Chemung Co Dept Health Chha

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on clinical record review and staff interview for three (3) of seventeen (17) patients (Patient #’s: 2, 5, and 12) requiring updates to the comprehensive assessment, the agency failed to ensure the assessments were of sufficient scope to identify current patient needs. Failure to ensure comprehensive assessments contain complete and accurate information has the potential for unmet patient needs. The agency failed to ensure the assessments were of sufficient scope to identify current patient needs as evidenced by: Patient #12- This 85- year- old patient with the diagnoses of urinary retention, neurogenic bladder, chronic indwelling catheter, and chronic obstructive pulmonary disease (COPD) was admitted to the home care agency on 01/17/2025. Review of the Skilled Nurse Routine Visit Note dated 01/28/2025 revealed: “patient did have sediments noted in foley bag. Skilled Nurse called physician’s office to report, left message. No other signs/ symptoms at this time.” Review of the clinical record lacks documented evidence the Skilled Nurse followed up with the patient’s physician regarding the sediments noted in the foley bag. During interview on 03/20/2025 at 02:20 PM, the Registered Nurse stated that a message was left for the patient’s primary care provider, but they did not receive a call back. The Registered Nurse added there should have been followed up with the physician. Patient #2 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. Review of the Physical Therapy Visit Routine Note dated 3/11/2025 revealed the following intervention: “Assess and evaluate effectiveness of all pain control measures including all prescribed pain medications, rest and repositioning: Patient reports severe low back pain radiating from the back to the hip, sometimes as high as 9/10 (nine out of ten, ten being the highest), patient only taking tylenol. Patient reports the pain comes and goes for the last few weeks and is not related to his recent fall. Primary care physician’s office notified (spoke with employee).” During interview on 03/20/2025 at 1:46 PM, the Physical Therapist stated that a message was left with the primary care physician’s office but they never received a call back from the provider. The Physical Therapist stated the patient was refusing to take any medications for pain besides tylenol, and the pain experienced was related to a chronic condition relieved by repositioning and stretching. The clinician did not feel it was necessary to follow-up on the call previously made to the physician regarding the fall and hip/back pain. Patient #5 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. A. Review of the Skilled Nurse Routine Note dated 03/04/2025 revealed the following intervention: “Reconcile and review all medications, including visualization of all prescription bottles, over the counter medications and creams in the home. Medical Doctor to be notified of any discrepancies with verbal orders being sent as necessary: Performed – Yes.” Review of the Skilled Nurse Routine Note dated 03/04/2025 revealed “Note: Patient also reports he has stopped taking torsemide. Patient reports he was unable to take as it was making him urinate way too much and he was having issues making it to the bathroom and was unable to stand up well from his chair. Patient reported he would be in agreement to discuss use of a different diuretic with primary care physician. Skilled Nurse called and informed primary care physician of above stated information. Skilled nursing waiting on return phone call.” Review of the Skilled Nurse Routine Note dated 03/11/2025 revealed: “Clinical findings/interventions: Right lower extremity +1 (plus one) edema. No edema left lower extremity. Skilled Nurse educated patient on importance of elevating bilateral lower extremities and reducing salt in the diet. Patient receptive and verbalized understanding and patient did elevate legs during visit. Patient has not received a call back from primary care physician re: torsemide but patient has appointment with medical doctor Thursday.” Review of the Skilled Nurse Routine Visit dated 03/15/2025 revealed the following intervention: “Reconcile and Review all medications, including visualization of all prescription bottles, over the counter medications and creams in the home. Medical Doctor to be notified of any discrepancies with verbal orders being sent as necessary: Performed – Yes.” Review of the Skilled Nurse Routine Visit dated 03/15/2025 revealed: “Note: patient reports no medication changes and no changes from primary care physician phone consult. Unable to follow up with office on changes due to weekend visit.” Review of the Skilled Nurse PRN (as needed) Visit dated 03/17/2025 revealed the following intervention: “Interdisciplinary communication/progress towards discharge/clinical note: Skilled Nurse reviewed office visit note from primary care physician for the following: torsemide 20 milligrams: take one (1) tablet by mouth daily as needed for edema.” During interview on 03/20/2025 at 02:28 PM, the Registered Nurse stated they would typically follow-up with the Registered Nurse Supervisor when a physician’s office doesn’t return a phone call but forgot this time.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on review of clinical records and interviews with staff, for five (5) of seventeen (17) patients (Patient #’s: 5, 6, 7, 13, and 14) the agency failed to ensure all documentation is legible, clear, complete, consistent, and appropriately authenticated, dated, and timed, in accordance with accepted standards of practice. Failure to ensure documentation is legible, clear, complete, and appropriately authenticated has the potential for patients to receive care from unlicensed staff. The home health agency failed to authenticate physician’s signatures and titles as evidenced by the following: Patient #5 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. Review of the Home Health Certification and Plan of Care for 03/02/2025 to 04/30/2025 revealed the physician’s signature lacks credentials. The agency failed to ensure documentation by staff is authenticated in accordance with accepted standards of practice. During an interview on 03/20/2025 at 03:13 PM, the Director of Patient Services confirmed credentials should be included with the signature but were not. Patient #6- This 78- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of left artificial hip joint, and unilateral primary osteoarthritis of the left hip was admitted to the home care agency on 03/05/2025. A. Review of the Home Health Certification and Plan of Care for 03/05/2025 to 05/03/2025 revealed the physician’s signature lacks credentials. B. Review of the Supplemental Physician Order dated 03/05/2025 revealed the physician’s signature lacks credentials. The agency failed to ensure documentation by staff is authenticated in accordance with accepted standards of practice. During an interview on 03/21/2025 at 12:05 PM, the Director of Patient Services stated that none of the Signature Log signatures include credentials, the agency is currently working on correcting that. Patient #7- This 73- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of left artificial knee joint, and unilateral primary osteoarthritis of the left knee was admitted to the home care agency on 02/27/2025. A. Review of the Review of the Home Health Certification and Plan of Care for 02/27/2025 to 04/27/2025 revealed the physician’s signature lacks credentials. B. Review of the Supplemental Physician Order dated 02/27/2025 revealed the physician’s signature lacks credentials. The agency failed to ensure documentation by staff is authenticated in accordance with accepted standards of practice. During an interview on 03/21/2025 at 12:05 PM, the Director of Patient Services stated that none of the Signature Log signatures include credentials, the agency is currently working on correcting that. Patient #13- This 67- year- old patient with the diagnoses of disruption of external operation (surgical) wound not elsewhere classified subsequent encounter, type 2 diabetes mellitus with diabetic neuropathic arthropathy, and cutaneous abscess of the left foot was admitted to the home care agency on 11/13/2023. A. Review of the Review of the Home Health Certification and Plan of Care for 11/13/2023 to 01/11/2024 revealed the physician’s signature lacks credentials. B. Review of the Supplemental Physician Orders dated 11/18/2023, 11/24/2023, and 12/0/2023 revealed the physician’s signature lacks credentials. The agency failed to ensure documentation by staff is authenticated in accordance with accepted standards of practice. During an interview on 03/21/2025 at 12:05 PM, the Director of Patient Services stated that none of the Signature Log signatures include credentials, the agency is currently working on correcting that. Patient #14- This 81- year- old patient with the diagnoses of occlusion and stenosis of right carotid artery, unspecified dementia of unspecified severity without behavioral, psychological, mood disturbance, or anxiety, and cirrhosis of the liver was admitted to the home care agency on 05/09/2024. A. Review of the Review of the Home Health Certification and Plan of Care for 05/09/2024 to 07/07/2024 revealed the physician’s signature lacks credentials. B. Review of the Supplemental Physician Orders dated 06/20/2024, 06/21/2024, and 07/01/2024 revealed the physician’s signature lacks credentials. The agency failed to ensure documentation by staff is authenticated in accordance with accepted standards of practice. During an interview on 03/21/2025 at 12:05 PM, the Director of Patient Services stated that none of the Signature Log signatures include credentials, the agency is currently working on correcting that.”

“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 review of clinical records and staff interview for three (3) of seventeen (17) patients (Patient #’s 1, 11, and 16), the agency failed to ensure the Registered Nurse conducted an initial assessment of the patient within twenty-four (24) hours of referral, the patient’s return home, or on the physician-ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. The agency failed to ensure the Registered Nurse conducted an initial assessment of the patient within twenty-four (24) hours of referral, the patient’s return home, or on the physician-ordered start of care date as evidenced by: Patient #1 – This 80-year-old patient with the diagnoses of encounter for surgical aftercare following surgery of the digestive system, acute cholecystitis, and type 2 diabetes mellitus without complications was admitted to the home care agency on 03/01/2025. Review of the hospital discharge/referral dated 02/25/2025 revealed the patient was referred to the home care agency on 02/25/2025, however the start of care was 03/01/2025 (four (4) days after referral). During interview on 03/20/2025 at 03:38 PM, the Registered Nurse Supervisor stated there is no documentation to explain why the start of care was delayed. Patient #11 – This 58-year-old patient with the diagnoses of disruption of external operation (surgical) wound, laceration without foreign body, left lower leg, and low back pain was admitted to the home care agency on 03/06/2025. Review of the hospital discharge/referral dated 03/04/2025 revealed the patient was referred to the home care agency on 03/04/2025, however the start of care was 03/06/2025 (48 (forty-eight) hours after referral). During interview on 03/20/2025 at 01:19 PM, the Registered Nurse Supervisor stated there is no documentation to explain why the start of care was delayed. Patient #16 – This 68-year-old with the diagnoses of partial intestinal obstruction, malignant neoplasm of unspecified site of right female breast, and malignant neoplasm of unspecified site of left female breast was admitted to the home care agency on 09/05/2024. Review of the hospital discharge/referral dated 08/28/2024 revealed the patient was referred to the home care agency on 08/28/2025, however the start of care was 09/05/2024 (eight (8) days after referral). During interview on 03/20/2025 at 03:38 PM, the Registered Nurse Supervisor stated there is no documentation to explain why the start of care was delayed.”

“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 review of clinical records and interviews with staff, for two (2) of seventeen (17) patients, (Patient #s: 6 and 14), the agency failed to ensure that a comprehensive assessment consistent with the patient’s needs was performed within five (5) calendar days after the start of care. Failure to ensure a comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. The agency failed to ensure that a comprehensive assessment consistent with the patient’s needs was performed within five (5) calendar days after the start of care as evidenced by: Patient #6- This 78- year- old patient with diagnoses that include aftercare following joint replacement surgery, presence of left artificial hip joint, and unilateral primary osteoarthritis of the left hip was admitted to the home care agency on 03/05/2025. Review of the hospital discharge/ referral dated 03/03/2025 revealed the patient was referred to the home care agency for Skilled Nursing, Physical Therapy and Occupational Therapy. Review of the clinical record lacks an order for Occupational Therapy, or documentation stating the patient declined. During interview on 03/20/2025 at 12:58 PM, the Registered Nurse stated that it was determined that Occupational Therapy was not needed, but that was not documented. The Registered nurse further stated that they only documented that Skilled Nursing services were not needed. Patient #14- This 81- year- old patient with diagnoses that include occlusion and stenosis of right carotid artery, unspecified dementia of unspecified severity without behavioral, psychological, mood disturbance, or anxiety, and cirrhosis of the liver was admitted to the home care agency on 05/09/2024. Review of the Skilled Nurse Resumption of Care Visit dated 06/13/2024 revealed the Registered Nurse documented the following: “Clinical Summary: Patient will also require Physical therapy services for gait training, strengthening, and therapeutic home exercises. Occupational therapy services for Activities of Daily Living teaching and adaptive equipment needs.” Review of the clinical record lacks an order for Occupational therapy, or documentation stating the patient declined. During interview on 03/20/2025 at 02:17 PM, the Registered Nurse Supervisor stated that there was no documented evidence of an order for Occupational therapy.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on review of patient care records and interview with agency staff for seventeen (17) of seventeen (17) patient records (Patient #’s: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17), the agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs. Failure to ensure the initial comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. The agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs as evidenced by: Patient #6- This 78- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of left artificial hip joint, and unilateral primary osteoarthritis of the left hip was admitted to the home care agency on 03/05/2025. Review of the Skilled Nurse Admission Visit Note dated 03/05/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:09 PM, the Registered Nurse stated that they did not know it was required to assess all patients for potential palliative care, and did not assess the patient for palliative care needs. Patient #7- This 73- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of left artificial knee joint, and unilateral primary osteoarthritis of the left knee was admitted to the home care agency on 02/27/2025. Review of the Skilled Nurse Admission Visit Note dated 02/27/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:20 PM, the Registered Nurse Supervisor stated that the patient was not assessed for potential palliative care needs. Patient #13- This 67- year- old patient with the diagnoses of disruption of external operation (surgical) wound not elsewhere classified subsequent encounter, type 2 diabetes mellitus with diabetic neuropathic arthropathy, and cutaneous abscess of the left foot was admitted to the home care agency on 11/13/2023. Review of the Skilled Nurse Admission Visit Note dated 11/13/2023 lacks an assessment of the patient’s palliative care needs. During interview on 03/21/2025 at 09:11 AM, the Registered Nurse Supervisor stated that the patient was not assessed for potential palliative care needs. Patient #14- This 81- year- old patient with diagnoses that include occlusion and stenosis of right carotid artery, unspecified dementia of unspecified severity without behavioral, psychological, mood disturbance, or anxiety, and cirrhosis of the liver was admitted to the home care agency on 05/09/2024. Review of the Skilled Nurse Admission Visit Note dated 05/09/2024 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 02:14 PM, the Registered Nurse stated that they were focused on getting the patient into an Assisted Living Facility and did not assess for potential palliative care needs. Patient #2 – This 70-year-old patient with the diagnoses of intestinal obstruction, Parkinson’s Disease without dyskinesia without mention of fluctuations, and essential primary hypertension, was admitted to the home care agency on 02/28/2025. Review of the Skilled Nurse Admission Visit Note dated 02/28/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 03:03 PM, the Director of Patient Services stated the agency was not aware of the requirement for each patient to be assessed for palliative care needs and therefore does not have a process currently in place. Patient #5 - This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. Review of the Skilled Nurse Admission Visit Note dated 03/02/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 2:52 PM, the Director of Patient Services stated the agency was not aware of the requirement for each patient to be assessed for palliative care needs and therefore does not have a process currently in place. Patient #3- This 49- year- old patient with the diagnoses of stroke, type 2 diabetes mellitus, and chronic pain syndrome, bipolar, and hemiplegia was admitted to the home care agency on 02/25/2025. Review of the Skilled Nurse Admission Visit Note dated 02/25/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:40 PM, the Director of Patient Services stated being unaware that each patient needs an assessment of palliative care needs. Patient #8- This 66- year- old patient with the diagnoses of cellulitis left foot ulcer, type 2 diabetes mellitus, acute osteomyelitis, anxiety, and depression was admitted to the home care agency on 12/26/2024. Review of the Skilled Nurse Admission Visit Note dated 12/26/2024 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:40 PM, the Director of Patient Services stated being unaware that each patient needs an assessment of palliative care needs. Patient #9- This 64- year- old patient with the diagnoses of osteoarthritis of hip unspecified, left anterior arthroplasty, chronic pain, and essential hypertension was admitted to the home care agency on 03/07/2025. Review of the Skilled Nurse Admission Visit Note dated 03/07/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:40 PM, the Director of Patient Services stated being unaware that each patient needs an assessment of palliative care needs. Patient #10- This 81- year- old patient with the diagnoses of covid pneumonia, peripheral neuropathy, arthritis, and frequent falls was admitted to the home care agency on 03/06/2025. Review of the Skilled Nurse Admission Visit Note dated 03/06/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:40 PM, the Director of Patient Services stated being unaware that each patient needs an assessment of palliative care needs. Patient #12- This 85- year- old patient with the diagnoses of urinary retention, neurogenic bladder, chronic indwelling catheter, chronic obstructive pulmonary disease (COPD) was admitted to the home care agency on 01/17/2025. Review of the Skilled Nurse Admission Visit Note dated 01/17/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:40 PM, the Director of Patient Services stated being unaware that each patient needs an assessment of palliative care needs. Patient #1 – This 80-year-old patient with the diagnoses of encounter for surgical aftercare following surgery of the digestive system, acute cholecystitis, and type 2 diabetes mellitus without complications was admitted to the home care agency on 03/01/2025. A. Review of the Skilled Nurse Admission Visit Note dated 03/01/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:10 PM, the Director of Patient Services stated the agency was not aware that each patient needs an assessment of palliative care needs. B. Review of the hospital discharge/referral dated 02/25/2025 revealed the patient was referred to the home care agency for Skilled Nursing, Physical Therapy, Occupational Therapy, and Home Health Aide services. Review of the Skilled Nurse Admission Visit Note dated 03/01/2025 revealed “made aware the patient would benefit from Home Health Aide services, Occupational Therapist to assess the need.” Review of the Occupational Therapy Evaluation Visit Note dated 03/04/2025 lacks documented evidence the Occupational Therapist assessed the patient’s need for Home Health Aide services. During interview on 03/20/2025 at 03:29 PM, the Registered Nurse Supervisor stated there is no note to explain why the need for Home Health Aide services was not addressed. Patient #4 – This 94-year-old patient with the diagnoses of osteoarthritis, rheumatoid arthritis, and chronic pain syndrome was admitted to the home care agency on 01/23/2025. Review of the Skilled Nurse Admission Visit Note dated 01/23/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:10 PM, the Director of Patient Services stated the agency was not aware that each patient needs an assessment of palliative care needs. Patient #11 – This 58-year-old patient with the diagnoses of disruption of external operation (surgical) wound, laceration without foreign body, left lower leg, and low back pain was admitted to the home care agency on 03/06/2025. Review of the Skilled Nurse Admission Visit Note dated 03/06/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:10 PM, the Director of Patient Services stated the agency was not aware that each patient needs an assessment of palliative care needs. Patient #15 – This 51-year-old with the diagnoses of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, type 2 diabetes mellitus with hyperglycemia, and hypertension was admitted to the home care agency on 10/16/2024. Review of the Skilled Nurse Admission Visit Note dated 10/16/2024 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:10 PM, the Director of Patient Services stated the agency was not aware that each patient needs an assessment of palliative care needs. Patient #16 – This 68-year-old with the diagnoses of partial intestinal obstruction, malignant neoplasm of unspecified site of right female breast, and malignant neoplasm of unspecified site of left female breast was admitted to the home care agency on 09/05/2024. Review of the Skilled Nurse Admission Visit Note dated 09/05/2024 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:10 PM, the Director of Patient Services stated the agency was not aware that each patient needs an assessment of palliative care needs. Patient #17 – This 67-year-old patient with the diagnoses of pressure of ulcer sacral region, stage 3, abscess of epididymis of testis, type 2 diabetes mellitus with hyperglycemia was admitted to the home care agency on 06/12/2024. Review of the Skilled Nurse Admission Visit Note dated 06/12/2024 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:10 PM, the Director of Patient Services stated the agency was not aware that each patient needs an assessment of palliative care needs.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for two (2) of seventeen (17) patients (Patient #s: 3 and 6), the clinical records lack documented evidence of a complete review of all medications the patient is currently using to identify any potential adverse effects and drug reactions or concerns. Failure to conduct a complete medication review has the potential for the patient to experience medication side effects or to receive incorrect medication dosages. The clinical staff failed to complete a review of all medications the patient is currently using to identify any potential adverse effects and drug reactions or concerns as evidenced by: Patient #6- This 78- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of left artificial hip joint, and unilateral primary osteoarthritis of the left hip was admitted to the home care agency on 03/05/2025. Review of the Discharge Medication Instructions dated 03/04/2025 revealed the order for “aspirin 81 milligram chewable tablet, by mouth, two (2) times per day.” Review of the Home Health Certification and Plan of Care for 03/05/2025 to 05/03/2025 revealed the order: “aspirin low- dose 81 milligram tablet, delayed release, tale one (1) tablet, (81 milligrams), by mouth, two (2) times per day from 03/05/2025 to 04/03/2025.” Review of the clinical records lacks documented evidence the Registered Nurse clarified the formulation of the patient’s aspirin. During interview on 03/20/2025 at 01:03 PM, the Registered Nurse stated that they did not realize that the formulations were different and did not clarify this medication. HV Patient #3- This 49- year- old patient with the diagnoses of stroke, type 2 diabetes mellitus, chronic pain syndrome, bipolar, and hemiplegia was admitted to the home care agency on 02/25/2025. Review of the Physician referral dated 02/24/2025 revealed the order for “vitamin D2 250 micrograms one (1) capsule oral every month.” Review of the Home Health Certification and Plan of Care for 02/25/2025 to 04/25/2025 revealed the order for “vitamin D2 1,250 micrograms (50,000 unit) capsule one (1) capsule oral every month.” Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancy. During interview on 03/20/2025 at 01:48 PM, the Registered Nurse Supervisor stated the doses of medication are different and the Registered Nurse did not contact the physician regarding the discrepancy.”

“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 review of clinical records and staff interviews for five (5) of seventeen (17) patients (Patient #s: 1, 5, 9, 12, and 15) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. The agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients as evidenced by: Patient #12- This 85- year- old patient with the diagnoses of urinary retention, neurogenic bladder, chronic indwelling catheter, and chronic obstructive pulmonary disease (COPD) was admitted to the home care agency on 01/17/2025. A.) Review of the Skilled Nurse Admission Visit Note dated 01/17/2025 revealed the Registered Nurse documented the patient has a chair lift. Review of the Home Health Certification and Plan of Care for 01/17/2025 to 03/17/2025 lacks an order for a chair lift. During interview on 03/21/202 at 09:30 AM, the Registered Nurse Supervisor stated that there is no order for a chair lift on the plan of care. B.) Review of the Skilled Nursing Routine Visit Note dated 01/20/2025 revealed the Skilled Nurse documented the following: “Patient to apply splint to left wrist daily as needed for comfort.” Review of the Home Health Certification and Plan of Care for 01/17/2025 to 03/17/2025 lacks an order for the application of splint to the left wrist. During interview on 03/21/202 at 09:30 AM, the Registered Nurse Supervisor stated that there is no order for a splint to be applied to left wrist on the plan of care. Patient #9- This 64- year- old patient with the diagnoses of osteoarthritis of hip unspecified, left anterior arthroplasty, chronic pain, and essential hypertension was admitted to the home care agency on 03/07/2025. Review of the Physical Therapy Evaluation visit note dated 03/07/2025 revealed the Physical Therapist documented the following: “Pain control measures: Heat/Cold.” Review of the Home Health Certification and Plan of Care for 03/07/2025 to 05/05/2025 lacks documentation of orders for the application of heat or cold. During interview on 03/20/2025 at 01:36 PM, the Physical Therapist they do not have the option to order either heat or cold. Patient #5 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. A. Review of the Home Health Certification and Plan of Care for 03/02/2025 to 04/30/2025 revealed an order for the medication “Repatha sureclick 140 milligram/milliliter subcutaneous pen injection. Inject 1 milliliter (140 milligrams) by subcutaneous route every two (2) weeks in the abdomen, thigh or outer area of upper arm (rotate sites). Patient to self-administer.” Review of the plan of care lacks an order for alcohol wipes to clean the site prior to injection. During an observational home visit with Registered Nurse on 03/19/2025, the patient requested alcohol wipes from Registered Nurse’s supply bag, stating he does not have any. He has been using lense cleansing wipes to clean the injection site prior to administering his repatha injection. The Registered Nurse provided the patient with alcohol wipes and instructed that he could purchase alcohol wipes from the pharmacy where he gets his prescriptions. During interview on 03/20/2025 at 02:25 PM, the Registered Nurse stated they weren’t sure if the alcohol wipes were provided by the agency. The Registered Nurse Supervisor stated that the alcohol wipes should be ordered on the plan of care. B. Review of the Skilled Nurse PRN (as needed) Visit on 03/17/2025 revealed the patient received an order for a new medication “torsemide 20 milligrams: take one (1) tablet by mouth daily as needed for edema.” Review of the clinical record lacks an order to for the torsemide medication. During interview on 03/20/2025 at 02:29 PM, the Registered Nurse confirmed she forgot to put an order in for the as needed torsemide, but did complete at the next visit. C. Review of the Skilled Nurse Routine Visit dated 03/05/2025 revealed a verbal order was obtained from the primary care physician office for the following: “xanax 0.25 milligrams: take one (1) tablet two (2) times per day as needed.” Review of the clinical record lacks an order for the new medication. During interview on 03/20/2025 at 02:25 PM, the Registered Nurse stated she forgot to put the medication order in. D. Review of the Home Health Certification and Plan of Care for 03/02/2025 to 04/30/2025 revealed an order “norco 5 milligram-325 milligram tablet. Take one (1) tablet by oral route every 6 (six) hours as needed for pain.” Review of the clinical record lacks orders for a bowel regimen for a patient receiving narcotics. During interview on 03/20/2025 at 02:56 PM, the Registered Nurse Supervisor confirmed there was no bowel regimen in place for the patient and stated the expectation for all patients receiving narcotics is education on constipation and at least an “as needed” medication order. E. Review of the Discharge Instruction Form from skilled nursing facility dated 02/26/2025 revealed the following discharge instructions: “Current treatment and therapies: Walk with rolling walker. Lab work scheduled for one week CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), magnesium level, and BNP (B-type Natriuretic Peptide). Continue consistent carbohydrate diabetic diet.” Review of the Skilled Nursing Admission Visit dated 03/02/2025 lacks evidence of follow-up on discharge orders for blood work. During interview on 03/20/2025 at 02:54 PM, the Registered Nurse Supervisor confirmed that there was no documentation at admission that the blood work appointment or services were confirmed or followed up on. Patient #1 – This 80-year-old patient with the diagnoses of encounter for surgical aftercare following surgery of the digestive system, acute cholecystitis, and type 2 diabetes mellitus without complications was admitted to the home care agency on 03/01/2025. Review of the Home Health Certification and Plan of Care for 03/01/2025 to 04/29/2025 revealed “Patient/caregiver will demonstrate understanding of how to live with diabetes, as evidenced by checking blood sugars and responding appropriately.” Review of the plan of care lacks orders for blood glucose testing supplies, parameters for when to call the physician, and medications to treat diabetes. During interview on 03/20/2025 at 03:30 PM, the Registered Nurse Supervisor stated the patient does not check her blood glucoses. The patient’s primary care provider manages her diabetes using A1C (glycated hemoglobin) levels. This information was missing from the plan of care. Patient #15 – This 51-year-old with the diagnoses of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, type 2 diabetes mellitus with hyperglycemia, and hypertension was admitted to the home care agency on 10/16/2024. Review of the Home Health Certification and Plan of Care for 10/16/2024 to 12/14/2024 revealed “Skilled Nursing to monitor for scabbed area to right breast from previous tear for signs and symptoms of infection. Patient may apply dressing for comfort daily.” Review of the plan of care lacks an order stating what dressing is to be used. During interview on 03/20/2025 at 03:15 PM, the Registered Nurse Supervisor said there is no order specifying what the dressing the patient is to use.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on clinical record review and staff interview for two (2) of seventeen (17) patient records (Patient #’s: 1 and 16), failed to include evidence that orders were obtained for changes in the plan of care. Failure to obtain an order for changes in the plan of care has the potential for agency staff to act on inaccurate and incomplete information and places patient health and welfare at risk. The clinical staff failed to include evidence that orders were obtained for changes in the plan of care as evidenced by: HV Patient #1 – This 80-year-old patient with the diagnoses of encounter for surgical aftercare following surgery of the digestive system, acute cholecystitis, and type 2 diabetes mellitus without complications was admitted to the home care agency on 03/01/2025. A. Review of the Home Health Certification and Plan of Care for 03/01/2025 to 04/29/2025 revealed the order for oxycodone 5 milligram tablet take one half tablet by oral route every six (6) hours as needed. During an observational home visit on 03/18/2025 at 11:30 AM, the patient told the Occupational Therapist that she wanted oxycodone to be taken off the medication list. The patient stated she never filled it and will never take it. Review of the clinical record lacks an order to discontinue the oxycodone. During interview on 03/20/2025 at 03:33 PM, the Registered Nurse Supervisor stated the medication was not discontinued. B. During an observational home visit on 03/18/2025 at 11:30 AM, the patient wore a splint on her right hand. Review of the clinical record lacks an order for the splint. During interview on 03/20/2025 at 03:33 PM, the Registered Nurse Supervisor stated there is no order for a splint. Patient #16 – This 68-year-old with the diagnoses of partial intestinal obstruction, malignant neoplasm of unspecified site of right female breast, and malignant neoplasm of unspecified site of left female breast was admitted to the home care agency on 09/05/2024. Review of the Home Health Certification and Plan of Care for 09/05/2024 to 11/03/2024 revealed the order for a “low residue diet.” Review of the Skilled Nurse Resumption of Care Visit Note dated 09/13/2024 revealed “diet to be regular.” Review of the clinical record lacks an order for a regular diet. During interview on 03/20/2025 at 03:23 PM, the Registered Nurse Supervisor stated the patient’s diet order was not updated.”

“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 review of clinical records, and interviews with agency staff for four (4) of seventeen (17) patients (Patient #s: 3, 5, 8, and 10), the agency failed to ensure drugs and treatments are administered in accordance with physician orders. Failure to administer drugs and treatments without a physician’s order has the potential to result in poor quality of care. The agency failed to ensure drugs and treatments are administered in accordance with physician orders as evidenced by: Patient #3- This 49- year- old patient with the diagnoses of stroke, type 2 diabetes mellitus, chronic pain syndrome, bipolar, and hemiplegia was admitted to the home care agency on 02/25/2025. Review of the Home Health Certification and Plan of Care for 02/25/2025 to 04/25/2025 revealed: “Vital sign parameters: report to medical doctor if: blood pressure less than 80/50 or higher than 170/110, heart rate less than 60 or more than 120, respirations less than 10 or greater than 24 per minute, temperature less than 96.0 or greater than 101.5, oxygen saturation less than 90 percent.” Review of the Physical Therapy Evaluation Visit Notes dated 02/25/2025 and 02/27/2025 lack documented vital signs at each visit. During interview on 30/20/2025 at 01:52 PM, the Physical Therapist stated that they would only assess the vital signs if patient presented with any concerns. The Registered Nurse Supervisor confirmed the expectation is that they are done at each visit. Patient #8- This 66- year- old patient with the diagnoses of cellulitis left foot ulcer, type 2 diabetes mellitus, acute osteomyelitis, anxiety, and depression was admitted to the home care agency on 12/26/2024. Review of the Skilled Nurse Routine Visit Note dated 12/30/2024 revealed the following intervention: “Vital sign parameters: report to medical doctor if: blood pressure less than 80/50 or higher than 170/110, heart rate less than 60 or more than 120, respirations less than 10 or greater than 24 per minute, temperature less than 96.0 or greater than 101.5, oxygen saturation less than 90 percent... Note: VSS (vital signs stable).” Review of the Skilled Nurse Routine Visit Note dated 12/30/2024 lacks documented vital signs. During interview on 03/20/2025 at 02:09 PM, the Registered Nurse stated that the vital signs were obtained but not documented. Patient #10- This 81- year- old patient with the diagnoses of covid pneumonia, peripheral neuropathy, arthritis, and frequent falls, was admitted to the home care agency on 03/06/2025. Review of the Home Health Certification and Plan of Care for 03/06/2025 to 05/04/2025 revealed the order for ‘‘Vital signs parameters to report to MD. Blood pressure less than 90/50, or greater than 170/110, heart rate less than 60 greater than 120, respiration less than 10 greater than 24, temperature less than 96. 0 greater than 101.5, oxygen saturation less than 90 percent.” Review of the Physical Therapy Visit Routine Note dated 03/16/2025 lacks documented vital signs. During interview on 03/21/2025 at 08:53 AM, the Registered Nurse Supervisor stated there weas no documentation of the patient’s vital signs. Patient #5 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. Review of the Skilled Nurse Routine Visit dated 3/15/2025 revealed the following intervention: Teach patient the signs and symptoms of urinary tract infection and methods of preventions: performed - yes Note: Patient called this writer requesting a urine sample because he reports he’s had dark, foul-smelling urine. Skilled Nurse called on-call services requesting a call back from the doctor-on-call for primary care physician. At 11:30 AM Skilled Nurse received a call back from on-call medical doctor and gave medical doctor patient’s report and verbal order given for urine sample. Urine not obtained because urine would have been obtained and then lab used by agency would have been closed. Lab closes at 12 noon on Saturday and is closed on Sunday. Lab behind mall is closed on weekends. Urine to be obtained at next scheduled visit. During interview on 3/20/2025 at 02:00 PM, the Registered Nurse stated the patient was only having foul dark urine and not his normal urinary tract infection symptoms. The lab was closed, they did not think it would be an issue to wait until Monday to obtain urine a sample. The Registered Nurse Supervisor confirmed the Registered Nurse should have made a plan to test the patient as soon as possible.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on review of clinical records and interviews with staff for one (1) of seventeen (17) patients (Patient #17), the agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest the plan of care may need to be altered. Failure to promptly notify the physician to changes in the patient’s condition or needs that may suggest that outcomes are not being achieved and/or the plan of care should be altered has the potential to result in unmet patient needs and negative patient outcomes. The agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest the plan of care may need to be altered as evidenced by: Patient #17 – This 67-year-old patient with the diagnoses of pressure of ulcer sacral region, stage 3, abscess of epididymis of testis, type 2 diabetes mellitus with hyperglycemia was admitted to the home care agency on 06/12/2024. Review of the Home Health Certification and Plan of Care for 06/12/2024 to 08/10/2024 revealed “Teach and instruct daily foot care including inspection, cleansing, keeping moisturized, and wearing shoes… patient has type 2 diabetes mellitus with hyperglycemia.” Review of the Skilled Nursing Routine Visit Note dated 06/19/2024 revealed “Patient has loose toenail on right second toe, no drainage or signs/symptoms of infection.” Review of the clinical record lacks documented evidence of an intervention for the toenail or notification to the physician. During interview on 03/20/2025 at 03:07 PM, the Registered Nurse Supervisor stated there is no documentation stating the physician was notified or a plan to treat the toenail.”

“Coordinate care delivery CFR(s): 484.60(d)(4) 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. This Element is not met as evidenced by: Based on review of clinical records and interviews with agency staff for one (1) of seventeen (17) patients (Patients #5), the agency failed to coordinate care delivery and ensure patient needs are addressed. Failure to coordinate care delivery has the potential for negative patient outcomes. The agency failed to coordinate care delivery and ensure patient needs are addressed as evidenced by: HV Patient #5 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis, was admitted to the home care agency on 03/02/2025. During an observational home visit on 03/19/2025 at 11:30 AM, the patient and Skilled Nurse discussed how the patient is not following through on set up of medication delivery as patient is having difficulty accessing pharmacy to obtain medications, missed cardiology visit due to difficulty leaving the home, and non-compliance with scheduling follow-ups with primary care provider as evidenced by patient changing in-person follow-up post-hospitalization to “phone consult.” The patient stated they were hesitant and not ready to leave the home. The Skilled Nurse was observed providing education on pharmacy delivery set up, importance of compliance with appointments, and offered to call to schedule cardiology follow-up. Review of the clinical record lacks evidence of coordination between the Skilled Nurse and Medical Social Worker to assess and address the patient’s needs. During interview on 3/20/2025 at 02:33 PM, the Skilled Nurse stated she tried to assist him through educating on resources such as delivery from pharmacy, but the patient had yet to complete set up. The Registered Nurse further stated that she did not think of a social work referral but does believe it would be appropriate for this patient.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on review of clinical records and interviews with staff, for five (5) of seventeen (17) patients (Patient #s: 2, 5, 4, 6, and 10), the agency failed to prepare and document complete and accurate clinical notes. Failure to document complete and accurate clinical and progress notes has the potential for unmet patient needs. The agency failed to prepare and document complete and accurate clinical notes as evidenced by: Patient #10- This 81- year- old patient with the diagnoses of covid pneumonia, peripheral neuropathy, arthritis, and frequent falls, was admitted to the home care agency on 03/06/2025. Review of the Physical Therapy Evaluation Visit Note dated 03/07/2025 revealed the following assessment: “Assistive Device: has single point cane.” Review of the Home Health Certification and Plan of Care for 03/06/2025 to 05/04/2025 lacks an order for a single point cane. During interview on 03/21/2025 at 08:55 AM, the Registered Nurse Supervisor stated the patient does not use a single point cane, the documentation was in error. Patient #2 – This 70-year-old patient with the diagnoses of intestinal obstruction, Parkinson’s Disease without dyskinesia without mention of fluctuations, and essential primary hypertension was admitted to the home care agency on 02/28/2025. A. Review of the Physical Therapy Evaluation Visit Note dated 03/04/2025 revealed the following intervention: Vital sign parameters: report to medical doctor if: blood pressure less than 80/50 or higher than 170/110, heart rate less than 60 or more than 120, respirations less than 10 or greater than 24 per minute, temperature less than 96.0 or greater than 101.5, oxygen saturation less than 90 percent. Performed: Yes Note: Vital Signs Stable (VSS) Review of the Physical Therapy Evaluation Visit Note dated 03/04/2025 lacks documented vital signs. During interview on 03/20/2025 at 01:29 PM, the Physical Therapist stated they did obtain vital signs but did not record them in the visit note. B. Review of the Physical Therapy Routine Visit Note dated 03/14/2025 revealed the following intervention: Vital sign parameters: report to medical doctor if: blood pressure less than 80/50 or higher than 170/110, heart rate less than 60 or more than 120, respirations less than 10 or greater than 24 per minute, temperature less than 96.0 or greater than 101.5, oxygen saturation less than 90 percent. Performed: Yes Note: O2 saturations staying between 95-98% during PT activities today Review of the Physical Therapy Visit Note dated 03/14/2025 lacks documented vital signs. During interview on 03/20/2025 at 1:29 PM, the Physical Therapist stated they did obtain vital signs but did not record them in the visit note. Patient #5 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. A. Review of the Physical Therapy Evaluation Note dated 03/4/2025 revealed the following: “Physical Therapy evaluation completed. Present as well as (Registered Nurse/Case Manager), joint visit scheduled as both Registered Nurse and Physical Therapist had a difficult time contacting patient/his family to schedule appointment. Present as well (patient’s friend), roommate, and “occ” caregiver.” Review of the Physical Therapy Visit Note dated 03/14/2025 contained use of an unidentified abbreviated term “occ.” During interview on 03/20/2025 at 1:53 PM, the Physical Therapist stated it was a documentation error and meant to type occasional. B. Review of the Patient Information Summary which contains the patient’s demographics revealed the following: Referral: 02/27/2025. Review of the Skilled Nurse Admission Visit dated 02/28/2025 revealed the following: “(M0104) Date of Referral: 02/21/2025.” During interview on 03/20/2025 at 3:01 PM, the Registered Nurse Supervisor confirmed the referral management department made a transcription error in the patient’s demographics, and the correct date of referral was 02/21/2025. Patient #6- This 78- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of left artificial hip joint, and unilateral primary osteoarthritis of the left hip was admitted to the home care agency on 03/05/2025. Review of the Skilled Nurse Admission Visit dated 03/05/2025 revealed the following: (O0110) G3. CPAP (continuous positive airway pressure): 0- No. Other (Assistive Device): Has- Other (specify): leg lifter, incentive spirometer, CPAP and associated supplies. There is a discrepancy as to whether the patient uses a continuous positive airway pressure (CPAP) device or not. During interview on 03/20/2025 at 01:05 PM, the Registered Nurse stated that the answer to G3. was a typographical error, the answer should be Yes, since the patient does use a CPAP during sleep. Patient #4 – This 94-year-old patient with the diagnoses of osteoarthritis, rheumatoid arthritis, and chronic pain syndrome was admitted to the home care agency on 01/23/2025. Review of the Physical Therapy Evaluation Visit Note dated 01/24/2025 revealed the following intervention: Vital sign parameters: report to medical doctor if: blood pressure less than 80/50 or higher than 170/110, heart rate less than 60 or more than 120, respirations less than 10 or greater than 24 per minute, temperature less than 96.0 or greater than 101.5, oxygen saturation less than 90 percent. Performed: Yes Review of the Physical Therapy Evaluation Visit Note dated 01/24/2025 lacks documented vital signs. During interview on 03/20/2025 at 1:45 PM, the Physical Therapist stated they did obtain vital signs but did not record them in the visit note.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on review of clinical records and interview with agency staff, for one (1) of one (1) patients receiving Home Health Aide services from the agency (Patient #4), the agency failed to ensure the Home Health Aide was supervised at least every fourteen (14) days. Failure to provide adequate supervision of paraprofessional staff places patients at risk for negative outcomes and unmet patient needs. The agency failed to ensure the Home Health Aide was supervised at least every fourteen (14) days as evidenced by: Patient #4 – This 94-year-old patient with the diagnoses of osteoarthritis, rheumatoid arthritis, and chronic pain syndrome was admitted to the home care agency on 01/23/2025. Review of the supplemental order dated 02/04/2025 revealed the order for “Home Health Aide services twice a week for the first week and three (3) times a week for six (6) weeks.” Review of the clinical record from 02/23/2025 to 03/15/2025 revealed the Home Health Aide provided services on 02/24/2025, 02/26/2025, 02/28/2025, 03/03/2025, 03/05/2025, 03/07/2025, 03/10/2025, 03/12/2025, and 03/14/2025. Review of the clinical record from 02/23/2025 to 03/15/2025 lacks documented evidence of supervision of the paraprofessional staff. During interview on 03/19/2025 at 11:25 AM, the Registered Nurse Supervisor stated there is no documentation of supervisory visits in the clinical record during this time period.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on review of clinical records, agency policy and procedure, and staff interview for one (1) of six (6) patients discharged from the agency (Patient #13), the agency failed to follow the agency policy and procedure for patient discharge. Failure to follow established agency discharge policies and procedures has the potential for patients to be placed at risk for unsafe or poor continuity of care. The home health agency failed to follow the agency discharge policy and procedure as evidenced by the following: Review of the agency’s policy entitled “General Practice Guidelines – Patient Discharge” dated 01/2018 revealed the following: Considerations: A patient can be discharged from home care services for the following reasons: If the patient’s (or other persons in the home) behavior is so disruptive, abusive, or uncooperative that the delivery of care to the patient or the ability of the home health agency to operate effectively and safely is seriously impaired; In this case, before discharge, the home health agency will advise the patient, the representative (if any) that a discharge is being considered, make efforts to resolve the problem(s) presented by the patient’s behavior or by other person(s) in the home (as applicable), or situation (such as a dangerous animal being loose in the home), document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical record. The home health agency will provide the patient and representative (if any), with contact information for other agencies or provide who would potentially be able to provide care following the discharge. Procedure: 1. If able, the agency will notify the patient of the decision to terminate services one to two visits prior to expected discharge. Medicare patients will receive generic discharge notice with their rights to appeal with the appropriate phone number provided. 3. Explain procedure to patient. 7. Provide discharge instructions and reinforcement of all teaching and assess comprehension and patient/ caregiver ability to repeat instruction, perform return demonstrations as needed. Patient #13- This 67- year- old patient with the diagnoses of disruption of external operation (surgical) wound not elsewhere classified subsequent encounter, type 2 diabetes mellitus with diabetic neuropathic arthropathy, and cutaneous abscess of the left foot was admitted to the home care agency on 11/13/2023 and was discharged from the home care agency on 12/13/2023. Review of the Case Communication Report dated 12/14/2023 revealed the Registered Nurse Supervisor documented the following: “Subject: Discharge Note- General; Patient will be attending outpatient wound care as arranged by the patient’s primary care physician. Patient is discharged from services as of 12/13/2023 for inappropriate behavior. No contact is to be made with this patient.” Review of the clinical record lacks documented evidence of any inappropriate behavior by the patient, that the patient was informed discharge was being considered, that the agency made efforts to resolve the problem, or that contact information was provided for other potential agencies who could provide care. Review of the clinical record also lacks documented evidence the patient was provided notice of discharge prior to the discharge from the agency, that the agency explained the discharge procedure to the patient, that the patient was provided a generic Medicare discharge notice or discharge instructions from the agency. During interview on 03/21/2025 at 09:16 AM, the Registered Nurse Supervisor stated there was only one incident of inappropriate behavior by the patient, and that other interventions were not attempted because when the Registered Nurse Supervisor spoke to the Administrator about the incident, it was the Administrator’s directive to discharge the patient. The Registered Nurse Supervisor further stated that they are aware the agency did not follow the agency discharge policy. During interview on 03/21/2025 at 09:27 AM, the Registered Nurse Supervisor stated that the patient’s primary care physician was contacted to report the patient’s inappropriate behavior and the physician’s office arranged for continued wound care through outpatient services. The patient was contacted by phone and notified that they were discharged from the agency and to contact their primary care physician for information on outpatient services. The Registered Nurse Supervisor also stated the patient was not provided discharge instructions because outpatient services would be taking over the patient’s care.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on review of clinical records, agency policy and procedure, and interviews with agency staff, for one (1) of six (6) discharged patients (Patient #: 13), the agency failed to complete a discharge summary and send it to the primary care practitioner within 5 (five) business days of the date of the order for discharge. Failure to complete a discharge summary and send it to the primary care practitioner within the required timeframes has the potential for unmet patient needs and an unsafe discharge. The home health agency failed to send a discharge summary to the primary care practitioner within five (5) business days of the date of the order for discharge as evidenced by the following: Review of the agency’s policy entitled “General Practice Guidelines – Patient Discharge” dated 01/2018 revealed “The agency discharge summary form will be faxed to the physician responsible for the home health agency plan of care within five (5) days of the discharge.” Patient #13- This 67- year- old patient with the diagnoses of disruption of external operation (surgical) wound not elsewhere classified subsequent encounter, type 2 diabetes mellitus with diabetic neuropathic arthropathy, and cutaneous abscess of the left foot was admitted to the home care agency on 11/13/2023 and was discharged from the home care agency on 12/13/2023. Review of the Discharge/ Transfer Summary dated 12/21/2023 revealed the patient was discharged on 12/13/2023, but the discharge summary was not signed and sent to the physician until 12/21/2023, six (6) business days later. The agency failed to complete and send the discharge summary within five (5) business days. During interview on 03/21/2025 at 09:14 AM, the Registered Nurse Supervisor stated that the discharge summary was sent on 12/21/2023, over five (5) business days after the patient was discharged.”