Bayada Home Health Care, Inc.

“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 agency policy, direct observation during home visits, clinical record review, staff interviews, and patient/caregiver interviews, the plan of care [POC] failed to include all/correct medications the patient was taking for 6 of 14 patients [ #5, 7, 6, 8, 3 and 4]; and failed to include the correct route of medication administeration for 1 of 1 patient who was NPO [nothing by mouth] [#1]; and the POC failed to include weight bearing status for 1 of 1 patient [#9]. The findings included: The policy, Medication Management and Administration [revised 5/6/24], was provided by the agency director on 2/26/25 at approximately 8:42 am. The policy stated, “...For Home Health...medication reconciliation should be completed on assessment and reassessment...” The policy, Client Care Plan [revised 7/5/21], was provided by the agency director on 2/26/25 at 11:29 am. The policy stated, “...Plan of Care Content...All medications and treatments...” 4. Patient # 6 had a Start of Care date of 11/8/24 with admitting diagnoses of puncture wound with foreign body, right foot and cutaneous abscess [a localized collection of pus (purulent material) that forms within the skin or subcutaneous tissues]. Review of the Plan of Care [POC] for the certification period 1/7/25-3/7/25 included a supplemental order dated 2/5/25 for PT [physical therapy] 1 time a week for 5 weeks. On 2/24/25 at approximately 2 pm, a joint visit was conducted with PTA # 5. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed: Amlodipine [blood pressure medication] 10 mg. Take 1 tablet daily. During an interview with the caregiver, who manages the medications, she reported the patient no longer takes the Amlodipine. Gabapentin [nerve pain medication] 300 mg. Take 1 capsule daily as needed. The caregiver reports that the patient does not take this medication. Levofloxacin [antibiotic] 500 mg. Take 1 tablet daily. The caregiver reports that the patient does not take this medication. Nifedipine ER [blood pressure/heart rate medication] 60 mg. Take 1 tablet daily. The caregiver reports that the patient does not take this medication. Prednisone [steroid] 20 mg. Take 2 tablets daily. Take 1 tablet daily. The caregiver reports that the patient does not take this medication. The caregiver presented the following medications that were not listed on the medication profile or were listed as discontinued: Losartan [blood pressure]100 mg. Patient is taking 100 mg daily. Farxiga [used for kidney disease] 10 mg. The patient is taking 10 mg daily. Ozempic [diabetic medication] 2 mg/3ml. The patient is taking 0.25 mg each week. During an interview with the agency director on 2/24/25 at approximately 9:30 am, the director confirmed the POC was incorrect. 5. Patient # 8 had a Start of Care date of 1/21/25 with an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. Review of the Plan of Care for the certification period 1/21/25-3/21/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks. On 2/25/25 at approximately 10 am, a joint visit was made with RN #. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile included- Alendronate [used to treat osteoporosis] 70 mg. Take 1 tablet weekly. Clorazepate Dipotassium [used to treat anxiety] 7.5 mg. Take 1 tablet daily. Pyridostigmine Bromide [used to treat muscle weakness] 60 mg. Take 0.5 tablets 3 times a day. During an interview with the son, who manages the medications, he reported his mother no longer takes any of these medications. During an interview with the agency director on 2/26/25 at approximately 3 pm, the director confirmed the POC did not include all the correct medications. 6. Patient # 3 had a Start of Care date of 12/10/24 with an admitting diagnosis of disruption of external operation (surgical) wound [surgical site reopens]. Review of the Plan of Care [POC] for the certification period 12/10/24-2/7/25 included orders for SN [skilled nursing] 2 times a week for 1 week, 3 times a week for 2 weeks, 2 times a week for 1 week. Review of the medication section of the POC included the following entry,” Novolog [insulin-used to treat diabetes] Flexpen U-100 Aspart 100 units/ml (3 ml) subcutaneous [under the skin]. Before meals inject 30-40 can titrate up to 50. The POC failed to include the blood sugar results and how much insulin to administer. During an interview with the agency director on 2/26/25 at approximately 3 pm, the director confirmed the POC was incomplete. 7. Patient # 4 had a Start of Care [SOC] date of 11/13/24 with an admitting diagnosis of acute cystitis [inflammation of the bladder]. Review of the Plan of Care for the certification period 11/13/24-1/11/25 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 4 weeks. Review of the clinical record revealed PT # 7 completed the SOC OASIS [Outcome and Assessment Information Set-data set used in home health] on 11/13/24. Review of the OASIS documentation M1100 revealed PT # 7 answered yes to this question [is oxygen in use]. Review of the POC did not include oxygen on the medication section. During an interview with the agency director on 2/26/25 at approximately 3 pm, the director confirmed the oxygen should have been included on the POC medication section. 8. Patient # 9 had a Start of Care of date of 2/1/25 with a terminal diagnosis of infection/inflammatory reaction due to internal left knee prosthesis. Review of the Plan of Care [POC] for the certification 2/1/25 to 4/1/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week, 1 time a week for 6 weeks. Further review of the POC included “Activities Permitted”- up as tolerated; walker; let knee immobilizer. Review of the discharge summary dated 1/31/25 included the following orders “TTWB [toe touch weight bearing] LLE [left lower extremity] with no range of motion for 3 weeks.” Further review of the POC revealed the weight bearing restrictions and no range of motion x 3 weeks was not included. During an interview with the agency director on 2/26/25 at 3 pm confirmed the weight bear limitation and no ROM [range of motion] for 3 weeks should have been included on the POC. 1.Patient #5 had a Start of Care date of 1/28/2025 with admitting diagnoses of Hemiplegia following cerebral infarction affecting the right dominant side (right sided weakness following a stroke), pneumonia (infection that inflames the air sacs in one or both lungs, which may fill with fluid), congestive heart failure (A chronic condition in which the heart doesn’t pump blood as well as it should), and Type 2 Diabetes (condition in which the body has trouble controlling blood sugar levels). Review of the Plan of care for the certification period 1/28/2025 to 3/28/2025 included orders for PT (physical therapy) 1 time a week for 2 weeks, 2 times a week for 3 weeks, 1 time a week for 3 weeks. On 2/24/2025 at approximately 3:30 pm a joint visit was conducted with PT #7. During the visit, a medication review was conducted using the medication profile on the patient’s plan of care, which was provided by the agency. The following discrepancies were noted: Oxycodone 10/325mg (a combination medication used to help relieve moderate to severe pain. Contains an opioid pain reliever -oxycodone 10mg and a non-opioid pain reliever -acetaminophen 325mg) was listed as every 8 hours as needed on the agency provided plan of care. The prescription bottle found in the home reads to take every 6 hours as needed and the patient confirmed he takes this medication every 6 hours. Diltiazem 120mg (used to treat high blood pressure and chest pain) was not listed on the agency provided plan of care. The prescription bottle containing this medication was found in the home. The patient stated he took this medication daily. Metoprolol 75mg (used to treat high blood pressure and chest pain) was not listed on the agency provided plan of care. The prescription bottle containing this medication was found in the home. The patient stated he took this medication 2 times a day. Tamsulosin 0.4mg (used to treat difficulty with urination) was not listed on the agency provided plan of care. The prescription bottle containing this medication was found in the home. The patient stated he took this medication daily. Loratadine 10mg (used to treat allergy symptoms) was listed on the agency provided plan of care. The patient stated he did not have this medication in his home and was not taking it. Ozempic 2mg/dose injector pen (used to lower high blood sugar levels) was found in the home. Directions stated to inject 2mg weekly. The agency provided plan of care instructed to inject monthly. 2. Patient #7 had a Start of Care date of 10/18/2024 with admitting diagnoses of Type 2 Diabetes (condition in which the body has trouble controlling blood sugar levels), chronic ulcer (an open sore or break in the skin or lining of an organ), of left heel and midfoot with fat layer exposure, and osteomyelitis (a bone infection). Review of the Plan of care for the certification periods of 12/17/2024 to 2/14/2025 included orders for SN (skilled nursing) 1 time a week for 9 weeks, and 2/15/2025 to 4/15/2025 included orders for SN 1 time a week for 8 weeks. On 2/25/2025 at approximately 1:15 pm a joint visit was conducted with RN #3. During the visit, a medication review was conducted using the medication profile on the patient’s plan of care, which was provided by the agency. The following discrepancies were noted: Doxycycline Hyclate 100mg (antibiotic used to treat bacterial infections) was not listed on the agency provided plan of care. The prescription bottle containing this medication was found in the home with a start date listed as 2/8/2025. The patient stated he takes this medication 2 times a day. 3. Patient #1 had a Start of Care date of 3/13/2024 with admitting diagnoses of Hemiplegia following cerebral infarction affecting the right dominant side (right sided weakness following a stroke), dysphagia (difficulty swallowing) following cerebral infarction (stroke), and encounter for attention to gastrostomy (a surgical procedure that creates an opening in the abdomen that leads to the stomach, used for inserting a percutaneous endoscopic gastrostomy (PEG) feeding tube). Review of the Plan of care for the certification period 3/13/2024 to 5/11/2024 included orders for SN (skilled nursing) 1 time a week for 4 weeks, 1 time every other week for 4 weeks, 1 time a week for 1 week. Then ordered for 1 time a week for 2 weeks starting 4/28/2024. PT (physical therapy) 1 time a week for 2 weeks, 2 times a week for 2 weeks, 1 time a week for 4 weeks. ST (speech therapy) 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. Further review of the POC revealed: Orders were written in Plan of Care for skilled nurse to instruct on PEG tube feeding. No tube feeding description or specifics listed on plan of care. Plan of care stated patient is to remain NPO (receive nothing by mouth). Acetaminophen 500 mg (a non-opioid pain reliever) take orally every 8 hours as needed was on plan of care medication list.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to include all orders in the Plan of Care for 2 of 8 patients who had a wound [#9, 10]. The findings included: The policy, Client Care Plan [revised 7/5/21], was provided by the agency director on 2/26/25 at 11:29 am. The policy stated, “...Plan of Care Content...All medications and treatments...” 1.Patient # 9 had a Start of Care [SOC] of date of 2/1/25 with a terminal diagnosis of infection/inflammatory reaction due to internal left knee prosthesis. Review of the Plan of Care [POC] for the certification 2/1/25 to 4/1/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week, 1 time a week, 1 time a week for 6 weeks. Review of the discharge instructions from _____ [name of hospital] dated 1/31/25 included the following instructions, “Remove the ace wrap and white bulky dressing postop day one after your surgery...” Review of the clinical record revealed RN # 13 completed the SOC [Outcome and Assessment Information Set-data set used in home health] on 2/1/25. Review of the documentation revealed the following information, “...Client has ace wrap on left leg and non-removable dressing to surgical site, to be removed at follow-up visit in 10 days...” The patient received SN visits on 2/1/25, 2/3/25, 2/6/25 and 2/10/25. The ace wrap and the white bulky dressing remained in place until the patient removed it on 2/10/25. During an interview with the agency director on 2/26/25 at approximately 3 pm, the director confirmed the SN failed to include the orders related to removal of the ace wrap and white bulky dressing on the POC. 2. Patient # 10 had a Start of Care date of 12/27/24 with and admitting diagnoses of pressure ulcer of other site, unstageable [the depth of the wound cannot be determined because it is covered by a thick layer of dead tissue caused slough or eschar] and type 2 diabetes with diabetic peripheral angiopath [complication of diabetes that affects the blood vessels] w/o gangrene. [ Review of the referral orders revealed the following order related to wound care “cleanse with soap and water. Pat dry. Apply Prisma, then adaptic and cover with convafoam. Change every other day and as needed if soiled or saturated”. Review of the Plan of Care for the certification period 12/27/24-2/24/25 revealed the following wound care order, “Skilled nurse will perform wound care...to pressure ulcer left anterior knee...cleanse wound with wound cleanser. Apply prisma to wound bed, cover and secure with adhesive foam dressing...” Further review of the clinical record revealed the patient received 6 SN visits from 12/27/24-2/14/25 for wound care. Each visit the SN documented the wound care completed was the wound care on the POC not the specific wound care ordered on the referral. During an interview with the agency director on 2/26/25 at approximately 3 pm, the director confirmed the nurses failed to complete wound care as ordered on the referral. “The ordered for the prisma and adaptic was not transcribed to the POC.””

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to obtain an order to flush a supra pubic catheter [catheter used to drain urine that is inserted into the bladder] for 1 of 1 patient with a supra pubic catheter [#2]; and failed to follow physician’s orders on the plan of care to montior blood sugars/weights for 3 of 14 patients [#10, 14 and 5]; and failed to obtain an order for a patient to have food/water by mouth for 1 of 1 patient who was NPO [nothing by mouth] [#1]. The findings included: The policy, Chart Data Requirements and Format [revised 10/23/23], was provided by the agency director on 2/26/25 at 8:42 am. The policy stated, “...physician/healthcare practitioner’s orders and the documentation of the nursing care plan process for the care and services to be provied...” 4. Patient #5 had a Start of Care date of 1/28/2025 with admitting diagnoses of Hemiplegia following cerebral infarction affecting the right dominant side (right sided weakness following a stroke), pneumonia (infection that inflames the air sacs in one or both lungs, which may fill with fluid), congestive heart failure (A chronic condition in which the heart doesn’t pump blood as well as it should), and Type 2 Diabetes (condition in which the body has trouble controlling blood sugar levels). Review of the Plan of care for the certification period 1/28/2025 to 3/28/2025 included orders for PT (physical therapy) 1 time a week for 2 weeks, 2 times a week for 3 weeks, 1 time a week for 3 weeks and for SN [skilled nursing] 1 time a week for 4 weeks, 1 time every other week for 4 weeks, 1 time a week for 1 week. Further review of the plan of care revealed the following orders: “Skilled nurse will assess and instruct on management of heart failure, early recognition of signs of exacerbation, client/caregiver self-management, and observation of client’s weight. Notify physician of weight gain of 3 pounds in one day or 5 pounds in one week.” “Skilled nurse will assess and instruct client/caregiver on diabetes management including…monitoring blood glucose…skilled nurse to perform/instruct the client/caregiver to monitor blood glucose as ordered daily and prn…notify physician of blood glucose greater than 350 or less than 60.” “Physical therapist perform/instruct the client/caregiver to monitor blood glucose as ordered daily and prn…notify physician of blood glucose greater than 350 or less than 60.” Review of the clinical record revealed LPN #10 did not record a blood glucose reading or a weight on SN visit on 2/4/25 and RN # 3 did not record a blood glucose reading on SN visit on 2/20/25. PT#7 did not record a blood glucose reading on PT eval visit on 1/31/25 and PTA #5 did not record a blood glucose reading on PTA visit on 2/5/25, 2/10/25, and 2/12/25. During interview with the agency director on 2/26/25 at approximately 3 pm, the director confirmed the SN and PT failed to follow the physician’s order on the POC related to monitoring blood sugars and weight. 5. Patient #1 had a SOC date of 3/13/2024 with admitting diagnoses of Hemiplegia following cerebral infarction affecting the right dominant side (right sided weakness following a stroke), dysphagia (difficulty swallowing) following cerebral infarction (stroke), and encounter for attention to gastrostomy (a surgical procedure that creates an opening in the abdomen that leads to the stomach, used for inserting a percutaneous endoscopic gastrostomy (PEG) feeding tube). Review of the POC for the certification period 3/13/2024 to 5/11/2024 included orders for SN (skilled nursing) 1 time a week for 4 weeks, 1 time every other week for 4 weeks, 1 time a week for 1 week. Then ordered for 1 time a week for 2 weeks starting 4/28/2024. Review of the SOC OASIS (Outcome and Assessment Information Set is the patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality) dated 3/13/24 revealed RN #6 answered OASIS question M1870 Feeding or Eating question with “unable to take in nutrients orally and is fed nutrients through nasogastric tube (a thin, flexible tube inserted through the nose, down the throat, and into the stomach) or gastrostomy.” The POC states “nutritional requirements as NPO (nothing by mouth). Review of the SN visit note dated 4/4/24 revealed RN #3 documented “patient is ‘having a few sips of water’ a day”. Review of the clinical record revealed no order for the patient to begin taking in food or drink orally. Per an interview with the agency director on 2/26/25 at approximately 3 pm, the director confirmed there was no physician’s order for the patient to have food/liquid by mouth. 1.Patient # 2 had a Start of Care date of 9/2/23 with admitting diagnoses of pressure ulcer of sacral area [base of spine], stage 3 [full thickness tissue loss where the subcutaneous fat layer is visible within the wound], pressure ulcer of sacral region, stage 2 [partial thickness loss of the skin], and quadriplegia [loss of movement and sensation in all 4 limbs]. Review of the Plan of Care for the certification period 4/29/24-6/27/24 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “Client continues to have supra pubic catheter [catheter used to drain urine that is inserted into the bladder] that is managed by the urologist...” Review of the clinical records revealed the following information; RN # 3 conducted a routine visit on 5/9/24 and documented the following information, “Patient home with sister...Flushed catheter per patient request...” RN # 3 made a routine visit on 5/24/24 and documented, “Patient home with sister...SN flushed foley per patient request...”Further review of the clinical record revealed no physician’s order for SN to flush catheter. During an interview with the agency director on 2/26/25 the director confirmed there was no physician’s order for the SN to flush the catheter. 2. Patient # 10 had a Start of Care date of 12/27/24 with and admitting diagnoses of pressure ulcer of other site, unstageable [the depth of the wound cannot be determined because it is covered by a thick layer of dead tissue caused slough or eschar] and type 2 diabetes with diabetic peripheral angiopath [complication of diabetes that affects the blood vessels] w/o gangrene. Review of the Plan of Care [POC] for the certification period 12/27/24-2/24/25 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 7 weeks and “Skilled nurse will assess and instruct client/caregiver on diabetes management...Skilled nurse to perform/instruct the client/caregiver to monitor blood glucose as ordered, daily...and notify physician of blood glucose greater than 350 or less than 60.” Review of the clinical record revealed the patient received 6 SN visits from 2/27/24-2/14/25. There were no blood sugar results documented for 4 of those visits. During an interview with the agency director on 2/26/25 at approximately 3 pm, the director confirmed the SN’s failed to follow the plan of care related to blood sugar testing/results. 3. Patient # 14 had a Start of Care date of 2/5/25 with an admitting diagnosis of type 2 diabetes with other specified complications. Review of the Plan of Care [POC] for the certification period 2/5/25-4/5/25 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks and “skilled nurse will assess and instruct client/caregiver on diabetes management...Skilled nurse to perform/instruct the client/caregiver to monitor blood glucose as ordered...notify physician of blood glucose greater than 180 and less than 70.” Review of the clinical record revealed the SN saw the patient 3 times from 2/5/25-2/20/25. No blood glucose readings were documented. During an interview with the agency director on 2/26/25 at approximately 3 pm, the director confirmed the SN failed to monitor blood glucose levels in accordance with the POC.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to communicate with the physician when the patiient reported pain medication was not controlling pain for 1 of 1 patient [#2]; failed to communicate with the physician when a patient was noted to have new skin breakdown for 1 of 8 patients with a wound [#8]; failed to communicate with the physician when a surgical wound was noted to have an open area for 1 of 1 patient [#8]; failed to communicate with the physician when a patient reported pain but was “out of pain medication” for 1 of 1 pain [#10]; failed to communicate with the physican when a patient had questions regarding a medication following a cerebral infarction [blood flow to the brain is interrupted] for 1 of 1 patient [#1]. The findings inclued: 4. Patient #1 had a Start of Care date of 3/13/2024 with admitting diagnoses of Hemiplegia following cerebral infarction affecting the right dominant side (right sided weakness following a stroke), dysphagia (difficulty swallowing) following cerebral infarction (stroke), and encounter for attention to gastrostomy (a surgical procedure that creates an opening in the abdomen that leads to the stomach, used for inserting a percutaneous endoscopic gastrostomy (PEG) feeding tube). Review of the Plan of care for the certification period 3/13/2024 to 5/11/2024 included orders for SN (skilled nursing) 1 time a week for 4 weeks, 1 time every other week for 4 weeks, 1 time a week for 1 week. Further review of the clinical record revealed: RN #6 completed the Start of Care OASIS (Outcome and Assessment Information Set is the patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality.) on 3/13/24. Review of the narrative note revealed the following documentation by RN #6, “In report physician stated client should be on aspirin but daughter stated it was not mentioned to her. Client has PCP appt 3/14/24 and stated she will address concern with PCP at appointment.” There was no documentation in the clinical record concerning communication with the physician on the patient taking aspirin (patient had history of cerebral infarction). Per an interview with the agency director on 2/26/25 at approximately 3 pm, the director confirmed that RN #6 said they had no memory of a call being made to the physician regarding the patient taking aspirin. 1.Patient # 2 had a Start of Care date of 9/2/23 with admitting diagnoses of pressure ulcer of sacral area [base of spine], stage 3 [full thickness tissue loss where the subcutaneous fat layer is visible within the wound], pressure ulcer of sacral region, stage 2 [partial thickness loss of the skin], and quadriplegia [loss of movement and sensation in all 4 limbs]. Review of the Plan of Care for the certification period 4/29/24-6/27/24 included orders for SN [skilled nursing] 1 time a week for 9 weeks. Review of the clinical record revealed RN # 3 conducted a routine visit on 5/16/24. Review of the clinical record revealed the patient reported a pain level 6/10 [no location included]. The SN visit note include the question “Is pain being managed to client’s satisfaction?” RN # 3 answered the question “no”. Further review of the clinical record revealed the SN documented, “SN will call ____ [md name] re changing pain meds [medication]”. Review of the clinical record revealed no evidence the RN notified the MD of the patient’s reports of pain. During an interview with the agency director on 2/26/25 at approximately 3 pm, the director reported, “Maybe she just didn’t document it.” 2. Patient # 8 had a Start of Care date of 1/21/25 with an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. Review of the Plan of Care for the certification period 1/21/25-3/21/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “SN will assess and monitor left lower abdomen. Cleanse with mild soapy water to surgical incision and leave open to air. Instruct client/caregiver on identifying signs and symptoms of infection and incisional care.” Review of the clinical record revealed RN # 6 conducted a routine visit on 2/4/25 and documented the following information, “...Son states that he noticed drainage from the wound for the first time last night. On the edge of the wound there is a small opening and client’s son states there was a scab on that area and he is unsure if the scab came off and now has drainage. Client’s son has not set up surgical F/U [follow up] appt [appointment] but I gave him the number and he states he will call and schedule appt ASAP [as soon as possible] ...Client also has a small red spot on coccyx [at the bottom of the spine]. Client has F/U with PCP [primary care practitioner] and son will let PCP know...” Review of the clinical record revealed no evidence that the RN communicated the change in the wound or the reddened area to the physician. During an interview with the agency director on 2/26/25 at approximately 3 pm, the director confirmed there was no evidence the physician was notified. 3. Patient # 10 had a Start of Care date of 12/27/24 with and admitting diagnoses of pressure ulcer of other site, unstageable [the depth of the wound cannot be determined because it is covered by a thick layer of dead tissue caused slough or eschar] and type 2 diabetes with diabetic peripheral angiopath [complication of diabetes that affects the blood vessels] w/o gangrene. Review of the Plan of Care [POC] for the certification period 12/27/24-2/24/25 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 7 weeks. Review of the clinical record revealed the following documentation by RN # 4 on 1/28/25, “Pain 7/10 L [left] bka [below knee amputation] ...says out of pain med x 2 mo [month]...” Further review of the visit note dated 1/28/25 revealed the following documentation, “I’m in a lot of pain, I been out for 2 mo...” Further review of the clinical record revealed no evidence the RN notified the physician. During an interview with RN # on 2/26/25 at approximately 2 pm, the RN stated, “I was told by the son the pain medication he had was the only one [sic] he was getting. I did not notify the physician.””

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on clinical record review, and staff interviews, the Home Health Aide failed to follow the instructions on the aide plan of care for 1 of 2 patients with home health aide services [#1]. The findings included: Patient #1 had a Start of Care date of 3/13/2024 with admitting diagnoses of Hemiplegia following cerebral infarction affecting the right dominant side (right sided weakness following a stroke), dysphagia (difficulty swallowing) following cerebral infarction (stroke), and encounter for attention to gastrostomy (a surgical procedure that creates an opening in the abdomen that leads to the stomach, used for inserting a percutaneous endoscopic gastrostomy (PEG) feeding tube). Review of the Plan of care for the certification period 3/13/2024 to 5/11/2024 included orders for Home Health Aide (HHA) 2 times a week for 1 week and 1 time a week for 3 weeks. Review of the aide plan of care revealed the following under the special instructions/tasks section: “Temperature – every visit, B/P - every visit”. Review of the home health aide visit notes revealed on 4/19/24, the aide failed to record patient temperature or blood pressure readings. Further review of the aide plan of care revealed no documentation as to why the aide failed to obtain a temperature or blood pressure. During an interview with the agency director on 2/26/25 at approximately 3 pm, the director confirmed that the aide failed to follow the instructions on the aide plan of care.”

“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 agency policy, clinical record review, and staff interviews the SN [skilled nurse] visit note report failed to include the most recent wound care order in the wound assessment of the visit note for 1 of 8 patients with a wound [#3]. The findings included: The policy, Chart Data Requirements and Format [revised 10/23/23], was provided by the agency director on 2/26/25 at 8:42 am. The policy stated, “...physician/healthcare practitioner’s orders and the documentation of the nursing care plan process for the care and services to be provided...” Patient # 3 had a Start of Care date of 12/10/24 with an admitting diagnosis of disruption of external operation (surgical) wound [surgical site reopens]. Review of the Plan of Care [POC] for the certification period 12/10/24-2/7/25 included orders for SN [skilled nursing] 2 times a week for 1 week, 3 times a week for 2 weeks, 2 times a week for 1 week and “Once wound vac arrives, skilled nurse to apply continuous negative pressure wound therapy pump [sic]...” Review of the clinical record revealed the following information: On 12/13/24, LPN # 10 documented the following information, “ Skilled nursing visit for assessment and wound care. Vac was delivered yesterday. Wound care was done as ordered. Vac applied...” Further review of the clinical record revealed the following documentation in the “wound care provided” section of the visit note, “Skilled nurse will perform wound care and instruct...to perform wound care to chest...Cleanse wound with wound cleanser, apply kerlix moistened [sic] wound bed, cover with dry gauze...” The “wound care provided” section does not include application of wound vac. RN # 11 conducted a routine visit on 12/16/24 and documented, “...Educated client and wife on wound vac foam changes, how to apply and take off. Also showed wife and client how to change cannister when full...Educated on skin prep and making sure black foam is not on good skin...” Review of the “wound care provided” section of the visit note revealed the following documentation, “Skilled nurse will perform wound care and instruct...to perform wound care to chest...Cleanse wound with wound cleanser, apply kerlix moistened [sic] wound bed, cover with dry gauze...” LPN # 10 conducted a routine visit on 2/20/24 and documented the following information, “Appt [appointment] with surgeon and no change in orders. Wound care was done as ordered...” Review of the wound assessment revealed the LPN reapplied the wound vac. Review of the “wound care provided” section of the visit note revealed the following documentation, “Skilled nurse will perform wound care and instruct...to perform wound care to chest...Cleanse wound with wound cleanser, apply kerlix moistened [sic] wound bed, cover with dry gauze...” LPN # 10 conducted a routine visit on 2/23/24 and documented the following information, “wound care was done as ordered. Tolerated procedure well...”. Review of the “wound care provided” section of the visit note revealed the following documentation, “Skilled nurse will perform wound care and instruct...to perform wound care to chest...Cleanse wound with wound cleanser, apply kerlix moistened [sic] wound bed, cover with dry gauze...” Further review of the clinical record revealed the section related to “wound care provided” was incorrect in all SN visits except the visit on 12/13/24. During an interview with the agency director on 2/26/25 at approximately 3 pm, the director stated, “The nurses should have written a specific order when the wound vac was applied so that order would carry over to the clinical note.”