Medi Home Health Agency

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, clinicians failed to document OASIS [Outcome and Assessment Information Set - mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] question N0415 [high risk drug classes] correctly for 5 of 13 [#1, 3, 6, 9 and 10] patients. The findings included: The policy, OASIS Collection and Reporting [last revised 12/2025], was provided by the agency administrator on 2/25/26 at 8:30 am. The policy stated, “...OASIS dated must accurately reflect the patient’s condition at the time of the assessment....” 1. Patient # 1 had a Start of Care date of 2/5/25 with an admitting diagnosis of Sepsis [infection in the blood stream]. Review of the Plan of Care [POC] for the certification period 2/5/25-4/5/25 revealed the patient was ordered Aspirin [antiplatelet] 81 mg daily. Review of the clinical record revealed RN # 6 conducted the OASIS [Outcome and Assessment Information Set - a mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] visit on 2/5/25. Review of OASIS documentation [N0415-high risk drug classes] revealed RN # 6 failed to include the use of the aspirin [antiplatelet]. Further review of the clinical record revealed a Resumption of Care [ROC-visit after inpatient stay] visit with an OASIS was conducted on 3/17/25. The ROC medications included Bactrim [antibiotic] 800-160 mg. Take 2 tablets two times a day for 10 days and Aspirin 81 mg daily. Review of the ROC OASIS [N0415-high risk drug classes] revealed RN # 3 failed to include the use of an antibiotic and the use of the antiplatelet. 2. Patient # 3 had a Start of Care [SOC] date of 1/15/25 with an admitting diagnosis of Aftercare following joint replacement surgery. Review of the Plan of Care [POC] for the certification period 1/15/25-3/15/25 revealed the patient was ordered Cefadroxil [antibiotic] 500 mg daily for 3 days. Review of the clinical record revealed PT # 6 completed the SOC OASIS [Outcome and Assessment Information Set - a mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] on 1/15/25. Review of OASIS documentation [N0415-high risk drug classes] revealed PT # 6 failed to include the use of an antibiotic. 3. Patient # 6 had a Start of Care [SOC] date1/23/26 with an admitting diagnosis of Urinary Tract Infection. Review of the Plan of Care [POC] for the certification period 1/23/26-3/23/26 revealed the patient was ordered Cefdinir [antibiotic] 300 mg twice a day for 5 days for a UTI [urinary tract infection]. Review of the clinical record revealed RN # 5 conducted the OASIS [Outcome and Assessment Information Set - a mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] visit on 1/23/26. Review of OASIS documentation [N0415-high risk drug classes] revealed RN # 5 failed to include the use of an antibiotic. 4. Patient # 9 had a Start of Care date of 1/7/26 with an admitting diagnosis of hypertensive heart and chronic kidney disease with heart failure [high blood pressure damaging the vessels in the kidneys] and chronic congestive heart failure [heart does not pump adequately]. Review of the Plan of Care [POC] for the certification period 1/7/26-3/7/26 revealed the patient was ordered Cefdinir [antibiotic] 300 mg twice daily and Aspirin [antiplatelet] 81 mg each day. Review of the clinical record revealed PT # 2 completed the SOC OASIS [Outcome and Assessment Information Set - a mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] on 1/7/26. Review of the OASIS documentation [N0415-high risk drug classes] revealed PT #2 failed to include the use of an antibiotic and antiplatelet when answering the OASIS question. 5. Patient # 10 had a Start of Care date of 1/27/26 with an admitting diagnosis of Alzheimer’s Disease. Review of the Plan of Care [POC] for the certification period 1/27/26-3/27/26 revealed the patient was ordered Aspirin [antiplatelet] 81 mg each day, Cefdinir [antibiotic] 300 mg twice a day and Quetiapine [antipsychotic] 25 mg daily. Review of the clinical record revealed PT # 2 completed the SOC OASIS [Outcome and Assessment Information Set - a mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] on 1/27/26. Review of the OASIS documentation [N0415-high risk drug classes] revealed PT #2 failed to include the use of an antibiotic and antiplatelet when answering the OASIS question. During an interview with the agency administrator on 2/25/26 at approximately 2 pm, the administrator confirmed the OASIS question N0415 was answered incorrectly.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the Registered Nurse failed to obtain wound measurements for 1 of 2 patients with a wound [2]. The findings included: The policy, Wound Care Standards [last revised 7/2025], was provided by the agency administrator on 2/25/26 at 8:30 am. The policy stated, “...Measure and document the wound at least weekly, unless the plan of care states otherwise...” Patient # 2 had a Start of Care [SOC] date of 3/15/25 with admitting diagnoses of encounter for other orthopedic aftercare, acute osteomyelitis [infection of the bone], and encounter for adjustment and management of VAD [catheter or tube inserted into a vein or artery to deliver fluids, blood products, nutrients, or medication directly into the bloodstream over an extended period]. Review of the Plan of Care for the certification period 3/15/25-5/15/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “ ...L [left] plantar [area of the foot used for walking] Cleanse with NS [normal saline] or wound cleanser, pat dry with gauze, apply Xeroform gauze, cover with 4x4 gauze, wrap with kerlix, cast padding and ACE wrap...Perform twice weekly...” RN # 8 conducted the SOC visit on 3/15/25. Review of the documentation revealed no wound measurements. Follow up SN visits were conducted on 3/18/25, 3/21/25, 3/24/25, 3/27/25, 3/31/25, 4/3/25, 4/7/25, 4/10/25, 4/14/25, and 4/14/25. The visit documentation for those visits revealed no wound measurements. During an interview with RNs # 9 and 10 on 3/25/26 at approximately 12 noon, the RN’s reported, “I would expect to see at least measurements of the incision line at each visit.””

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to complete the occupational therapy [OT] evaluation within 5 days for 2 of 8 patients [#6 and 7] with OT orders . The findings included: The policy, Comprehensive Assessment [last revised 9/2025], was provided by the agency administrator on 2/25/26 at 8:30 am. The policy stated, “...If additional disciplines are ordered the initial evaluations ordered at Start of Care [SOC] are completed withing 5 days of the SOC visit...” 1.Patient # 6 had a Start of Care [SOC] date1/23/26 with an admitting diagnosis of Urinary Tract Infection. A review of the referral dated 1/22/26 revealed an order for OT [occupational therapy] to eval and treat. Review of the clinical record revealed the OT evaluation was not conducted until 2/5/26. The clinical record revealed no evidence that the physician was notified of the late OT evaluation. 2.Patient # 7 had a Start of Care date of 1/16/26 with an admitting diagnosis of Chron’s Disease [a chronic inflammatory bowel disease causing inflammation anywhere along the digestive tract, most commonly the end of the small intestine]. A review of the hospital discharge orders dated 1/14/26 revealed an order for OT [occupational therapy] to eval and treat. Review of the clinical record revealed the OT evaluation was not completed until 1/23/26. There was no evidence that the physician was notified of the delay of the OT evaluation. During an interview with the agency administrator on 2/25/26 at 2:30 pm, the administrator confirmed the OT evaluations were completed outside the required timeframe.”

“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, clinically record review, home visits, and staff interviews, the Plan of Care failed to included the correct/current medications for 5 of 5 patients who received home visits [#9, 10, 11, 12 and 13]. The findings included: The policy, Medication Management [last reviewed 12/2024], was provided by the agency administrator on 2/25/26 at 8:30 am. The policy stated, “...Any changes to the medications...are conveyed to the ordering physician, and changes are made...” 1. Patient # 9 had a Start of Care date of 1/7/26 with an admitting diagnosis of hypertensive heart and chronic kidney disease with heart failure [high blood pressure damaging the vessels in the kidneys] and chronic congestive heart failure [heart does not pump adequately]. Review of the Plan of Care [POC] for the certification period 1/7/26-3/7/26 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. Patient # 9 resided in an assisted living facility [ALF]. On 2/24/26 at approximately 9:30 am a joint visit was made with PTA [physical therapy assistant] 1. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile provided by the agency listed Cetirizine [allergies] 10 mg. Take 1 daily. The medication administration mar [MAR] provided by the ALF listed Cetirizine 5 mg. Take 1 tablet daily with a start date of 12/8/25. The medication profile provided by the agency listed Torsemide [edema] 20 mg. Take 1 tablet daily. The MAR provided by the ALF listed Torsemide 20 mg. Take 1 daily as needed [PRN] for edema with start date of 12/8/25. The medication profile provided by the agency listed Simvastatin [cholesterol] 10 mg daily. This medication was not listed on the MAR provided by the ALF. The medication profile provided by the agency listed Pyridostigmine [weakness] 60 mg. Take 1 table two times a day. The MAR provided by the agency listed Pyridostigmine 60 mg. Take 1 tablet two times per day. May take 1 tablet 3 times a day as needed for weakness with a start date of 12/8/25. 2. Patient # 10 had a Start of Care date of 1/27/26 with an admitting diagnosis of Alzheimer’s Disease. Review of the Plan of Care [POC] for the certification period 1/27/26-3/27/26 included order for PT [physical therapy] 1 time a week for 9 weeks. Patient # 10 resided in an assisted living facility [ALF]. On 2/24/26 at 10 am a joint visit was made with PT # 2. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile provided by the agency listed Klonopin [anxiety]. Take 1 mg every 4 hours for seizures. The MAR provided by the ALF listed Klonopin 1mg. Take 1 tablet every 4 hours as needed [PRN] for anxiety with a start date of 12/8/25. The MAR provided by the ALF listed Acetaminophen [over the counter pain reliever] 500 mg. Take 1 tablet every 4 hours as needed for headache or fever with a start date of 12/8/25. The medication profile provided by the agency did not include Acetaminophen. The MAR provided by the ALF listed Zofran [nausea] 4 mg. Take 1 tablet every 6 hours as needed for nausea/vomiting with a start date of 12/8/25. The medication profile provided by the agency did not include Zofran. The MAR provided by the ALF listed Mirtazapine [antidepressant] 15 mg. Give ½ tablet at bedtime with a start date of 12/8/25. The medication profile provided by the agency did not include Mirtazapine. 3. Patient # 11 had Start of Care date of 12/24/25 with an admitting diagnosis of Chronic Venous Hypertension with ulcer and inflammation of left lower extremity and non-pressure chronic ulcer of unspecified part of left lower leg. Review of the Plan of Care for the certification period 2/22/26-4/26/26 included orders for SN [Skilled nursing] 2 times a week for 9 weeks. On 2/24/26 at 12 noon a joint visit was made with RN # 3. A medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication list included Lantus [insulin] 100 unit/ml. Take 30 units twice a day. During an interview with the patient, she stated, “I only take 50 units every day now. “ 4. Patient # 12 had a Start of Care date of 1/23/26 with an admitting diagnosis of Chronic Obstructive Pulmonary Disease [COPD-respiratory condition]. Review of the Plan of Care [POC] for the certification period 1/23/26-3/23/26 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks. On 2/25/26 at approximately 11 am a joint visit was made with RN # 5. During the visit a medication review was conducted using a medication list profile by the agency. The following discrepancies were noted: The medication profile provided by the agency included Pantoprazole [reflux] 20 mg daily. Take 1 tablet daily. During the visit the patient presented a bottle of Pantoprazole 40 mg. Take 1 tablet daily. The patient reported taking 40 mg daily with a start date of 11/5/25. The patient presented a bottle of Docusate [stool softener] 100 mg. Take 1 capsule two times a day with a start date of 1/22/26. The medication profile provided by the agency did not include Docusate. 5. Patient # 13 had a Start of Care date of 1/18/26 with an admitting diagnosis of Chronic Obstructive Pulmonary Disease [COPD-respiratory condition]. Review of the Plan of Care for the certification period 1/18/26-3/18/26 included orders for OT [occupational therapy] 1 time a week for 5 weeks. On 2/25/26 at approximately 10 am a joint visit was made with OT # 4. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile provided by the agency did not include Slow Fe [iron supplement] 45 mg. Take 1 daily. The patient reported taking this medication for about 2 months. The medication profile did not include Oxycodone/acetaminophen 10 mg-325 mg [pain medication]. Take 1 tablet every 6 hours as needed for pain. The patient reported she had been using the pain medicine for “a very long time.” During an interview with the agency administrator on 2/25/26 at approximately 1 pm, she confirmed the POCs for the joint visits did not include the correct/current medications.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on agency policy review, clinical record review, and staff interviews the Registered Nurse failed to follow the physician’s order related to the amount of heparin used for flushing a PICC line [a thin, flexible tube inserted into a large arm vein and threaded toward the heart to deliver long-term treatments like antibiotics, chemotherapy, or nutrition] for 1 of 1 patient with a PICC line [#2]; and failed to follow the physician’s order related to wound care for 1 of 2 patients with a wound [#2]. The findings included: The policy, Physician Telephone/Verbal Orders [last revised 11/2025] was provided by the agency administrator on 2/25/26 at 8:30 am. The policy stated, “...__________ [name of the agency] provides all care, treatment, and services only according to current, signed, and authorized orders...” 1A. Patient # 2 had a Start of Care [SOC] date of 3/15/25 with admitting diagnoses of encounter for other orthopedic aftercare, acute osteomyelitis [infection of the bone], and encounter for adjustment and management of VAD [catheter or tube inserted into a vein or artery to deliver fluids, blood products, nutrients, or medication directly into the bloodstream over an extended period]. Review of the Plan of Care [POC] for the certification period 3/15/25-5/15/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and...”SN to change PICC line [a thin, flexible tube inserted into a large arm vein and threaded toward the heart to deliver long-term treatments like antibiotics, chemotherapy, or nutrition] dressing...weekly... SN to educate pt [patient]/caregiver on SASH [ Saline, Administration, Saline, Heparin- a method used to safely flush, administer medication, and maintain PICC lines at home, reducing the risk of blockages] administer 10 ml of normal saline administer heparin [anticoagulant] 100 u [unit]/ml...” The medication section of the POC included the following order...” Heparin Sodium...100 units/ml 2 ml via PICC...” Review of the clinical record revealed RN # 11 conducted routine visits on 3/18/25, 3/21/25, 3/24/25, 3/27/25, 3/31/25, 4/3/25, 4/7/25, 4/10/25, 4/14/25, and 4/14/25. Further review of RN # 11’s documentation revealed she flushed the PICC line with 5 ml of heparin instead of the physician’s order of 2 ml. During an interview with RN # 9 on 3/25/26 at approximately 12 noon, RN # 9 confirmed the RN failed to follow the physician’s order. 1B. Patient # 2 had a Start of Care [SOC] date of 3/15/25 with admitting diagnoses of encounter for other orthopedic aftercare, acute osteomyelitis [infection of the bone], and encounter for adjustment and management of VAD [catheter or tube inserted into a vein or artery to deliver fluids, blood products, nutrients, or medication directly into the bloodstream over an extended period]. Review of the Plan of Care for the certification period 3/15/25-5/15/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “ ...L [left] plantar [area of the foot used for walking] Cleanse with NS [normal saline] or wound cleanser, pat dry with gauze, apply Xeroform gauze, cover with 4x4 gauze, wrap with kerlix, cast padding and ACE wrap...Perform twice weekly...” RN # 11 conducted a routine visit on 3/18/25 and documented the following information, “...Patient saw the surgeon yesterday...we [SN] don’t need to change the dressing until he goes back there in a week...” RN # 11 conducted a routine visit on 3/24/25 and documented the following regarding wound care, “...Wrapped the top of the ACE wrap tighter on left foot, but patient is to leave dressing on until next appointment with surgeon...” RN # 11 conducted a routine visit on 3/27/25 and documented the following, “...Patient saw surgeon today...wife reports she [physician] removed every other suture and dressed his foot...said that dressing can stay on until he returns in 1 week...” RN # 11 documented the following on 3/31/25, “...Foot [sic] dressing not changed as it again [sic] non removable [sic] until he sees surgeon...” Review of the clinical record revealed no change in the physician’s order related to wound care after the SOC. RN # 9 confirmed the RN failed to follow the physician’s order related to wound care to the left foot.”