Pruitthealth at Home - Wake

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Condition level Determination The cumulative effect of this systemic problem resulted in the agency’s ability to ensure that the physicians are promptly notified of the need for changes to the plan of care and the inability to complete care as ordered. Cross Refer to 484.75(b)(7), Tag G0718; Cross Refer to 484.75(b)(3) Tag G0710; Cross Refer to 484.75(c)(1), Tag G0726.”

“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, observation, clinical record review and staff interviews, the registered nurses failed to obtain PICC (peripherally inserted central catheter) line measurements for 1 of 3 patients with a PICC line (#12); and failed to obtain Labs for 1 of 3 patients with lab orders (#13); and failed to measure wounds for 1 of 8 patients with wound (#17). Findings included: A policy, Coordination and Management of Home Health Services (revised 9/22/22), received on 4/28/26 at 4:00 PM from the administrator stated, “Services are provided in accordance with the attending physician’s orders and the written plan of care…” A policy, Skilled Nursing Services for Home Health (revised 11/21/22), received on 4/28/26 at 4:00 PM from the administrator stated, “The home health agency will provide nursing services to the extent necessary to meet the needs of the patient as ordered by the physician.” 1. Patient #12 was admitted on 1/24/26 with a diagnosis of postsurgical malabsorption (inability of intestines to absorb nutrients). The plan of care for 3/25/26-5/23/26 included orders for skilled nurse visits 1 time a week for 9 weeks with 2 PRN (as needed) and, “Skilled nurse to change PICC [peripherally inserted central catheter] line dressing weekly and as needed… PICC line should be measured from insertion site to hub weekly…” Review of the clinical record revealed that for the SN visits on 3/27/26, 4/03/26, 4/15/26, and 4/24/26 registered nurse (RN) #8 failed to document the PICC line measurement. During an interview conducted on 4/29/26 at 9:14 AM RN #8 stated, “That, [PICC line measurements] I did not do… I looked at it and it didn’t change.” An interview conducted on 4/29/26 at 1:30 PM with the administrator revealed that the PICC line should be measured as ordered. 2. Patient #13 was admitted on 3/28/26 with a diagnosis of acute and subacute infective endocarditis (infection of the inner heart valves). The plan of care for 3/28/26-5/26/26 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 1 time a week for 9 weeks and, “Labs to be obtained weekly beginning with 3/30/26 Using a septic [sic] technique, skilled nurse to obtain Weekly CBC with diff [compete blood count] and CMP [comprehensive metabolic panel] while on IV cefazolin [antibiotic] …” and “cefazolin 2 g Intravenous powder for injection; Inject 2 gm(s) intravenously…” Review of the clinical record revealed that for the SN visit on 4/27/26 there was no documentation that RN #8 completed the labs. An interview conducted on 4/29/26 at 8:55 AM revealed that RN #8 did not complete the lab order. An interview conducted on 4/29/26 at 9:00 AM with the administrator revealed that the expectation is for labs to be drawn if ordered. 3. Patient #17 was admitted on 4/20/26 with a diagnosis of, Athscl native arteries of left leg w ulceration oth prt foot (plaque buildup in left leg arteries with a wound). The plan of care for 4/20/26-6/18/26 included orders for skilled nurse visits 1 time a week for 3 weeks and “Venous ulcer/Left Scattered Foot Great Toe Cleanse wound with vase [sic] soak 5-10 minuted [sic]. Pat dry Apply iodoflex [wound dressing] to wound bed, cover with gauze, secure with tape on Tuesday and Friday.” During a home visit conducted on 4/28/26 at 11:30 AM with registered nurse (RN) #5 failed to obtain measurements of the left foot great toe wound and failed to assess and measure a new wound on the right shin. An interview conducted on 4/28/26 at approximately 12:00 PM revealed that RN #5 was not aware of the agency’s policy on wound measurements. An interview conducted on 4/29/26 at approximately 1:00 with the administrator revealed that the expectation is for wound to be measured weekly.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to provide notice of the patient’s rights and responsibilities in a language understandable for 1 of 1 patient with Spanish as the preferred language (# 11). Findings included: A policy, Meaningful Access for Patients with Limited English Proficiency (revised 10/26/2016), received on 04/28/26 at approximately 4:00 PM from the agency director stated, “It is the policy of [agency name] and it’s affiliated providers… to provide meaning access to each individual with Limited English Proficiency (LEP)… [agency name] contracts with [agency name], a qualified interpreter and translator service…” The agency Patient Admission Book (not dated) received on 04/27/26 at 10:15 AM from the administrator stated, “Patient’s Bill of Rights… Right to Be Informed and Involved in Your Care. You have the right to be informed of your rights before care begins, in a language you understand…” Patient #11 was admitted on 03/23/26 with a diagnosis of Congestive Heart Failure (heart can not pump blood effectively]. The plan of care for 3/23/26-5/21/26 included orders for Skilled Nursing to Assess and Evaluate 3/20/26 through 3/24/26 and 1 time a week for 9 weeks. A review of the clinical record revealed that on 3/23/26 registered nurse (RN) #10 documented, “What is your preferred language? Spanish. Do you need or want an interpreter to communicate with a doctor or health care staff? 1. Yes” Further review revealed that there was no documentation that RN #10 utilized an interpreter for the admission or provided the patient with the patient rights and responsibilities in Spanish. A review of the agency’s patient admission book revealed that it was written only in English. During an interview conducted on 4/29/26 at 9:20 AM RN#10 stated, “No [did not use a translator] … Yes [provided the patient rights in Spanish] … I gave them the patient handbook, the other agencies that I have worked for included Spanish in the handbook…” During an interview conducted on 4/28/26 at 4:27 PM the agency administrator stated that the agency’s does not have the patient right available in Spanish. During an interview conducted on 4/29/26 at 9:24 AM the administrator stated, “Everyone has access to the language line; she (RN#10) should have used it.””

“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 interviews, the agency failed to include all medications in the plan of care for 1 of 2 patients with a urinary tract infection (#3); and 1 of 2 patients with a home visit conducted (#17). Findings included: A policy, Medication Management for Home Health (revised 7/21/21) received on 4/29/26 at 11:18 AM from the administrator stated, “The home health agency will maintain accurate documentation of all medications that the patient is taking.” 1. Patient #3 was admitted on 9/18/25 with a diagnosis of encounter for orthopedic aftercare following a surgical amputation. The plan of care for 9/18/25-11/16/25 included orders for physical therapy (PT) 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 5 weeks. Review of the clinical record reveal that on 11/13/25 PT #9 completed a discharge from PT not from the agency and documented, “Patient reports that he is doing fine other than a urinary infection which he is being treated with antibiotics.” Further review revealed that the antibiotic was not included on the medication list. During an interview conducted on 4/29/26 at 10:39 AM PT #9 stated, “Normally I would add the med but may not have because it was a discharge…” 2. Patient #17 was admitted on 4/20/26 with a diagnosis of, Athscl native arteries of left leg w ulceration oth prt foot (plaque build up in left leg arteries with a wound). The plan of care for 4/20/26-6/18/26 included orders for skilled nurse visits 1 time a week for 3 weeks. During a home visit conducted on 4/28/26 at 11:30 AM with registered nurse #5 the patient’s spouse stated that patient #17 was prescribed oxycodone (narcotic pain medication) 5mg as needed. Review of the clinical record revealed that oxycodone was not included on the medication list. Further review revealed that RN #5 did not update the medication list after the visit. RN #5 was not available for an interview. An interview conducted on 4/29/26 at 11:34 AM with the agency administrator revealed that the medications should have been included in the plan of care.”

“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 occupation therapist failed to contact the physician for an order prior to documenting an order for a delayed assessment for 1 of 3 patients with a delayed occupation therapy assessment (#9). Findings included: A policy, Plans of Care for Home Health Patients (revised 11/06/2018), received on 4/28/26 at 8:00 AM from the administrator stated, “If a physician refers a patient under a plan of care that can not be completed until after an evaluation visits, the physician is consulted to approve additions or modification to the original plan.” Patient #9 was admitted on 3/29/26 with a diagnosis of acute kidney failure. The plan of care for 3/29/26-5/27/26 included orders for occupational therapy (OT) assess and evaluate the week of 3/30/26-4/04/26. Review of the clinical record revealed that on 4/03/26 OT# 13 documented, “OT eval scheduled for week of 4/5.” An interview conducted on 4/29/26 at 9:37 AM with OT #13 revealed that order for the delay in the evaluation was documented in the plan of care without contacting a physician. An interview conducted on 4/29/26 at approximately 9:40 AM with the administrator revealed that the physician should be contacted to obtain a verbal order prior to documenting an order and changing the plan of care.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on agency policy, observation, clinical record review, patient/caregiver interviews, staff interviews, the clinicians failed to provide services as ordered in the plan of care for 6 of 16 active patients (#’s 8, 9, 11, 14, 18, &20). Findings included: A policy, Coordination and Management of Home Health Services (revised 9/22/22), received on 4/28/26 at 4:00 PM from the administrator stated, “Services are provided in accordance with the attending physician’s orders and the written plan of care…” Findings included: 1. Patient #8 was admitted on 1/19/26 with a diagnosis of pressure ulcer of the sacral region, stage 3 (full-thickness wound at the base of the spine). The plan of care for 1/19/26-5/18/26 included orders for skilled nurse (SN) visits 1 time a week for 1 week and 2 times a week for 7 weeks. Review of the clinical record revealed there was no evidence that the patient refused the visits or was unavailable for the SN visits that were not conducted on 3/31/26, 4/07/26, 4/14/26. 4/17/26, 4/21/26, and 4/24/26. 2. Patient #9 was admitted on 3/29/26 with a diagnosis of acute kidney failure. The plan of care for 3/29/26-5/27/26 included orders for skilled nurse (SN) visits 1 time a week for 6 weeks; and occupational therapy (OT) assess and evaluate 3/30/26-4/04/26. Review of the clinical record revealed no nursing visit was made the week of 4/17/26 nor was the OT evaluation conducted. Further review of the clinical record revealed there was no evidence that the patient refused the visits or was unavailable 3. Patient #11 was admitted on 3/23/26 with a diagnosis of acute on chronic diastolic (congestive) heart failure (heart with ineffective pumping of blood). The plan of care for 3/23/26-5/21/26 included orders for skilled nurse (SN) visits 1 time a week 9 weeks. Review of the clinical record revealed there was no evidence that the patient refused the visits or was unavailable for the SN visits of 4/03/26, 4/07/26 that were not conducted. 4. Patient #14 was admitted on 3/19/26 with a diagnosis of malignant neoplasm of the parietal lobe (brain cancer). The plan of care for 3/19/26-5/17/26 included orders for skilled nurse (SN) visits 1 time a week for 4 weeks; and speech therapy (ST) visits 1 time a week for 7 weeks. Review of the clinical record revealed there no nursing visits made the week of 4/1/26 nor 4/15/26; no ST visit was conducted the week of 4/13/26. Further review of the revealed that there was no evidence that the patient refused the visits or was unavailable 5. Patient #18 was admitted on 3/17/26 with a diagnosis of peritoneal abscess (collection of pus in the abdomen). The plan of care for 3/17/26-5/15/26 included orders for skilled nurse (SN) visits 1 time a week for 8 weeks, home health aide (HHA) visits 1 time a week for 9 weeks, and occupational therapy (OT) 0 times a week for 1 week and 1 time a week for 3 weeks. Review of the clinical record revealed there was no SN visit was made the week of 4/25/26; no HHA visits were conducted for the weeks of 3/27/26, 4/03/26, 4/10/26 or 4/17/26; and no OT visits were conducted the week of 3/31/26. Review of the clinical record revealed there was no evidence that the patient refused the visits or was unavailable. During a home visit was conducted on 04/28/26 at 12:00 PM an interview with the patient revealed that patient #18 did not know why a nurse didn’t come the week before and stated that she liked the HHA visit and didn’t know why it stopped. 6. Patient #20 was admitted on 3/09/26 with a diagnosis of acute and subacute infective endocarditis (infection of the inner heart valves). The plan of care for 3/09/26-5/07/26 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 2 times a week for 1 week, and 1 time a week for 7 weeks. Review of the clinical record revealed there was no documentation any completed SN visits after 3/17/26. During an interview conducted on 4/28/26 at 3:09 PM the patient stated, “I haven’t had [agency name] in more that 35 days. I was in the hospital.” During an interview conducted on 4/29/26 at 10:20 AM RN #11 stated, “They were missed because we couldn’t contact them or doctors’ appointments. I need to go back and make sure that they submitted…” An interview conducted on 4/29/26 at 11:29 AM with HHA #12 revealed that they did not know who the patient was and stated, “I’m guessing that I was calling and didn’t get an answer…” During an interview conducted on 4/29/26 at 10:27 AM LPN #6 stated, “If I miss a patient I try to put why…” During an interview conducted on 4/29/26 at 10:02 AM OT #15 stated, “I had this assigned to another OT because it’s out of my area.” RN #5 was not available for an interview. An interview conducted on 4/29/26 at 11:20 AM with the administrator revealed that the expectation is for of all missed visit documentation to include the reason why it was not conducted.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on agency policy, observation, clinical record review, and staff interviews, the agency failed to provide accurate documentation for 6 of 20 patients with record reviews. (#2, 3, 13, 18, &19). Findings included: A policy, Home Health Clinical Record (Revised 11/12/18), received on 4/28/26 at 8:00 AM from the administrator stated, “Information contained in the clinical record is to be complete, promptly and accurately documented…” 1. Patient #2 was admitted on 12/3/25 with a diagnosis of Unspecified fracture of left patella (kneecap). The plan of care for 12/3/25-1/31/26 included orders for skilled nurse visits 1 time a week for 8 weeks and “Assess blood sugar monitoring and results.” Review of the clinical record revealed that there was no diagnosis or medication that would indicate that there was a need to monitor blood sugars. During an interview conducted on 4/29/26 at 10:23 AM RN #11 stated, “She said she was diabetic, so I know she checked her blood sugar. Or if not, I need to go in and change that.” 2. Patient #3 was admitted on 9/18/25 with diagnoses of encounter for orthopedic aftercare following a surgical amputation and type 2 diabetes mellitus. The plan of care for 9/18/25-11/16/25 included orders for physical therapy (PT) 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 5 weeks and “Trulicity Pen 3mg/0.5mL [injectable diabetes medication] subcutaneous solution; Inject 3 milliliter(s) subcutaneously.” Review of the clinical record revealed the following: On 9/30/25 PT #9 documented, “Diabetes… Diet controlled Oral-Hypoglycemics… Patient reports pain over the medial aspect of the left eye, especially with knee flexion…” On 10/21/25 PT #9 documented, “… however has not been able to progress to no weight-bearing status on the left lung…” During an interview conducted on 4/29/26 at 10:39 AM with PT #9 stated, “Eye should be leg and lung should be lower leg.” On 10/30/25 PT #9 documented, “Diabetes… Diet controlled Oral-Hypoglycemics… they will transfer sit to stand weight-bearing on the left leg somebody to walker…” On 11/6/25 PT #9 documented, “Diabetes… Diet controlled.” On 11/13/25 PT #9 documented, “Diabetes… Oral-Hypoglycemics.” During an interview conducted on 4/29/26 at 10:39 AM with PT #9 stated, “Generally, I look at the medication list [before documenting diabetes management]. I try to proofread my notes” 4. Patient #13 was admitted on 3/28/26 with a diagnosis of acute and subacute infective endocarditis (infection of the inner heart valves). The plan of care for 3/28/26-5/26/26 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 1 time a week for 9 weeks and physical therapy (PT) visits 2 times a week for 3 weeks. Review of the clinical record revealed that on 4/17/26 PT #17 documented “Patient in seated physician upon arrival” and on 4/27/26 RN #8 documented, “Interventions Performed this Visit Infusion therapy/Venous catheter care.” Further review revealed that there was no order for venous catheter care. During an interview conducted on 4/29/26 at 9:16 AM PT #17 stated, “He was seated on a couch.” During an interview conducted on 4/29/28 at 8:55 AM RN #8 stated, “That was a mistake, I would not be doing venous catheter care.” 5. Patient #18 was admitted on 3/17/26 with a diagnosis of peritoneal abscess (collection of pus in abdominal cavity). The plan of care for 3/17/26-5/15/26 included orders for home health aide (HHA) visits 1 time a week for 9 weeks. Review of the clinical record revealed that HHA #12 documented that a tub bath, a shower chair shower, a partial bath, a complete shower was completed and documented, “She got washed off.” During an interview conducted on 4/29/26 at 10:56 AM HHA #12 stated, “I probably gave her shower… if the shower is in a bathtub then it’s all off them.” 6. Patient #19 was admitted on 3/21/26 with a diagnosis of hypertensive heart and chronic kidney disease. The plan of care for 3/21/26-5/19/26 included orders for skilled nurse visits 2 times a week for 2 weeks and 1 time a week for 7 weeks. Review of the clinical record revealed that on 3/30/26 registered nurse (RN) #5 documented that the PICC line (Peripherally Inserted Central Line, long term intravenous access) dressing was intact. Further review revealed that the patient did not have a PICC line. A home visit was conducted on 4/28/26 at 1:15 PM. During a home visit conducted on 4/28/26 at 1:15 PM it was confirmed that the patient did not have a PICC line. RN #5 was not available for an interview. An interview on 4/29/26 at approximately 1:30 PM with the administrator revealed that the expectation is for the documentation to be accurate.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on agency policy, clinical record review, observation, and staff interviews, the registered nurses, physical therapist, occupational therapist, and home health aides failed to notify the physicians of missed visits for 13 of 16 active patient records reviewed (#’s 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 18, 19, 20); and failed to notify the physician of a new wound for 1 of 8 patients with wounds (#17); and failed to notify the physician of a low blood pressure (#6); and failed to notify the physician of a newly identified patient which needed a medical social work (MSW) consult for 1 of 6 patient requiring a MSW (#9). Findings included: A policy, Coordination and Management of Home Health Service (revised 9/22/22), received on 4/28/26 at 4:00 PM from the administrator stated, “Services are provided in accordance with the attending physician’s orders… The Clinician will communicate with the team members and the physician regarding the patient’s status and response to the plan of treatment as often as indicated … Coordination of care efforts/outcomes will be documented in the patient’s medical record…” A policy, Skilled Nursing Services for Home Health (revised 11/21/22), received on 4/28/26 at 4:00 PM from the administrator stated, “Nursing visits are individually based on the need, but not necessarily limited, to: … Inform the physician of the patient’s condition…” A policy, Assessments and Reassessments-Home Health (revised 6/19/24), received on 4/28/26 at 4:00 PM from the administrator stated, “The physician will be notified of all findings to obtain appropriate orders.” 1. Patient #6 was admitted on 1/23/26 with a diagnosis of unspecified open wound. The plan of care for 1/23/26-3/23/26 included orders for skilled nurse (SN) visits 3 times a week for 9 weeks and, “Report parameters to MD/NPP outside: Systolic blood pressure > [greater than] 140 90 <60.” Review of the clinical record revealed no nursing visits were made on 1/30/26, 2/2/26, or 3/5/26. Further review of the clinical record revealed there was no documentation of the physician being notified of the missed nursing visits. Further review revealed that on 2/6/26 LPN #18 documented a blood pressure of 98/56. There was no documentation of the physician being notified. 2. Patient #7 was admitted on 3/15/26 with a diagnosis of hypersomnia (severe sleepiness). The plan of care for 3/15/26-5/13/26 included orders for skilled nurse (SN) visits 1 time a week for 8 weeks and occupational therapy (OT) visits 1 time a week for 1 week, 0 times a week for 3 weeks, and 1 time a week for 1 week. Review of the clinical record revealed there was no documentation of the physician being notified that on 4/1/26 and 4/14/26 the SN visits were not conducted and on 3/18/26, 4/10/26 the OT visits were not conducted. 3. Patient #8 was admitted on 1/19/26 with a diagnosis of pressure ulcer of the sacral region, stage 3 (full-thickness wound at the base of the spine). The plan of care for 1/19/26-5/18/26 included orders for skilled nurse (SN) visits 1 time a week for 1 week and 2 times a week for 7 weeks. Review of the clinical record revealed no nursing visits were made on 3/31/26, 4/07/26, 4/14/26, 4/17/26, 4/21/26, or 4/24/26. There was no documentation of the physician being notified of the missed SN visits. 4. Patient #9 was admitted on 3/29/26 with a diagnosis of acute kidney failure. The plan of care for 3/29/26-5/27/26 included orders for skilled nurse (SN) visits 1 time a week for 6 weeks and occupational therapy (OT) assess and evaluate the week of 3/30/26-4/04/26. Review of the clinical record revealed no nursing visit was made the week of 4/17/26 nor was the OT evaluation conducted. The clinical record revealed no evidence of the physician being notified of the missed nursing visit or the missed OT evaluation. 5. Patient #10 was admitted on 2/24/26 with a diagnosis of cellulitis of left upper limb (serious bacterial infection). The plan of care for 2/24/26-4/24/26 included orders for skilled nurse (SN) visits 1 time a week for 6 weeks. Review of the clinical record revealed there was no nursing visits were made for the weeks 3/11/26 or 3/18/26. Further review of documentation revealed no evidence of the physician being notified of the missed nursing visits. 6. Patient #11 was admitted on 3/23/26 with a diagnosis of acute on chronic diastolic (congestive) heart failure (heart with ineffective pumping of blood). The plan of care for 3/23/26-5/21/26 included orders for skilled nurse (SN) visits 1 time a week 9 weeks. Review of the clinical record revealed no nursing visits were conducted for the weeks of 3/25/26, 4/03/26, 4/07/26. Further review of the clinical record revealed no documentation of the physician being notified of the missed nursing visits 7. Patient #13 was admitted on 3/28/26 with a diagnosis of acute and subacute infective endocarditis (infection of the inner heart valves). The plan of care for 3/28/26-5/26/26 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 1 time a week for 9 weeks, physical therapy (PT) visits 2 times a week for 3 weeks, and occupational therapy (OT) 1 time a week for 7 weeks. Review of the clinical record no nursing visits were conducted; no PT visits were made on 4/22/26 or 4/27/26; no OT visit was conducted on 4/2/26. Further review revealed there was no documentation of the physician being notified of the missed visits. 8. Patient #14 was admitted on 3/19/26 with a diagnosis of malignant neoplasm of the parietal lobe (brain cancer). The plan of care for 3/19/26-5/17/26 included orders for skilled nurse (SN) visits 1 time a week for 4 weeks and speech therapy (ST) visits 1 time a week for 7 weeks. Review of the clinical record revealed there no nursing visits made the week of 4/1/26 nor 4/15/26; no ST visit was conducted the week of 4/13/26. Further review revealed no documentation of the physician being notified of the missed visits. 9. Patient #15 was admitted on 2/28/26 with a diagnosis of occlusion and stenosis of bilateral carotid arteries (narrowing and blockage of the large artery of the neck). The plan of care for 2/28/26-4/28/26 included orders for occupation therapy (OT) 1 time a week for 9 weeks. Review of the clinical record revealed no OT visit was made for the week of 3/05/26 or 3/11/26. Further review revealed no evidence that the physician was notified of the missed OT visits. 10. Patient #16 was admitted on 1/30/26 with a diagnosis of Non-ST elevation myocardial infarction (heart attack). The plan of care for 1/30/26-3/30/26 included orders for physical therapy (PT) 2 times a week for 2 weeks and 1 time a week for 7 weeks. Review of the clinical record revealed there was no PT visit was made the week of 4/23/26. Further review revealed that on 4/06/26 OT #13 documented, “Community resource needs identified Other: MSW to assist.” Further review revealed that was no documentation of the physician being notified that the patient needed MSW visits or of the missed PT visit. 11. Patient #17 was admitted on 4/20/26 with a diagnosis of, Athscl native arteries of left leg w ulceration oth prt foot (plaque buildup in left leg arteries with a wound). The plan of care for 4/20/26-6/18/26 included orders for skilled nurse visits 1 time a week for 3 weeks. During a home visit conducted on 4/28/26 at 11:30 AM with registered nurse #5 the spouse reported a new wound to the right shin, which was covered by a bandage. When the spouse began to remove the dressing for the RN to assess RN #5 stated, “Don’t worry about it” and failed to notify the physician of the new wound. 12. Patient #18 was admitted on 3/17/26 with a diagnosis of peritoneal abscess (collection of pus in the abdomen). The plan of care for 3/17/26-5/15/26 included orders for skilled nurse (SN) visits 1 time a week for 8 weeks, home health aide (HHA) visits 1 time a week for 9 weeks, and occupational therapy (OT) 0 times a week for 1 week and 1 time a week for 3 weeks. Review of the clinical record revealed there was no SN visit was made the week of 4/25/26; no HHA visits were conducted for the weeks of 3/27/26, 4/03/26, 4/10/26 or 4/17/26; and no OT visits were conducted the week of 3/31/26. Further review of the clinical record revealed no evidence the physician was notified of the missed visits. 13. Patient #19 was admitted on 3/21/26 with a diagnosis of hypertensive heart and chronic kidney disease. The plan of care for 3/21/26-5/19/26 included orders for skilled nurse (SN) visits 2 times a week for 2 weeks and 1 time a week for 7 weeks and physical therapy (PT) 0 times a week for 1 week and 2 times a week for 7 weeks. Review of the clinical record revealed no SN visits were made on 4/17/26 and 4/20/26; no PT visits were conducted on 3/24/26, 4/7/26, 4/11/26 4/17/26, and 4/25/26; and no OT visit was conducted on 3/24/26. Further review of the clinical record revealed no evidence the physician was notified of the missed visits. 14. Patient #20 was admitted on 3/09/26 with a diagnosis of acute and subacute infective endocarditis (infection of the inner heart valves). The plan of care for 3/09/26-5/07/26 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 2 times a week for 1 week, and 1 time a week for 7 weeks. Review of the clinical record revealed there was no SN visit conducted on 3/20/26. Further review of the clinical record revealed no evidence the physician was notified of the missed visit. The following interviews were conducted regarding missed visits: RN #5 was not available for an interview. During an interview on 4/29/26 at 9:50 AM RN #14 stated, “Normally, I would notify the physician… and document it.” During an interview conducted on 4/29/26 at 10:27 AM LPN #6 stated, “If I miss a patient I try to document why and notify the doctor.” An interview conducted on 4/29/26 at 10:56 AM with HHA #12 revealed that they were not aware of the need to document notification of missed visits. An interview conducted on 4/29/26 at 10:20 AM with RN #11 revealed that they are aware that the physician needs to be notified of missed visits. An interview conducted on 4/29/26 at 9:37 AM with OT #13 revealed that they thought the MSW was already ordered. An interview conducted on 4/29/26 at 11:20 AM with the administrator revealed that the expectation is for the clinicians to notify the physician by telephone of all missed visits, changes of conditions, and any need to change the plan of care.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, the registered nurse documented Licensed Practical Nurse (LPN) supervisory visits for patients that did not receive care from an LPN for 3 of 16 active patients (#13, 17, 19). Findings included: A policy, Plans of Care for Home Health Patients (revised 11/06/2018), received on 4/28/26 at 8:00 AM from the administrator stated, “Nursing services will be provided under the direction of a Registered Nurse (RN)… The RN will monitor and evaluate LPN/LVN performance…” Patient #13 was admitted on 3/28/26 with a diagnosis of acute and subacute infective endocarditis (infection of the inner heart valves). The plan of care for 3/28/26-5/26/26 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 1 time a week. Review of the clinical record revealed that on 04/01/26 and 04/15/26 RN #5 documented LPN supervisory visits. Further review revealed that the patient had not received any LPN visits. Patient #17 was admitted on 4/20/26 with a diagnosis of, Athscl native arteries of left leg w ulceration oth prt foot (plaque buildup in left leg arteries with a wound). The plan of care for 4/20/26-6/18/26 included orders for skilled nurse visits 1 time a week for 3 weeks. Review of the clinical record revealed that on 4/28/26 RN #5 documented an LPN supervisory visit. Further review revealed that the patient had not received any LPN visits. Patient #19 was admitted on 3/21/26 with a diagnosis of hypertensive heart and chronic kidney disease. The plan of care for 3/21/26-5/19/26 included orders for skilled nurse (SN) visits 2 times a week for 2 weeks and 1 time a week for 7 weeks. Review of the clinical record revealed that on 3/30/26 RN #5 documented an LPN supervisory visit. Further review revealed that the patient had not received any LPN visits. RN #5 was not available for an interview. During an interview conducted on 4/29/26 at 1:21 PM the administrator stated, “She [RN #5] should not document a supervisory visit for an LPN if they [LPN] haven’t seen the patient.””