Excelacare Home Health

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on observation, interview, record review, and policy review, the home health agency (HHA) failed to implement an effective discharge planning process to reduce factors that can lead to preventable readmissions for one of one patient (Patient (P) 10) discharged from physical therapy services during an observed home visit from a total of four home visits. This deficient practice had the potential to cause patients to have unmet care needs. Findings include: Review of the policy titled, “Care Planning Process & [and] Comprehensive Assessment,” dated 12/2023, indicated, “. . . Necessary arrangements are made for continuing needs after discharge from home health, if possible . . .” Review of P10’s “Home Health Certification and Plan of Care,” for the certification period of 03/27/25 to 05/25/25 and located under the “Orders” tab of the electronic medical record (EMR), indicated P10’s primary diagnosis was primary generalized osteoarthritis. Review of a physician’s order, located under the “Orders” tab of the EMR and dated 05/01/25, indicated, “. . . Physical therapy to establish/upgrade home exercise program and provide therapeutic exercises and soft tissue/joint mobilization designed to restore functional strength and ROM [range of motion]. Physical therapy to provide balance training to reduce fall risk during functional activities. Physical therapy to evaluate gait and provide gait training using appropriate assistive device to ensure patient safety . . .” Observation during a home visit on 05/21/25 at 1:40 PM revealed Physical Therapist (PT) 1 performed a discharge visit with P10. Observation at the conclusion of the visit revealed PT1 instructed P10 to tell his/her physician on his/her next visit that P10’s walker was broken, and P10’s physician could write an order for P10 to receive a new walker. There was no observed attempt of PT1 attempting to call P10’s physician to obtain a new walker. During an interview on 05/22/25 at 8:43 AM, Administrator stated PT1 should have contacted P10’s physician for an order for a new walker or contacted P10’s primary nurse or Administrator to follow-up to obtain a walker for P10.”

“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 record review and interview, the facility failed to ensure services were provided as established in the written care of plan for one of 10 (Patient (P)1) sampled patients. A visit was not conducted per the physician signed plan of care. This deficient practice had the potential to cause the patient’s needs to not be met. Findings include: Review of the facility policy titled, “Notification Regarding Missed Service or Treatment,” dated 12/2023, revealed, “Policy: A missed visit or treatment is an alteration in the plan of care, and therefore, requires notification to the ordering physician . . . Documentation of a missed visit or treatment are as follows: A. Physician allowed practitioner notification- 1. Fax with details of details of date and time; 2. Telephone notification with details of date, time, and person notified; or 3, Mailed copy of the documentation with date of mailing . . .” Review of P1’s “Home Health Certification and Plan of Care,” located under the “Orders” tab in the electronic medical record (EMR), revealed a start of care (SOC) date of 03/07/25 with diagnoses of chronic respiratory failure with hypoxia and malignant neoplasm of mouth. Further review of the undated “Home Health Certification and Plan of Care” revealed Skilled Nursing (SN) visits were to occur one time a week for five weeks, and then one visit every two weeks for four weeks. The plan of care was signed by the physician on 03/25/25. Review of the calendar, located under the “Medical Record” tab in the EMR, revealed the week of 03/23/25 through 03/29/25, which fell within the one visit for five weeks timeframe, a telehealth visit was performed on 03/28/25 and further revealed a SN visit did not occur any time during the week. During an interview on 05/21/25 at 8:15 AM, the Administrator was asked about the telehealth being performed. The Administrator stated the nurse should have made a visit on 03/26/25, but it was missed, and the nurse followed up with a phone call later in the week. When asked if a phone call can replace a physical visit, the Administrator stated, “No, a visit should have been made.””

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on interview, policy review, and quality assessment performance improvement (QAPI) document review, the home health agency (HHA) failed to analyze adverse patient events (hospitalization) that would enable the HHA to assess processes of care, HHA services, and operations. This deficient practice had the potential to prevent the HHA from making changes in procedures, policy, or interventions to improve services provided to home health patients and had the potential to affect 118 of 118 patients. Findings include: Review of the policy titled, “Quality Assessment Performance Improvement,” dated 12/2023 indicated, “. . . I. The agency’s QAPI program must, at minimum, be able to show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. II. The agency must measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that enable the agency to assess processes of care, their services, and operations . . . The agency must use data collected to: A. Monitor the effectiveness and safety of services and quality of care; and B. Identify opportunities for improvement . . .” Review of the agency’s “Transfer to Inpatient Facility History” report, presented for review by Administrator, indicated the labeled columns on the report included patient name, start of episode date, end of episode date, visit date, physician name, referring facility, primary diagnosis code, and reason for hospitalization. Review indicated the column for reason for hospitalization had “N/A” (not applicable) documented for each patient listed. Review of the data presented indicated for the first quarter of 2025, there were 39 patients (33%) hospitalized. There was no documentation presented that indicated an analysis was conducted to identify opportunities for improvement. During an interview on 05/22/25 at 12:07 PM, the Administrator stated they have not analyzed the hospitalized patients and have not developed an improvement plan to address hospitalizations.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on interview, policy review, and quality assessment performance improvement (QAPI) document review, the home health agency (HHA) failed to utilize data collected to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement. This deficient practice had the potential to prevent the HHA from making changes in procedures, policy, or interventions to improve services provided to home health patients and could affect 118 of 118 patients. Findings include: Review of the policy titled, “Quality Assessment Performance Improvement,” dated 12/2023, indicated, “. . . I. The agency’s QAPI program must, at minimum, be able to show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. II. The agency must measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that enable the agency to assess processes of care, their services, and operations . . . The agency must use data collected to: A. Monitor the effectiveness and safety of services and quality of care; and B. Identify opportunities for improvement . . . The agency must document the quality improvement projects undertaken, reasons for conducting these projects and the measurable progress achieved . . .” Review of the “Potentially Avoidable Event Overview” report for 10/01/24 to 12/31/24, presented for review by Administrator, indicated the agency’s falls with major injury (2.33%) and falls with no injury (9.30%) were above the national average (0.94% and 5.82% respectively), while the falls with minor injury (2.33%) were below the national average (3.99%). Review of the “Potentially Avoidable Event Overview” report for 01/01/25 to 03/31/25 presented by Administrator for review indicated falls with minor injury was 10.31% while the national average was 3.82%. Review of a “Home Health Performance Improvement Plan (PIP),” dated 01/07/25 and presented by Administrator, indicated, “Reason for Improvement Plan: . . . During quarterly review for QAPI it was noted that patient falls with minor injury was over the national average for fa1ls with no injury 9.30%.” Review indicated actions to be taken included, “Clinicians that create the POC will individualize each patient’s POC [plan of care] to their specific needs, including fall prevention interventions. Field staff will be educated regarding proper fa11 risk assessment and contacting patient’s provider to request therapy evaluations as indicated. Case conferences will include discussions to identify patients that are high risk for falls and appropriate fall prevention measures to implement. Field staff will be educated regarding proper reporting and documentation of falls so that they can be tracked . . .” Review indicated “Patient falls with minor injury will be under 3%% [sic] by end of Q2 2025 [quarter two].” No documentation of revisions to the action plan with the first quarter’s increase in falls was presented by Administrator. During an interview on 05/22/25 at 12:07 PM, the Administrator stated they had not made revisions to the QAPI improvement plan actions since the first quarter data showed an increase in falls.”

“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, interview, and policy review, the home health agency (HHA) failed to ensure accepted standards of practice to prevent the transmission of infections and communicable diseases were implemented during home visits for two of four patients (Patient (P) 7 and P8) who were observed during home visits out of a total sample of 10. This had the potential to cause cross contamination between patients and staff and had the potential to affect all patients receiving services provided by the agency and all employees employed by the agency. Findings include: Review of the agency policy titled, “Equipment Cleaning, Calibration, and Maintenance,” dated 12/2023, indicated, “Policy: Employees are responsible for cleaning all patient care equipment on a regular basis and keeping the equipment in good condition and calibrated . . . Stethoscopes - Wipe with agency approved disinfectant when visibly soiled or used on open areas of skin, rash, etc. [and so on]. . . Blood Pressure Cuffs - These do not have to be cleaned between patients. If a patient has a rash or grossly infected wound, place a piece of plastic wrap around the arm before applying cuff. Cuff should be cleaned when the cuff becomes soiled. . . All reusable equipment will be cleaned and decontaminated after contact with blood or other potentially infectious materials . . .” Review of the policy indicated a contradiction of the cleaning process for blood pressure cuffs with the policy titled “Infection Prevention & [and] Control in the Home Setting” written below. Review of the agency policy titled, “Gloves,” dated 12/2023, indicated, “. . . Gloves are to be changed between patients and worn in the following circumstances: A. With any established patient care precautions as defined by policy, CDC [Centers for Disease Control and Prevention] and OSHA [Occupational Safety and Health Administration] guidance; B. With any procedure where there is the possibility of contact with any potentially infectious materials (blood, body secretions, excretions, soiled dressings); C. When a health care worker has non-intact skin; D. When a health care worker performs an invasive procedure; E. When a health care worker performs personal hygiene care for a patient. F. When changing linens soiled with blood/body fluids; and G. When performing procedures to another area of the body in which other parts of the body may be cross contaminated from first area of care . . .” Review of the agency policy titled, “Infection Prevention & [and] Control in the Home Setting,” dated 06/2024, indicated, “. . . Hand hygiene shall be performed at a minimum: Before and after contact with a patient; Before performing an aseptic task and the donning of gloves; After contact with the patient or objects in the immediate vicinity of the patient; After contact with blood, body fluids or contaminated surfaces; After contact with the patient’s immediate environment When moving from a contaminated body site to a clean body site during patient care; and After removal of PPE [personal protective equipment] . . . Agency staff shall maintain clean equipment and supplies during the home visit, during transport of reusable patient care items in the vehicle, and for use in multiple patients’ homes . . . Agency staff shall practice proper clinician bag technique when carrying the bag into the home. This includes: A. Identification of a clean area in the home to place a single-use, moisture resistant surface barrier for the placement of the clinician’s bag and supplies. B. Cleansing of soiled items used on multiple patients, such as stethoscope, shall be performed with approved cleaning wipes or disinfectant prior to placing the item back in the bag . . .” Review of the policy indicated a contradiction of the cleaning process for blood pressure cuffs with the policy titled “Equipment Cleaning, Calibration, and Maintenance” written above. 1. Observation on 05/21/25 at 8:00 AM during a home visit with Patient (P) 7 revealed Registered Nurse (RN) 1 entered P7’s home carrying two stools and a personal bag used to carry patient care equipment. RN1 placed each stool on the patient’s floor without placing a barrier between the stool and the floor. Observation revealed RN1 assessed P7’s heart and lungs with bare hands and then donned gloves without first performing hand hygiene in accordance with agency policy. Observation on 05/21/25 at 8:40 AM revealed RN1 placed a plastic bag containing gloves on P7’s chest of drawers with no barrier beneath the plastic bag. Observation revealed after RN1 assisted P7 to bed to assess P7’s wound on the buttock, RN1 placed the bag of gloves on P7’s bed with no barrier beneath the plastic bag. Observation revealed the plastic bag of gloves fell on the floor, and RN1 picked the bag of gloves off the floor and replaced the bag on P7’s bed. Observation on 05/21/25 at 8:48 AM revealed RN1 wiped the bag of gloves with a disinfectant wipe with bare hands and then donned gloves without performing hand hygiene. Observation revealed RN1 removed his/her gloves, did not perform hand hygiene after removing the gloves, and used RN1’s personal cell phone to take a picture of P7’s wound. Observation revealed RN1 used a disinfectant wipe to clean used equipment with bare hands (had not performed hand hygiene after removing his/her gloves). During an interview on 05/21/25 at 8:55 AM after the surveyor reviewed the above observations with RN1, RN1 stated the observations were breaches in infection control practice. 2. Observation during a home visit with P8 on 05/21/25 at 10:00 AM revealed Licensed Practical Nurse (LPN) 1 placed his/her personal bag on P8’s dining room chair with no barrier beneath the personal bag. Observation revealed LPN1 removed his/her gloves after assessing P8’s vital signs and did not perform hand hygiene before documenting on LPN1’s tablet. Observation revealed LPN1 performed hand hygiene, donned gloves, performed wound care to P8’s right lower leg, removed gloves, performed hand hygiene, donned gloves, and then removed gloves to obtain supplies to wrap P8’s leg without performing hand hygiene after removing his/her gloves. Observation revealed LPN1 obtained gauze wrap from the bag of supplies, performed hand hygiene, and donned gloves to wrap P8’s right lower leg with Coban wrap (self-adherent wrap with latex used to hold the dressing in place). Observation revealed LPN1 performed the following procedures while wearing contaminated gloves used to wrap P8’s leg: reached in LPN1’s personal bag to get a container of disinfectant wipes; opened the new container of wipes and removed the cover to get wipes; wiped all patient care equipment used to assess P8 with disinfectant wipes; placed the disinfected equipment on the same barrier LPN1 had placed the contaminated equipment after use; placed the disinfectant wipe cover on the container and pulled a wipe through the opening; returned all equipment that was cleaned with contaminated gloves to LPN1’s personal bag. During an interview on 05/21/25 at 10:55 AM, LPN1 stated the nurse is supposed to perform hand hygiene before starting patient care, before applying a dressing and after applying a dressing, and any time his/her hands are soiled. LPN1 stated he/she was supposed to sanitize his/her hands each time he/she removed gloves. After the surveyor reviewed the above observations with LPN1, LPN stated he/she thought she had performed hand hygiene when he/she was supposed to perform hand hygiene.”

“Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This Standard is not met as evidenced by: Based on observation, interview, and policy review, the Home Health Agency (HHA) failed to monitor, manage, and maintain the equipment used to access the web-based electronic medical record (EMR). The choice for staff to purchase and use tablets and personal cell phones to access the EMR, receive and send texts related to patients serviced by the HHA, and to photograph patients’ wounds sent to the patient’s physician had the potential to compromise personal patient information and could affect 118 of 118 patients currently receiving services from the HHA, and all patients who have received past services. Findings include: Review of the agency policy titled, “Bring Your Own Device (BYOD) Policy,” dated 08/2021, indicated, “[name of agency management group] grants its employees the privilege of purchasing and using smartphones and tablets of their choosing at work for their convenience. [name of agency management group] reserved the right to revoke this privilege if users do not abide by the policies and procedures outlined below . . . Work -related images captured on devices may only be utilized via the RingCentral app . . . Employees may use their mobile device to access the following company-owned resources: email, calendars. contacts, documents. RingCentral, etc. [and so on] . . .” During an interview on 05/20/25 at 8:32 AM, the Administrator stated the staff uses the HomeCare HomeBase system for documentation. The Administrator stated the staff was provided with tablets by the agency, and they used personal cell phones for patient and staff communication through Ring Central, a HIPPA-compliance app. Observation during a home visit with Patient (P) 7 on 05/21/25 at 8:48 AM revealed Registered Nurse (RN) 1 used his/her personal cell phone to take a picture of P7’s pressure ulcer on P7’s buttock. During an interview on 05/21/25 at 8:55 AM, RN1 stated the tablet he/she used to document P7’s visit was provided by the agency. RN1 stated he/she uses his/her personal cell phone to take pictures of patients’ wounds to send to the patients’ physician. RN1 stated his/her personal cell phone was not inspected by the HHA. During an interview on 05/21/25 at 1:40 PM, Physical Therapist (PT) 1 stated he/she uses his/her personal cell phone to contact patients’ physicians and receive messages about patients from the HHA office staff.”

“Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This Element is not met as evidenced by: Based on interview and policy review, the home health agency (HHA) failed to ensure the agency’s grievance policy included the removal of an employee from direct patient care when involved in an abuse allegation until an investigation was complete. This had the potential to affect 118 of 118 patients served by the agency and any future patients and could place patients at risk for abuse. Findings include: Review of the agency’s policy titled, “Grievance/Complaint – Patient,” dated 12/2023, indicated, “. . . Action will be taken to prevent further potential violations, including retaliation, while the complaint is being investigated. This may include but may not [be] limited to: A. Removal of the accused employee from the care team of the patient involved in the complaint. B. Instruction to the accused employee to refrain from any communication with the accuser until the investigation is complete, at minimum . . .” Review of the HHA’s grievance policy did not include removing an employee alleged to have abused a patient from direct care of all agency patients in an effort to remove any risk to all patients while the complaint is investigated. During an interview on 05/22/25 at 10:30 AM, Administrator confirmed the grievance policy has the abuser to be removed only from the patient alleging abuse.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview, record review, and policy review, the home health agency (HHA) failed to ensure the registered nurse (RN) conducted the patient’s initial assessment within 48 hours of the referral from the physician for two of 10 patients (Patient (P) 7, P9) whose records were reviewed for the start of care initial assessment from a total sample of 10. This deficient practice had the potential to cause the patient to have unmet care needs. Findings include: Review of the agency’s policy titled, “Care Planning Process & [and] Comprehensive Assessment,” dated 12/2023, indicated, “. . . A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home from an inpatient admission, or on the physician/allowed practitioner-ordered start of care date . . .” 1. Review of P7’s electronic medical record (EMR) indicated a discharge order form, dated 03/17/25 and located under the “Attachment” tab, to discharge P7 home with home health for “Nursing Services” and “Bath Aide.” Review of P7’s “Home Health Certification and Plan of Care,” for the certification period of 03/25/25 to 05/23/25 and located under the “Orders” tab of the EMR, indicated the start of care date (date of the initial assessment) was 03/25/25, eight days after the signed physician’s referral. Review of P7’s EMR indicated no documentation that P7’s physician was notified of the delay in the initial assessment and/or a physician order approving the delay in the start of care. During an interview on 05/20/25 at 12:43 PM, the Administrator stated P7’s referral for home health was sent by the nursing home when P7 was discharged home from the nursing home. The Administrator stated the agency got the referral from the nursing home. He/She stated they did not call the physician about the delay in providing care and did not have the nursing home get a new order for home health services. The Administrator confirmed the initial assessment was conducted eight days after the date the physician signed the referral order. 2. Review of P9’s EMR indicated a discharge order form, dated 03/27/25 and located under the “Attachments” tab of the EMR, indicating P9 was to be discharged on 03/28/25 and would need home health services of nursing, physical therapy, and occupational therapy. Review of P9’s “Home Health Certification and Plan of Care,” for the certification period of 04/02/25 to 05/31/25 and located under the “Orders” tab of the EMR, indicated the start of care date (date of the initial assessment) was 04/02/25, five days after the nurse practitioner’s referral. Review of P9’s EMR indicated no documentation that P9’s nurse practitioner was notified of the delay in the initial assessment and/or a nurse practitioner order approving the delay in the start of care. During an interview on 05/22/25 at 9:44 AM, the Administrator confirmed P9’s initial assessment was conducted five days after P9 was discharged from an inpatient admission.”

“Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This Element is not met as evidenced by: Based on interview, record review, and policy review, the home health agency (HHA) failed to ensure the patient’s plan of care (POC) included patient-specific goals with measurable outcomes for 10 (Patient (P) 1, P2, P3, P4, P5, P6, P7, P8, P9, P10) of 10 sampled patients. This deficient practice had the potential to prevent the patient and agency from being able to monitor actual changes in patient health status. Findings include: Review of the agency policy titled, “Care Planning Process & [and] Comprehensive Assessment,” dated December 2023, indicated, “. . . Each patient must receive, and an agency must provide, a patient-specific, comprehensive assessment. 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 need as identified in the comprehensive assessment . . . The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: . . . The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the agency . . . Goals and outcome criteria are identified for each problem. Goals are based on the patient’s problems and needs, condition, wishes, and ability to respond to care and services . . .” 1. Review of P1’s “Home Health Certification and Plan of Care,” located under the “Orders” tab in the electronic medical record (EMR), revealed a start of care (SOC) date of 03/07/25 with diagnoses of chronic respiratory failure with hypoxia and malignant neoplasm of mouth. Further review of the “Home Health Certification and Plann of Care” revealed the following goals: “. . . Respiratory exacerbation will be identified promptly and interventions initiated to minimize associated risk . . . Patient /Caregiver will verbalize/ demonstrate an ability to care for altered respiratory status by end of episode . . . Abnormal oxygen saturation levels will be reported to physician . . . Patient/ Caregiver will be able to verbalize/ demonstrate self-management of gastrostomy/ jejunostomy by end of episode . . . Increased pain or pain control measures will be identified and promptly reported to the physician . . . Patient/ Caregiver will verbalize understanding of pharmacologic and non-pharmacologic pain control measures . . . Patient will receive medication as prescribed . . . Changes in skin integrity status will be identified and reported to the physician for prompt intervention . . . Patient/ Caregiver will verbalize/demonstrate adequate knowledge of integumentary status and appropriate measures to promote skin integrity and prevent injury . . . Patient will demonstrate/ verbalize knowledge of interventions to prevent falls and safety hazard . . . Patient will remain safe within home environment . . .” 2. Review of P2’s “Home Health Certification and Plan of Care,” located under the “Orders” tab in the EMR, revealed a SOC date of 08/14/24 with diagnoses of malignant neoplasm of the left breast, and malignant neoplasm of bone. Further review of the “Home Health Certification and Plann of Care” revealed the following goals: “. . . Gastrointestinal status will be evaluated and exacerbations identified with interventions implemented to minimize complications . . . Patient/Caregiver will verbalize/demonstrate ability to care for altered gastrointestinal status by end of episode . . . Increased pain or pain control measures will be identified and promptly reported to the physician . . . Patient/ Caregiver will verbalize understanding of pharmacologic and non-pharmacologic pain control measures . . . Patient will receive medication as prescribed . . . Patient/ Caregiver will verbalize/demonstrate appropriate methods to maintain/gain weight by the end of episode . . . Patient will demonstrate/ verbalize knowledge of interventions to prevent falls and safety hazard . . . Patient will remain safe within home environment . . .” 3. Review of P3’s “Home Health Certification and Plan of Care,” located under the “Orders” tab in the EMR, revealed a SOC date of 04/04/25 with diagnoses of venous insufficiency, hypertensive heart disease with heart failure and type two diabetes mellitus. Further review of the “Home Health Certification and Plann of Care” revealed the following goals: “. . . Patient’s blood glucose levels will be documented and managed by end of episode . . . Patient will demonstrate improved blood sugar levels as a direct result of hypoglycemia interventions . . . Patient/ Caregiver will verbalize/ demonstrate adequate knowledge of endocrine status . . . Patient/Caregiver will verbalize/demonstrate ability to care for hypertension . . . Increased pain or pain control measures will be identified and promptly reported to the physician . . . Patient/ Caregiver will verbalize understanding of pharmacologic and non-pharmacologic pain control measures . . . Patient will receive medication as prescribed . . . Patient will demonstrate/ verbalize knowledge of interventions to prevent falls and safety hazard . . . Patient will remain safe within home environment . . .” 4. Review of P4’s “Home Health Certification and Plan of Care,” located under the “Orders” tab in the EMR, revealed a SOC date of 08/10/24 with diagnoses of Guillan-Barre syndrome. Further review of the “Home Health Certification and Plann of Care” revealed the following goals: “. . . Patient/Caregiver will verbalize/demonstrate ability to care for hypertension . . . Changes in neurological status will be identified and reported to the physician for prompt intervention . . . Increased pain or pain control measures will be identified and promptly reported to the physician . . . Patient/ Caregiver will verbalize understanding of pharmacologic and non-pharmacologic pain control measures . . . Patient will receive medication as prescribed . . . Patient will demonstrate/ verbalize knowledge of interventions to prevent falls and safety hazard . . . Patient will remain safe within home environment . . .” 5. Review of P5’s “Home Health Certification and Plan of Care,” located under the “Orders” tab in the EMR, revealed a SOC date of 02/08/25 with diagnoses of acute respiratory failure with hypoxia and type two diabetes mellitus. Further review of the “Home Health Certification and Plann of Care” revealed the following goals: “. . . Patient’s blood glucose levels will be documented and managed by end of episode . . . Patient will demonstrate improved blood sugar levels as a direct result of hypoglycemia interventions . . . Patient/ Caregiver will verbalize/ demonstrate adequate knowledge of endocrine status . . . Patient/Caregiver will verbalize/demonstrate ability to care for hypertension . . . Increased pain or pain control measures will be identified and promptly reported to the physician . . . Patient/ Caregiver will verbalize understanding of pharmacologic and non-pharmacologic pain control measures . . . Patient will receive medication as prescribed . . . Patient will demonstrate/ verbalize knowledge of interventions to prevent falls and safety hazard . . . Patient will remain safe within home environment . . .” 6. Review of P6’s “Home Health Certification and Plan of Care,” located under the “Orders” tab in the EMR, revealed a SOC date of 04/19/25 with diagnoses of hemiplegia following cerebral infarction of right dominant side. Further review of the “Home Health Certification and Plann of Care” revealed the following goals: Patient’s blood glucose levels will be documented and managed by end of episode . . . Patient will demonstrate improved blood sugar levels as a direct result of hypoglycemia interventions . . . Patient/ Caregiver will verbalize/ demonstrate adequate knowledge of endocrine status . . . Patient/Caregiver will verbalize/demonstrate ability to care for hypertension . . . Increased pain or pain control measures will be identified and promptly reported to the physician . . . Patient/ Caregiver will verbalize understanding of pharmacologic and non-pharmacologic pain control measures . . . Patient will receive medication as prescribed . . . Patient will demonstrate/ verbalize knowledge of interventions to prevent falls and safety hazard . . Patient will remain safe within home environment . . .” During an interview on 05/22/25 at 9:56 AM, the Administrator and Area Director of Operations (ADO) were asked about the goals not being patient specific and measurable. The administrator and ADO stated the program was set up with set goals and the staff just click the button. 7. Review of P7’s “Home Health Certification and Plan of Care,” for the certification period of 03/25/25 to 05/23/25 and located under the “Orders” tab of the EMR, indicated P7’s primary diagnosis was pressure ulcer of the left buttock, stage four. Review of P7’s goals developed on P7’s POC indicated the following goals: “. . . Patient / caregiver will verbalize/demonstrate ability to care for altered genitourinary status . . . Patient /caregiver will verbalize/demonstrate required knowledge to manage urinary catheter care and will be able to verbalize signs and symptoms of urinary tract infection. Patient will verbalize/tolerate catheter change . . . Patient / caregiver will verbalize/demonstrate adequate knowledge of integumentary status and appropriate measures [sic] promote skin integrity and prevent injury. Patient will demonstrate improved wound status as evidenced by a decrease in size/drainage of wound, absence infection, and decreased pain. Patient will demonstrate/verbalize knowledge of interventions to prevent falls and safety hazards. Patient will remain safe within home environment . . . Patient / caregiver will verbalize understanding of pharmacologic and non-pharmacologic pain control measures . . .” Review of P7’s goals developed by the registered nurse (RN) indicated the goals were not patient-specific and did not include measurable outcomes to determine when the goals were met. During an interview on 05/21/25 at 8:55 AM, RN1 confirmed P7’s goals on the “Home Health Certification and Plan of Care” for the certification period of 03/25/25 to 05/23/25 were not written as measurable outcomes. 8. Review of P8’s “Home Health Certification and Plan of Care,” for the certification period of 05/08/25 to 07/06/25 and located under the “Orders” tab of the EMR, indicated P8’s primary diagnosis was cellulitis of the right lower limb. Review of P8’s goals developed on P8’s POC indicated the following goals: “. . . Patient’s blood glucose levels will be documented and managed by end of episode. Patient will demonstrate improved blood sugar levels as a direct result of hypoglycemic intervention . . . Patient / caregiver will verbalize/demonstrate adequate knowledge of endocrine status . . . Patient / caregiver will verbalize/demonstrate ability to care for hypertension . . . Patient / caregiver will verbalize/demonstrate an ability to care for altered respiratory status by end of episode . . . Patient / caregiver will verbalize/demonstrate ability to care for altered gastrointestinal status by end of episode. Patient / caregiver will verbalize understanding of pharmacologic and non-pharmacologic pain control measures . . .” Review of P8’s goals developed by the RN indicated the goals were not patient-specific and did not include measurable outcomes to determine when the goals were met. 9. Review of P9’s “Home Health Certification and Plan of Care,” for the certification period of 04/02/25 to 05/31/25 and located under the “Orders” tab of the EMR indicated P9’s primary diagnosis was chronic obstructive pulmonary disease with acute exacerbation. Review of P9’s goals developed on P9’s POC indicated the following goals: “. . . Patient / caregiver will verbalize/demonstrate ability to care for hypertension . . . Patient / caregiver will verbalize/demonstrate ability to care for altered gastrointestinal status by end of episode . . . Patient / caregiver will verbalize understanding of pharmacologic and non-pharmacologic pain control measures . . . Patient / caregiver will verbalize/demonstrate appropriate methods to maintain/gain weight by the end of episode. Patient will demonstrate/verbalize knowledge of interventions to prevent falls and safety hazards. Patient will remain safe within home environment . . . Patient / caregiver [sic] verbalize/demonstrate ability to care for chronic obstructive pulmonary disease (COPD) by end of episode . . . Patient / caregiver [sic] verbalize/demonstrate ability to care for congestive heart failure by end of episode.” Review of P9’s goals developed by the RN indicated the goals were not patient-specific and did not include measurable outcomes to determine when the goals were met. Review of a physician order for P9, located under the “Orders” tab of the EMR and dated 04/17/25, indicated the following physical therapy goals: “. . . Patient will demonstrate improved function in response to specific exercise(s) and/or manual therapy techniques, as evidenced by increased independence in activities of daily living. Patient / caregiver will demonstrate decreased fall risk during functional activities. Patient will demonstrate safe gait technique with assistive devices as needed to minimize risk of injury.” Review of P9’s goals developed by the physical therapist indicated the goals were not patient-specific and did not include measurable outcomes to determine when the goals were met. 10. Review of P10’s “Home Health Certification and Plan of Care,” for the certification period of 03/27/25 to 05/25/25 and located under the “Orders” tab of the EMR, indicated P10’s primary diagnosis was primary generalized osteoarthritis. Review of P10’s goals developed on P10’s POC indicated the following goals: “. . . Patient / caregiver will verbalize/demonstrate ability to care for altered cardiovascular status by end of episode . . . Patient / caregiver will verbalize/demonstrate ability to care for hypertension . . . Patient / caregiver will verbalize/demonstrate ability to care for altered gastrointestinal status by end of episode. Patient will demonstrate/verbalize knowledge of interventions to prevent falls and safety hazards. Patient will remain safe within home environment . . . Patient / caregiver will verbalize understanding of pharmacologic and non-pharmacologic pain control measures . . . Patient / caregiver will verbalize understanding of osteoarthritis including definition, signs and symptoms, possible complications and measures to prevent or control.” Review of P10’s goals developed by the RN indicated the goals were not patient-specific and did not include measurable outcomes to determine when the goals were met. Review of a physician order for P10, located under the “Orders” tab of the EMR and dated 04/23/25, indicated the following physical therapy goals: “. . . Patient will demonstrate improved function in response to specific exercise(s) and/or manual therapy techniques, as evidenced by increased independence in activities of daily living. Patient / caregiver will demonstrate decreased fall risk during functional activities. Patient will demonstrate safe gait technique with assistive devices as needed to minimize risk of injury.” Review of P10’s goals developed by the physical therapist indicated the goals were not patient-specific and did not include measurable outcomes to determine when the goals were met. During an interview on 05/21/25 at 3:20 PM, Physical Therapist (PT) 1 stated he/she does not usually see the patient’s “Home Health Certification and Plan of Care.” PT1 stated the goals on P9’s and P10’s “Home Health Certification and Plan of Care” were not patient-specific and did not include measurable outcomes. PT1 stated those goals were “computer-generated” and not what he/she writes as goals. During an interview on 05/22/25 at 10:08 AM, the Administrator and Area Director of Operations (ADO), confirmed the patients’ goals written on the patients’ “Home Health Certification and Plan of Care” were not patient-specific and did not include measurable outcomes.”

“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 interview, record review, and policy review, the home health agency (HHA) failed to ensure home health services were provided as ordered for five of 10 sampled patients (Patient (P) 6, P7, P8, P9, P10). This deficient practice had the potential to cause patient care needs to not be met and could affect all patients cared for by the agency. Findings include: Review of the agency policy titled, “Care Planning, Coordination of Services and Quality of Care” dated December 2023, indicated “. . . Drugs, services, and treatments are administered only as ordered by a physician/allowed Practitioner. . . Review of the agency policy titled, “Clinical Note,” dated December 2023, indicated “. . . Documentation of the services rendered shall reflect the physician/allowed practitioner’s orders in the plan of care. . . Any contact with the physician/allowed practitioner and/or the receipt of new orders, such as changes in treatment, shall be documented in the visit note or a communication note. . .” Review of the agency policy titled, “Clinical Records,” dated August 2024, indicated “. . . The record shall contain pertinent past and current medical and social data and include but not limited to the following information: . . . Physician/allowed practitioner orders. . .” 1. Review of P6’s “Home Health Certification and Plan of Care,” located under the “Orders” tab in the electronic medical record (EMR) revealed a start of care (SOC) date of 04/19/25 with diagnoses including hemiplegia following cerebral infarction of right dominant side. Review of P6’s physician orders, located under the “Orders” tab in the EMR and dated 04/24/25, revealed, “Discontinue daptomycin [an antibiotic] and start vancomycin [an antibiotic] 500 mg [milligrams] every 48 hours. CBC [complete blood count], CMP [comprehensive metabolic panel], CK [creatine kinase], and a vancomycin trough prior to dose on 04/29/25. . .” Review of the Skilled Nurse (SN) visit notes, located under the “Medical Record” tab in the EMR, revealed a visit was done on 04/28/25 and then on 04/30/25. During an interview on 05/22/25 at 8:30 AM, the Administrator was asked about the visit on 04/28/25 when the physician orders indicated the draw should have been on 04/29/25. The Administrator stated, “The labs should have been drawn on the 29th as ordered. The nurse drew the labs on the 28th and did not get the Vanco trough and had to go back to the patients’ home and draw the Vanco trough on the 30th. There should have been a verbal order in the computer for the missed lab.” The Administrator was asked if the physicians’ orders were followed. The Administrator stated, “No.” The facility was asked for a policy for following physician orders. On 05/22/25 at 1:00 PM the Area Director of Operations (ADO) stated, “There is no policy for following physician orders.” 2. Review of P7’s “Home Health Certification and Plan of Care,” for the certification period of 03/25/25 to 05/23/25 and located under the “Orders” tab of the EMR indicated P7’s primary diagnosis was pressure ulcer of the left buttock, stage four. Review of P7’s EMR indicated a discharge order form, located under the “Attachment” tab and dated 03/17/25, discharge P7 home with home health for “Nursing Services” and “Bath Aide.” Review of P7’s EMR indicated no documentation that aide services were provided or that P7’s physician was notified that the agency did not provide aide services. Review of the “Home Health Certification and Plan of Care,” for the certification period of 03/25/25 to 05/23/25, indicated an order to “Hold home health services for transfer to inpatient facility. May resume care upon discharge from facility.” There was no documentation in P7’s EMR that P7 had been admitted to an inpatient facility and then had care resumed by the HHA. During an interview on 05/20/25 at 12:43 PM, the Administrator confirmed that the EMR had no documentation P7’s physician was notified that the HHA could not provide aide services so that the physician could determine if he/she wanted P7 referred to another agency that could provide aide services. 3. Review of P8’s “Home Health Certification and Plan of Care,” for the certification period of 05/08/25 to 07/06/25 and located under the “Orders” tab of the EMR, indicated P8’s primary diagnosis was cellulitis of the right lower limb. Further review indicated an order to “Hold home health services for transfer to inpatient facility. May resume care upon discharge from facility.” There was no documentation in P8’s EMR that P8 had been admitted to an inpatient facility and then had care resumed by the HHA. 4. Review of P9’s “Home Health Certification and Plan of Care,” for the certification period of 04/02/25 to 05/31/25 and located under the “Orders” tab of the EMR, indicated P9’s primary diagnosis was chronic obstructive pulmonary disease with acute exacerbation. Review of P9’s EMR indicated a discharge order form, located under the “Attachment” tab of the EMR and dated 03/25/25 to discharge P9 home with home health for nursing services, physical therapy, and occupational therapy. Review of P9’s EMR indicated no documentation that occupational therapy services were provided or that P9’s physician was notified that occupational therapy services would not be provided so that the physician could determine if he/she wanted P9 referred to another agency that could provide occupational therapy services. Review of the “Home Health Certification and Plan of Care,” for the certification period of 04/02/25 to 05/31/25, indicated an order to “Hold home health services for transfer to inpatient facility. May resume care upon discharge from facility.” There was no documentation in P9’s EMR that P9 had been admitted to an inpatient facility and then had care resumed by the HHA. During an interview on 05/22/25 at 9:44 AM, Administrator stated the EMR had no documentation why occupational therapy was not provided or that the physician was notified of P9’s plan of care not being implemented as ordered. 5. Review of P10’s “Home Health Certification and Plan of Care,” for the certification period of 03/27/25 to 05/25/25 and located under the “Orders” tab of the EMR indicated P10’s primary diagnosis was primary generalized osteoarthritis. Review of the “Home Health Certification and Plan of Care” for the certification period of 03/27/25 to 05/25/25 indicated an order to “Hold home health services for transfer to inpatient facility. May resume care upon discharge from facility.” There was no documentation in P10’s EMR that P10 had been admitted to an inpatient facility and then had care resumed by the HHA. During an interview on 05/20/25 at 12:43 PM, the Administrator stated they included the order on each patient’s plan of care (POC) to hold home health services in the event the patient has to be transferred to another facility during the certification period. The Administrator stated the manner in which the order was written on each patient’s POC did not mean each patient had been transferred to another facility.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on interview, record review, and policy review, the home health agency (HHA) failed to ensure there was documentation of coordination of care among all disciplines providing patient care for two of 10 patients (Patient (P) 7 and P8) reviewed for coordination of care out of a total sample of 10. This deficient practice had the potential to affect the safety and treatment effectiveness of all patients receiving HHA services provided by multiple disciplines. Findings include: Review of the agency policy titled, “Care Planning, Coordination of Services and Quality of Care,” dated 12/2023, indicated,”. . . The agency shall: . . . integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. D. Coordinate care delivery to meet the patient’s needs and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities . . .” Review of the agency policy titled, “Care Planning Process & [and] Comprehensive Assessment,” dated 12/2023, indicated, “. . . A communication log/note may be used to continue documentation of health teaching by all skilled disciplines for coordination of teaching between the skilled disciplines. The communication log is also used to note new and/or changed conditions (coordination of care) by all disciplines and for verification of visits . . .” Review of the agency policy titled, “Clinical Note,” dated 12/2023, indicated, “. . . Any coordination of care with other disciplines, agencies or services shall be documented . . .” 1. Review of P7’s “Home Health Certification and Plan of Care,” for the certification period of 03/25/25 to 05/23/25 and located under the “Orders” tab of the electronic medical record (EMR), P7’s primary diagnosis was pressure ulcer of the left buttock, stage four. Review of P7’s “Visit Note Report,” dated 03/31/25, signed by Licensed Practical Nurse (LPN) 2, and located under the “Visit Notes” tab of the EMR,, indicated, “. . . boggy skin noted to the left heel . . .” Review of the section of the “Visit Note Report” that included “Care Coordination Indicate if you communicated with other disciplines involved in this case:” included documentation of “No.” Review of P7’s “Visit Note Report,” dated 04/02/25, signed by LPN2, and located under the “Visit Notes” tab of the EMR, indicated, “. . . boggy skin noted to the left heel.” Review of the section of the “Visit Note Report” that included “Care Coordination Indicate if you communicated with other disciplines involved in this case:” included documentation of “No.” Review of P7’s “Visit Note Report” dated 04/04/25, signed by LPN2, and located under the “Visit Notes” tab of the EMR, indicated, “. . . boggy skin noted to the left heel . . .” Review of the section of the “Visit Note Report” that included “Care Coordination Indicate if you communicated with other disciplines involved in this case:” included documentation of “No.” There was no documentation LPN2 reported the negative findings of boggy skin to the left heel to the Registered Nurse (RN) or LPN2’s supervisor. There was no documentation of coordination of care between the LPN and the RN in P7’s electronic medical record. During an interview on 05/20/25 at 2:52 PM, the Administrator (who was an RN) stated LPN2 should have reported the negative findings during P7’s visits of 03/31/25, 04/02/25, and 04/04/25 to P7’s primary RN or to Administrator. 2. Review of P8’s “Home Health Certification and Plan of Care,” for the certification period of 05/08/25 to 07/06/25 and located under the “Orders” tab of the EMR, indicated P8’s primary diagnosis was cellulitis of the right lower limb. Review of P8’s “Visit Note Report,” dated 05/19/25, signed by LPN1, and located under the “Visit Notes” tab of the EMR, indicated the section that included that included “Care Coordination Indicate if you communicated with other disciplines involved in this case:” included documentation of “Yes,” and the section that included “What discipline did you communicated with:” had the answer “Supervisor.” Review of P8’s entire electronic medical record (EMR) indicated no documentation of communication between the LPN and the RN providing home health services to P8 to coordinate care. During an interview on 05/22/25 at 8:43 AM, Administrator confirmed there was no documentation of coordination of care by the LPN and RN in the EMR of P7 and P8.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observations, interviews, and policy review, the home health agency (HHA) failed to ensure medications in the patient’s home were the same medications listed on the patient’s medication profile developed and placed in the electronic medical record (EMR) for two of three patients (Patient (P) 7 and P8) whose medications were reviewed during home visits from a total of four home visits conducted. The total sample was 10 patients. This deficient practice had the potential to cause medication errors and could affect all patients receiving home health services provided by the agency. Findings include: Review of the agency policy titled, “Drug Regimen Review,” dated 12/2023, indicated, “Policy: All patients will have a drug regimen review (DRR) performed each time a comprehensive assessment is completed, and as needed to accommodate changes in the patient’s medication regimen that occur between comprehensive assessment time points . . . Upon admission to service, and other required comprehensive assessment time points, all patients will have a thorough review of all current prescribed and over-the-counter medications the patient is currently taking . . . administered by any route . . . All medications that the patient is currently taking will be listed on the patient’s plan of care . . . All changes in medications shall be noted in the clinical record as soon as the clinician becomes aware of the change . . .” 1. Observation during a home visit to P7 on 05/21/25 at 8:00 AM revealed Registered Nurse (RN) 1 reviewed P7’s medications in the home and compared them to P7’s medication profile in P7’s electronic medical record (EMR). Review of P7’s “Client Medication Report,” printed from P7’s EMR and presented to the surveyor by Administrator prior to the home visit, indicated P7 was prescribed Vitamin C (water-soluble vitamin that the body needs for various functions, including immune health, collagen production, and wound healing) chewable tablet 500 mg (milligrams) daily and Vitamin D3 (vitamin important for healthy bones, muscles, and immune health) 25 mcg (micrograms) (1000 unit) tablet daily. Observation during the home visit revealed P7 had Vitamin C 1000 mg and Vitamin D3 2000 units in the home. During an interview on 05/21/25 at 8:00 AM, P7 stated he/she was taking Vitamin C 1000 mg and Vitamin D3 2000 units. During the interview, RN1 stated the Licensed Practical Nurse (LPN) had been doing P7’s visits three times a week, and he/she (RN1) had not visited P7 since 04/24/25. 2. Observation during a home visit to P8 on 05/21/25 at 10:00 AM revealed P8’s medications in the home that were not listed on P8’s “Client Medication Report,” printed from P8’s EMR and presented to the surveyor by Administrator prior to the home visit, included the following medications: Gvoke Hypopen (glucagon injectable) (treatment for severe hypoglycemia [low blood sugar] in adults) one mg per 0.2 milliliters (ml); Naloxone HCl spray (used along with emergency medical treatment to reverse the life-threatening effects of a known or suspected opiate (narcotic) overdose) four mg, one spray one time; Calcium 600 mg (ingredient found in a variety of supplements and vitamins used to lower potassium in the blood or treat magnesium poisoning) and Vitamin D3 (vitamin important for healthy bones, muscles, and immune health) 20 mcg, one each daily; B12 supplement (maintaining healthy blood cells, the nervous system, and DNA synthesis) 2500 mcg tablet, once daily; Acetaminophen (used to treat minor aches and pains) 650 mg as needed for pain. During an interview on 05/21/25 at 10:55 AM, LPN1 stated he/she reviewed P8’s medications about one week ago, and some of the medications were not in P8’s bag used to store medications when LPN1 reviewed them.”

“Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure four of five staff files reviewed had received annual abuse training. This deficient practice had the potential to allow staff to work without updated in-service training to protect the patients. Findings include: Review of the facility policy titled, “Inservice Training,” revised 12/2023, revealed, “Policy All employees are required to attend applicable in-service educations. Purpose: To ensure employees maintain current knowledge required to perform their job roles . . . Procedure: This organization provides annual inservice educations required by accrediting agencies (when applicable), state and federal regulations and documents the attendance of staff in their personnel records and/or organization’s education records . . .” Review of the undated State policy for Home Health Agency’s titled, “Incident Reporting, Intake, Processing and Training Requirements” revealed “. . . Incident Management System Requirements . . . B. Training curriculum . . . Refresher training shall be provided annually, not to exceed twelve (12) month intervals . . .” 1. Review of Physical Therapy Aid (PTA)1 employee file revealed the date of hire (DOH) was 11/06/08. Further review of the required training revealed a form titled Reporting Elder and/or Child Abuse was dated 11/06/08. 2. Review of Physical Therapist (PT)1 employee file revealed the date of hire (DOH) was 02/27/19. Further review of the required training revealed a form titled Reporting Elder and/or Child Abuse was dated 02/27/19. 3. Review of Registered Nurse (RN)1 employee file revealed the date of hire (DOH) was 03/03/21. Further review of the required training revealed a form titled Reporting Elder and/or Child Abuse was dated 03/03/21. 4. Review of Administrator’s employee file revealed the (DOH) was 04/16/21. Further review of the required training revealed a form titled Reporting Elder and/or Child Abuse was dated 04/16/21. During an interview on 05/22/25 at 1:00 PM, the Administrator and Area Director of Operations (ADO) were both asked about the last abuse training. They both confirmed that abuse was an annual training topic, but there was nothing to prove that they were doing in-service training for abuse annually.”

“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 observation, interview, record review, and policy review, the home health agency (HHA) failed to ensure the Registered Nurse (RN) monitored and evaluated the Licensed Practical Nurse’s (LPN) performance in the provision of services for one of four patients (Patient (P) 7) observed during home visits out of a total sample of 10. LPN2 obtained a verbal physician’s order changing the plan of care (POC) for P7 without the RN assessing the resident. This deficient practice had the potential to cause patients to have unwarranted and potentially harmful changes to the POC. Findings include: Review of the agency policy titled, “Care Planning Process & [and] Comprehensive Assessment,” dated 12/2023, indicated, “. . . The comprehensive assessment must be updated and revised (including OASIS) [Outcome and Assessment Information Set] as frequently as the patient’s condition warrants due to a major decline or improvements in the patient’s health status . . . The RN, qualified therapist, or MSW [medical social worker] is responsible for changes to the POC. Reassessment utilizing the OASIS data elements or other comprehensive assessment must be performed by an RN or qualified therapist . . .” Review of P7’s “Home Health Certification and Plan of Care,” for the certification period of 03/25/25 to 05/23/25 and located under the “Orders” tab of the electronic medical record (EMR), indicated P7’s primary diagnosis was pressure ulcer of the left buttock, stage four, with a skilled nurse visit frequency of two times a week for 1 week and then three times a week for eight weeks. Review of a physician order, located under the “Orders” tab of the EMR, dated 05/16/25, and received verbally by LPN2, indicated, “. . . Decrease visits to 1x weekly (one visit each week); wound healed . . .” There was no documentation of P7 being assessed by an RN prior to changes being made to P7’s POC (decrease in visits was a change in the POC). Observation during a home visit to P7 on 05/21/25 at 8:40 AM with RN1 revealed RN1 assessed P7’s buttock wound. During the visit, RN1 stated LPN2 left P7’s wound open to air and decreased the nursing visits to one time a week. During an interview on 05/21/25 at 8:40 AM, RN1 stated the LPN can increase and decrease the frequency of visits and make changes to the POC. During an interview on 05/22/25 at 8:43 AM, the Administrator stated in New Mexico, the RN cannot delegate the patient assessment to the LPN. The Administrator stated the LPN should not have taken a verbal order from the physician to decrease visits because the wound was healed to the buttock. The Administrator stated the RN should have assessed P7 to determine if there needed to be a change to P7’s POC. The Administrator confirmed LPN2’s visit note on 05/16/25 indicated that LPN2 had informed the Administrator that he/she had received a verbal order with the change to P7’s POC. The Administrator confirmed he/she did not tell LPN2 at that time that the RN needed to perform the assessment before the POC could be changed.”