Yadkin Valley Home Health

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on policy and procedure review, medical record review, and staff interview the agency failed to follow the plan of care for assessing vital signs for 2 of 22 records reviewed (#3 and #6). Findings included: A policy, “Ongoing Assessments”, revised 05/15/2026 was received from the agency director on 08/04/2026 at 0902. The policy stated, “…the clinician will reassess the patient as appropriate for blood pressure, pulse, respirations, temperature...”. 1.Patient #3 had a SOC (start of care) of 02/17/2026 and included diagnoses encounter for surgical aftercare, chronic obstructive pulmonary disease (lung disease), and pulmonary edema (swelling in the lungs). Review of vital sign parameters- T (temperature) 96.8-100.4, P (pulse) 60-100, R (respirations) 12-20, B/P (blood pressure) 95/60-140/90, O2 sat 90-100. Review of physical therapist evaluation visit note for 02/18/2026 revealed a pulse of 65, and an oxygen level of 92 percent. No other vital signs are documented in the record for this visit. Interview with agency director on 08/04/2026 at 0900 confirmed the other vital signs are missing; employee no longer works for the agency. 2.Patient #6 had a SOC of 06/22/2026 and included diagnoses of type 2 diabetes, pressure ulcer and chronic kidney disease. Review of vital sign parameters- T (temperature) 96.8-100.4, P (pulse) 60-100, R (respirations) 12-20, B/P (blood pressure) 95/60-140/90, O2 sat 90-100. Review of the licensed practical nurse visit note on 07/01/2026 revealed the blood pressure was not documented. Interview with the agency director on 09/04/2026 at 0900 revealed, “…the nurse did the blood pressure doesn’t remember what it was …it’s not documented…”.”

“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 and procedure, clinical record review, observation and patient interview the agency failed to review all current medications for 1 of 2 home visits (#14). Findings included: A policy “Medication Profile” revised on 05/15/2026 was received on 08/04/2026 at 1323 from the quality assurance staff. The policy stated, “… a drug regimen review will be performed at least weekly or each visit.. this will include visualization of medication and medication list…”. Patient #1 was admitted on 07/20/2026 with unspecified displaced cervical (neck) fracture, encounter for change or removal of nonsurgical wound dressing and acute pain due to trauma. The plan of care for 07/20/2026 to 09/17/2026 included the following orders: skilled nursing 1 time a week for 2 weeks, physical therapy 2 times a week for 4 weeks, and occupational therapy 1 time a week for 4 weeks. A home visit was conducted on 08/04/2026 at 0930 with the registered nurse. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: Pre-biotic fiber tablet- take daily for stomach (supplement) Interview with the patient on 08/04/2026 at 0950 revealed “I’ve been taking this daily for a while”.”

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, the agency failed to assist the patient to find provider to meet needs when the patient was identified as needing a higher level or care for 1 of 1 patient discharged due to needing a higher level of care [#4]. The findings included: The policy, Discharge Criteria and Process [10/7/22] was provided by the assistant director on 4/23/24 at 11 am. The policy stated, “...The organization will verbally notify the patient of the decision to terminate or reduce services prior to the last scheduled visit...The decision to terminate or reduce services must be documented in the clinical record, citing the circumstances and notification to the patient...and the patient’s physician.” Patient # 4 had a Start of Care [SOC] date of 1/3/24 with an admitting diagnosis of pulmonary fibrosis [scarring of the lungs makes breathing difficult]. Review of the Plan of Care for the certification period 1/3/24-3/2/24 included orders for SN [skilled nursing] 1 time a week for 3 weeks, 1 time a week for 1 weeks, 1 time a week for 3 weeks, 1 time a week for 1 week [1 time a week for 8 weeks]. Review of the clinical record revealed RN #5 completed the SOC visit on 1/3/24. Review of the clinical record revealed LPN # 1 documented the following information on 1/11/24 for 1/8/24”Contacted patient to schedule appointment for 1/9/24...patient did finally agree to visit between 145 and 345 [sic]...” LPN # 1 completed a routine visit on /9/24 and documented the following information, “...Arrived at home, firetruck noted departing patient’s home...Call placed to EMS and they advised that patient received lift assist and patient was not transported...SN entered home...patient stated, ‘you are too late’...patient was asked if he would allow SN to perform visit, he stated ‘your place called the ambulance and I told them not to because I was on the floor’. Patient speaking very rudely to SN...Patient’s assistant arrived at the home and informed SN that patient had had two falls already today and that herself and her husband had come this am to assist patient off the floor...Call was placed to PCP’s office, spoke with ______, she was made aware of interaction with patient and probability of discharge due to patient refusal and unsafe environment...1/10/24 spoke with ______ at pcp [sic] office and she was made aware that patient will be discharged from services. She informed pcp [sic] as well.” Further review of the clinical record revealed the following documentation related to a phone call to Patient # 4 dated 1/14/24 for 1/12/24 by RN # 5, “...I told him I had some unfortunate news and told him with chart review it was determined that he needed a different level of care than we could provide. He raised his voice and said something like ‘who made that decision? And that was the wrong decision’...He said he would fight the decision...He asked for the number to call to appeal, and I reminded him of his admission booklet that details how to file a grievance...” Further review of the clinical record revealed RN # 5 completed a non-visit discharge on 1/13/24 and documented the following information on 1/14/24, “Non visit agency discharge completed due to patient’s willingness [sic] to comply with nursing visits...frequent falls. Patient was verbally aggressive to clinical staff when staff appropriately contacted EMS for assistance when patient reported he had fallen in the floor. Due to not having caregiver available on a regular basis to assist patient with meals and hygiene and fall prevention...Recommended to patient to seek higher lever of care, or to get personal care services such as _______ [name of agency]...” Review of the clinical record revealed no evidence the agency attempted to assist the patient in finding another agency which might be able to provide the higher level of care prior to discharge.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to resolve non-compliance issues before discharging patient for cause for 1 of 2 discharged patients [#3]. The findings included: The policy, Discharge Criteria and Process [10/7/22] was provided by the assistant director on 4/23/24 at 11 am. The policy stated, “...The organization will verbally notify the patient of the decision to terminate or reduce services prior to the last scheduled visit...The decision to terminate or reduce services must be documented in the clinical record, citing the circumstances and notification to the patient...and the patient’s physician.” Patient # 3 had a Start of Care [SOC] date of 3/5/24 with admitting diagnoses of unspecified fracture of lower end of left tibia, acquired absence of right leg above the knee, and type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the Plan of Care for the certification period 3/5/24-5/3/24 included orders for SN [skilled nursing] 1 time a week for 3 week and 1 time a week for 1 week. Review of the clinical record revealed RN # 3 completed the SOC visit on 3/5/24. LPN # 4 completed a routine visit on 3/12/24 and documented the following information, “...Patient has oxygen concentrator on and tubing in bed and is smoking cigarettes in bed beside of it. SN educated patient that he needs to turn off oxygen concentrator when he is smoking and remove tubing from bed. Educated no smoking in home due to oxygen, but family does smoke in the next room...FSBS [finger stick blood sugar] is supposed to be checked daily. Patient does not know his last FSBS because he has to [sic] been checking it. SN educated that he needs to check it daily since he does [sic] diabetic medication...Patient does not follow diabetic diet, patient had a 24 pack of mtn dew [sic] beside of bed...Medplanner filled for 2 weeks. Patient did not complete all medication that was in medplanner from last week because he states he was sick. SN educated patient to take all medication in medplanner and if not this would be non-compliance. LPN # 4 conducted the weekly visit scheduled for 3/21/24 and documented the following information, “...Educated no smoking in home due to oxygen, but family does smoke in next room while concentrator is on and running. Patient did smoke throughout the visit...FSBS is suppose [sic] to be checked daily. Patient reports he does not know what his last FSBS [sic] because he has not been checking it...No medication was missing from the medplanner and they did not need to be filled this visit. Patient did not take any medications that was in medplanner from last week...SN educated patient again to take all medication in medplanner again this time and if not this would be non-compliance and we would have to discharge...”Review of the medical record revealed no evidence the LPN contacted the RN or the physician to report compliance issues related to oxygen safety or diabetic precautions. Further review of the clinical record revealed RN # 3 completed a non-visit discharge on the patient dated 3/25/24 at 4:29 pm. Documentation on the discharge revealed the following information, “...NV [non-visit] discharge completed this date due to noncompliance...” Further review of the clinical record revealed RN # 3 documented the following communication with the physician on 3/25/24 at 4:30 pm, “Patient was discharged from agency today, no visit made r/t [related to] noncompliance...” There was no evidence the agency attempted to solve or address the issues related to non-compliance prior to discharging the patient for cause.”