Frontier Medical Home Care, Inc.

“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 observation, record review, interviews, and policy review, the home health agency (HHA) failed to reconcile medications and update the medication profile for one patient observed, for one of three patients (Patient (P) 1) during three home visits completed on 05/06/25 to 05/07/25. This deficient practice had the potential to affect the current 96 patients, and any future patient admitted to the HHA in need of services. Findings include: Review of the undated agency’s policy titled, “Medication Monitoring” revealed, “The Monitoring Process includes at least the following elements…Reviewing and evaluating the medication profile…The findings, conclusions and recommendations of medication monitoring are communicated to the physician. The findings, conclusions and recommendations of medication monitoring are documented in the patient’s medical record.” Review of P1’s 485 plan of care (POC) located under the “Orders” tab of the electronic medical record (EMR) and provided by the facility, for the certification periods of 02/28/25 to 04/28/25 and 04/29/25 to 06/27/25, indicated that P1 began services with the HHA on 02/28/25 and Physical Therapy (PT) services were to be provided two times per week. Review of P1’s “Patient Medication Record (medication profile)” located under the “Orders” tab of the EMR for these certification periods revealed that P1 was taking a total of nineteen medications including Tamsulosin HCL 0.4 milligrams (mg) every day as a genitourinary agent. During the home visit observation in P1’s home and interview on 05/06/25 beginning at approximately 4:20 PM, Physical Therapist Assistant (PTA) 1 began assisting P1 with exercises. Near the end of the visit at approximately 5:10 PM when the Surveyor noticed no mention of PTA1 reviewing medications P1 was currently taking, the Surveyor reviewed the list of medications on the medication profile the HHA had provided for the home visit with P1 and P1 provided a list of the current medications that were on a piece of lined paper from P1’s wallet to compare with the profile provided by the HHA. There was no Tamsulosin on the list provided by P1 who stated, “Oh I quit taking that about a month ago.” P1 had mentioned earlier in the visit that he/she was no longer urinating and was having hemodialysis treatments three times per week. P1 stated the HHA folder was misplaced in P1’s home and thus could not be reviewed for a medication list. During a daily debriefing interview on 05/07/25 at 3:00 PM, the Director of Nursing (DON) reported that the HHA no longer provided a medication list (medication profile) in any of the agency’s patients’ home folders since patients had “misplaced them too often.” The DON indicated that if patients’ weeks were therapy only cases (Physical Therapy, Occupational Therapy, or Speech Therapy), such as that of P1, the therapists were to ensure that medications were current and updated in the patients’ medical record. During a telephone interview with PTA1 on 05/08/25 at 11:47 AM, PTA1 stated, “I’ll be honest. I don’t ask about medications at every visit, but I generally ask about every two weeks.””

“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 record review, interviews, and policy review, the home health agency (HHA) failed to ensure services were provided that were ordered by the physician as indicated in the patient’s plan of care (POC) for one (Patient (P) 4) of seven sampled patient records reviewed. This deficient practice had the potential to affect the current 96 patients, and any future patient admitted to the HHA for services. Findings include: Review of the undated agency’s policy titled “Medical Policies” indicated “…The attending physician certifies the need for [name of HHA] services and establishes a Plan of Treatment… which includes: Frequency of visits…Treatment and drugs can be administered only as ordered by the physician.” Review of P4’s POC located under the “Orders” tab of the electronic medical record (EMR) for the certification period of 04/16/25 to 06/14/25 indicated that Occupational Therapy (OT) services were to be provided three times per week for eight weeks. Review of OT visits located under the “OT therapy” tab of the EMR, revealed that two OT visits were made for week one beginning on 04/16/25; one OT visit was made and there was one missed OT visit for week two beginning on 04/19/25; two OT visits were made in week three beginning on 04/26/25. During an interview on 05/08/25 at 8:51 AM with the Director of Nursing (DON), the POC and OT visits for this certification period were reviewed. The DON indicated that the orders for the frequency of OT visits on the POC were “A mistake. It [the POC frequency of OT orders] should have been two times a week not three. I forgot that insurance won’t let us order frequencies of one to two or three times per week and make us order specific frequency.” The DON confirmed that the OT visits were not conducted three times per week as ordered by the physician on the POC.”

“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 record review, interview, and policy review, the home health agency (HHA) failed to ensure communication related to the patient’s plan of care (POC) with the physician was documented in the patient’s electronic medical record (EMR) for one (Patient (P) 4) of seven patient records reviewed. This deficient practice had the potential to affect the current 96 patients, and any further patient admitted to the HHA in need of services. Findings include: Review of the undated agency’s policy titled, “Coordination of Services” indicated “…staff promptly contacts the physician…When there are changes in the patient’s condition…When changes occur in caregiver support…” Review of the undated agency’s policy titled, “Assessment” indicated “…Missed visit reports will be completed for any visits not made…” Review of P4’s EMR under the “Occupational Therapy (OT)” tab for the certification period of 04/16/25 to 06/14/25, revealed that on 04/25/25 there was a missed OT visit. Review of the physician “Orders” tab of the EMR revealed no missed visit report was documented, and no missed visit notification was made to P4’s physician of the missed visit. During an interview on 05/08/25 at 1:45 PM the Director of Nursing (DON) confirmed that a missed visit report should have been documented for the missed OT visit on 04/25/25 and that the report should have been sent to the physician, but it was not done.”