Cape Fear Valley Home Health

“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 agency policy, clinical record review, complaint log review, and staff interviews, the agency failed to notify the physician of a patient’s discharge and a delay in the resumption of care for 1 of 1 patient with a discharge and a resumption of care (start of care after discharge) (patient #1). Findings included: A policy, Patient Discharge/Transfer Process (revised 10/01/23), received on 3/18/26 at 3:22 PM from the Business Manager stated, “Revisions to plan for patient’s discharge will be communicated to: … All physicians issuing orders…” A policy, Coordination of Care, From Admit Through Discharge (revised 12/01/25), received on 03/18/26 at 3:22 PM from the Business Manager stated, “Coordination of care with physician/authorized practitioner: … When a missed visit occurs altering the Plan of Care… When there is a need to change the patient’s plan of care…” Patient #1 was admitted on 04/28/25 and 02/24/26 with diagnoses of venous insufficiency (reduced blood flow in legs), non-pressure chronic ulcer (wound) right lower leg, and non-pressure chronic ulcer of left lower leg. The plan of care for 12/24/25- 2/21/26 included orders for skilled nurse (SN) visits 2 times a week effective 01/12/25 for wound care. Review of the clinical record revealed that on 02/28/26 a communication note stated, “Please discharge by end of episode per OASIS requirement [Outcome and Assessment Information Set] and readmit to the new payor listed below…” A follow up comment documented by the clinical manager stated, “Patient will be DC [discharged] this week.” Further review revealed that patient #1 was discharged from the agency on 02/17/26. There was no documentation that the physician was notified. Review of the clinical record and the complaint logs revealed that patient #1 refused the resumption of care (ROC) on 02/19/26 and 02/21/26. The patient had a ROC on 02/24/26. There was no documentation that the physician was notified of the delay in ROC. During an interview conducted on 03/18/26 at 10:00 AM the complainant stated, “I did tell them not to bother coming [for the resumption of care] a few times.” An interview conducted on 03/18/26 at 12:37 PM with the Executive Director revealed that the physician should have been notified and documented in the clinical record.”

“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 clinical record review, and staff interviews, the agency failed to identify high risk medications when answering OASIS [The Outcome and Assessment Information Set] question N0415 for 2 of 16 records [2 and 8]. The findings included: 1. Patient # 2 had a Start of Care [SOC] date of 10/16/24 with admitting diagnoses of non-pressure chronic ulcer of skin and type 2 diabetes mellitus with hyperglycemia [high blood sugar]. The SOC OASIS [Outcome and Assessment Information Set-data collection instrument used to measure quality and outcomes of care] was completed on 10/16/24. Review of the SOC OASIS information dated 10/16/24, revealed N0415 [high risk medications] indicated the patient was using an opioid, antiplatelet and hypoglycemic medication. The patient was discharged on 12/10/24. The discharge OASIS indicated the patient was on an antiplatelet. Review of the medication revealed the patient was also ordered an opioid and hypoglycemic medication at the time of discharge. During an interview with RN # 8 on 5/7/25 at approximately 2 pm, RN # 8 confirmed the OASIS question related to high-risk medication was not answered correctly. 2. Patient # 8 had a Start of Care [SOC] date of 4/6/25 with an admitting diagnosis of venous insufficiency [improper function of the vein valves in the legs, causing swelling and skin changes]. The SOC OASIS [Outcome and Assessment Information Set-data collection instrument used to measure quality and outcomes of care] was completed on 4/6/25 by RN # 16. Review of the OASIS documentation [N0415-high risk medications] indicated the patient was not prescribed any high-risk medications. Review of the plan of care for the episode 4/6/25-6/4/25 revealed the patient was prescribed an antibiotic [high risk medication], Cephalexin 250 mg 2 times per day. During an interview with RN # 10 on 5/7/25 at approximately 2 pm, RN # 10 confirmed the OASIS documentation was not accurate.”

“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 agency policy, observation, and staff interviews, the agency failed to remove gloves and perform hand hygiene and failed to disinfect reuseable equipment for 1 of 4 patients with skilled nurse home visits conducted. (patient #13) Findings included: A policy, Cleaning of Re-Usable Equipment (revised 06/01/2022), received on 05/06/2025 from the Office Manager stated, “Equipment used for more than one patient is cleaned between each patient use.” A policy, Hand Hygiene (revised 05/01/2019) received on 05/07/2025 at 10:15 AM from the Executive Director stated, “Staff performs hand hygiene… after contact with… wound dressing, or contaminated surfaces.” Patient #13 was admitted on 12/28/2024 with a diagnosis of pressure ulcer of sacral region, unstageable (wound at the base of the spine where the depth cannot be determined).The plan of care for 04/27/2025-06/25/2025 included orders for skilled nurse visits 2 times a week for 8 weeks, 1 time a week for 1 week, 2 PRN (as needed), and “skilled nurse to perform/instruct patient/caregiver procedure of wound care to sacral wound 2x [times] a week and PRN. Cleanse with wound cleanser and paint with betadine. Apply polymen [dressing] with silver and cover with foam using clean technique.” A home visit was conducted on 05/06/25 at approximately 12:00 PM with registered nurse (RN) #1. With gloved hands RN #1 removed the reusable vital sign equipment from the clinical bag and assessed the patient’s vital signs. RN #1 used a retractable tape measure to take ankle measurements. The measuring tape retracted completely into the plastic casing prior to sanitizing the tape. RN #1 withdrew the tape measure 3-4 inches, sanitized the outer plastic case, the exposed portion of tape, and placed it in the clinical bag. With clean gloves RN #1 removed and discarded the soiled bandage. RN #1 failed to remove the gloves and perform hand hygiene prior to removing gauze pads from a large multiuse package. RN #1 failed to perform hand hygiene after carrying the patient’s trash can and proceeded to return unused supplies to the patient’s storage area. An interview conducted on 04/07/2025 at 3:40 PM with RN #1 revealed that RN #1 was not aware that the retractable measuring tape should have left in the home or discarded after the inside of the plastic casing became contaminated and RN #1 would normally remove gloves and perform hand hygiene after removing the soiled dressing and after handling the patient’s trash can. An interview conducted on 04/06/2025 at 12:48 PM with the patient care manager that the measuring tape should be sanitized prior to retracting it or disposed of. An interview on 04/07/2025 at 3:55 PM with the Executive Director revealed that the expectation is for the clinicians to follow the procedures.”

“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 SN [skilled nurse] failed to obtain weekly wound measurements for 2 of 6 patients with a wound [2 and 14]; and failed to obtain weekly PICC [peripherally inserted central catheter- form of intravenous access that can be used for a prolonged period of time] line measurements for 1 of 1 patient with a PICC line [#6]. The findings included: The policy, Dressing Change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters [10/1/16], was provided by RN # 7 on 5/6/25 at approximately 2:47 pm. The policy stated, “...Obtain upper arm circumference...and compare to baseline measurement...Measure external length of catheter from the insertion site to the catheter hub...” 1. Patient # 2 had a Start of Care date of 10/16/24 with admitting diagnoses of non-pressure chronic ulcer of skin and type 2 diabetes mellitus with hyperglycemia [high blood sugar]. Review of the Plan of Care for the certification period 10/16/24-12/14/24 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks. A supplemental order for wound care was noted in the clinical record dated 10/30/24. The order to, “...Cleanse wound [left buttock] with NS [normal saline or wound cleanser. Pat dry. Apply Nystatin Powder or Cream to peri wound. Appy calcium alginate to wound bed. Cover with dry dressing. To be done by HH [home health] 2 times per week.” Review of the clinical record revealed no wound measurements for the left buttock for the week of 11/5/24. During an interview with RN # 8 on 5/7/25 at 2 pm, RN # 8 confirmed all wounds are to be measured at least weekly. 2. Patient # 14 had a Start of Care date of 1/4/25 with an admitting diagnosis of necrosis [death of cells in body tissues] of amputation stump. Review of the Plan of Care for the certification episode 1/14/25-3/14/25 included SN [skilled nurse] 2 times a week for 8 weeks, 1 time a week for 1 week. Review of the clinical record revealed the patient had a surgical wound noted to the left foot. Review of the clinical record revealed a wound measurement for the left foot of 2.5 cm x 4.5 cm x 0.3 cm documented on 3/17/25. The clinical record did not include wound measurements for the week of 3/24/25 or the week of 4/7/25. During an interview with RN # 8 on 5/7/25 at approximately 2 pm, RN # 8 confirmed wound measurements are supposed to be done “at least on a weekly basis”. 3. Patient # 6 had a Start of Care date of 3/17/25 with admitting diagnoses of sepsis [infection of the blood] due to Methicillian Resistant Staphylococcus Aureus [MRSA] and encounter for adjustment and management of VAD [vascular access device-medical device inserted into a blood vessel to allow for the delivery of medications, fluids, or other therapies or for the withdrawal of blood for testing]. Review of the Plan of Care for the certification period included orders for SN [skilled nursing] 2 times a week for 6 weeks, 1 time a week for 3 weeks and “ Skilled nurse to perform site care for infusion access device- PICC [peripherally inserted central catheter- form of intravenous access that can be used for a prolonged period of time] line to RUE [right upper extremity]. Dressing changes 1 time a week...” Review of the clinical record revealed on 3/20/25 LPN # 15 documented an arm circumference of 33.5 cm with 1 cm of exposed catheter length. Further review of the clinical record revealed the PICC line was discontinued and pulled on 4/24/25. There were no more PICC line measurements/arm circumferences documented after the 3/20/25 visit. During an interview with RN # 8 on 5/7/25 at approximately 2 pm, the RN confirmed the measurements related to the PICC line should have been obtained at least weekly.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on agency policy, clinical record review, complaint log review, and staff interviews the agency failed to document the existence of complaints, investigations, and resolutions for 1 of 1 patient with complaints. (patient #3) Findings included: A policy, Grievance Procedure, Patient Complaints (revised 09/01/2024) received on 05/06/2025 at 12:37 PM from the Executive Director stated, “Staff receiving complaints either in person, by phone, or through the mail shall document the patient complaint… The Executive Director or Clinical Director interviews the patient, family, and involved staff… and takes appropriate actions to resolve the issue… After the investigation and analysis is completed, but no later than 30 days after the grievance/complaint filing, the Executive Director or Clinical Director will follow-up with the patient and/or complainant and document within the information system.” Patient #3 was admitted on 01/23/2025 with a diagnosis of Hypertensive Heart Disease with Heart Failure. The plan of care for 03/24/2025-05/22/2025 included orders for skilled nurse visits (SN) 1 time a week for 3 weeks with 2 PRN (as needed). During the SN visits on 04/02/2025 register nurse (RN) #2 documented, “Not happy because she called after hours and spoke to a nurse that gave her false information…” During the SN visit on 04/09/2025 RN #2 documented, “All she wanted was a call back. Patient states she is going to start a lawsuit.” A review of the agency’s complaint logs conducted on 05/05/2025 had no documentation of patient #3’s complaints/concerns. A complaint report dated as initiated on 03/20/2025 and dated as processed on 05/05/2025 received on 05/06/2025 at approximately 9:00 AM from the Executive Director stated, “On 03-20-25 nurse [RN #2’s name] called ED [Executive Director] while in home and expressed PT [patient] had a complaint about a nurse. PT got on phone and this SN [skilled nurse] spoke with PT. PT states that nurse [RN #1’s name] came and saw her and did her medication did he [sic] medication wrong… states it [narcotic pain medication] was a full bottle and that som e [sic] was missing from the bottle… Then she proceeds to say that she thinks the RN got some of her medication…” The complaint investigation included documentation of an interview with RN #1. An interview conducted on 05/07/2025 at 1:59 PM with RN #2 revealed that the Executive Director was made aware of the concerns on 04/02/2025 and 04/09/2025. During an interview conducted on 05/07/2025 at 3:38 PM with RN #1stated that they were made aware of a patient accusing them of stealing medication today (05/07/2025). RN #1 stated that they were never interviewed by the Executive Director about this complaint. During an interview conducted on 05/07/2025 at 2:00 PM the Executive Director stated, “I assume that I was notified of it [complaint of drug diversion] on 03/20/2025.””

“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, home visit observations, clinical record review, and staff interviews the plan of care failed to include all/correct medications the patient was taking for 2 of 4 patients who received home visits [#10 and 11]. The findings included: The policy, Monitoring Medications [7/1/24], was provided by RN # 7 on 5/7/25 at 11:30 am. The policy stated, “...A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode...” 1. Patient # 10 had a Start of Care date of 4/23/25 with an admitting diagnosis of atrial fibrillation [abnormal heart rhythm]. Review of the Plan of Care [POC] for the certification period 4/23/25-6/21/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks. On 5/6/25 at approximately 11:30 am, a joint visit was conducted with LPN # 15. During the visit a medication review was conducted using the medication profile provided by the agency. The following discrepancies were noted: The patient’s caregiver reported she was taking Vitamin C [supplement] 500 mg daily, potassium chloride [supplement] er [extended release] 15 mEq daily, Entresto [used to treat congestive heart disease] 24 mg-26 mg 2 times per day, digoxin [used to control heart rate] 125 mcg daily, colchicine [used for gout] 0.6 mg daily. None of the above medications were listed on the medication profile/plan of care. During an interview with RN # 10 on 5/6/25 at 2 pm, RN # 10 confirmed the plan of care failed to include all the correct medications the patient was taking. 2. Patient # 11 had a Start of Care date of 5/1/25 with an admitting diagnosis of unspecified atrial fibrillation [abnormal heart rhythm]. Review of the Plan of Care [POC] for the certification period 5/1/25-6/29/25 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. On 5/6/25 at approximately 10 am a joint visit was made with PT # 16. During the visit a medication review was conducted using a medication profile provided by the agency. The patient had supplemental oxygen in the home and stated, “I use it at night.” Review of the medication profile did not include oxygen as a medication. During an interview with RN # 10 on 5/6/25 at approximately 12 pm, RN # 10 confirmed the oxygen should have been included on the medication profile/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 follow the physician’s orders for wound care for 4 of 6 patients with a wound [2, 14, 15 and 13]. The findings included: A policy, Wound Assessment, Documentation, and Photography (revised 09/01/2024) received on 05/06/2025 at 12:37 PM from the Executive Director stated, “Perform wound care according to [agency name] adopted clinical skills guidelines and physician orders.” 4. Patient #13 was admitted on 12/28/2024 with a diagnosis of pressure ulcer of sacral region, unstageable (wound at the base of the spine where the depth cannot be determined). The plan of care for 04/27/2025-06/25/2025 included orders for skilled nurse visits 2 times a week for 8 weeks, 1 time a week for 1 week, 2 PRN (as needed), and “skilled nurse to perform/instruct patient/caregiver procedure of wound care to sacral wound 2x [times] a week and PRN. Cleanse with wound cleanser and paint with betadine. Apply polymen [dressing] with silver and cover with foam using clean technique.” During a home visit conducted on 05/06/25 at approximately 12:00 PM registered nurse (RN) #1 cleansed the wound with wound cleanser and applied the dressing. RN #1 failed to paint with betadine as ordered. During an interview conducted on 05/07/2025 at 3:40 PM RN #1 stated, “I didn’t use betadine because the wound is not macerated. Yes [normally verify an order prior to wound care].” An interview conducted on 05/07/2025 at 3:50 PM with the Executive Director revealed that the expectation is to follow the order. The policy, Plan of Care [9/1/24], was provided by RN # 8 on 5/6/25 at approximately 1:15 pm. The policy stated, “...Medications, treatments, and interventions are provided by qualified agency staff as ordered...” The policy, Physician’s Orders [10/1/23], was provided by RN # 7 on 5/7/25 at approximately 9:50 am. The policy stated, “...No medications, treatments, diagnostic studies, or therapeutics will be administered without the order of a qualified physician...” 1. Patient # 2 had a Start of Care date of 10/16/24 with admitting diagnoses of non-pressure chronic ulcer of skin and type 2 diabetes mellitus with hyperglycemia [high blood sugar]. Review of the Plan of Care for the certification period 10/16/24-12/14/24 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks. Review of the clinical record revealed RN # 1 conducted a routine visit on 10/29/24 and documented, “...Buttocks wound assessed and added to ICC [wound section of the visit note] will obtain orders from the provider.” Further review of the clinical record revealed a physician’s order dated 10/30/24. The order stated, “RN LVM [left voice message] with ____ [name] for WC [wound care] we would like to obtain for order [sic] to L [left] buttocks as follows: If provider can prescribe Nystatin [antifungal] powder or cream; Cleanse wound with NS [normal saline or wound cleanser. Pat dry. Apply Nystatin Powder or Cream to peri wound. Appy calcium alginate to wound bed. Cover with dry dressing. To be done by HH [home health] 2 times per week. PCP [primary care provider] office returned call and approved above wound care request. Spoke with ______/______ [name]. LPN # 18 conducted a routine visit on 10/31/24 and did not complete wound care to the buttock. The LPN documented, “wound care not completed, awaiting orders.” RN # 1 conducted routine visits on 11/12/24, 11/14/24, and 11/26/24. Review of the visit notes revealed no treatment to the left buttock was completed. RN # 1 documented, “awaiting orders for left buttock.” LPN # 15 completed visits on 11/19/24, 11/22/24, 11/29/24, and 12/3/24 and documented wound care to buttocks not done, “awaiting orders.” During an interview with RN # 8 on 5/7/25 at approximately 2 pm, The RN confirmed there was an order for wound care but stated, “The order may not have flowed over to the ICC.” 2. Patient # 14 had a Start of Care date of 1/4/25 with an admitting diagnosis of necrosis [death of cells in body tissues] of amputation stump. Review of the Plan of Care for the certification episode 1/14/25-3/14/25 included SN [skilled nurse] 2 times a week for 8 weeks, 1 time a week for 1 week and “Skilled nurse to perform wound care to open surgical incision on left foot two times per week...Apply back foam to wound...Attach continuous suction at 125 MMHG...” Review of the clinical record revealed a supplemental wound care order was written on 4/7/25 by __________ [name of physician]. The wound care order was to “hold wound vac therapy for 2 weeks and cleanse area on left foot with wound cleanser, apply prisma, cover with hydrofera blue. Wrap the left lower extremity with 2 layer compression wrap...” Review of the visit documentation revealed RN # 13 conducted routine visits on 4/11/25 and 4/14/25. RN # 13 documented the left leg was wrapped with 3-layer compression wrap during both of those visits. LPN # 14 completed wound care on 4/17/25 and documented a 3-layer compression wrap was applied to the left leg. During an interview with RN # 8 on 5/7/25 at 2 pm, RN # 8 confirmed the wound care was not completed in accordance with the order received on 4/7/25. 3. Patient # 15 had a Start of Care date of 3/13/25 with an admitting diagnosis of encounter for change or removal of surgical wound dressing, encounter for surgical aftercare following surgery on the digestive system. Review of the Plan of Care for the certification period 3/13/25-5/11/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks and “Skilled nurse to perform/instruct patient/caregiver procedure of wound care to midline surgical incision every other day...cleanse with soap and water. Apply aquacel ag rope to wound bed, cover with aquacel foam...Skilled nurse to complete wound care once a week...” Review of the clinical record revealed SN visits were conducted on 3/13/25, 3/19/25, 3/21/25, 3/28/25, and 4/5/25. Further review of the clinical record revealed the wound care was not completed by the SN until 4/5/25. During an interview with RN # 10 on 5/7/25 at approximately 2 pm, RN # 10 confirmed the wound care was not completed in accordance with the physician’s orders.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient 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 revise the plan of care to reflect current information for 1 of 1 patient requiring additional education. (patient #3) Findings included: A policy, Plan of Care (POC) (revised 04/01/2025), received on 05/06/2025 at 1:15 PM from the Patient Care Manager stated, “Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff integrates comprehensive assessment findings to address patient problems…” Patient #3 was admitted on 01/23/2025 with a diagnosis of Hypertensive Heart Disease with Heart Failure. The plan of care for 01/23/2025-03/23/2025 included orders for skilled nurse visits (SN) 1 time a week for 4 weeks, 1 every other week for 2 weeks, 1time a week for 2 weeks with 2 PRN (as needed). Review of the clinical record revealed that during the SN visit of 01/25/2025 registered nurse (RN) #6 documented, “Patient will need more education about signs and symptoms of high or low potassium.” Further review revealed that the plan of care did not include orders for education related to potassium levels. RN #6 was not available for an interview. During an interview conducted on 05/07/2025 at 10:25 AM the Executive Director stated, “She [RN #6] should have added that to the care plan and follow through with the process.””

“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 report vital signs outside the given parameters for 2 of 16 patients [#6 and 16]. The findings included: 1.Patient #6 was admitted on 03/25/2025 with a diagnosis of chronic lymphocytic leukemia of B-cell [cancer of the blood and bone marrow]. The plan of care for 03/25/2025-05/23/2025 included orders for home health aide (HHA) 2 times a week for 7 weeks, 1 time a week for 1 week, effective 03/30/2025 and “Report vital signs falling outside the following established parameters … systolicbp[sic] [systolic blood pressure [greater than] 166 diastolicbp [sic] [diastolic blood pressure] [greater than] 100.” Review of the clinical record revealed that on 03/31/2025 HHA #5 documented a blood pressure “Reading 100/55, Physician Contacted N [no].” Further review revealed that there was no documentation of the registered nurse or physician being notified. 2.Patient #16 was admitted on 03/29/2025 with a diagnosis of hypertensive heart and chronic kidney disease. The plan of care for 03/29/2025-05/27/2025 included orders for physical therapy visits 1 time a week for 6 weeks and “Report vital signs falling outside the following established parameters … systolicbp[sic] [systolic blood pressure [greater than] 166 diastolicbp [sic] [diastolic blood pressure] [greater than] 100.” Review of the clinical record revealed that on 04/07/2025 physical therapy assistant #3 documented a blood pressure, “Reading 96/54, Physician contacted N [no].” Further review revealed that there was no evidence of the physician being notified.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on observation, clinical record review, and staff interviews, the agency failed to accurately document a treatment that was provided for 1 of 4 patients with a home visit conducted. (patient #13) Findings included: Patient #13 was admitted on 12/28/2024 with a diagnosis of pressure ulcer of sacral region, unstageable (wound at the base of the spine where the depth cannot be determined). The plan of care for 04/27/2025-06/25/2025 included orders for skilled nurse visits 2 times a week for 8 weeks, 1 time a week for 1 week, 2 PRN (as needed), and “skilled nurse to perform/instruct patient/caregiver procedure of wound care to sacral wound 2x [times] a week and PRN. Cleanse with wound cleanser and paint with betadine. Apply polymem [dressing] with silver and cover with foam using clean technique.” During a home visit conducted on 05/06/2025 at approximately 12:00 PM registered nurse (RN) #1 cleansed the wound with wound cleanser and applied the dressing. RN #1 failed to paint with betadine as ordered. Review of the clinical record revealed that for the visit of 05/06/2025 RN #1 documentation indicated that the wound care was provided as ordered. During an interview conducted on 05/07/2025 at 3:40 PM RN #1 stated, “I don’t know if I typed [documented] that I withheld that [betadine]. Yes [normally verify an order prior to wound care]. Yes, I normally document when I don’t follow [an order].” An interview conducted on 05/07/2025 at 3:50 PM with the Executive Director revealed that the expectation is to follow the order and document accurately.”