Catholic Home Care

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical record review, observational home visits, and staff interviews, the Governing Authority failed to establish a complete individualized Plan of Care that identifies all of the patient’s needs. This was evident in two (2) of the seventeen (17) clinical records reviewed (Patient #4 and #5). Failure to ensure a complete individualized Plan of Care is developed for each patient has the potential for negative patient outcomes. The findings are: 1) Patient #4 has a start of care date of 03/15/2025 with diagnoses of “Malignant Neoplasm of Esophagus, Partial Intestinal Obstruction, Pleural Effusion and Benign Prostatic Hyperplasia” as documented on the “Home Health Plan of Care” for certification period of 3/15/2025 to 5/13/2025. The “Home Health Plan of Care” for certification period of 03/15/2025 to 05/13/2025 document orders for “Skilled Nursing 6 to 7 visits every week for 2 weeks (six to seven visits every week for two weeks), 6 to 7 visits every week for 1 weeks (six to seven visits every week for one week). Skilled Nurse to drain chest catheter to right chest daily. Skilled Nurse to evaluate respiratory status. Skilled Nurse to perform dressing change to chest catheter site – cleanse site with alcohol, apply drain sponge, gauze dressing and cover with transparent dressing using sterile technique to location right chest -daily”. The Skilled Nurse visit report dated 03/16/2025 lack documentation of an evaluation of the patient’s respiratory status. There is no documented evidence of an assessment of the patients’ lungs. The “Skilled Nurse routine visit” reports dated 03/17/25, 3/18/25, 03/19/25, 03/31/25, 04/01/25 lacks documentation of dressing change to chest catheter site – “cleanse site with alcohol, apply drain sponge, gauze dressing and cover with transparent dressing using sterile technique to location right chest -daily”. The Agency did not provide services and chest catheter site treatments as ordered in the Plan of Care. Survey findings were reviewed with the Director of Patient Services and Assistant Vice President on 04/10/2025 at 03:50PM. An Interview was conducted on 04/14/2025 at 11:15 AM with the Assistant Vice President, no explanation was provided. 2) Patient #5 has a start of care date of 03/29/2025 with diagnoses of “Encounter for change or removal of non-surgical wound dressing, Pressure Ulcer of sacral region: stage 4, Alzheimer’s Disease, Dementia, Chronic Atrial Fibrillation, and Essential Hypertension” as documented on the “Home Health Plan of Care” for certification period 03/29/2025 to 05/27/2025. The “Home Health Plan of Care” for certification period 03/29/2025 to 05/27/2025 document orders for “Medical Social Worker 1 to 2 visits every month for 2 months, Skilled Nursing 1 visit every day for 1 day, 1 to 2 visits every week for 4 weeks, 2 visits as needed for CV (Cardiovascular), CP (Cardiopulmonary), wound complications, monitor the patient’s weight”. The plan of care lacks documented evidence of the frequency, the parameters, and the interventions to obtain and monitor the patient’s weight. Survey findings were conducted with the Director of Patient Services and Assistant Vice President on 04/14/2025 at 10:30 AM. An Interview was conducted on 04/14/2025 at 12:30 PM with Director of Patient Services, no explanation was provided.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on clinical record review and staff interview the Governing Authority failed to ensure a complete assessment of patient needs and referral for other skill services. This was evident in one (1) of seventeen (17) clinical records reviewed (Patient #4). Failure to ensure the assessment of all patient needs and services has the potential for negative patient outcomes. Findings are: 1) Patient #4 has a start of care date of 03/15/2025 with diagnoses of “Malignant Neoplasm of Esophagus, Partial Intestinal Obstruction, Pleural Effusion and Benign Prostatic Hyperplasia” as documented on the “Home Health Plan of Care” for certification period of 3/15/2025 to 5/13/2025. The “Home Health Plan of Care” for certification period of 03/15/2025 to 05/13/2025 documents orders for “Skilled Nursing 6 to 7 visits every week for 2 weeks (six to seven visits every week for two weeks), 6 to 7 visits every week for 1 weeks (six to seven visits every week for one week). Functional Limitations- endurance, ambulation. Durable Medical Equipment - standard wheelchair, wheeled walker”. The referral for services dated 03/14/2025 documents “assess for Physical Therapy needs”. The “Start of Care” comprehensive assessment dated 03/15/2025, the Skilled Nurse/Registered Nurse documents “Musculoskeletal problems: muscle weakness, ambulation - standby assist, transfer - standby assist. Functional Limitations- endurance, ambulation”. The clinical record lacks documented evidence of Physical Therapy referral, evaluation to assess the patient’s need related to muscle weakness, ambulation assist, transfer assist, poor endurance, and usage of the Durable Medical Equipment. Survey findings were reviewed with the Director of Patient Services and Assistant Vice President on 04/10/2025 at 03:50PM. An Interview was conducted on 04/14/2025 at 11:15 AM with the Assistant Vice President, no explanation was provided.”

“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 clinical record reviews, home visit observation and staff interview, the Governing Authority failed to ensure the review of all medications the patient is currently using to identify any potential adverse effects and drug interaction. This was evident in one (1) of seventeen (17) clinical records reviewed (Patient #3). Failure to review all medications the patient is currently using to identify any potential adverse effects and drug interaction has the potential for negative patient outcomes. The findings are: 1) Patient #3 has a start of care date of 03/30/2025 with diagnoses including “Unspecified open wound to Right Lower Leg, Peripheral Vascular Disease, Unspecified Atrial Fibrillation, Rheumatoid Arthritis, Pan lobular Emphysema, Essential Hypertension, Age-related Osteoporosis, and Long-term use of anticoagulants” as documented on the “Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025. The “Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025 document orders for “Medical Social Worker 1 to 2 visits every month for 2 months, Physical Therapy 1 to 2 visits every week for 3 weeks, Skilled Nursing 2 to 4 visits every week for 3 weeks. Medications include Acidophilus caps – take by mouth, Fluticasone 50 micrograms/ACT nasal spray, Metoprolol succinate 50 milligram 24-hour tablet – take by mouth, Silver sulfadiazine 1% cream – apply to affected area on the leg every day, and Warfarin (Coumadin) 4 milligram tablet take one time daily except 2 milligram every Monday and Fridays”. On 04/08/25, a home visit observation was conducted with the agency Registered Nurse. The following medications were observed in the patient’s home, but were not documented on the Plan of Care updated on 04/03/25: Ammonium Lactate 10% cream apply daily as needed, lacked route and indications for as needed), Blink tears 0.25% - one drop both eyes two times a day, Silver sulfadiazine 1% cream (lacked route and frequency of use), Clobetasol 0.05% cream apply 2 times a day as needed (lacked route and the indications for as needed order), Docusate sodium 100 milligram capsules take 1 capsule two times a day as needed (lacked indication for as needed order), Aspercreme (4% Lidocaine) apply daily as needed, (lacked route and indications for as needed), Fiber Powder 1 application daily as needed, (lacked dosage and indication for the as needed), Pepto Bismol 262 milligram take 1-2 tablets daily as needed, (lacked indication for as needed), Warfarin 4 milligram by mouth one time daily. Take 4 milligram daily except 2 milligram every Monday and Friday. On 04/08/25 at 11:45 AM the patient was interviewed by a surveyor. The patient stated the above “Warfarin dose is not what he/she is taking”. The patient stated, “I am currently taking Warfarin 2 milligram on Saturday and Sunday, 4 milligrams on Monday, 2 milligrams on Tuesday, 4 milligrams on Wednesday, 2 milligrams on Thursday, and 4 milligrams on Friday”. The patient verbalized “a non-agency nurse comes to the home and draws blood to determine if the warfarin dose needs to be adjusted. Per the patient the last blood draw was on 03/25/25. The patient stated the nurse calls the day after the blood draw with the results and instructs the patient on what dose of warfarin to take until the next blood draw. The nurse’s do not physically check the pill bottles or medications in the box every visit”. The clinical record lacks documented evidence of a review of all current medications. On 04/8/2025 the Registered Nurse was interviewed and stated, “The One Source of Truth (patient’s in home medication list) is updated every visit.” On 04/08/25 the Registered Nurse and Director of Clinical Education acknowledged the findings. On 04/08/25 at 4:15 PM the Director of Patient Services, Assistant Vice President and Administrative staff were notified regarding the survey findings. No additional information was provided.”

“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 clinical record review, observational home visits, and staff interviews, the Governing Authority failed to establish a comprehensive Plan of Care that include all diagnoses, all medications, treatments and supplies based on the patient’s needed home care services. This was evident in eight (8) of the seventeen (17) clinical records reviewed (Patients #3, #4, #7, #8, #11, #10, #12 and #16). Failure to ensure a complete Plan of Care is developed for each patient has the potential for negative patient outcomes. The findings are: 6) Patient #3 has a start of care date of 03/30/2025 with diagnose including “Unspecified open wound to Right Lower Leg, Peripheral Vascular Disease, Unspecified Atrial Fibrillation, Rheumatoid Arthritis, Pan lobular Emphysema, Essential Hypertension, Age-related Osteoporosis, and Long-term use of anticoagulants” as documented on the “Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025. The Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025 document orders for “Medical Social Worker 1 to 2 visits every month for 2 months, Physical Therapy 1 to 2 visits every week for 3 weeks, Skilled Nursing 2 to 4 visits every week for 3 weeks. Medications include Acidophilus caps – take by mouth, Fluticasone 50 micrograms/ACT nasal spray, Metoprolol succinate 50 milligram 24-hour tablet – take by mouth, Silver sulfadiazine 1% cream – apply to affected area on the leg every day, and Warfarin (Coumadin) 4 milligram tablet take one time daily except 2 milligram every Monday and Fridays”. On 4/8/25, a home visit observation was conducted with the agency Registered Nurse. The following medications were observed in the patient’s home, but were not documented on the Plan of Care updated on 4/3/25: Ammonium Lactate 10% cream apply daily as needed, lacked route and indications for as needed), Blink tears 0.25% - one drop both eyes two times a day, Silver sulfadiazine 1% cream (lacked route and frequency of use), Clobetasol 0.05% cream apply 2 times a day as needed (lacked route and the indications for as needed order), Docusate sodium 100 milligram capsules take 1 capsule two times a day as needed (lacked indication for as needed order), Aspercreme (4% Lidocaine) apply daily as needed, (lacked route and indications for as needed), Fiber Powder 1 application daily as needed, (lacked dosage and indication for the as needed), Pepto bismol 262 milligram take 1-2 tablets daily as needed, (lacked indication for as needed), Warfarin 4 milligram by mouth one time daily. Take 4 milligram daily except 2 milligram every Monday and Friday. On 4/8/25 at 11:45 AM the patient was interviewed by a surveyor. The patient stated the above “Warfarin dose is not what he/she is taking”. The patient stated, “I am currently taking Warfarin 2 milligram on Saturday and Sunday, 4 milligrams on Monday, 2 milligrams on Tuesday, 4 milligrams on Wednesday, 2 milligrams on Thursday, and 4 milligrams on Friday”. The Plan of Care lacks an order for all medications dosage, route and frequency, bleeding precautions, anticoagulant precautions, and blood clotting testing International Normalized Ratio (INR) related to prolonged use of anticoagulant. Survey findings were reviewed with the Director of Patient Services and Assistant Vice President on 04/14/2025 at 10:15 AM. An Interview was conducted on 04/14/2025 at 02:05 PM with Director of Patient Services, no explanation was provided. 7) Patient #4 has a start of care date of 03/15/2025 with diagnoses of “Malignant Neoplasm of Esophagus, Partial Intestinal Obstruction, Pleural Effusion and Benign Prostatic Hyperplasia” as documented on the “Home Health Plan of Care” for certification period of 3/15/2025 to 5/13/2025. The “Home Health Plan of Care” for certification period of 3/15/2025 to 5/13/2025 documents orders for “Skilled Nursing 6 to 7 visits every week for 2 weeks (six to seven visits every week for two weeks), 6 to 7 visits every week for 1 weeks (six to seven visits every week for one week). Functional Limitations- endurance, ambulation. Durable Medical Equipment - standard wheelchair, wheeled walker”. The addendum to the Plan of Care dated 04/02/2025 documents an order for “Skilled Nurse 6 to 7 visits every week for 1 weeks (six to seven visits every week for one week)”. The referral for services dated 03/14/2025 documents “assess for Physical Therapy needs”. The Plans of Care lacks an order for Physical Therapy services to evaluate and treat. The Agency did not establish an individualized Plan of Care to include Physical Therapy services to meet the patient’s needs related to functional limitations, muscle weakness, ambulation assist, transfer assist, poor endurance, and Durable Medical Equipment’s. Survey findings were reviewed with the Director of Patient Services and Assistant Vice President on 04/10/2025 at 03:50PM. An Interview was conducted on 04/14/2025 at 11:15 AM with the Assistant Vice President, no explanation was provided. 8) Patient #7 has a start of care date of 02/27/2025 with diagnoses of “Encounter for change or removal of drains, Aftercare following surgery for Neoplasm, Malignant Pleural Effusion, Malignant Neoplasm of unspecified part of Right Bronchus or Lung, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypothyroidism, and Atherosclerotic Heart Disease, Native Coronary without Angina Pectoris” as documented on the “Home Health Plan of Care” for certification period 02/27/2025 to 04/27/2025. The “Home Health Plan of Care” for certification period 02/27/2025 to 04/27/2025 documents orders for “Skilled Nursing 1 visit every day for 21 days (one visits every day for twenty-one days), 1 to 3 visits (one to three visits) as needed to assess for any issues chest drain. Skilled Nurse to drain a maximum amount of 1000 ml (milliliters) from chest drain daily”. The addendum to the Plan of Care dated 03/18/2025 documents an order for “Skilled Nurse 1 visit every day for 38 days (one visits a day for thirty-eight days), effective 03/21/2025. The Plans of Care lack orders for wound care dressing change to the chest drain site. Survey findings were reviewed with the Director of Patient Services and Assistant Vice President on 04/10/2025 at 03:30PM. An Interview was conducted on 04/14/2025 at 11:15 AM with the Assistant Vice President, no explanation was provided. 1) Patient # 8 has a start of care date of 06/06/2024 with diagnoses of “Hypertensive Heart and Chronic Kidney Disease with Heart Failure, End Stage Renal Disease and Type II Diabetes” as documented on the “Home Health Plan of Care” for certification period of 04/02/2025 to 05/31/2025. The “Home Health Plan of Care” certification period 04/02/2025 to 05/31/2025 documents orders for “Skilled Nursing 1 to 2 visits every month for 2 months and 1 to 3 visits as needed for Foley complications, infection or falls, safety measures as- adequate lighting, nutritional requirements: renal diet, Oxygen inhale 2 liters per minute and the durable medical equipment (DME): wheelchair cushion and walker”. The “Skilled Nurse recertification” dated 03/31/2025 documents “Foley catheter 16 French 10cc balloon in place with 100ml clear yellow urine in drainage bag, poor appetite on diabetic diet”. The Plan of Care lacks documented evidence of the safety measures of oxygen precautions, the nutritional requirements of diabetic diet, and durable medical equipment of oxygen concentrator and Foley catheter supplies. Interview conducted with the Director of Patient Services and acknowledges findings, an updated list including the oxygen concentrator and Foley catheter supplies provided on 04/14/2025. The survey findings were reviewed with the Director of Patient Services (DPS), Assistant Vice President, Director of Clinical Education (DCE), and Director of Performance Improvement on 4/14/2025 at 4:00PM. The team acknowledged findings, no further explanation was given. 2) Patient # 10 has a start of care date of 05/10/2024 with diagnoses of “Pressure Ulcer of right hip: stage 4, Lumbar Spina Bifida, Paraplegia, Type II Diabetes, Essential Hypertension, Gastro-esophageal Reflux, Sleep Apnea, and Depression” as documented on the “Home Health Plan of Care” for certification period of 03/06/2025 to 05/04/2025. The “Home Health Plan of Care” for certification period 03/06/2025 to 05/04/2025 documents orders for “Skilled Nursing 3 visits every week for 8 weeks and 4 visits as needed for wound complications and dressing changes, under discharge plans:(not documented). Medication: Bupropion (Wellbutrin XL) 150mg 24-hour tablet: 150mg every morning for depressive disorder, and Polyethylene glycol 17 grams per scoop: Take 17 grams by mouth daily as needed”. The Plan of Care lacks documented evidence of the patient’s discharge plans. The Plan of Care lacks the medication route for Bupropion 150mg and the indication for the Polyethylene glycol 17 grams “as needed” order. The Governing Authority failed to maintain a comprehensive plan of care. Interview conducted with the Assistant Vice President on 04/14/2025 at 4:00pm and acknowledges findings, stated “a ticket was entered to the Information Technology (IT) department to address the issue”. The survey findings were reviewed with the Director of Patient Services (DPS), Assistant Vice President, Director of Clinical Education (DCE), and Director of Performance Improvement were interviewed on 04/14/2025 at 4:00PM. The team acknowledged findings, no further explanation was given. 3) Patient #11 has a start of care date of 07/05/2024 with diagnoses of “Pressure Ulcer right buttocks stage 4, Paraplegia, Neuralgia and Neuritis, complete lesion at the Thoracic (T11-T12), Epilepsy and Colostomy” as documented on the “Home Health Plan of Care” for the certification period of 03/02/2025 to 04/30/2025. The “Home Health Plan of Care” for certification period 03/02/2025 to 04/30/2025 documents orders for “Skilled Nurse visits every week for 8 weeks and 3 to 4 visits as needed for additional wound care due to increased drainage when caregiver unavailable”. The “Skilled Nurse Oasis” start of care assessment dated 02/28/2025 documents “Patient independent with colostomy care and intermittently urinary catheterization every 2-3 hours”. The Plan of Care lacks documented evidence of complete orders for genitourinary self-catheterization, colostomy care and care planning with intervention and goals. On 4/11/25 at 12:45 pm the Assistant Vice President was interviewed and stated, “You were accurate in your findings”, no additional information was provided. On 4/11/25 at 4:10 pm the survey findings were reviewed with the administrative team including the Director of Patient Services and Assistant Vice President. No explanation or additional information was provided. 4) Patient #12 has a start of care with diagnoses of “Diabetes type 2 with foot ulcer, Chronic ulcer of the left foot, Osteomyelitis left ankle, Atherosclerosis of the native arteries with intermittent claudication, Neuropathy Arthropathy, Charcot’s joint, left ankle and foot, Hypertension and Hypercholesterolemia” as documented on the “Home Health Plan of Care” for certification period of 03/04/2025 to 05/02/2025. The “Home Health Plan of Care” for certification period of 03/04/2025 to 05/02/2025 documents orders for “Skilled Nursing: one (1) visit every week for one (1) week, one to three (1 to 3) visits every week for three (3) weeks for cardiovascular, cardiopulmonary assessment and wound complications, one to two (1 to 2) visits every week for eight (8) weeks”. The “Skilled Nurse Recertification” dated 02/28/2025 documents “Peripheral inserted central catheter (PICC line) double lumen placed 01/20/2025 to left arm, dressing clean dry and intact, reason: Antibiotics”. The Plan of Care lacks documented evidence of who is responsible for the care of the Peripheral inserted central catheter, dressing change and flushing to maintain patency. An interview conducted with the Assistant Vice President on 04/10/2025 at 11:27AM acknowledges findings and stated, “spoke to nurse, central line is being manage by another agency”. Surveyor was provided with an Interim order sent on 04/09/2025 to provider. 5) Patient #16 has a start of care date of 6/17/2024 and discharge date 12/18/2024 with the diagnoses of “Acute on Chronic Systolic Congestive Heart Failure, permanent Atrial Fibrillation, Spondylosis, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease of native Coronary Artery, Obstructive Sleep Apnea, long-term use of Anticoagulants, and long-term use of Aspirin” as documented on the “Home Health Plan of Care” for certification period of 11/15/2024 to 01/13/2025. The “Home Health Plan of Care” for certification period 11/15/2024 to 01/13/2025 documents orders for “Skilled Nursing 1 to 2 visits every week for 4 weeks and 1 to 3 visits as needed for Cardiopulmonary assessments, home safety and falls prevention. Physical Therapy one visit every two weeks for two weeks. Skilled clinicians to instruct patient and caregiver causes and prevention of skin breakdown. Under Intervention: Respiratory device- BIPAP machine”. The Plan of Care lacks documented evidence of the settings for the BIPAP machine. The Plan of Care lacks documented evidence of a complete order for the equipment and supplies required. The “Skilled Nurse Oasis” start of care assessment dated 11/15/2024 documents “Patient has Stage 2 pressure ulcer on left buttocks measuring 0.5 cm x 0.5 cm x 0.1 cm. Picture sent to Wound Ostomy Certified Nurse (WOCN) who recommended that wound be cleaned with wound cleanser and patted dry, apply Triad cream to wound daily and as needed (prn)”. The Plan of Care lacks documented evidence of the pertinent diagnosis of the stage 2 pressure ulcer. The Plan of Care lacks documented evidence of a complete order for wound care and supplies required. On 4/10/25 at 3:55 pm the survey findings were reviewed with the administrative team including the Director of Patient Services and Assistant Vice President, no explanation provided. On 4/11/25 at 12:45 pm the Assistant Vice President was interviewed and stated, “You were accurate in your findings”, no additional information was provided.”

“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 clinical record review and staff interviews, the Governing Authority failed to ensure that treatment and services are administered in accordance with the orders of the patient’s primary care provider. This was evident in one (1) of the seventeen (17) clinical records reviewed (Patient #15). Failure to ensure treatment and services are administered in accordance with the orders of the patient’s primary care provider has the potential for negative patient outcomes. Findings are: Patient # 15 has a start of care date of 01/10/2024 and discharge date of 01/23/2025 with diagnoses of “Pressure Ulcer of sacral region: stage 4, Dementia, Type II Diabetes, Nonrheumatic Mitral valve insufficiency, Barrett’s Esophagus, Atrioventricular Block, Ventricular Block, and Hyperlipidemia” as documented on the “Home Health Plan of Care” for certification period of 01/02/2025 to 03/02/2025. The “Home Health Plan of Care” for certification period of 01/02/2025 to 03/02/2025 documents orders for “ skilled nursing: one visit every week for one week, one visit day for one day, 2 to 4 visits every week for three weeks, 1 to 2 visits as needed for wound care 2-4 visits every week for two weeks 2 to 4 every week for 7 weeks for cardiovascular and cardiopulmonary assessment, weekly wound measurements, nutritional requirements: diabetic diet, low cholesterol diet, low fat diet, and low sodium diet and under (Discharge Plans) documents: discharge plans not documented”. The “Skilled Nurse visit” notes dated 01/13/2025 and 01/15/2025 lacks documented evidence that the patient’s wound was measured the week of 01/13/2025. Interviewed conducted on 04/14/2025 at 4:00PM with the Assistant Vice President and acknowledged findings. The survey findings were interviewed on 04/14/2025 at 4:00PM with the Director of Patient Services, Assistant Vice President (AVP), Director of Clinical Education, and Director of Performance Improvement. The team acknowledged the survey findings and no further explanation provided.”

“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 clinical record review and staff interviews, the Governing Authority failed to ensure that treatment and services are administered in accordance with the orders of the patient’s primary care provider. This was evident in one (1) of the seventeen (17) clinical records reviewed (Patient #16). Failure to ensure treatment and services are administered in accordance with the orders of the patient’s primary care provider has the potential for negative patient outcomes. Findings are: Patient #16 has a start of care date of 6/17/2024 and discharge date of 12/18/2024 with diagnoses of “Acute on Chronic Systolic Congestive Heart Failure, Permanent Atrial Fibrillation, Spondylosis, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease of native coronary artery, Obstructive Sleep Apnea, long-term use of anticoagulants, and long-term use of aspirin” as documented on the “Home Health Plan of Care” for certification period of 11/15/2024 to 1/13/2025. The “Home Health Plan of Care” for certification period 11/15/2024 to 1/13/2025 documents orders for “Skilled Nursing 1 to 2 visits every week for 4 weeks and 1 to 3 visits as needed for Cardiopulmonary assessments, home safety and falls prevention. Physical Therapy one visit every two weeks for two weeks. Skilled clinicians to instruct patient and caregiver causes and prevention of skin breakdown. Under Intervention: Respiratory device- BIPAP machine”. The Skilled Nurse home visit note dated 11/21/24 documented, “Patient has additional stage 2 pressure sore on sacrum – wound #1 measures 1.0 cm x 0.25 cm x 0.1 cm and wound #2 measures 0.5 cm x 0.25 cm x 0.1 cm. Caregiver instructed to turn and reposition patient every 2 hours. All pressure sores including pressure sore on left buttock were cleaned with wound cleanser and patted dry. Applied Triad cream to wounds and left open to air.” The record lacks documented evidence the physician was promptly notified regarding the additional stage 2 pressure ulcer. On 4/11/25 at 12:45 pm the Assistant Vice President was interviewed and stated, “You were accurate in your findings”. No additional information was provided. On 4/11/25 at 3:55 pm the survey findings were reviewed with the administrative team including the Director of Patient Services and Assistant Vice President. No explanation or additional information was provided.”

“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 clinical record review and staff interview, the Agency failed to ensure the coordination of care and services to meet the needs of the patients. This was evident in six (6) of seventeen (17) clinical records reviewed (Patients #3, #4, #5, #9, #12 and #15). Failure to ensure coordination of care, has the potential for negative patient outcomes. Findings are 3) Patient #3 has a start of care date of 03/30/2025 with diagnose including “Unspecified open wound to Right Lower Leg, Peripheral Vascular Disease, Unspecified Atrial Fibrillation, Rheumatoid Arthritis, Pan lobular Emphysema, Essential Hypertension, Age-related Osteoporosis, and Long-term use of anticoagulants” as documented on the “Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025. The Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025 document orders for “Medical Social Worker 1 to 2 visits every month for 2 months, Physical Therapy 1 to 2 visits every week for 3 weeks, Skilled Nursing 2 to 4 visits every week for 3 weeks. Warfarin (Coumadin) 4 milligram tablet take one time daily except 2 milligram every Monday and Fridays”. The Skilled Nurse visit reports dated 04/01/2025 and 04/02/2025 lack documented evidence of patient education for Coumadin precautions, bleeding precautions, and anticoagulant therapy monitoring. On 04/08/25 at 11:45 AM the patient was interviewed by a surveyor. The patient stated the above “Warfarin dose is not what I am taking”. The patient stated, “I am currently taking Warfarin 2 milligram on Saturday and Sunday, 4 milligrams on Monday, 2 milligrams on Tuesday, 4 milligrams on Wednesday, 2 milligrams on Thursday, and 4 milligrams on Friday. The patient verbalized a non-agency nurse comes to the home and draws blood to determine if the warfarin dose needs to be adjusted. Per the patient the last blood draw was on 03/25/25. The patient stated the nurse calls the day after the blood draw with the results and instructs the patient on what dose of Warfarin to take until the next blood draw. The nurse’s do not physically check the pill bottles or medications in the box every visit”. The clinical record lacks documented evidence of coordination with the Physician for blood testing and Warfarin dosage adjustments. The Agency did not coordinate care delivery involving the patient’s health needs. Survey findings were conducted with the Director of Patient Services and Assistant Vice President on 04/14/2025 at 10:15 AM. An Interview was conducted on 04/14/2025 at 02:05 PM with Director of Patient Services, no explanation was provided. 4) Patient #4 has a start of care date of 03/15/2025 with diagnoses of “Malignant Neoplasm of Esophagus, Partial Intestinal Obstruction, Pleural Effusion and Benign Prostatic Hyperplasia” as documented on the “Home Health Plan of Care” for certification period of 03/15/2025 to 05/13/2025. The “Home Health Plan of Care” for certification period of 03/15/2025 to 05/13/2025 documents orders for “Skilled Nursing 6 to 7 visits every week for 2 weeks (six to seven visits every week for two weeks), 6 to 7 visits every week for 1 weeks (six to seven visits every week for one week). The “Routine Licensed Practical Nurse” visit reports dated 03/18/2025, 03/27/2025, 03/31/25, 04/01/25, and 04/03/25 lack documented evidence of coordination with the Registered Nurse. The Agency did not coordinate care delivery involving the patient’s needs. Survey findings were reviewed with the Director of Patient Services and Assistant Vice President on 04/10/2025 at 03:50PM. An Interview was conducted on 04/14/2025 at 11:15 AM with the Assistant Vice President, no explanation was provided. 5) Patient #5 has a start of care date of 03/29/2025 with diagnoses of “Encounter for change or removal of non-surgical wound dressing, Pressure Ulcer of sacral region: stage 4, Alzheimer’s Disease, Dementia, Chronic Atrial Fibrillation, and Essential Hypertension” as documented on the “Home Health Plan of Care” for certification period 3/29/2025 to 5/27/2025. The “Home Health Plan of Care” for certification period 03/29/2025 to 05/27/2025 document orders for “Medical Social Worker 1 to 2 visits every month for 2 months, Skilled Nursing 1 visit every day for 1 day, 1 to 2 visits every week for 4 weeks, 2 visits as needed for CV (Cardiovascular), CP (Cardiopulmonary), wound complications, monitor the patient’s weight”. The “Initial Medical Social Worker” visit report dated 04/03/2025 documents the patient has “severe Intellectual impairment, oriented to person, place, time, situation, and has no memory loss”. The clinical record lacks documentation of an accurate assessment of the patient’s mental health status. The “Routine Licensed Practical Nurse” visit report dated 04/07/25 documents the patient’s daughter is “overwhelmed with patient care as she is the primary care giver”. Case Manager notified. The clinical record lacks documentation of social work intervention to address the patient’s primary caregivers’ patient care needs. The clinical record lacks the frequency, the parameters, and the interventions to obtain and monitor the patient’s weight. The Agency did not coordinate care delivery involving the patient/caregiver needs. Survey findings were conducted with the Director of Patient Services and Assistant Vice President on 04/14/2025 at 10:30 AM. An Interview was conducted on 04/14/2025 at 12:30 PM with Director of Patient Services, no explanation was provided. 6) Patient #9 has a start of care date of 11/02/2024 with diagnoses of “Encounter for attention to colostomy, Diverticulosis large intestines, Hypertensive Chronic Kidney Disease, Type 2 Diabetes Mellitus, Chronic Kidney Disease and Encounter for fitting and adjustment of urinary devices” as documented on the “Home Health Plan of Care” for certification period 02/06/2025 to 04/06/2025. The “Home Health Plan of Care” for certification period 02/06/2025 to 04/06/2025 documents orders for “Skilled Nurse 1 to 2 visits every week for 4 weeks (one to two visits a week for four weeks), 1 to 4 visits as needed for Ostomy issues, Cardiovascular, and falls”. The “Routine Registered Nurse” visit report dated 02/05/2025 documents “Patient unable to urinate after procedure,14 French,10 cubic centimeter balloon (Foley catheter) in place”. The “Routine Licensed Practical Nurse” visit report dated 02/09/25 documents “Foley Catheter removed by Urologist with no further issues”. There is no documented evidence that the Registered Nurse was notified of the change in patient’s Foley catheter removal. The Agency did not coordinate care delivery involving the patient’s needs. Survey findings were conducted with the Director of Patient Services on 04/14/25 at 02:30 P.M. An Interview was conducted on 04/15/2025 at 12:45 PM with Director of Patient Services, no explanation was provided. 1) Patient #12 has a start of care with diagnoses of “Diabetic type 2 with foot ulcer, Chronic ulcer of the left foot, Osteomyelitis left ankle, Atherosclerosis of the native arteries with intermittent claudication, Neuropathy Arthropathy, Charcot’s joint, left ankle and foot Hypertension, Hypercholesterolemia” as documented on the “Home Health Plan of Care” for certification period of 03/04/2025 to 05/02/2025. The “Home Health Plan of Care” for certification period of 03/04/2025 to 05/02/2025 documents orders for “Skilled Nursing: one (1) visit every week for one (1) week, one to three (1 to 3) visits every week for three (3) weeks for wound complications, one to two (1 to 2) visits every week for eight (8) weeks”. The “Licensed Practical Nurse home visit” reports dated 01/01/2025,01/13/2025, 01/27/2025, 02/14/2025, 03/14/2025, 02/24/2025 03/14/2025, 03/21/2025, 03/31/2025 and 04/04/2025 lacked documented evidence of coordination with the Registered Nurse. An Interview conducted with the Director of Patient Services on 04/09/2025 at 02:53 PM and acknowledges issue, stated “Licensed Practical Nurses should be coordinating with Registered Nurse/Team Manager of daily visits. We are in the process of implemented a new future on Epic for Licensed Practical Nurses to submit visit notes to Registered Nurse/Team Manager for review”. 2) Patient # 13 has a start of care date of 09/28/2024 and discharged date of 01/29/2025 with diagnoses of “Laceration right lower leg, Alzheimer’s Disease, Dementia, Hypertension, Thoracic Aortic Aneurysm and Neuromuscular dysfunction of the bladder” as documented on the “Home Health Plan of Care” for certification period of 01/03/2025 to 03/03/2025. The “Home Health Plan of Care” for certification period of 01/03/2025 to 03/03/2025 documents orders for “Skilled Nursing; one (1) visit every week for one (1) week, one to two (1 to 2) visits every week for three (3) weeks”. The “Licensed Practical Nurse home visit” reports dated 10/07/2024, 10/09/2024, 10/15/2024, 10/18/2024, 11/27/2024, 11/29/2024, 12/06/2024, 01/20/2025 and 01/24/2025 lacked documented evidence of coordination with the Registered Nurse. An Interview conducted with the Director of Patient Services on 04/09/2025 at 02:53 PM and acknowledges issue, stated “Licensed Practical Nurses should be coordinating with Registered Nurse/Team Manager of daily visits. We are in the process of implemented a new future on Epic for Licensed Practical Nurses to submit visit notes to Registered Nurse/Team Manager for review”. Survey findings were reviewed with the Director of Patient Services and the Assistant Vice President on 4/09/2025 at 4:00 PM, no additional explanation was provided.”

“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 a review of clinical records, and staff interviews, the Governing Authority failed to ensure the Registered Nurse follow standard Infection Control practice. This is evident in two (2) of seventeen (17) clinical records reviewed. (Patients #3 and#7). Failure to ensure the Registered Nurse follow standard Infection Control practice places the patient at risk for negative outcomes. Findings are: 1) Patient #3 has a start of care date of 03/30/2025 with diagnose including “Unspecified open wound to Right Lower Leg, Peripheral Vascular Disease, Unspecified Atrial Fibrillation, Rheumatoid Arthritis, Pan lobular Emphysema, Essential Hypertension, Age-related Osteoporosis, and Long-erm use of anticoagulants” as documented on the “Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025. The Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025 document orders for “Skilled Nursing 2 to 4 visits every week for 3 weeks. Skilled Nurse to perform wound care dressing change using clean technique: remove old dressing, cleanse with normal saline/wound cleanser, dry with sponge or gauze pad, apply Medi-honey and alginate to wound bed, cover with dry clean dressing, and secure with ace bandage. Change dressing every other day and measure wound length, depth, width weekly”. On 04/08/2025 a home visit observation was conducted with the agency’s Registered Nurse and Director of Clinical Education. The Surveyor observed the Registered Nurse perform wound care to the Right Lower Leg, the Registered Nurse removed the soiled gloves, sanitized her hands, applied clean gloves, cleansed the wound, and then measured the wound. The Registered Nurse did not remove the potentially soiled gloves and sanitize her hands before applying Medi-honey, alginate, rolled gauze, and Ace wrap to the wound. On 04/08/25 the Registered Nurse and Director of Clinical Education were interviewed, acknowledged the findings and provided no additional information. On 04/08/25 at 4:15 PM the Director of Patient Services, Assistant Vice President, and Administration staff were notified of the survey findings. No additional information was provided. 2) Patient #7 has a start of care date of 02/27/2025 with diagnoses of “Encounter for change or removal of drains, Aftercare following surgery for Neoplasm, Malignant Pleural Effusion, Malignant Neoplasm of unspecified part of Right Bronchus or Lung, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypothyroidism, and Atherosclerotic Heart Disease, Native Coronary without Angina Pectoris” as documented the “Home Health Plan of Care” for certification period 02/27/2025 to 04/27/2025. The “Home Health Plan of Care” for certification period 02/27/2025 to 04/27/2025 documents orders for “Skilled Nursing 1 visit every day for 21 days (one visits every day for twenty-one days), 1 to 3 visits (one to three visits) as needed to assess for any issues chest drain. Skilled Nurse to drain a maximum amount of 1000 ml (milliliters) from chest drain daily”. The agency’s policy “Chest or Abdominal Drainage” for symptom management of pleural effusion and ascites effective date 2006, most recently revised 6/2014, and last reviewed on 6/2024 documented the following: “Orders will include frequency of dressing change and frequency of drainage. Applying a new dressing: Wash hands, gather equipment, and set-up a clean workspace. Don sterile gloves, cleanse around catheter site with alcohol pad. Handle catheter with clean hand and dressing and supplies with sterile hand. Place the foam catheter pad, or split drain sponge around the catheter”. On 04/08/2025 aa home visit observation was conducted with the agency Registered Nurse and the Director of Clinical Education. The Surveyor observed the Registered Nurse performing wound care to the right chest Pleurex Drain site, at 01:08 pm the nurse removed the soiled dressing, disposed of dressing, removed sterile gloves sanitized her hands, applied clean gloves and attached the plural vacuum. At 01:15 pm the nurse detached the pleural vacuum canister and placed it directly on the floor (without a barrier) while holding the patient end of the tubing in her gloved right hand. At 01:16 pm the Director of Clinical Education intervened. The nurse picked the canister up off the floor, the Director of Clinical Education placed a drape on the floor and then the nurse placed the canister on the drape. At 01:18 pm the nurse removed the potentially soiled gloves, applied new gloves, and dressed the wound. The nurse was not observed to sanitize her hands after removing potentially soiled gloves before applying new clean gloves. On 04/08/25 the Director of Clinical Education observed and acknowledged the findings. On 04/08/25 at 4:15 pm the Director of Patient Services, Assistant Vice President and Administrative staff were notified of the survey findings. No additional information was provided.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on a review of clinical records, and staff interviews, the Governing Authority failed to ensure the patient current comprehensive assessments includes all assessments and clinical notes. Failure to ensure all content of the comprehensive assessment is in the clinical record have the potential for negative patient outcomes. This is evident in three (3) of seventeen (17) clinical records reviewed. (Patients #15, #16 and #17). Findings are: 1) Patient # 15 has a start of care date of 01/10/2024 and discharge date of 01/23/2025 with diagnoses of “Pressure Ulcer of sacral region: stage 4, Dementia, Type II Diabetes, Non-Rheumatic Mitral valve insufficiency, Barrett’s Esophagus, Atrioventricular Block, Ventricular Block and Hyperlipidemia” as documented on the “Home Health Plan of Care” for certification period of 01/02/2025 to 03/02/2025. The “Home Health Plan of Care” for certification period of 01/02/2025 to 03/02/2025 documents orders for “skilled nursing: one visit every week for one week, one visit day for one day, 2 to 4 visits every week for three weeks, 1 to 2 visits as needed for wound care 2-4 visits every week for two weeks 2 to 4 every week for 7 weeks for cardiovascular and cardiopulmonary assessment, weekly wound measurements, nutritional requirements: diabetic diet, low cholesterol diet, low fat diet, and low sodium diet and under (Discharge Plans) documents: discharge plans not documented”. The “skilled nursing visit” notes dated 01/06/2025, 01/08/2025, 01/13/2025, 01/15/2025, 01/17/2025, 01/20/205 and 01/22/2025 lacked documented evidence of diabetic diet and patient discharge plans. The “Skilled Nurse visit” notes dated 01/13/2025 and 01/15/2025 lacks documented evidence that the patient’s wound was measured the week of 01/13/2025. The Director of Patient Services, Assistant Vice President (AVP), Director of Clinical Education, and Director of Performance Improvement were interviewed on 4/14/2025 at 4:00PM and Assistant Vice President states that “the records should include patient plans for after discharge from the Agency”. The team acknowledged the survey findings, and no further explanation provided. 2) Patient #16 has a start of care date of 06/17/2024 and discharge date of 12/18/2024 with diagnoses of “Acute on Chronic Systolic Congestive Heart Failure, Permanent Atrial Fibrillation, Spondylosis, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease of native Coronary Artery, Obstructive Sleep Apnea, long-term use of Anticoagulants, and long-term use of Aspirin” as documented on the “Home Health Plan of Care” for certification period of 11/15/2024 to 01/13/2025. The “Home Health Plan of Care” for certification period 11/15/2024 to 01/13/2025 documents orders for “Skilled Nursing 1 to 2 visits every week for 4 weeks and 1 to 3 visits as needed. Skilled Nurse to evaluate edema, location, and amount. Skilled Nurse to measure and document degree of edema”. The “Skilled Nurse home visit” notes dated 11/19/24, 11/21/24, 11/29/24, 12/03/24, and 12/11/24 lacks documentation that the nurse evaluated, measured, and documented the degree of edema. On 04/11/25 at 12:45 pm the Assistant Vice President was interviewed and stated, “You were accurate in your findings.” No additional information was provided. On 4/11/25 at 4:10 pm the survey findings were reviewed with the administrative team including the Director of Patient Services and Assistant Vice President. No explanation or additional information was provided. 3) Patient # 17 has a start of care date of 10/7/2023 and discharge date of 11/19/2024 with diagnoses of “Myelodysplastic Syndrome, Anemia, Atrial Fibrillation, Nonrheumatic Mitral Valve Insufficiency, Essential Hypertension, and Hypothyroidism” as documented on the “Home Health Plan of Care” for certification period of 09/21/2024 to 11/19/2024. The “Home Health Plan of Care” for certification period of 09/21/2024 to 11/19/2024 documents orders for “home health aide 1 to 2 visits every week for 9 weeks for 1 to 1.5 hours, Physical Therapy 1 to 2 visits every week for 9 weeks, and the most recent Skilled Nursing orders for 1 to 2 visits every week for 6 weeks”. The “Skilled Nurse Oasis Visit” assessment dated 09/16/2024 documents the Registered Nurse conducted the patient assessment on 09/16/2024 and submitted the document on 09/23/2024. The Governing Authority failed to ensure the Oasis reassessment documentation is submitted within forty-eight (48) hours of the nursing assessment as per agency protocol. Interview conducted on 04/14/2025 at 4:00PM with the Director of Patient Services (DPS) and states “the Oasis document must be submitted within forty-eight (48) hours of the Registered Nurse assessment”. The survey findings were reviewed on 04/14/2025 at 4:30 PM with the Director of Patient Services (DPS), Assistant Vice President, Director of Clinical Education, and Director of Performance Improvement. The team acknowledged findings with no further explanation given.”