Well Care Home Health

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to document an incident report for 1 of 1 patient with falls (patient #1). Findings included: A policy, Incident Report Policy (approved 12/2024), received on 4/6/26 at 1:51 PM from the Executive Director of Clinical Operations stated, “Staff will promptly complete an Incident Report for any of the incidents/accidents or concerns. This will include, but is not limited to the following: … All falls (Attended or Unattended) …” Patient #1 was admitted on 1/10/26 with a diagnosis of orthostatic hypotension (sudden drop in blood pressure with position changes). The plan of care (POC) for 1/10/26-3/10/26 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 5 weeks, 1 every other week for 2 weeks; and occupational therapy 1 time a week for 1 week and 1 time a week for 6 weeks. Review of the clinical record revealed that on 1/19/26 the Certified Occupational Therapy Assistant (COTA) #4 documented a caregiver reported fall on 1/17/26 and on 2/26/26 COTA #4 documented, “CG [care giver] reports PNT [patient] fall yesterday…” An interview conducted on 4/6/26 at 11:37 AM with the Manager of Compliance and Quality revealed that the incident reports were not documented for the falls on 1/19/26 or 2/26/26 and should have been.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to include an order for Social Worker (SW) visits in the plan of care for 1 of 1 patient with a referral for SW visits (patient #1). Findings included: A policy, Initial and Comprehensive Assessment Policy (approved 12/2024), received on 4/6/26 at 1:48 PM from the Regional Director of Clinical Operations stated, “The assessment will be patient-specific and comprehensive to include the patient’s need for home health care, rehabilitative care, social services, and discharge planning…” Patient #1 was admitted on 1/10/26 with a diagnosis of orthostatic hypotension (sudden drop in blood pressure with position changes). The plan of care (POC) for 1/10/26-3/10/26 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 5 weeks, 1 every other week for 2 weeks; and physical therapy visits 2 times a week for 2 weeks, 1 time a week for 2 weeks, 2 every other week for 4 weeks; and occupational therapy 1 time a week for 1 week. Review of the clinical record revealed that the physician that referred the patient for home health included an order for social worker (SW) visits. Further review revealed that there was no order for SW visits included in the POC. During an interview conducted on 4/6/26 at 1:38 PM the Regional Director of Clinical Operations stated, “It [the order for SW visits] should have been added [to the POC] by the start of care clinician.””

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on clinical record review and staff interviews the medication Ozempic [GLP-1 glucagon-like peptide] was documented as an insulin (patient #3). Findings included: Patient #3 was admitted on 2/23/26 with diagnoses of hemiplegic migraine (severe migraine with temporary paralysis on one side of the body), type 2 diabetes (bodies inability to produce insulin), and long term (current) use injectable non-insulin antidiabetic drugs. The plan of care for 2/23/26-4/23/26 included orders for skilled nurse visits 2 times a week for 1 week, 1 time a week for 2 weeks, 1 every other week for 6 weeks with 3 PRN (as needed) and “Ozempic 0.25 mg or 0.5 mg (injectable non-insulin antidiabetic drug) subcutaneous (sub-Q) pen, inject Sub-Q weekly.” Review of the clinical record revealed that on 2/23/26 registered nurse (RN) #5 documented, “Is the patient taking any of the following categories of high alert medication? … Insulins…” Further review revealed that patient #3 did not have an order for insulin. During an interview conducted on 4/6/26 at 1:02 PM RN #5 stated, “We were listing all the GLP-1 [Glucagon-like-peptide-1, injectable non-insulin medication] medications under insulins...” The interview revealed that RN #5 understood that Ozempic was not insulin. During an interview conducted on 4/6/26 at 1:10PM the Regional Director of Clinical Operations stated, “We are including the GLP-1 medication as insulin… there is a misunderstanding about [documentation of] the high-risk care pathway and high-risk medications.””