Medi Home Health Agency

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to ensure that the individualized plan of care included appropriate bleeding precautions/interventions/goals for 13 of 13 patients being at risk for bleeding due to anticoagulant or antiplatelet therapy (#2, 3, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, &19); Failed to include appropriate respiratory interventions and goals for 2 of 5 patients with respiratory disorders (#10 &11); Failed to include goals and interventions for Diabetes Mellitus for 1 of 6 patients with diabetes mellitus (#16), and included bleeding precautions in the plan of care for 1 of 5 patients without orders for anticoagulant or antiplatelet therapy (#10). Condition level Determination The cumulative effect of this systemic problem resulted in the agency’s ability to ensure all patients received individualized care based on the risks identified during the comprehensive assessment, including proper safety measures related to patients receiving ongoing anticoagulant and antiplatelet therapy. Findings included: A policy, Care Plan Implementation (revised 09/2025) received on 03/10/2026 at 12:23 PM from the Director of Professional Services stated, “Each patient shall have a written POC [plan of care] that specifies the care and services to be provided, measurable outcomes, responsible disciplines, and patient/caregiver needs… Ensures the plan identifies patient-specific measurable goals (individualized based on the patient’s medical diagnosis, orders, comprehensive assessment and patient input…” 6. Patient #8 had a Start of Care date of 2/29/26 with an admitting diagnosis of Pressure Ulcer sacral region, stage 4 [full thickness wound with extensive tissue loss]. Review of the Plan of Care [POC] for the certification period 2/19/26-4/19/26 revealed that the patient was ordered Brilinta [prescription antiplatelet medication] and Aspirin [antiplatelet medication that reduces the ability of blood platelets to clump together] 81 mg daily. The POC did not include “Bleeding Precautions” in the “Safety Measures” section. Further review of the POC revealed no goals or interventions related to “bleeding precautions”. 7. Patient #9 had a start of care of 2/10/26 with an admitting diagnosis of Unspecified open wound of right great toe. Review of the Plan of Care [POC] for the certification period of 2/10/26-4/10/26 revealed that the patient was ordered Aspirin [antiplatelet medication that reduces the ability of blood platelets to clump together] 81 mg daily. The POC did not include “Bleeding Precautions” in the “Safety Measures” section. Further review of the POC revealed no goals or interventions related to “bleeding precautions”. 8. Patient #10 had a start of care of 2/24/26 with an admitting diagnosis of Alzheimer’s disease [condition with cognitive impairment]. Review of the plan of care [POC] for the certification period of 2/24/26-4/24/26 revealed that the patient was ordered Albuterol Sulfate HFA inhalation [rescue inhaler for shortness of breath] and Fluticasone Propionate Inhalation [steroid inhaled medication to reduce wheezing and shortness of breath]. Further review of the POC revealed no documented diagnosis of any lung disorder or interventions related to shortness of breath. Documented in the POC in the “Safety Measures” section was “Anticoagulant Precautions.” Review of the medication profile revealed that the patient was not ordered an anticoagulant medication. 9. Patient #11 had a start of care of 2/26/26 with an admitting diagnosis of traumatic subarachnoid hemorrhage [bleeding into the space between the brain and the membrane]. Review of the Plan of Care [POC] for the certification period of 2/26/26-4/26/26 revealed that the patient was ordered Albuterol Sulfate HFA inhalation [rescue inhaler for shortness of breath] and Stilolto [inhalation spray used for long term treatment of congestive obstructive pulmonary disorder [COPD]. Further review of the POC revealed no documented diagnosis of any respiratory conditions or interventions related to shortness of breath. 10. Patient #12 had a start of care of 1/13/26 with an admitting diagnosis of encounter for fitting and adjustment of urinary device [internal catheter for urination]. Review of the Plan of Care [POC] for the certification period of 1/13/26-3/13/26 revealed that the patient was ordered Aspirin [antiplatelet medication that reduces the ability of blood platelets to clump together] 81 mg daily. The POC did not include “Bleeding Precautions” in the “Safety Measures” section. Further review of the POC revealed no goals or interventions related to “bleeding precautions”. 11. Patient #13 had a start of care of 1/29/26 with an admitting diagnosis of sepsis [reaction to an infection that causes harm to body tissues]. Review of the Plan of Care [POC] for the certification period of 1/29/26-3/29/26 revealed that the patient was ordered Aspirin [antiplatelet medication that reduces the ability of blood platelets to clump together] 81 mg daily. The POC did not include “Bleeding Precautions” in the “Safety Measures” section. Further review of the POC revealed no goals or interventions related to “bleeding precautions”. 12. Patient #14 had a start of care of 10/17/25 with an admitting diagnosis of Gastrostomy infection [infection at the site of an artificial opening in the abdomen for feeding]. The Plan of Care [POC] for the certification period of 2/14/26-4/14/26 revealed that the patient was ordered Aspirin [antiplatelet medication that reduces the ability of blood platelets to clump together] 81 mg daily. The POC did not include “Bleeding Precautions” in the “Safety Measures” section. Further review of the POC revealed no goals or interventions related to “bleeding precautions”. 13. Patient #15 had a start of care of 2/4/26 with an admitting diagnosis of of Displ intertoch fx r femur [fracture of the right upper leg]. Review of the Plan of Care [POC] for the certification period of 2/4/26-4/4/26 revealed that the patient was ordered Aspirin [antiplatelet medication that reduces the ability of blood platelets to clump together] 325 mg daily. The POC did not include “Bleeding Precautions” in the “Safety Measures” section. Further review of the POC revealed no goals or interventions related to “bleeding precautions”. 14. Patient #19 had a start of care of 1/12/26 with an admitting diagnosis of Chronic Obstructive Pulmonary Disease [progressive lung disease making breathing difficult]. Review of the Plan of Care for the certification period for 1/12/26-3/12/26 revealed that the patient was ordered Aspirin [antiplatelet medication that reduces the ability of blood platelets to clump together] 81 mg daily. The POC did not include “Bleeding Precautions” in the “Safety Measures” section. Further review of the POC revealed no goals or interventions related to “bleeding precautions”. An interview conducted on 3/11/26 at 09:11 AM with the Director of Professional Services revealed that the expectation is that the plan of care includes patient/caregiver education for all high-risk medications. 1. Patient # 2 had a Start of Care date of 9/6/25 with an admitting diagnosis of Interstitial Pulmonary Disease [chronic disorders causing inflammation and irreversible scarring [fibrosis] of lung tissue, specifically the area around air sacs, which impairs oxygen absorption]. Review of the Plan of Care [POC] for the certification period 9/6/25-11/4/25 revealed the patient was taking Aspirin [antiplatelet-medication that reduces the ability of blood platelets to clump together] 81 mg. Take 1 tablet daily for heart. The POC did not include “bleeding precautions” in the “Safety Measures” section. Further review of the POC revealed no goals or interventions related to “bleeding precautions”. 2. Patient # 3 had a Start of Care date of 8/25/28 with admitting diagnoses of Parkinson’s Disease [ type of movement disorder- linked to nerve cells in the brain not producing enough brain chemicals called dopamine] and Type 2 Diabetes Mellitus with diabetic polyneuropathy [complication where high blood sugar cause nerve damage]. Review of the Plan of Care [POC] for the certification period 8/25/25-10/23/25 revealed the patient was taking Aspirin [antiplatelet-medication that reduces the ability of blood platelets to clump together] 81 mg. Take 1 tablet by mouth daily as a blood thinner. The POC did not include “bleeding precautions” in the “Safety Measures” section. Further review of the POC revealed no goals or interventions related to “bleeding precautions”. 3. Patient # 6 had a Start of Care date of 2/18/26 with an admitting diagnosis of Acute on Chronic Systolic [congestive] Heart Failure [heart doesn’t pump effectively]. Review of the Plan of Care [POC] for the certification period 2/16/26-4/18/26 revealed orders for Eliquis [anticoagulant-medication that inhibits clotting factors] 5 mg. Take 1 tablet 2 times a day and Aspirin antiplatelet-medication that reduces the ability of blood platelets to clump together] 81 mg. Take 1 tablet daily. The POC did not include “bleeding precautions” in the “Safety Measures” section. Further review of the POC revealed no goals or interventions related to “bleeding precautions”. 4. Patient # 7 had a Start of Care date of 2/20/26 with an admitting diagnosis of Unspecified Dementia. Review of the Plan of Care [POC] for the certification period 2/20/26-4/20/26 revealed the patient was ordered Aspirin [antiplatelet-medication that reduces the ability of blood platelets to clump together] 81 mg daily. Take 1 tablet daily for heart health. The POC did not include “Bleeding Precautions” in the “Safety Measures” section. Further review of the POC revealed no goals or interventions related to “bleeding precautions”. 5. Patient # 16 had a Start of Care date of 2/5/26 with an admitting diagnosis of Pressure Ulcer of sacral region, stage 2 [a partial-thickness skin loss involving the epidermis and part of the dermis, appearing as a shallow, open pink/red wound or an intact/ruptured serum-filled blister] and Type 2 diabetes Mellitus with Diabetic Polyneuropathy [complication where high blood sugar cause nerve damage]. Review of the Plan of Care [POC] for the certification period 2/5/26-4/5/26 revealed the patient was ordered Apixaban [anticoagulant-medication that inhibits clotting factors] 5 mg. Take 1 tablet twice daily for blood thinner and Glimepiride [used to treat high blood sugar levels caused by type 2 diabetes] 2 mg. Take 1 tablet daily. The POC did not include “bleeding precautions or diabetic precautions” in the “Safety Measures” section. Further review of the POC revealed no interventions or goals related to “bleeding precautions”. The POC also failed to include goals/interventions related to diabetes.”

“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, OASIS [Outcome and Assessment Information Set- a mandatory, standardized data collection tool used by Medicare-certified home health agencies to assess the adult patient] question NO415 [related to high risk medications] was answered incorrectly for 4 of 19 records reviewed [#1, 2, 3, and 7]. The findings included: The policy, OASIS Collection and Reporting [last revised 12/2025], was provided by the agency administrator on 03/11/26. 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 [SOC] date of 10/15/24 with admitting diagnoses of aftercare following surgery for neoplasm [cancer] and malignant neoplasm of unspecified site of left female breast. Review of the Plan of Care [POC] for the certification period 10/15/24-12/13/24 revealed the patient was ordered Percocet [opioid] 7.5-3.25 mg. Take 1 tablet 3 times a day. Review of the clinical record revealed RN # 15 completed the SOC OASIS [Outcome and Assessment Information Set- a mandatory, standardized data collection tool used by Medicare-certified home health agencies to assess the adult patient] on 10/15/24. Review of the OASIS documentation N0415 [high risk medication] revealed the RN failed to capture the use of Percocet as an opioid. 2. Patient # 2 had a Start of Care date of 09/06/25 with an admitting diagnosis of Interstitial Pulmonary Disease [chronic disorders causing inflammation and irreversible scarring [fibrosis] of lung tissue, specifically the area around air sacs, which impairs oxygen absorption]. Review of the Plan of Care [POC] for the certification period 09/06/25-11/04/25 revealed the patient was taking the following medications: Aspirin [antiplatelet-medication that reduces the ability of blood platelets to clump together] 81 mg. Take 1 tablet daily for heart. Bactrim DS [antibiotic] 800-160 mg. Take 1 tablet on Monday, Wednesday and Friday. Review of the clinical record revealed RN # 14 completed the SOC OASIS [Outcome and Assessment Information Set- a mandatory, standardized data collection tool used by Medicare-certified home health agencies to assess the adult patient] on 9/6/25. Review of OASIS question N0415 [high risk medications] revealed the RN documented the patient was receiving an anti-coagulation medication but did not include the antiplatelet or the antibiotic when answering OASIS question NO415. 3. Patient # 3 had a Start of Care [SOC] date of 08/25/25 with admitting diagnoses of Parkinson’s Disease [A type of movement disorder. It happens when nerve cells in the brain don’t produce enough brain chemicals called dopamine] and Type 2 Diabetes Mellitus with diabetic polyneuropathy [complication where high blood sugar cause nerve damage]. Review of the Plan of Care [POC] for the certification period 08/25/25-10/23/25 revealed the patient was taking Aspirin [antiplatelet-medication that reduces the ability of blood platelets to clump together] 81 mg. Review of the clinical record revealed RN # 16 completed the SOC OASIS [Outcome and Assessment Information Set- a mandatory, standardized data collection tool used by Medicare-certified home health agencies to assess the adult patient] on 08/25/25. The POC included Aspirin [antiplatelet-medication that reduces the ability of blood platelets to clump together] 81 mg. Take 1 tablet by mouth daily as a blood thinner. Review of OASIS question N0415 [high risk medications] did not include the use of the Aspirin making the OASIS inaccurate. 4. Patient # 7 had a Start of Care [SOC] date of 02/20/26 with an admitting diagnosis of Unspecified Dementia. Review of the Plan of Care for the certification period 02/20/26-04/20/26 revealed the patient was ordered Aspirin [antiplatelet] 81 mg daily for heart health. Review of the clinical record revealed RN # 14 completed the SOC OASIS [Outcome and Assessment Information Set- a mandatory, standardized data collection tool used by Medicare-certified home health agencies to assess the adult patient] on 02/20/26. Review of the OASIS documentation N0415 [high risk medications] revealed the RN failed to capture Aspirin when answering the OASIS question related to high risk medications. During an interview with the agency administrator on 03/11/26 at approximately 11:30 am, it was confirmed the OASIS was inaccurate.”

“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, observation, clinical record review, and staff, patient/caregiver interviews, the agency failed to maintain an accurate medication list for 3 of 5 patients with home visits conducted (patients #15, 16 &17). Findings included: 2. Patient # 16 had a Start of Care date of 02/5/26 with an admitting diagnosis of pressure ulcer of sacral region, stage 2 [a partial-thickness skin loss involving the epidermis and part of the dermis, appearing as a shallow, open pink/red wound or an intact/ruptured serum-filled blister] and type 2 diabetes mellitus with diabetic polyneuropathy [complication where high blood sugar cause nerve damage]. Review of the Plan of Care [POC] for the certification period 02/5/26-4/5/26 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “SN to instruct patient/caregiver on the medications prescribed and SN will monitor if patient is compliant with taking medications ordered...” On 03/10/26 at approximately 9:30 am a joint visit was made with RN #6. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Amlodipine [blood pressure] 5 mg. Take 1 tablet by mouth daily. During the visit, the Amlodipine could not be located in the home. The medication profile listed Eligard [antineoplastic] 22.5 mg. Inject under the skin every 3 months. During the visit, the medication could not be located. The medication profile listed Eplerenone [blood pressure] 25 mg. Take 1 tablet daily. During the visit, the medication could not be located. After the visit, RN # contacted the caregiver who reported the medications above had been discontinued at the last physician’s appointment. During an interview with RN # 6 on 03/11/26 at approximately 11 am, it was confirmed the medications on the POC were not correct. 2. Patient # 17 had a Start of Care date of 02/16/26 with an admitting diagnosis of Sarcoidosis [an inflammatory disease characterized by the growth of tiny, abnormal cell clumps called granulomas in organs]. Review of the Plan of Care [POC] for the certification period 02/16/26-04/16/26 included orders for PT [physical therapy] 1 time a week for 6 weeks. On 03/10/26 at approximately 11:00 am, joint visit was made with PT # 17. A medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Estradiol [hormone replacement] transderminal 0.05 mg/24 hr. 1 patch two times a week. During the visit, the patient produced Estradiol .037 mg/hr. Apply 1 patch 2 times a week. During the interview with the patient, she reported the dose had changed “last spring”. During an interview with PT # on 03/10/26 at approximately 12:30 pm, PT # 17 confirmed the POC did not include the correct medications. A policy, Medication Error Prevention and Management (revised 07/2025), received on 03/10/2026 at 2:03 PM from the director of professional services (DOPS) stated, “Medication Reconciliation Occurs at SOC [start of care], ROC [restart of care], recert [recertification of care], 30-day therapy evals [evaluations], RN [registered nurse] supervisory visits, and with med [medication] changes… Discrepancies are resolved with the prescriber and documented in the clinical record.” Patient #15 was admitted on 02/04/2026 with a diagnosis of Displ intertoch fx r femur (fracture of the right upper leg). The plan of care for 02/04/2026-04/04/2026 included orders for physical therapy visits 2 times a week for 3 weeks and 1 time a week for 1 week. During a home visit conducted on 03/10/2026 at 10:31 AM physical therapy assistant (PTA) #4 completed a comprehensive medication review and found the following discrepancies:Patient #15’s caregiver provided a prescription bottle of Meloxicam 7.5 mg (anti-inflammatory drug) 1 tablet by mouth 1 time a day. The caregiver stated that this was ordered at his discharge from the hospital. Review of the clinical record revealed that Meloxicam was not included in the medication profile. Patient #15’s caregiver provided a prescription bottle of oxycodone-acetaminophen 10-325mg (narcotic pain medication) take 1 tablet by mouth every 6 hours as needed. The caregiver stated that he was taking ½ a tablet per the physician. Review of the clinical record revealed that the agency has documented this order as discontinued on 02/24/2026. Review of the clinical record revealed that the agency listed Prozac Oral 20 mg (antidepressant) 1 capsule daily and aspirin 81 mg (anti-platelet) 1 tablet by mouth daily. The caregiver stated that both medications were discontinued when the patient was discharged from the hospital. An interview conducted on 03/11/2026 at 10:23 AM with PTA #4 revealed that they were aware of the Meloxicam order and that the aspirin 81mg was not being taken and failed to update the clinical record. PTA #4 stated that they believed that the incorrect narcotic pain medication order was discontinued. During an interview conducted on 03/11/2026 at 10:36 AM the DOPS stated, “They [clinicians] should call the doctor, update the medication list, and document it.””

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the clinical record failed to evidence of a discharge summary that was sent to the physician within 5 days for 3 of 5 discharged records [1, 2, and 5]. The findings included: The policy, Discharge, Transfer, and Referral of Patients [last revised 07/2025] was received by the agency administrator on 03/11/26 at 11:45 am. The policy stated, “...Complete discharge summary at final visit and share with primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge within five (5) business days of the patient’s discharge...” 1. Patient # 1 had a Start of Care date of 10/15/24 with an admitting diagnosis of Aftercare following surgery for Neoplasm [cancer]. Review of the clinical record revealed the patient was discharged from the agency on 12/4/24. The clinical record revealed no discharge summary as off 3/11/26. 2. Patient # 2 had a Start of Care date of 9/6/25 with an admitting diagnosis of Interstitial Pulmonary Disease [chronic disorders causing inflammation and irreversible scarring [fibrosis] of lung tissue, specifically the area around air sacs, which impairs oxygen absorption]. Review of the clinical record revealed the patient was discharged from the agency on 10/30/25. The clinical record revealed no discharge summary as of 3/11/26. 3. Patient # 5 had a Start of Care date 10/13/25 with an admitting diagnosis of Mild Cognitive Impairment of uncertain or unknown etiology. Review of the clinical record revealed the patient was discharged from the agency on 10/30/25. Further review of the clinical record revealed no discharge summary. An interview was conducted with the agency administrator on 3/11/26 at approximately 12:00 pm. During the meeting the administrator confirmed the clinical records were missing the discharge summaries.”