewed (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect the provision of care for all the patients served by the provider. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/29/2025 with a primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of diabetes (a group of diseases that results in too much sugar in the blood), chronic kidney disease (a condition where the kidneys are damaged and can’t filter blood effectively, leading to a buildup of waste and fluid in the body), traumatic subarachnoid hematoma (a condition where bleeding occurs in the space between the brain and the tissue covering it), fractures of the second cervical (neck), first lumbar (lower back), and fourth thoracic (chest) vertebrae, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), atherosclerotic heart disease (ASHD; thickening of the arterial wall that results in decreased supply of blood flow), and convulsions. The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “Home Health Certification and Plan of Care,” dated 05/29/2025, showed in part the document failed to contain orders and interventions for: - The monitoring of the patient’s weight and physician notification of weight gain associated with heart failure; - The frequency that the patient self-monitored his/her blood sugars, and need to assess the patient’s findings each visit to report readings outside of physician assigned parameters; and - An identification of the location of the patient’s pain or orders for the length of therapy for the use of warm or cold compresses. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home heath services on 10/03/2025 with a primary diagnosis of respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The patient had secondary diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), diabetes, atherosclerotic heart disease, cancer of the larynx (voice box), trachea (windpipe), and lung, and dysphagia (difficulty swallowing). The patient utilized a ventilator for breathing, a PEG tube (enteral feeding tube; a tube placed surgically through the abdominal wall into the stomach for the administration of food, fluids, and medication), and a PureWick system (a system used to control urine incontinence). The patient resided in his/her own home with the assistance of his/her spouse and adult children. Review of the document titled, “Home Health Certification and Plan of Care,” dated 05/31/2025, showed in part the document failed to contain orders for assessment and interventions for: - The patient’s tracheostomy; - The patient’s ventilator; - The care and use of the PEG tube; - The use of the PureWick system; - The frequency that the patient self-monitored his/her blood sugars and need to assess the patient’s findings each visit. Identification of physician assigned parameters for blood sugar readings; and - The length of therapy for the use of warm or cold compresses. During an interview on 06/11/2025 at 10:00 AM, the administrator and clinical manager stated that: - They would expect the plans of care to contain orders for assessments interventions to: * Monitor the patient’s weight for a patient with heart failure; * Assess the patient’s self-reported blood sugar readings; * Define parameters related to the patient’s blood sugar monitoring; * Manage a patient with a tracheostomy, ventilator, PEG tube, and PureWick system; * An identification of the length of therapy for the use of warm or cold compresses; and - They were unable to find the above interventions on the patients plans of care. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated February 2024, showed in part the individualized plan of care must include the following: - All pertinent diagnosis; - The patient’s mental, psychosocial, and cognitive status; - The types of services, supplies, and equipment required; - The frequency and duration of visits to be made; - Prognosis; - Rehabilitation potential; - Functional limitations; - Activities permitted; - Nutritional requirements; - All medications and treatments; - Safety measures to protect against injury; and - Patient-specific interventions and education, measurable outcomes and goals identified by the provider and the patient. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health service on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses including pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. Review of the POC dated 06/04/2025 to 08/02/2025, showed an order for the skilled nurse (SN) to instruct the patient/caregiver regarding strategies to mitigate pain including medication administration, recording and reporting pain, non-pharmacological (managing without medications) treatments, including positioning, massage, visualization, distraction and cold or warm compresses. During an observation visit with the registered nurse (RN) on 06/10/2025 at 11:45 AM, the patient was observed to have a heating pad in his/her recliner. The patient stated that he/she used the heating pad several times a day and applied it to his/her neck and back. The RN assisted the patient in positioning the heating pad to the patient’s neck and down to the lower part of the patient’s back. The patient turned on the heating pad, and the caregiver in the home stated the heating pad has a timer on it, and it shuts off automatically after about 15 or so minutes. The POC failed to include a complete order for the heat treatment used by the patient. During an interview on 06/10/2025 at 1:40 PM, the home health administrator stated that if the patient is using a heat treatment, he/she would expect the order for the treatment to include a location, how long to use it and the frequency.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the provider failed to ensure the patient was provided with a written visit schedule, including the frequency of visits by all personnel, in two of three home visit observations conducted (Records/Patients #2 and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/16/2024 with a primary diagnosis of a urinary tract infection (an infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra (UTI)). Review of the patient’s home folder showed the folder failed to contain a visit schedule, including frequency of visits for all disciplines seeing the patient. During an interview on 06/10/2025 at 2:00 PM, the home health administrator stated that he/she would expect the visit schedule of the disciplines to be present in the home folder. Findings included: Review of the provider’s policy titled, “Coordination of Patient Care,” dated February 2024, showed in part the provider would coordinate care with the patient by providing a copy of written instructions outlining the patient’s visit schedule including the frequency of visits. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health service on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses including pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. During a home visit observation, on 06/10/2025 at 11:45 AM, with the registered nurse (RN), the home admission folder (a packet of information given to the patient at the time of admission to home health) was reviewed. The folder failed to contain a written visit schedule. The caregiver in the home stated that would be nice to have, to help coordinate visits. The RN confirmed that the patient did not have a visit schedule in the home.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the provider failed to ensure the patient was provided a written medication schedule/list, in three of three home visit observations conducted (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/16/2024 with a primary diagnosis of a urinary tract infection (an infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra (UTI)). Review of the patient’s home folder showed a medication list dated 02/16/2024 – 04/15/2024. The folder failed to contain an accurate and updated medication list. During an interview on 06/10/2025 at 2:00 PM, the home health administrator stated that he/she would expect the updated medication list to be present in the home folder. Findings included: Review of the provider’s policy titled, “Coordination of Patient Care,” dated February 2024, showed in part the provider would coordinate care with the patient by providing a copy of the written patient medication schedule/instructions. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health service on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses including pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. During a home visit observation on 06/10/2025 at 11:45 AM with the registered nurse (RN), the home admission folder (a packet of information given to the patient at the time of admission to home health) was reviewed. The folder failed to contain a written medication schedule with instructions (six days after admission). The RN confirmed that the patient did not have a written medication schedule in the home and stated the provider mails this (medication schedule/list) to the patient. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/29/2025 with a primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of diabetes (a group of diseases that results in too much sugar in the blood), chronic kidney disease (a condition where the kidneys are damaged and can’t filter blood effectively, leading to a buildup of waste and fluid in the body), traumatic subarachnoid hematoma (a condition where bleeding occurs in the space between the brain and the tissue covering it), fractures of the second cervical (neck), first lumbar (lower back), and fourth thoracic (chest) vertebrae, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), atherosclerotic heart disease (ASHD; thickening of the arterial wall that results in decreased supply of blood flow), and convulsions. The patient resided in his/her own home with the assistance of his/her spouse. Observation on 06/10/2025 at 9:30 AM, during the patient’s home visit: - A review of the documentation in the patient information folder in the patient’s home failed to contain a written list of the patient’s medications; - The visiting clinician confirmed the folder failed to contain a written list of the patient’s medications; and - The patient stated he/she had not received a written list of his/her medications. During an interview on 06/11/2025 at 10:00 AM, the administrator stated they would expect the clinicians to provide a written list of medications to their patients.”

“Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient’s care and treatments that the HHA will provide, specific to the patient’s care needs. This Element is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the provider failed to ensure the patient and caregiver received a copy of written instructions specific to the patient’s needs in one of three home visit observations conducted (Record/Patient #1). This deficient practice has the potential to affect the quality of care for all the provider’s patients. Findings included: Review of the provider’s policy titled, “Coordination of Patient Care,” dated February 2024, showed in part the agency would coordinate care with the patient by providing a copy of written instructions outlining pertinent instruction related to the patient’s care and treatments specific to the patient’s care needs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/29/2025 with a primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of diabetes (a group of diseases that results in too much sugar in the blood), chronic kidney disease (a condition where the kidneys are damaged and can’t filter blood effectively, leading to a buildup of waste and fluid in the body), traumatic subarachnoid hematoma (a condition where bleeding occurs in the space between the brain and the tissue covering it), fractures of the second cervical (neck), first lumbar (lower back), and fourth thoracic (chest) vertebrae, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), atherosclerotic heart disease (ASHD; thickening of the arterial wall that results in decreased supply of blood flow), and convulsions. The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “Home Health Certification and Plan of Care,” dated 05/29/2025, showed in part the patient’s primary diagnosis was heart failure. Observation and interview on 06/10/2025 at 9:30 AM, showed: - A review of the documentation in the patient information folder in the patient’s home failed to contain written instructions on the management of heart failure; - The visiting clinician confirmed the folder failed to contain written instructions on the management of heart failure; and - The patient stated that he/she had not received written information on the management of heart failure. During an interview on 06/11/2025 at 10:00 AM, the administrator stated that they would expect the clinicians to provide written instructions to their patients on the management of the primary diagnosis for care.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the provider failed to ensure the contact information for the clinical manager was provided to the patient in two of three home visit observations conducted (Records/Patients #2 and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/16/2024 with a primary diagnosis of a urinary tract infection (an infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra (UTI)). Review of the patient’s home folder showed the folder failed to contain the contact information for the clinical manager. During an interview on 06/10/2025 at 2:00 PM, the home health administrator stated that he/she would expect the contact information for the clinical manager to be present in the home folder. Findings included: Review of the provider’s policy titled, “Coordination of Patient Care,” dated February 2024, showed in part the provider would coordinate care with the patient by providing the name and contact information of the provider’s director of clinical services. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health service on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses including pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. During a home visit observation on 06/10/2025 at 11:45 AM with the registered nurse (RN), the home admission folder (a packet of information given to the patient at the time of admission to home health) was reviewed. The folder failed to contain the contact information for the clinical manager. During an interview on 06/11/2025 at 10:00 AM, the home health administrator confirmed that the contact information for the clinical manager was missing from the admission folder and stated he/she planned to add that information to the admission folder.”

“Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures. This Element is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure the aide reported changes in the patient’s condition to a registered nurse (RN) or other skilled professional in three of three reviewed records of patient’s receiving home health aide services (Records/Patients #2, #3, and #4). This deficient practice has the potential to affect the care of all the provider’s patients. Findings included: Review of the provider’s policy titled, “Home Health Aide Services and Training Program,” dated February 2024, showed in part the duties of a home health aide include reporting changes in the patient’s condition to a registered nurse or other appropriate skilled professional. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home heath services on 10/03/2025 with a primary diagnosis of respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The patient had secondary diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood), atherosclerotic heart disease (ASHD; thickening of the arterial wall that results in decreased supply of blood flow), cancer of the larynx (voice box), trachea (windpipe), and lung, and dysphagia (difficulty swallowing). The patient resided in his/her own home with the assistance of his/her spouse and adult children. Review of home health aide documentation for the dates of 04/30/2025 to 05/28/2025 showed in part the patient refused for the aide to perform oral care, cleaning of dentures, assistance with bedpan/urinal, incontinence care, dangling on the side of the bed, use of the Hoyer lift, equipment care, and changing of the patient’s linens. The visit notes failed to include documentation that the HHA reported the refusals of care to the registered nurse or other skilled professional. During an interview on 06/11/2025 at 10:00 AM, the administrator and clinical supervisor stated they would expect the home health aide to report patient refusals of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/16/2024 with a primary diagnosis of a urinary tract infection (an infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra (UTI)). Review of the home health aide (HHA) visits dated 04/08/2025 – 06/03/2025 showed the patient refused to have the HHA shampoo and comb the patient’s hair. The HHA failed to report the refusals of care to the registered nurse (RN). During an interview on 06/10/2025 at 2:00 PM, the home health administrator stated that he/she would expect the refusals of care to be reported to the RN and those tasks taken off the aide care plan. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health service on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses including pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. Review of the home health aide care plan dated 06/04/2025 showed the aide was tasked with notifying the registered nurse (RN) of refusal of care and had a list of tasks to complete that included apply lotion, comb hair, change linens, and clean/file nails at every visit. Review of the home health aide (HHA) visit note dated 06/05/2025 showed the patient refused to have the HHA apply lotion, comb hair, or change linens. The HHA marked not applicable (N/A) to the task of clean/file nails. The visit note failed to include documentation that the HHA reported the refusals of care to the RN and the box on the visit note for notifying the case manager of problems/concerns was not marked. During an interview on 06/10/2025 at 1:40 PM, the home health administrator stated that he/she would expect the refusals of care to be reported to the RN so the task plan (aide care plan) could be updated, would expect a communication note in the chart (clinical record) and would expect the notified case manager of problems/concerns box to be marked.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure an accurate home health aide (HHA) supervision included ensuring the HHA reported changes in the patient’s condition in one of three reviewed records of patient’s receiving home health aide services (Record/Patient #4). This deficient practice has the potential to affect the home health aide services for all of the provider’s patients. Findings included: Review of the provider’s policy titled, “HHA Supervisory Visit,” dated February 2024, showed in part home health aide supervision must ensure that aides furnish care in a safe and effective manner, including but not limited to: - Following the patient’s plan of care for completion of tasks assigned to an HHA by the registered nurse or other appropriate skilled professional; and - Reporting changes in the patient’s condition. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/03/2025 with a primary diagnosis of respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The patient had secondary diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood), atherosclerotic heart disease (ASHD; thickening of the arterial wall that results in decreased supply of blood flow), cancer of the larynx (voice box), trachea (windpipe), and lung, and dysphagia (difficulty swallowing). The patient resided in his/her own home with the assistance of his/her spouse and adult children. Review of HHA documentation for the dates of 04/30/2025 to 05/28/2025, showed in part the HHA failed to notify the registered nurse or other skilled professional of the patient’s refusal to allow the HHA to perform oral care, clean dentures, assist with bedpan/urinal, provide incontinence care, dangle on the side of the bed, use the Hoyer lift (a mechanical lift used for transferring patients), equipment care, and change the patient’s linens. Review of the documents titled, “HHA Supervisory visit,” with the dates of 05/08/2025 and 05/23/2025, showed in part: - The aide followed the plan of care for completion of tasks as assigned; - Informed the supervisor of client’s needs and changes in the patient’s condition as required; and - The supervisory visit documentation failed to address the HHA’s failure to notify the registered nurse or other skilled professional of the patient’s refusal for the HHA to perform tasks. During an interview on 06/11/2025 at 10:00 AM, the administrator and clinical manager stated that they would expect the HHA supervision documentation to reflect the HHA’s failure to report that the patient had refused the provision of tasks listed on the HHA assignment sheet.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on the Missouri statute review, employee file review, and interview, the home health provider failed to ensure Missouri Family Care Safety Registry (FCSR) results were obtained prior to patient contact in two of three employee records reviewed (Employees #1 and #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Safety Registry regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Safety Registry. Review of Section 192.2495.6, RSMo: “A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, 566 or 569, or any violation of subsection 3 of section 198.070 or section 568.020.” Review of Section 192.2495.7, RSMo (effective August 28, 2018): “Any in-home services provider agency or home health agency shall be guilty of a class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the family care safety registry or if such person: (1) Has any of the disqualifying factors listed in subsection 6 of this section; (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under chapter 195 or 579; (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under section 568.045, 568.050, 568.060, 568.175, 570.023, 570.025, 570.030, 570.040 as it existed prior to January 1, 2017, 570.090, 570.145, 570.223, 575.230, or 576.080; (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of section 577.010 or 577.012 and who is alleged and found by the court to be an aggravated or chronic offender under section 577.023; (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under section 589.400; (6) Is listed on the department of health and senior services employee disqualification list under section 192.2490; (7) Is listed on the department of mental health employee disqualification registry under section 630.170; or (8) Has a finding on the child abuse and neglect registry under sections 210.109 to 210.183.” EMPLOYEE #1: Review of the employee record showed: -Date of first patient contact: 03/23/2022; and -The provider failed to show a FCSR result prior to 03/23/2022. EMPLOYEE #2: Review of the employee record showed: -Date of first patient contact: 12/07/2022; and -The provider failed to show a FCSR result prior to 12/07/2022. During an interview on 06/10/2025 at 1:21 PM, the administrator stated that he/she did not have the FCSR result for the two employees, he/she only had a copy of the request, not the results.”