Assistedcare Home Health Inc.

“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, clinical record review, and staff interviews, the registered nurse (RN) failed to perform hand hygiene after removing soiled gloves, failed to remove soiled gloves and perform hand hygiene after handling contaminated objects, failed to remove contaminated gloves and perform hand hygiene before handling clean supplies, failed to remove gloves and perform hand hygiene before removing items from the clinical bag, failed to remove gloves and perform hand hygiene after removing a wound dressing, and placed a contaminated object on the patients skin for 1 of 2 RN home visits conducted (#13) and failed implement increased precautions for 1 of 1 patient being treated for clostridium difficile (C. diff, highly contagious bacteria that causes severe diarrhea), (#20). Findings included: A policy, Hand Hygiene (reviewed 7/10/25), received on 7/21/26 at 4:41 PM from the Director of Operations stated, “Perform Hand Hygiene as follows: Before having direct contact with patients, before donning gloves… after contact with a patient’s skin, after contact with body fluid or excretions, mucous membranes, nonintact skin, and wound dressings… after contact with inanimate objects…after removing gloves.” A policy, Bag Technique (reviewed 7/10/250 received on 7/21/26 at 4:41 PM from the Director of Operations stated, “The field staff member cleansed hands prior to accessing materials from the supply bag… Wash hands again if you need to re-enter the bag for additional supplies during patient care. Do not go back into the bag without removing gloves and performing hand hygiene.” A policy, Transmission-Based Precautions (reviewed 5/7/250 received on 7/22/26 at 10:07 AM from the Director of Operations stated, “Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent the spread of infection… The following list contains examples for using Transmission-Based Precautions… clostridium difficile infection…” 1. Patient #13 was admitted on 6/27/26 with a diagnosis of encounter for change or removal of surgical wound dressing. The plan of care for 6/27/26-8/26/26 included orders for skilled nurse visits 1 time a week for 5 weeks and 1 every other week for 4 weeks and, “RN/LPN/LVN [skilled nurse] to perform/teach wound care to 2nd toe amputation [right] area. Irrigate/cleanse with wound cleanser, pat dry with gauze apply iodoform [wound dressing] may apply skin barrier…cover with dry gauze secure with kerlix [rolled gauze] and ace wrap change dressing every other day and PRN [as needed]. Patient #13 was a resident of a facility. A home visit was conducted on 7/21/26 with registered nurse (RN) #6 at approximately 1:30 PM. RN #6 failed to remove the gloves and perform hand hygiene after removing the dressing from the right shin before removing the patients shoe and sock. RN #6 failed to remove gloves and perform hand hygiene after removing the shoe and sock before removing the soiled dressing from the 2nd toe. RN #6 removed the glove from the left hand and failed to perform hand hygiene before entering the clinical bag. RN #6 failed to remove both contaminated gloves and perform hand hygiene before cleansing the wound on the 2ed toe and applying a new dressing. RN #6 failed to remove gloves and perform hand hygiene before moving to the shin wound. Using a single use measuring tape RN #6 measured the shin wound, dropped the measuring tape on the floor, picked up the measuring tape, wrote on it with an ink pen, and placed the soiled measuring tape directly onto the patient’s skin. RN #6 failed to remove soiled gloves and perform hand hygiene before removing supplies from the patient’s stock. RN #6 failed to remove gloves and perform hand hygiene after wiping her nose with the back of the gloved hand before performing wound care to the shin wound. RN #6 failed to remove gloves and perform hand hygiene after wound care before assessing the patient’s skin on the left leg. An interview conducted on 7/22/26 at 8:15 AM with RN #6 revealed that RN #6 does not normally remove gloves and perform hand hygiene after removing a patient’s shoes, before wound care, does not perform hand hygiene before retrieving items from the clinical bag. RN #6 stated that they normally perform hand hygiene after removing gloves, before removing supplies from a patient’s stock, and when moving from 1 wound to another. When asked about picking up the measuring tape from the floor RN #6 stated, “I didn’t put it on the wound.” An interview conducted on 7/22/26 at 8:26 AM with the Director of Operations revealed that the expectation is to perform hand hygiene every time you change gloves, every time you enter the bag, when moving from one wound to another, after removing shoes/socks, and before entering the patient’s supply. The measuring tape should have been discarded and a clean one used for wound measurement. 2. Patient #20 was admitted on 6/30/26 with diagnoses of permanent atrial fabulation (irregular heartbeat), other bacterial agents as the cause of diseases elsewhere classified, and diarrhea. The plan of care for 6/30/26-8/28/26 included orders for skilled nurse visits 1 time a week for 5 weeks and 1 every other week for 4 weeks. Review of the clinical record revealed that the patient was admitted to the hospital on 7/14/26 and has a resumption of care on 7/17/26. Further review revealed that on 7/17/26 RN #6 documented, “Gastrointestinal: Yes, Abnormal Findings…Diarrhea… She was started on vancomycin for CDIFF [for clostridium difficile highly contagious bacteria that causes severe diarrhea].” Review of the hospital discharge summary revealed the discharge diagnosis was, “recurrent clostridium difficile.” Further review revealed that RN #6 did not document the use of increased transmission-based precautions.” During an interview conducted on 7/22/26 at 11:05 AM RN #6 stated, “No, I didn’t initiate contact precautions.” During an interview conducted on 7/22/6 at 10:10 AM the Director of Operations stated, “Yes, I would have initiated contact precaution and discontinue once the loose stools have resolved.””

“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 bleeding precautions in the plan of care for 4 of 8 patients taking anticoagulants (prevents blood clots) (#’s 2, 6, 11, & 18) and 1 of 6 patients taking antiplatelets (prevents blood clots) (#4). Findings included: A policy, Plan of Care (POC)/Care (reviewed 2/9/26) received on 7/21/26 at 3:03 PM from the Director of operations stated, “The individualized plan of care must include the following… Safety measures to protect against injury…” A policy, Physician Orders and Medical Supervision of the Plan of care (reviewed (7/15/26) received on 7/22/26 at approximately 10:00 AM from the Director of Operations stated, “The current 485/Plan of Care will include… Safety measures to protect against injury…” 1. Patient #2 was admitted on 5/15/25 with a diagnosis of aftercare following joint replacement surgery. The plan of care for 5/15/25-7/13/25 included orders for skilled nurse visits 1 time a week for 4 weeks and, “RN [registered nurse] to observe, assess, evaluate, and develop an individualized plan of care” and “Xarelto [anticoagulant] 20 mg daily.” Review of the plan of care revealed that bleeding precautions were not included. 2. Patient #4 was admitted on 1/21/26 with diagnoses of pressure ulcer of sacral region, unstageable (wound at the lower spine with an undetermined depth) and long term use of aspirin. The plan of care for 1/21/26-3/21/26 included orders for skilled nurse visits 1 time a week for 7 weeks and 1 every other week for 2 weeks and Ecotrin low strength (antiplatelet) 81mg 1 tablet daily. Review of the plan of care revealed that bleeding precautions were not included. 3. Patient #6 was admitted on 7/6/26 with diagnoses of type 2 diabetes mellitus with diabetic neuropathy (prolonged high blood sugars causing nerve damage) and long term use of anticoagulants. The plan of care for 7/6/26-9/3/26 included orders for physical therapy visits 2 times a week for 3 weeks, 1 time a week for 4 weeks, 1everyother week for 2 weeks, and “Eliquis [anticoagulant] 5mg tablet 2 times a day.” Review of the plan of care revealed that bleeding precautions were not included. 4. Patient #11 was admitted on 6/29/26 with a diagnosis of acute cholecystitis (inflammation of the gall bladder). The plan of care for 6/29/26-8/27/26 included orders for skilled nurse visits 1 time a week for 4 weeks, 1 every other week for 2 weeks, “RN [registered nurse] to observe, assess, evaluate, and develop an individualized plan of care, Tricagrelor (antiplatelet) 90mg tablet 2 times a day, and “Aspirin [antiplatelet] 81mg 1 tablet daily,” Review of the plan of care revealed that bleeding precautions were not included. 5. Patient #18 was admitted on 7/4/26 with diagnoses of Fx unsp part of nk R femr (fracture of right thigh) and long term use of anticoagulants. The plan of care for 7/4/26-9/1/26 include orders for physical therapy visits 1 time a week for 6 weeks, 1 every other week for 2 weeks, and “Eliquis [anticoagulant] 2.5 mg tablet 2 times a day.” Review of the plan of care revealed that bleeding precautions were not included. During an interview conducted on 7/22/26 at 8:15 AM registered nurse #6 stated, “I don’t usually add bleeding precautions for a baby aspirin [81mg]” During an interview conducted on 7/22/26 at 10:59 AM physical therapist #3 stated, “Typically, yes (add to POC), to educate.” During an interview conducted on 7/22/26 at 10:36 AM the Director of Operations stated, “The expectation is to have bleeding precautions for anti-platelet and anti-coagulant medications.””

“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, and staff interviews, the registered nurses failed to notify changes of condition for 2 of 15 active patients (#’s15 & 20) and the physical therapist failed to notify a physician of abnormal blood sugar readings for 1 of 8 patients with diabetes mellitus (condition where the body cannot properly use sugar) (#6). Findings included: A policy, Coordination of Care (reviewed 7/10/25) received on 7/22/26 at 10:30 AM from the Area Vice President stated, “Any revisions to the plan of care due to a change in patient health status must be communicated to the… all physicians or allowed practitioners issuing orders for the HHA [home health agency] plan of care… The overseeing physician/allowed practitioner is notified promptly of any changes in the patient’s condition or needs that suggest that the outcomes are not being achieved and/or that the plan od care should be altered.” 1. Patient #6 was admitted on 7/6/26 with diagnoses of type 2 diabetes mellitus with diabetic neuropathy (prolonged high blood sugars causing nerve damage) and long term (current) use of insulin (treats diabetes). The plan of care for 7/6/26-9/3/26 included orders for physical therapy visits 2 times a week for 3 weeks, 1 time a week for 4 weeks, 1every other week for 2 weeks. Review of the clinical record revealed that during the physical therapist visit (PT) on 7/6/26 PT #3 documented, “Usual BS [blood sugar] 200-400.” During an interview conducted on 7/22/26 at 10:59 AM PT #3 stated, “I did not call the Doctor, we were not seeing her for diabetes.” During an interview conducted on 7/11/26 at 11:02 AM the Director of Operations stated, “Yes, they should have notified the doctor.” 2. Patient #15 was admitted on 6/11/26 with a diagnosis of hemiplegia following cerebral infarct affecting left nondominant side (partial paralysis after a stroke). The plan of care for 6/11/26-8/9/26 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 6/11/26 the patient was experiencing constipation and registered nurse (RN) #8 documented, “RN mentioned trying milk of magnesia (laxative).” Further review revealed no documentation of the physician being notified prior to RN#8 recommending a new medication. An interview conducted on 7/22/26 at 111:21 AM with RN #8 revealed that the physician was not contacted. 3. Patient #20 was admitted on 6/30/26 with diagnoses of permanent atrial fabulation (irregular heartbeat) and other bacterial agents as the cause of diseases elsewhere classified. The plan of care for 6/30/26-8/28/26 included orders for skilled nurse visits 1 time a week for 5 weeks and 1 every other week for 4 weeks. Review of the clinical record revealed that the patient had a recent history of C-DIFF (clostridium difficile highly contagious bacteria that causes severe diarrhea). Further review revealed that on 7/7/26 RN #6 documented, “She has a bout of liquid stools Friday and called me. I suggested Immodium [sic] 2 at first and 1 in 6 hrs [hours] if reoccurred.” Further review revealed that there was no documentation of the physician being notified. Further review revealed that the patient was readmitted to the hospital on 7/14/26 with a diagnosis of recurrent clostridium difficile. An interview conducted on 7/22/26 at 11:03 AM with RN #6 revealed that the physician was not contacted because the patient made contact after the physician’s office closed. RN #6 stated, “No [did not call physician before recommending a medication], it was an over-the-counter thing.” During an interview conducted on 7/22/26 at 11:30 AM the Director of Clinical Operations stated, “They [nurses] should contact a physician before making recommendations.””

“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 agency policy, clinical record review, and staff interviews the agency failed to alert the relevant physician of changes in the patient’s condition that suggested expected outcomes were not being achieved for 1 of 3 records reviewed. (Patient #2). Findings included: Policy TX-002, last revised 05/22/24 and titled “Coordination of Care,” revealed, “The HHA [Home Health Agency] 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.” Patient #2 was admitted on 03/08/24 with a diagnosis of Hyperkalemia (elevated potassium level in blood); pain in left ankle; Hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke) affecting left, non-dominate side. The plan of care (POC) dated 03/08/24-05/03/24 included orders for physical therapy (PT) to see the patient 1 time a week for 1 week, 2 times a week for 2 weeks, then 1 time a week for 5 weeks. During the PT visit on 03/08/24 at 8:43 AM, Employee #5, physical therapist, stated, “Patient states her left shoulder has gotten significantly worse… Patient states she was given pain medication at the hospital but that it has not been effective at managing her pain.” During the PT visit on 03/27/24 at 1:19 PM, Employee #5 stated, “Patient states that her right shoulder is beginning to hurt her more… Patient is beginning to have pain in a [sic] right upper extremity, at this time therapist does recommend that patient limit ambulation to whatever is absolutely necessary to reduce strain on right upper extremity.” On 04/01/24 at 12:14 PM Employee #5 stated, “Patient states she hurt her left wrist while performing sit/stand transfer and is utilizing a brace.” On 04/10/24 at 12:14 PM, Employee #5 stated, “Adaptive equipment using [brand name of resistance bands] for assisted ambulation has been effective in improving ambulation distance however patient continues to be dependent on [brand name of resistance bands] for safe ambulation and it is not a long-term solution… Patient is unable to safely ambulate without use of adaptive [brand name of resistance bands] equipment. Patient has been attempting to ambulate frequently by dragging her left foot or hopping on right lower extremity only…. patient has difficulty putting on and off adaptive [brand name of resistance bands] equipment due to little to no left hand function and decreased strength in right hand.” On 04/17/24 at 11:13 AM, Employee #5 stated, “Patient states his [sic] shoulder has been bothering her more and more… Patient does not have appropriate caregiver assistance with dawning [sic] and doffing [brand name of resistance bands] adaptive equipment which is limiting her ability to ambulate between therapy sessions.” There was no evidence in the clinical record that any of the above changes were communicated with the physician. An interview was conducted on 06/18/24 at 1:45 PM with Employee #5. Employee #5 stated, “Pain in the left shoulder, a rotator cuff injury, as far as I believe they were not planning on treating at the time, it didn’t actually become more of an issue until later when she tried to use the rollator to walk…No, I did not talk to the doctor about the pain or any changes…I’m not sure if I talked to the doctor or not [about the new pain in right shoulder as documented on 03/27/24]…I did not notify the doctor…she got the brace from the doctor…I did not verify that with the doctor’s office.” An interview with Employee #1, agency director, was conducted on 06/18/24 at 2:00 PM. Employee #1 stated, “Mine [expectation] would be that they [clinicians] would notify Employee #and let them know that the regime is not working…I would expect to see that he [Employee #5] documented confirmation on where the brace came from.””

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA 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). This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interview, the agency failed to provide adequate notice of discharge to the patient and/or responsible party or physician for 1 of 3 records reviewed. (Patient #1). Findings included: Policy AA-0016, last revised 05/23/24 and titled “Discharge of Patients” was received from the agency director on 06/18/24 at 2:10 PM. This policy revealed, “If a decision is made to terminate services, staff will normally verbally notify non-institutionalized patients and their attending physician/licensed practitioner at least 2 days prior to discharge of the date and time of termination of services…or within a specified time frame according to state regulation. These verbal communications will be documented in the patient’s chart.” Patient #1 was admitted to the agency on 04/01/24 with diagnoses including chondrocalcinosis of the right knee (a form of arthritis that causes calcium crystal deposits in the joints) and muscle weakness. Plan of Care from 04/01/24 to 05/30/24 revealed orders for skilled nursing one time per week for nine weeks, physical therapy one time per week for one week, two times per week for two weeks, and one time per week for six weeks, occupational therapy one time per week for five weeks, and speech therapy effective 04/14/24 one time per week for one week, once every three weeks for three weeks, and one time per week for three weeks. On 05/03/24, Employee #4, scheduler, entered a coordination note and documented, “Left message to discuss ins [insurance] denial with patient requesting a return phone call.” There was no evidence of further follow-up or attempts to notify the patient or caregiver of the insurance denial. Patient #1 continued to receive home health services as ordered until 05/29/24. On 05/29/24, Employee #6, speech therapist, documented that Patient #1 had dementia and “…educated pnt [patient] on reasons for DC [discharge] today vs [versus] recertification as her current dx [diagnosis] provided by PCP [primary care provider] does not support continuing ST [speech therapy] services as needed…instructed pnt as communicated by [name of clinical manager], that if she wishes to continue with ST services she will need to fu [follow up] with PCP and have new order sent to HH [home health] agency…also reviewed pnt NOMNC [Notice of Medicare Non-Coverage] and ability to appeal if she decides.” The NOMNC document listed 05/29/24 as the effective date of coverage. There was no evidence in the clinical record of care coordination with the patient, responsible party or PCP prior to 05/29/24. In an interview on 06/18/24 at 1:12 PM, Employee #4 stated that she did not receive a return call from Patient #1 and “If we’re not able to [reach the patient by phone] then yes, we return calls, but I think they [Patient #1 and/or caregiver] were made aware by clinicians.” In an interview on 06/18/24 at 1:55 PM, Employee #6 stated “Originally my plan was to continue [speech therapy services] …I was notified that I was unable to recert [recertify] and it had to be a discharge per insurance. I communicated that to the patient and the patient’s son who was present that day…he’s not the primary caregiver who lives in the home. He was visiting from out of town. I would typically always include whoever the POA [power of attorney] is…and I document that as well.” In an interview on 06/18/24 at 1:56 PM, Employee #1, agency director, stated “We let families know, we let patients know and we let physicians know that we will not be able to continue services. We reach out to physicians to let them know that we don’t have an additional auth [insurance authorization]. We try to let the patient know as soon as we find out so they can contact their case manager and see if they can help us get additional auth.””

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on agency policy, clinical record review, and staff interview, the agency failed to conduct an ordered medical social work evaluation for 1 of 1 record reviewed with orders for medical social work evaluation. (Patient #5) Findings included: Policy TX-001, last revised 06/22/23 and titled, “Physician Orders and Medical Supervision of the Plan of Care” was received from the agency’s area vice president on 12/12/23 at 11:00 AM. This policy revealed, “The agency provides care and services according to the most recent physician order. Policy TX-002, last revised 05/04/23 and titled, “Coordination of Care” was received from the agency director on 12/12/23 at 10:45 AM. This policy revealed, “The HHA [home health agency] must…integrate orders from all physicians involved in the plan of care.” Patient #5 was admitted to the agency 10/28/23 with diagnoses including left humerus (bone between shoulder and elbow joint), atrial fibrillation (irregular heart rhythm), weakness and a history of falls. Clinical record review included a Plan of Care from 10/28/23 to 12/26/23 which revealed, “…PATIENT IS VERY WEAK AND UNSTEADY ON HER FEET AND WOULD GREATLY BENEFIT FROM PT [physical therapy], OT [occupational therapy], SLP [speech and language pathologist], AND A SOCIAL WORK EVALUATION. FAMILY LIVES IN CHARLOTTE SO THEY ARE UNABLE TO BE THERE ON A DAILY BASIS…” An order for a medical social worker evaluation was entered into the electronic medical record (EMR) and added to the 485 on 11/15/23. At the time of survey, there was no evidence that a medical social worker evaluation was conducted. In an interview on 12/12/23 at 10:23 AM, the agency’s area vice president stated, “It looks like the social worker order was put in [the EMR] and they didn’t put the order in for the next week to get it plotted and scheduled…””