Encompass Home Health of North Carolina

“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, clinical record review, and staff interviews, the agency failed to include orders for urinary catheters for 2 of 2 patients with urinary catheters (#1, & 3) and failed to include orders for oxygen therapy for 1 of 1 patient with oxygen (#2). Findings included: A policy, Clinical Records (revised 4/2/26) received on 8/3/26 at 2:58 PM from the Director of Operations stated, “The record includes… Drug, dietary, treatment… orders… The clinical record includes essential components… Significant history and/or medical information including diagnose, medications, allergies, treatments, etc.…” Patient #1 was admitted on 5/28/26 with a diagnosis of rheumatoid arthritis (causes swelling and/or deformities of the joints). The plan of care for 5/28/26-7/26/26 included orders for skilled nurse visits 1 time a week for 1 week and 1 every other week for 4 weeks. Review of the clinical record revealed that on 5/28/26 registered nurse #3 documented, “Suprapubic catheter [tube in the lower abdomen to drain urine] in place.” Further review revealed that the suprapubic catheter was not included in the plan of care. Patient #2 was admitted on 6/4/26 with a diagnosis of hypertensive heart disease (long term high blood pressure) and chronic kidney disease with heart failure (inability to pump blood normally). The plan of care for 6/4/26- 8/2/26 included orders for physical therapy (PT) 1 time a week for 1 week, 2 times a week for 4 weeks, and 1 time a week for 3 weeks. Review of the clinical record revealed that on 6/4/26 PT #4 documented, “Does the patient require oxygen YES, continuous…She is on continuous 2L [2 liters a minute] oxygen…” Further review revealed that oxygen was not included in the plan of care. Patient #3 was admitted on 5/7/26 with a diagnosis of paraplegia (partial or complete immobility of the lower limbs). The plan of care for 5/7/26- 7/5/26 included orders for skilled nurse visits 1 time a week for 1 week, 1 every other week for 4 weeks, and 1 time a week for 4 weeks. Review of the clinical record revealed that on 6/10/26 RN #3 documented, “Indwelling catheter insitu [sic] size 16 Foleys [catheter brand name]…” Further review revealed that the urinary catheter was not included in the plan of care. An interview conducted on 8/4/26 at 3:00 PM with RN #3 revealed that they normally include urinary catheters in the plan of care. An interview conducted on 8/4/26 at 3:07 PM with PT #4 revealed that they normally include oxygen in the plan of care. An interview conducted on 8/4/26 at 3:04 PM with the Director of Operations revealed that urinary catheters, including the size and who is managing it, should be included in the plan of care. An interview conducted on 8/4/26 at 3:10 PM with the Director of Operation revealed that oxygen should be included in the plan of care on the medication profile.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to include orders for occupational therapy (OT) for 2 of 2 patients with orders from the referring physician for OT (#1 & 3). Findings included: A policy, Admission process and patient assessment (revised 4/28/26) received on 8/3/26 at 3:13 PM from the Director of Operations stated, “Evaluations for additional Licensed Professional services will be conducted as ordered by the physician… no later than 1 week post referral…” Patient #1 was admitted on 5/28/26 with a diagnosis of rheumatoid arthritis (causes swelling and/or deformities of the joints). The plan of care for 5/28/26-7/26/26 included orders for skilled nurse visits 1 time a week for 1 week and 1 every other week for 4 weeks. Review of the clinical record revealed that the home health order of 5/26/26 included orders for occupational therapy, the transition of care discharge note from the referring physician stated, “HH [home health] arranged: RN [registered nurse], PT [physical therapy], OT [occupational therapy]” and on 5/28/26 RN #3 documented, “Primary focus: PT, OT…” Further review revealed that there was no order for OT in the plan of care until 6/14/26. An OT did not complete an evaluation. Patient #3 was admitted on 5/7/26 with a diagnosis of paraplegia (partial or complete immobility of the lower limbs). The plan of care for 5/7/26- 7/5/26 included orders for skilled nurse visits 1 time a week for 1 week, 1 every other week for 4 weeks, and 1 time a week for 4 weeks. Review of the clinical record revealed that the home health referral order of 4/30/26 included orders for occupational therapy (OT). Further reviewed that the order for OT was not included in the plan of care and an OT did not complete an evaluation. An interview conducted on 8/3/26 at 3:04 PM with the branch director revealed that the expectation is for all referrals to get reviewed, each ordered discipline should contact the patient/caregiver within 5 days to conduct the evaluation.”

“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, home visit observation, and staff interviews, the RN failed to perform hand hygiene prior to entering the nursing bag and failed to place the documentation device on a clean barrier when not in use for 1 of 2 nursing home visits. The findings included: The policy, Bag/equipment technique [no date], was provided by RN # 1 on 10/30/24 at 8:15 am. The policy stated, “ …The clinical bag and related equipment will be used in accordance with the following directions...The inside pouches of the bag must be kept clean at all times and will not be entered into until hands are thoroughly cleaned...Remove a minimum of 2 barriers from the bag to be used for clean and dirty fields...Open bag and remove all items needed for the visit. Items are to be placed on the clean barrier...” Patient # 13 had a Start of Care date of 12/5/23 and admitting diagnoses of encounter for fitting and adjustment of urinary device, retention of urine, and type 2 diabetes mellitus without complications. Review of the Plan of Care for the certification period 9/30/24-11/28/24 included orders for SN [skilled nursing] 1 time a week for 1 week, 1 time every 4 weeks for 8 weeks and “Skilled nurse for insertion of foley catheter using catheter # 18...Skilled nurse to change Q [every] month ...” On 10/29/24 at approximately 11:30 am a joint visit was conducted with RN # 3. During the visit, the RN was observed putting clean barriers on a spare bed in the patient’s bedroom. The RN then placed her device [used for documentation] directly on the bed, not on the barrier. The RN was then observed entering the nursing bag without performing hand hygiene to retrieve the hand sanitizer which was in the center portion of the bag, not in a side pocket. During an interview with the RN on 10/29/24 at approximately 2 pm, the RN stated, “I should have put the device on the barrier. I was so nervous. I normally keep my sanitizer in the side pocket.””

“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 policy and procedure, clinical record review, and staff interview, the registered nurse removed the huber needle without a physician’s order for 1 of 1 records reviewed with an implanted port (medical device that allows for the administration of treatments and blood draws) [3]; and failed to monitor weights and blood sugar levels for 4 of 19 patients [ #5, 7, 13, 19]. Findings included: 2. Patient # 5 had a Start of Care date of 8/7/24 with admitting diagnosis of hemiplegia [paralysis of half of body] following cerebral infarct [stroke] and diabetes with hyperglycemia [high blood sugar]. Review of the Plan of Care [POC] for the certification period 8/7/24-10/5/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 2 weeks; OT [occupational therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 1 week and “Licensed professional to report vital signs falling outside of following established parameters...Weight less than 145 pounds or greater than 155 pounds, FBS [fasting blood sugar] less than 70 and greater than 180, Random blood sugar less than 70 and greater than 180...” Review of the clinical record revealed a weight of 150 pounds at the time of admission. The patient received 3 OT visits from 8/7/24-8/15/24. There were no blood sugar results or weights documented. The patient received 3 PT visits from 8/7/24-8/15/24. The only weight documented was obtained on admission. There were no blood sugar results documented. During an interview with RN # 2 on 10/30/24 at 2:230 pm, the RN confirmed the staff failed to monitor blood sugar levels and weights in accordance with the POC. 3. Patient # 7 had a Start of Care date of 9/14/24 and admitting diagnoses of radiculopathy lumbar region [painful condition that occurs when the nerve roots in the lower back are compressed or irritated] and type 2 diabetes mellitus with diabetic neuropathy [high blood sugars have damaged nerves]. Review of the Plan of Care [POC] for the certification period 9/14/24-11/12/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week every 2 weeks for 2 weeks, 2 times a week for 4 weeks, 1 time a week for 2 weeks and “ Licensed professional to report vital signs falling outside the following established parameters...weight less than 215 or greater than 225, fasting blood sugar less than 70 or greater than 180, random blood sugar less than 70 or greater than 180...” Review of the clinical record revealed a weight of 220 obtained on 9/14/24. Further review of the clinical record revealed the patient received 8 visits from PT from 9/14/24-10/22/24. There was only 1 weight documented and no blood sugar readings. During an interview with RN # 2 on 10/30/24 at approximately 3 pm, the RN confirmed the clinicians failed to monitor the patient’s weight and blood sugar levels in accordance with the POC. 4. Patient # 13 had a Start of Care date of 12/5/23 and admitting diagnoses of encounter for fitting and adjustment of urinary device, retention of urine, and type 2 diabetes mellitus without complication. Review of the Plan of Care [POC] for the certification period 9/30/24-11/28/24 included orders for SN 1 time a week for 1 week, 1 time every 4 weeks for 8 weeks; PT [physical therapy] 1 time a week for 8 weeks and “ Licensed professional to report vital signs falling outside the following established parameters...Weight less than 235 and greater than 245...FBS [fasting blood sugar] less than 70 or greater than 180, RBS [random blood sugar] less than 70 or greater than 180...” ”Review of the clinical record revealed the patient received 8 visits [between SN and PT] from 10/2/24 and 10/29/24. The clinical record revealed no documented weights or blood sugars. During an interview with RN # 2 on 10/30/24 at approximately 3 pm, the RN confirmed the staff failed to obtain weights/blood sugars in accordance with the POC. 5. Patient # 19 had a Start of Care date of 9/13/23 with admitting diagnoses of hypertensive heart disease with heart failure [group of conditions that can occur when hypertension damages the heart] and chronic systolic heart failure [heart doesn’t pump effectively]. Review of the Plan of Care [POC] for the certification period 9/13/23-11/11/23 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; PT [physical therapy] effective 9/17/23 1 time a week for 1 week, then 2 times a week for 4 weeks, 1 time a week for 3 weeks; OT [occupational therapy] 1 time a week for 4 weeks, 2 times a week for 1 week and “Licensed professional to report vital signs falling outside the following established parameters...weight less than 156 or greater than 166...” Review of the clinical record revealed an admission weight of 161.2. Further review of the clinical record revealed the patient received 12 visits [between all disciplines] from 9/13/23 -10/12/23. The only weight was documented at the time of admission. During an interview with RN # 2 on 10/30/24 at approximately 3 pm, the RN confirmed the clinicians failed to monitor the patient’s weight in accordance with the POC. A policy “Physician’s role” revised 10/18/23 was provided by the administrator alternate on 10/30/24 at 8:15 AM. The policy stated…” verbal order is an order communicated from the physician prior to rending services…” 1.Patient #3 was admitted on 1/18/24 with diagnosis of malignant neoplasm (cancer) of the brain, fracture (break) of the fibula, and peripheral vascular disease. The plan of care for 1/18/24 to 3/17/24 had orders for skilled nursing 1 time a week for 4 weeks, and physical therapy 1 time a week for 1 week, 2 times a week for 3 weeks, and 1 time a week for 3 weeks. Review of the skilled nursing admission visit 1/18/24 on 10/28/24 revealed the registered nurse documented removing the huber needle from the implanted port per patient request. No physician’s order was in the record to remove the needle. Interview with the agency director on 10/31/24 at 3:01PM revealed, “she did pull the needle and didn’t think to get a doctor’s order”.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to notify the physician prior to educating a patient to increase fluid intake [diagnosis of congestive heart failure] for 1 of 1 patients [#2]; and failed to notify physician when a patient reported the home was infested with bugs for 1 of 1 patients [#9]. The findings included: 1. Patient # 2 had a Start of Care [SOC] date of 5/30/24 and admitting diagnoses of type 2 diabetes with hypoglycemia [low blood sugar] without coma and acute systolic (congestive) heart failure [heart does not pump effectively. Review of the Plan of Care [POC] for the certification period 5/30/24-7/28/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 4 weeks. Review of the clinical record revealed PT # completed the SOC visit on 5/30/24. Review of the clinical record revealed the following documentation,”...urine dark in urinal. Encouraged increased fluid intake...” There was no evidence the PT notified the physician before educating the patient to increase fluid intake [dx of CHF]. During an interview with RN # on 10/30/24 at approximately 2:30 pm, the RN confirmed the PT should have notified the MD prior to educating the patient to increase fluid intake. 2. Patient # 9 had a Start of Care date of 10/1/24 with an admitting diagnosis of sepsis [infection in the blood], type 2 diabetes mellitus with heart failure and stage 1-4 unspecified chronic kidney disease, and chronic combined systolic and diastolic heart failure [heart does not pump effectively]. Review of the Plan of Care [POC] for the certification period 10/1/24-11/29/24 included orders for OT [occupational therapy] 1 time a week for 1 week [initial visit], 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week. Review of the clinical record revealed OT # 4 completed the initial OT evaluation on 10/9/24 and documented, “...The client reports that it [apartment] is bug infested, but that her family cannot get approved for anything [likely due to the fact that she admitted they had failed to pay the rent for several months in a row]. The client is currently sleeping in a non-reclining chair...” On 10/23/24, COTA # 5 documented “evidence of infestation by insects or rodents.” There is no evidence that the physician was notified by the OT or COTA related to bug infestation. During an interview with RN # 2 on 10/30/24 at approximately 2:15 pm, RN # stated, “OT did not tell the physician because the presence of bugs was reported by the patient. They did not assess for any bug infestation.””