Patient Care

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on a review of facility policy, medical record review and staff interview, it was determined that the facility failed to provide services to Patient (P)1 in accordance with his/her plan of care. Findings include: Facility policy titled “Plan of Care (POC),” last revised 3/1/26, stated, “Purpose: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner’s orders are followed....Procedure...2. This POC includes:...b. Types, frequency, and duration of services required which may include virtual services...8. Medications, treatments, and interventions are provided by qualified agency staff as ordered by the physician or authorized provider...” On 05/20/26, at 9:26 AM, an entrance conference was conducted with Staff (S)1. At 12:59 PM, Medical Record (MR) review was conducted for Patient (P)1 and the following was revealed: On 12/31/2025, P1 was accepted to service by the facility with a diagnosis of Pneumonia. P1 was to receive Occupational Therapy (OT) services “Effective 01/04/2026 1WK6 [once a week for six weeks].” On 01/07/26, the first OT assessment was conducted on P1. P1 was due for an OT visit between 01/18/26-01/24/26. P1’s schedule indicated he/she was to receive OT service on 01/21/26. The facility was unable to provide documentation that P1 received OT service on 01/21/26 or on any other date between 01/18/26 through 01/24/26. On 05/20/26 at 1:29 PM, S1 confirmed P1 did not receive OT services from 1/18/26 through 1/24/26.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on a review of facility policy, medical record review and staff interview, it was determined that the facility failed to ensure Patient (P)1 received a comprehensive Occupational Therapy (OT) assessment within five days after the start of care. Findings include: Facility policy titled “Patient Assessment, Initial and Reassessment,” revised 12/01/25, stated, “POLICY:...The comprehensive assessment is the responsibility of one clinician. However, the assessing clinician may obtain input from the patient, caregiver, or other healthcare personnel (i.e., physician, pharmacist, agency staff) if within the comprehensive 5-day window timeframe. For assessment items, the collaborating healthcare providers must have had direct in-person contact with the patient...PROCEDURE:...3...d. Physical Therapist, Speech Therapist, Occupational Therapist, medical Social Worker, and Dietitian may make initial evaluation of the patient status to determine the need for specific therapist. This initial discipline specific evaluation(s) will occur within 5 days from the Start of Care (SOC) date or order date or sooner if medically necessary...” On 5/20/26, at 9:26 AM, an entrance conference was conducted with Staff (S)1. At 12:59 PM, Medical Record (MR) review was conducted for Patient (P)1 and P2 and the following was revealed: On 12/31/2025, P1 was accepted for service by the facility with a diagnosis of Pneumonia. On 01/01/26, an initial assessment was conducted on P1 by his/her Registered Nurse (RN) On 01/07/26, an Occupational Therapy (OT) assessment was conducted on P1, six days after P1’s initial assessment. On 12/26/25, P2 was accepted for service by the facility for “aftercare following a joint replacement surgery”. On 12/27/25, an initial assessment was conducted on P2 by his/her RN. On 01/02/26, an OT assessment was conducted on P2, six days after P2’s initial assessment. On 05/20/26, at 1:56 PM, S1 confirmed the above finding and stated that additional disciplines, such as physical therapy and occupational therapy, have five days to evaluate a patient after the initial assessment is completed.”

“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 a review of facility policy, medical record review and staff interview, it was determined that the facility failed to ensure changes in Patient (P)1’s plan of care are communicated with his/her provider. Findings include: Facility policy titled “Coordination of Care, From Admit Through Discharge,” revised 12/1/25, stated, “...PROCEDURE:...4. Coordination of care with physician/authorized practitioner: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician:...c. When a missed visit occurs altering the Plan of Care...5. Coordination of care among disciplines and between in-person and virtual clinicians: Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care form admission to discharge. This includes:... c...i...Missed visits and changes to scheduled visits. a. Reason for missed visit b. Changes to patient schedule... On 05/20/26, at 9:26 AM, an entrance conference was conducted with Staff (S)1. At 12:59 PM, Medical Record (MR) review was conducted for Patient (P)1 and the following was revealed: On 12/31/2025, P1 was accepted to service by the facility with a diagnosis of Pneumonia. P1 was to receive Occupational Therapy (OT) services “Effective 01/04/2026 1WK6 [once a week for six weeks].” On 01/07/26, the first OT assessment was conducted on P1. P1 was due for an OT visit between 01/18/26-01/24/26. P1’s schedule indicated he/she was to receive OT service on 01/21/26. The facility was unable to provide documentation that P1 received OT services on 01/21/26, or any other day between 01/18/26 through 01/24/26. The facility was unable to provide documentation that P1’s provider was notified of the missed visit. On 05/20/26, documentation between S1 and P1’s Occupational Therapist, via email, was reviewed and indicated P1’s OT therapist requested a personal leave of absence from 01/21/26-03/08/26. On 05/20/26 1:29 PM, S1 confirmed P1 did not receive OT services the week of 01/18/26 through 01/24/26, and that there was no documentation of notification to P1’s provider of the missed visit.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on observations, staff interview, and review of facility policies and documents, it was determined the facility failed to ensure an individualized emergency preparedness plan was available in one of five patient homes visited (Patient (P) 5). Findings include: On 7/31/24 at 11:08 AM, S13, a Licensed Practical Nurse (LPN) was observed providing care for P5. A review of P5’s Plan of Care revealed the following: 1) Start of Care date: 11/13/23. 2) Functional limitations: “ambulation”. 3) Safety measures: “1 person transfer” and “ambulation precautions”. At 12:20 PM, the admission packet was asked of P5 and P5’s caregiver for review by this surveyor. P5 and P5’s caregiver, were unable to locate the admission packet. P5’s caregiver stated, “it must be in my house.” S13 stated that P5 was living in the caregiver’s house prior to moving to his/her current residence. P5 and P5’s caregiver stated that P5 moved to the current residence “a couple months ago.” When questioned about an emergency disaster plan, P5 stated, “I would call 911. I would get out the window.” P5 and P5’s caregiver were unable to state a clear evacuation plan for P5 in the event of an emergency or disaster. On 7/31/24 at 1:45 PM, a review of P5’s medical revealed there was no emergency disaster plan in P5’s medical record. On 7/31/24 at 3:05 PM, S1, Executive Director, confirmed the facility did not have an emergency disaster plan in the medical record for P5. Facility policy titled “Patient Assessment, Initial, and Reassessment” last revised 1/1/24 states “Purpose: to describe the process of patient assessments … Procedure: 1. Upon admission and reassessments, the qualified clinician performs the following assessment activities and collects the following data: … p. Emergency disaster plan.””

“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 observation, patient and staff interview, and a review of facility documents, it was determined the facility failed to ensure staff followed the policy to prevent transmission of infections and communicable diseases in two of four patients (Patient (P) 5 and P15). On 7/30/24 at 12:26 PM, Staff (S) 10, a Physical Therapist (PT), was observed providing care for P15. At 12:28 PM, S10 donned gloves and placed a barrier pad on a table in the patient’s living room. S10 placed his/her equipment bag in the center of the pad. S10 then placed a second barrier on P15’s dining room table and removed vital signs equipment (thermometer, sphygmomanometer and blood pressure cuff, pulse oximeter, stethoscope, and tablet) from the equipment bag and placed them on the barrier pad on the dining room table. S10 then began taking P15’s vital signs. S10 completed vital signs and entered vital signs onto tablet without doffing gloves. At 12:58 PM, after the completion of the PT exercises, S10 began cleaning the vital signs equipment. After cleaning the vital signs equipment, S10 placed the cleaned equipment on the barrier pad that also shared space with the equipment bag. The equipment bag was occupying most of the space on the barrier pad and there was only a narrow space around the bag for the clean equipment to be placed. The cleaned stethoscope and sphygmomanometer were observed touching the outside of the equipment bag and touching the living room table thus creating an opportunity for cross-contamination from the outside of the bag and the patient’s table to the newly cleaned equipment. S10, without re-cleaning the equipment, placed the equipment back into the clean interior of the equipment bag. At 1:00 PM, S10 asked P15 for a signature on the tablet. P15 used his/her finger to sign the tablet. S10 failed to clean the tablet before placing it back in the equipment bag. On 7/31/24 at 11:08 AM, S13, a Licensed Practical Nurse (LPN), was observed providing care for P5 in the patient’s bedroom. At 11:10 AM, S13 performed hand hygiene, donned gloves, and began placing barrier pads on P5’s bed. S13’s badge fell off his/her uniform and landed on the floor of the bedroom. P5’s mother picked up the badge and handed it to S13. S13 placed it back on his/her uniform without cleaning it. At 12:02 PM, after finishing P2’s wound care, S13 was observed leaning over the bed and the dirty badge on S13’s uniform touched the clean wound care supplies that were on a clean barrier pad that had been placed on the bed thus providing a potential for cross-contamination. S13 did not replace the wound care supplies that were touched by the badge and continued with providing care to the patient. At 12:09 PM, S13 began cleaning the vital signs equipment (pulse oximeter, stethoscope, thermometer, sphygmomanometer and blood pressure cuff) and placed them on a clean barrier pad. The cleaned stethoscope and thermometer were observed hanging off the edge of the designated clean barrier pad and touching P5’s bed before being placed back in the equipment bag. S13 placed used, dirty supplies in P5’s trash can near bed and returned to cleaning the remaining pieces of vital signs equipment (pulse oximeter, blood pressure cuff and sphygmomanometer) without changing gloves and performing hand hygiene. On 8/1/24 at 1:13 PM, the above findings were shared with S1, Executive Director during exit conference. S1 confirmed that there was an opportunity for cross-contamination if the above techniques were used. Facility policy titled “Standard Precautions” last reviewed 12/01/21 states “Purpose: to prevent the spread of disease and infection between and among patients and staff … Procedure: … 4. Standard Precautions include: a. Hand Hygiene … ii. Perform hand hygiene immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments…” Facility policy titled “Standard Precautions” last revised 12/01/21 states “Purpose: to prevent the spread of disease and infection between and among patients and staff … Procedure: … 4. Standard Precautions include: d. Patient-Care Equipment: … ii. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned appropriately.” Facility policy titled “Cleaning of Re-Useable Equipment” last revised on 6/01/22 states “Purpose: to assure equipment required for patient care is clean and sanitized to prevent the spread of infections … Procedure: … 6. … a. The hand-held computer device (i.e. tablet or Smartphone) should be wiped down with a low-level disinfectant at the beginning and end of each visit…””