Schofield Certified Home Care

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on review of the agency’s Outcome Assessment Information Set (OASIS) submissions, clinical records and interviews with agency staff for one (1) of seven (7) patients (Patient #6), the agency failed to ensure OASIS data accurately reflects the patient’s status at the time of the assessment. Failure to ensure accurate documentation of OASIS data has the potential for negative outcomes. Findings are: Patient #6- This 100-year-old patient with diagnoses that include generalized primary osteoarthritis, essential primary hypertension, and atherosclerotic heart disease of native coronary artery without angina pectoris was admitted to the home health agency on 03/27/2025. This record was chosen as a potentially avoidable event: Development of Urinary Tract Infection. Review of the Registered Nurse (RN) OASIS Admission note dated 3/27/20125 revealed the Registered Nurse documented the patient’s urinary status as follows: - Has this patient been treated for a Urinary Tract Infection in the past 14 days? No, - Urinary Incontinence or Urinary Catheter Presence: 1- patient is incontinent -Frequent infections: No Review of the Physical Therapy Oasis Discharge from agency note dated 04/28/2025 revealed the Physical Therapist documented the patient’s urinary status as follows: - Has this patient been treated for a Urinary Tract Infection in the past 14 days? Yes, -Frequent infections: other: patient took antibiotics for fifteen (15) days that ended on 4/27/2025. Review of the Physical Therapy (PT) Initial visit note dated 4/3/2025 revealed the Physical Therapist documented the following: General systems review\Bowel and Bladder: Frequent infections: Patient finished antibiotics on 4/2/2025 for Urinary Tract Infection (UTI). The agency failed to ensure the RN Admission OASIS Data Collection Only accurately reflects the patient’s status at the time of assessment. During an interview on 8/18/2025 at 12:37 PM, the Registered Nurse stated that they were not aware of the patient’s frequent urinary tract infections or antibiotic use at the time of admission and was not able to complete a complete medication reconciliation at the time of admission as patient was going to review medication changes from rehabilitation center at upcoming primary care appointment.”

“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 three (3) of seven (7) patients (Patient #s: 4, 5, and 7), the agency failed to ensure all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice. Failure to authenticate documentation with professional credentials has the potential for patient to received care from unlicensed staff. The Certified Home Health Agency (CHHA) failed to ensure documentation by professional staff is appropriately authenticated as evidenced by the following: Patient #7 – This 84-year-old patient with diagnoses that include chronic atrial fibrillation, unspecified, hypertensive heart disease with heart failure, and congestive heart failure was admitted to the home health agency on 07/23/2024. This record was chosen as a Potentially Avoidable: Discharge to the Community Needing Wound Care or Medication Assistance. A.) Review of the SN – Nursing (OASIS E) Routine Visit note, Visit Record note, and Charts/Clinical Notes dated 08/02/2024 revealed the notes were electronically signed by Employee M but lacked documented evidence of the employee’s professional credentials. During an interview on 08/18/2025 at 11:08 AM, the Director of Patient Services stated that the employee is a registered nurse and that there are no credentials by the employee’s electronic signature but that there should be. B.) Review of the SN – Nursing (OASIS E) Routine Visit note, Visit Record note, and Charts/Clinical Notes dated 08/21/2024 revealed the notes were signed electronically by Employee N but lacked documented evidence of the employee’s professional credentials. During an interview on 08/18/2025 at 11:18 AM, the Director of Patient Services stated that the employee is a Licensed Practical Nurse and that there are no credentials by the employee’s electronic signature but that there should be. Patient #4 – This 72-year-old patient with diagnoses that include chronic obstructive pulmonary disease, type II diabetes with diabetic polyneuropathy was admitted to the home health agency on 01/18/2024. A.) Review of the PT (Physical Therapy) with Treatment (OASIS E1) Visit note, Visit Record note, and Charts/Clinical Notes dated 07/16/2025, 07/23/2025, and 07/30/2025 revealed the notes were electronically signed by Employee L but lacked documented evidence of the employee’s credentials. During an interview on 08/18/2025 at 10:56 AM, the Quality Assurance Nurse stated that the employee is a Physical Therapist Assistant (PTA) and that there are no credentials by the employee’s electronic signature but that there should be. B.) Review of the SN – Nursing (OASIS E1) Route Visit note, Visit Record note, and Charts/Clinical Notes dated 07/18/2025 and 08/08/2025 revealed the notes were electronically signed by Employee K but lacked documented evidence of the employee’s credentials. During an interview on 08/18/2025 at 10:58 AM, the Quality Assurance Nurse stated that the employee is a Licensed Practical Nurse (LPN) and that there are no credentials by the employee’s electronic signature but that there should be. Patient #5 – This 82-year-old patient with the diagnoses of fall on same level, unspecified, chronic kidney disease, and unspecified diastolic congestive heart failure was admitted to the home care agency on 7/14/2025. A. Review of the Skilled Nursing Routine Visits dated 7/21/2025, 7/31/2025 and 8/9/2025 lacked documented evidence of the professional’s credentials. Review of the Skilled Nursing Clinical Notes dates 7/21/2025, 7/31/2025, and 8/9/2025 lacked documented evidence of the professional’s credentials. During interview on 8/18/2025 at 11:37 AM, the Administrator stated that the lack of credentials is a system issue and is unsure why the clinician’s credentials are not included. During interview on 8/18/2025 11:37 AM, the Administrator verified that employee K is a Licensed Practical Nurse. B. Review of the Occupational Therapy Routine Visit dated 8/12/2025 lacked documented evidence of the paraprofessional’s credentials. Review of the Occupational Therapy Clinical Notes dates 7/28/2025, 7/30/2025, and 8/9/2025, and 8/12/2025 lacked documented evidence of the professional’s credentials. During interview on 8/18/2025 at 11:37 AM, the Administrator stated that the lack of credentials is a system issue and is unsure why the clinician’s credentials are not included. During interview on 8/18/2025 11:37 AM, the Administrator verified that employee O is a Certified Occupational Therapy Assistant (COTA).”

“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, agency policy and procedure, and interviews with staff for two (2) of seven (7) patients (Patient #s: 5 and 6) the agency failed to ensure a complete and accurate comprehensive assessment consistent with the patient’s immediate needs was completed within five (5) days of the start of care. Failure to ensure that a comprehensive assessment is complete and accurate has the potential for unmet needs and possible negative outcomes. Patient #5 – This 82-year-old patient with the diagnoses of fall on same level, unspecified, chronic kidney disease, and unspecified diastolic congestive heart failure was admitted to the home care agency on 7/14/2025. A. Review of the referral orders on the Skilled Nursing Facility discharge instructions dated 7/10/2025 revealed the following: Discharge services requested: Nursing, OT (occupational therapy) evaluation, PT (physical therapy) evaluation. Review of the Home Health Certification and Plan of Care for 7/14/2025 to 9/11/2025 revealed an order for Physical Therapy evaluation effective week of 7/21/2025 for strength and endurance, safety. Review of the clinical record revealed the Physical Therapist provided an initial visit for evaluation on 7/23/2025, 9 (nine) days after the start of care. During interview on 8/18/2025 at 11:27 AM the Director of Patient Services confirmed that Physical Therapy Services were requested at time of referral prior to start of care and is unaware of why an order was placed for the evaluation to occur the following week. The Director of Patient Services further confirmed that the expectation is that all requested services complete a comprehensive assessment within five (5) days of the start of care date. B. Review of the referral orders on the Skilled Nursing Facility discharge instructions dated 7/10/2025 revealed the following: Discharge services requested: Nursing, OT (occupational therapy) evaluation, PT (physical therapy) evaluation. Review of the Home Health Certification and Plan of Care for 7/14/2025 to 9/11/2025 revealed an order for Occupational Therapy evaluation effective week of 7/21/2025 for ADL’s (activities of daily living) and safety. Review of the clinical record revealed the Occupational Therapist provided an initial visit for evaluation on 7/22/2025, 8 (eight) days after the start of care. During interview on 8/18/2025 at 11:27 AM the Director of Patient Services confirmed that Occupational Therapy Services were requested at time of referral prior to start of care and is unaware of why an order was placed for the evaluation to occur the following week. The Director of Patient Services further confirmed that the expectation is that all requested services complete a comprehensive assessment within five (5) days of the start of care date. Patient #6- This 100-year-old patient with diagnoses that include generalized primary osteoarthritis, essential primary hypertension, and atherosclerotic heart disease of native coronary artery without angina pectoris was admitted to the home health agency on 03/27/2025. This record was chosen as a potentially avoidable event: Development of Urinary Tract Infection. A. Review of the referral orders on the Skilled Nursing Facility discharge instructions dated 3/24/2025 revealed the following: Discharge services requested: Nursing, OT (occupational therapy) evaluation, PT (physical therapy) evaluation. Review of the Home Health Certification and Plan of Care for 3/27/2025 to 5/25/2025 revealed an order for Physical Therapy evaluation for strength and endurance effective the week of 3/31/2025. Review of the clinical record revealed the Physical Therapist provided an initial visit for evaluation on 4/3/2025, 7 (seven) days after the start of care. During interview on 8/18/2025 at 12:16 PM the Director of Patient Services confirmed that Physical Therapy Services were requested at time of referral prior to start of care and was unaware the agency could not request an updated order from the physician for a later start date for services to begin outside of the 5 (five) day comprehensive assessment requirement. B. Review of the referral orders on the Skilled Nursing Facility discharge instructions dated 3/24/2025 revealed the following: Discharge services requested: Nursing, OT (occupational therapy) evaluation, PT (physical therapy) evaluation. Review of the Home Health Certification and Plan of Care for 3/27/2025 to 5/25/2025 revealed an order for Occupational Therapy evaluation for ADL (activities of daily living) training and safety in the home effective week of 3/31/2025. Review of the clinical record revealed the Occupational Therapist provided an initial visit for evaluation on 4/3/2025, 7 (seven) days after the start of care. During interview on 8/18/2025 at 12:16 PM the Director of Patient Services confirmed that Occupational Therapy Services were requested at time of referral prior to start of care and was unaware the agency could not request an updated order from the physician for a later start date for services to begin outside of the 5 (five) day comprehensive assessment requirement.”

“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 agency policy and procedure, clinical records and interviews with agency staff, for three (3) of seven (7) patients (Patient #s: 2, 6, and 7), the clinical record lacked 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. Findings are: Review of the agency’s policy and procedure entitled “Nurse Medication Reconciliation” dated October 2022 revealed the following: “Medication reconciliation is a formal process in which health care professionals ensure accurate and complete medication information. Medication Reconciliation is the process of identifying the most accurate list of all medications that the patient is taking, including the name, dosage, frequency, and route, by comparing the medical record to the external list of medications obtained from a hospital or facility discharge or medical office visit. The nurse will perform medication reconciliations. Developing a list of medications: 1) Compare initial 485, Resumption of Care, or recertification orders to the patient’s current medications in the home. 2) A patient’s medication list will include all medications the patient is taking including over the counter (OTC) meds and herbal preparations. 3) Compare medications on discharge instructions from the hospital or facility. 4) Help and instruct patient to discard any expired medications. Current medications: 1) Check for any missing medications or any unfilled prescriptions. 2) Check for duplicate medications. 3) Check for any medications that may adversely interact with other meds or are contraindicated (call pharmacy if needed). 4) Transcribe all medications including OTC (over-the-counter) into Medication section of Allscripts. 5) Do Not use abbreviations on Medication List. 6) Medications without MD (Medical Doctor) order: a) Call MD to confirm or discontinue medication. b) Submit the interim or verbal order for the MD signature.” Patient #7 – This 84-year-old patient with diagnoses that include chronic atrial fibrillation, unspecified, hypertensive heart disease with heart failure, and congestive heart failure was admitted to the home health agency on 07/23/2024. This record was chosen as a Potentially Avoidable: This record was chosen as a Potentially Avoidable: Discharge to the Community Needing Wound Care or Medication Assistance. Review of the Skilled Nursing Facility Medication Report dated 07/18/2024 and faxed to the agency on 07/18/2024 at 17:00 (05:00 PM) revealed the following medications: - Acetaminophen Tablet 325 mg (milligrams) give two (2) tablets by mouth every four (4) hours for pain not to exceed three (3) grams in twenty-four (24) hours. - Acetaminophen tablet 325 mg give two (2) tablets by mouth every four (4) hours as needed for temperature 100F or above. - Bisacodyl Suppository 10 mg insert one (1) suppository rectally every twenty-four (24) hours as needed for bowel management daily if no results from MOM (milk of magnesia). - Eliquis Oral tablet (Apixaban) give 2.5 mg by mouth two (2) times a day for atrial fibrillation. - Fleet Enema Enema 7-19 GM (grams)/118 ml (milliliters) (Sodium Phosphates) insert one (1) application rectally every twenty-four (24) hours as needed for constipation. Fleet enema per rectal when no results from Dulcolax suppository and prn (as needed). - Furosemide tablet 20 mg – give one (1) tablet by mouth one (1) time a day for edema. - Levothyroxine Sodium tablet 112 mcg (micrograms) give one (1) tablet by mouth one (1) time a day for low thyroid hormone. - Metoprolol tartrate tablet – give 12.5 mg by mouth two (2) times a day for HTN (hypertension). - Milk of Magnesia oral suspension 400mg/5ml (magnesium hydroxide) give thirty (30) ml by mouth every twenty-four (24) hours as needed for bowel management. - Oxycodone HCL oral tablet five (5) mg (oxycodone HCL) give one (1) tablet by mouth every four (4) hours as needed for pain not relieved by Tylenol/Naprosyn. - Potassium Chloride ER (Extended Release) 10 MEQ (Milliequivalent) – give one (1) tablet by mouth one (1) time a day for Lasix therapy. - Vitamin D3 Ultra Potency oral tablet 1250 mcg (Cholecalciferol) give one (1) tablet by mouth one (1) time a day every Wednesday for supplement. Review of the Home Health Certification and Plan of Care for certification period 07/23/2024 to 09/20/2024 revealed the following: - Allegra Allergy by mouth tablet sixty (60) mg one (1) tablet daily PO PRN (as needed) allergies. - Allopurinol by mouth tablet 300 mg one (1) tablet daily PO Gout. - Eliquis by mouth tablet 2.5 mg one (1) tablet twice daily PO CHF (Congestive Heart Failure). - Levothyroxine Sodium by mouth capsule 112 mcg 1 cap (capsule) daily Po hypothyroidism. - Metoprolol Tartrate by mouth tablet 25 mg 0.5 tablet twice a day PO hypertension. - Oxycodone HCL by mouth tablet five (5) mg one (1) tablet every four (4) hours as needed PO pain. - Potassium Chloride Crys ER by mouth tablet extended release ten (10) MEQ one (1) tablet daily PO hypokalemia. - Vitamin D3 by mouth capsule (fifty) 50 mcg one (1) capsule daily PO supplement. Review of the Charts/Clinical Noters dated 07/23/2024 revealed the Registered Nurse documented the following:” patient did not have oxycodone, states that the patient does not take acetaminophen, is taking vitamin D3 50 mcg daily. In addition to discharge list of medications patient is also taking Allopurinol 300mg QD (every day), Allegra D QD as needed. Mediations checked for drug interactions and no major interactions noted. Called placed to doctor’s office, agreeable to physical therapy, occupational therapy, MSW referrals, nursing visit frequency, and medications reconciled.” There is a lack of documented evidence that the patient should be taking the following or evidence that the following medications have been discontinued: - Bisacodyl Suppository 10 mg insert one (1) suppository rectally every twenty-four (24) hours as needed for bowel management daily if no results from MOM (milk of magnesia). - Fleet Enema 7-19 GM (grams)/118 ml (milliliters) (Sodium Phosphates) insert one (1) application rectally every twenty-four (24) hours as needed for constipation. Fleet enema per rectal when no results from Dulcolax suppository and prn (as needed). - Milk of Magnesia oral suspension 400mg/5ml (magnesium hydroxide) give thirty (30) ml by mouth every twenty-four (24) hours as needed for bowel management. During an interview on 08/18/2025 at 10:36 AM, the Registered Nurse (RN) stated that maybe the RN had looked at the discharge summary that was in the home. The Registered Nurse continued to state Bisacodyl, Fleets Enema, and Milk of Magnesia would have been medications on the patient’s MAR (Medication Administration Record) while at subacute rehab in the skilled nursing facility and that the patient would not be continuing those medications. Patient #2- This 72-year-old patient with diagnoses that include type 2 diabetes, non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin, and , non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin was admitted to the agency on 7/25/2025. A. Review of the History of Present Illness office visit and referral dated 06/25/2025 revealed the following medication order: - Saline Nasal 0.65% spray aerosol one squirt in each nostril every 4 (four) hours as needed for dryness Review of the Home Health Certification and Plan of Care for certification period 7/25/2025 to 9/22/2025 lacks an order for Saline Nasal Spray. Review of the Registered Nurse OASIS Start of Care lacked documentation that the Registered Nurse discussed the need to add Saline Nasal Spray to the patient’s medication regime. During interview on 8/18/2025 at 1:37 PM the Registered Nurse stated that they do not recall whether the medication was on the referral medication list and confirmed that there is no documented reason why the medication was not ordered at start of care. B. Review of the History of Present Illness office visit and referral dated 06/25/2025 revealed the following medication order: - Diclofenac 1% topical gel apply 2 (two) grams by topical route 2 (two) times every day to both knees. Review of the Home Health Certification and Plan of Care for certification period 7/25/2025 to 9/22/2025 lacks an order for Diclofenac topical gel. Review of the Registered Nurse OASIS Start of Care lacked documentation that the Registered Nurse discussed the need to add Diclofenac topical gel to the patient’s medication regime. During interview on 8/18/2025 at 1:37 PM the Registered Nurse stated that they do not recall whether the medication was on the referral medication list and confirmed that there is no documented reason why the medication was not ordered at start of care. C. Review of the History of Present Illness office visit and referral dated 06/25/2025 revealed the following medication order: - Carboxymethylcell 0.5% eye drops instill 1 (one) drop into both eyes twice daily for dry eyes Review of the Home Health Certification and Plan of Care for certification period 7/25/2025 to 9/22/2025 lacks an order for Carboxymethylcell eye drops. Review of the Registered Nurse OASIS Start of Care lacked documentation that the Registered Nurse discussed the need to add Carboxymethylcell eye drops to the patient’s medication regime. During interview on 8/18/2025 at 1:37 PM the Registered Nurse stated that they do not recall whether the medication was on the referral medication list and confirmed that there is no documented reason why the medication was not ordered at start of care. D. Review of the History of Present Illness office visit and referral dated 06/25/2025 revealed the following medication order: - Polyethylene Glycol 3350 17 gram per dose oral powder. Take 17 grams by oral route every day for constipation, mixed with 8 ounces of water. Review of the Home Health Certification and Plan of Care for certification period 7/25/2025 to 9/22/2025 lacks an order for Polyethylene Glycol. Review of the Registered Nurse OASIS Start of Care lacked documentation that the Registered Nurse discussed the need to add Polyethylene Glycol to the patient’s medication regime. During interview on 8/18/2025 at 1:37 PM the Registered Nurse stated that they do not recall whether the medication was on the referral medication list and confirmed that there is no documented reason why the medication was not ordered at start of care. Patient #6- This 100-year-old patient with diagnoses that include generalized primary osteoarthritis, essential primary hypertension, and atherosclerotic heart disease of native coronary artery without angina pectoris was admitted to the home health agency on 03/27/2025. Review of the RN OASIS Start of Care visit dated 3/27/2025 revealed the Registered Nurse documented that a review of medications were reconciled without issue, no changes made, patient compliance with medications, and the drug regimen review identified no potentially clinically significant medication issues. Review of the Skilled Nursing Clinical Note dated 3/27/2025 revealed the following: “Medications reconciled via discharge medication list and medications in the home. Primary Care office representative confirmed medication list. No major drug-to-drug interactions identified. Patient’s daughter has scheduled primary care physician follow-up for 3/31/2025.” A. Review of the Discharge Summary dated 03/24/2025 revealed the order for: Cozaar oral tablet 100mg (milligrams) 1 capsule by mouth 1 (one) time a day Review of the Home Health Certification and Plan of Care for certification period 3/27/2025 to 5/25/2025 lacks an order for Cozaar. Review of the Registered Nurse OASIS Start of Care lacked documentation that the Registered Nurse discussed the need to add Cozaar to the patient’s medication regime. B. Review of the Discharge Summary dated 03/24/2025 revealed the order for: Fish Oil Capsule 1,000mg (milligrams) 1 (one) capsule by mouth 1 (one) time a day Review of the Home Health Certification and Plan of Care for certification period 3/27/2025 to 5/25/2025 lacks an order for Fish Oil. Review of the Registered Nurse OASIS Start of Care lacked documentation that the Registered Nurse discussed the need to add Fish Oil to the patient’s medication regime. C. Review of the Discharge Summary dated 03/24/2025 revealed the order for: Meloxicam tablet 15mg (milligrams) 1 (one) tablet by mouth 1 (one) time a day Review of the Home Health Certification and Plan of Care for certification period 3/27/2025 to 5/25/2025 lacks an order for Meloxicam. Review of the Registered Nurse OASIS Start of Care lacked documentation that the Registered Nurse discussed the need to add Meloxicam to the patient’s medication regime. D. Review of the Discharge Summary dated 03/24/2025 revealed the order for: Cholecalciferol tablet 1,000 units 1 (one) tablet my mouth 1 (one) time a day Review of the Home Health Certification and Plan of Care for certification period 3/27/2025 to 5/25/2025 lacks an order for Cholecalciferol. Review of the Registered Nurse OASIS Start of Care lacked documentation that the Registered Nurse discussed the need to add Cholecalciferol to the patient’s medication regime. E. Review of the Discharge Summary dated 03/24/2025 revealed the order for: Amlodipine Besylate tablet 5mg (milligrams) 1 (one) tablet my mouth 1 (one) time a day Review of the Home Health Certification and Plan of Care for certification period 3/27/2025 to 5/25/2025 lacks an order for Amlodipine Besylate. Review of the Registered Nurse OASIS Start of Care lacked documentation that the Registered Nurse discussed the need to add Amlodipine Besylate to the patient’s medication regime. F. Review of the Discharge Summary dated 03/24/2025 revealed the order for: Cyanocobalamin Tablet 1000mcg (micrograms) 1 (one) tablet my mouth 1 (one) time a day Review of the Home Health Certification and Plan of Care for certification period 3/27/2025 to 5/25/2025 lacks an order for Cyanocobalamin. Review of the Registered Nurse OASIS Start of Care lacked documentation that the Registered Nurse discussed the need to add Cyanocobalamin to the patient’s medication regime. G. Review of the Discharge Summary dated 03/24/2025 revealed the order for: Metoprolol Tartrate Tablet 25mg (milligrams) 1 (one) tablet my mouth 2 (two) times a day Review of the Home Health Certification and Plan of Care for certification period 3/27/2025 to 5/25/2025 lacks an order for Metoprolol Tartrate. Review of the Registered Nurse OASIS Start of Care lacked documentation that the Registered Nurse discussed the need to add Metoprolol Tartrate to the patient’s medication regime. During interview on 8/18/2025 at 9:38 AM, the Registered Nurse stated that the patient had been in skilled nursing rehabilitation prior to admission to the agency and started on several new medications. The daughter had scheduled a follow up to review discharge from rehab and all changes with primary care physician on 3/31/2025, so the medication list from the patient’s discharge summary were not reconciled at visit. H. Review of the Home Health Certification and Plan of Care for certification period 3/27/2025 to 5/25/2025 revealed an order for Tramadol Hydrochloride by mouth tablet 50mg (milligrams) 1-2 (one to two) tablets 3 (three) times a day as needed by mouth for pain. Review of the Discharge Summary dated 3/24/2025 lacked orders for Tramadol Hydrochloride. I. Review of the Home Health Certification and Plan of Care for certification period 3/27/2025 to 5/25/2025 revealed an order for Daily Multiple Vitamins by mouth tablet one tablet daily for supplement Review of the Discharge Summary dated 3/24/2025 lacked orders for Daily Multiple Vitamins. J. Review of the Home Health Certification and Plan of Care for certification period 3/27/2025 to 5/25/2025 revealed an order for Hydromorphone Hydrochloride by mouth tablet 2mg (milligrams) 1 (one) tablet 3 (three) times a day as needed for pain. Review of the Discharge Summary dated 3/24/2025 lacked orders for Hydromorphone Hydrochloride. K. Review of the Home Health Certification and Plan of Care for certification period 3/27/2025 to 5/25/2025 revealed an order Celebrex 200mg (milligrams) 1-2 (one to two) capsules by mouth daily as needed for osteoarthritis. Review of the Discharge Summary dated 3/24/2025 lacked orders for Celebrex. During interview on 8/18/2025 at 9:40 AM, the Registered Nurse stated that the patient had been in skilled nursing rehabilitation prior to admission to the agency and started on several new medications. The daughter had scheduled a follow up to review the discharge instructions from the rehabilitation facility and all changes with primary care physician on 3/31/2025. Additionally, the medications listed in the Plan of Care were present in the home.”

“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, agency policies and procedures, and staff interviews for five (5) of seven (7) patients (Patient #s: 1, 2, 4, 5 and 6) the agency failed to develop individualized plans of care (POC) that are complete and accurate and address the total needs of the patients. The issues are: - The POC lacked orders for PERS (personal emergency response system) - The POC lacked documentation of a primary diagnosis - The POC lacked diabetic safety precautions - The POC lacked order for knee sleeve - The POC lacked order for topical medicated cream -The POC contained inaccurate diet order Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. Patient #4 – This 72-year-old patient with diagnoses that include chronic obstructive pulmonary disease, type II diabetes with diabetic polyneuropathy was admitted to the home health agency on 01/18/2024. A. Review of the Home Health Certification and Plan of Care for certification period 01/18/2024 to 03/17/2024 revealed the following: - Type 2 Diabetes Mellitus with diabetic polyneuropathy. - Perform blood glucose monitoring Q (every) Visit. - Durable Medical Equipment and Supplies: Glucometer supplies. - Call MD (Medical Doctor) if BS (Blood Sugar) Parameters (greater than) 240 for two consecutive tests. - Metformin HCL ER (MOD) by mouth tablet Extended Release 24-hour 500 mg (milligram) 2 tab (tablet) daily PO DMII (type II diabetes mellitus). - Patient is a type 2 diabetic managed by medications; no insulin prescribed. Last blood sugar taken on 01/11/2024 by skilled nurse was 128. There is a lack of documented evidence of diabetic precautions on the plan of care. During an interview on 08/18/2025 at 10:45 AM, the Director of Patient Services stated there were no diabetic precautions but there should be diabetic precautions listed on the plan of care under safety measures. B. Review of the Home Health Certification and Plan of Care for certification period 07/11/2025 to 09/08/2025 revealed the following: - Type 2 Diabetes Mellitus with diabetic polyneuropathy. - Perform blood glucose monitoring Q (every) Visit. - Durable Medical Equipment and Supplies: Glucometer supplies. - Call MD (Medical Doctor) if BS (Blood Sugar) Parameters (greater than) 240 for two consecutive tests. - Metformin HCL ER (MOD) by mouth tablet Extended Release 24-hour 500 mg (milligram) 2 tab (tablet) daily PO DMII (type II diabetes mellitus). - Patient has history of long-term use of oral hypoglycemic drugs…. Random BG (Blood glucose) 134, patient reports he finished lunch just ½ hour prior to this visit. There is a lack of documented evidence of diabetic precautions. During an interview on 08/18/2025 at 09:33 AM, the Quality Assurance (QA) Nurse stated that there are no diabetic precautions but there should be diabetic precautions listed on the plan of care under safety measures. Patient #2- This 72-year-old patient with diagnoses that include type 2 diabetes, non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin, and non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin was admitted to the agency on 7/25/2025. A.) Review of the Home Health Certification and Plan of Care for certification period 7/25/2025 to 9/22/2025 revealed the following diagnosis: Type 2 diabetes mellitus with diabetic neuropathy, unspecified. Review of the Home Health Certification and Plan of Care for certification period 7/25/2025 to 9/22/2025 revealed the following safety measures: universal precautions, falls precautions, oxygen precautions, and bleeding precautions. The agency failed to include diabetic precautions as a safety measure in the Plan of Care for a patient with an active diagnosis of diabetes. During interview on 8/18/2025 at 1:41 PM, the Registered Nurse stated that diabetic precautions should be listed as a safety measure but is not. B.) Review of the Home Health Certification and Plan of Care for certification period 7/25/2025 to 9/22/2025 revealed the following: nutritional requirement – Regular. Review of the Skilled Nursing Star of Care visit dated 7/25/2025 revealed the Registered Nurse documented the following: Nutrition education: Instructed on: Prescribed diet: Low Sodium During interview on 8/18/2025 at 1:46 PM, the Registered Nurse stated that the Regular diet ordered on the Plan of Care was incorrect; the patient is on a low sodium diet due to Edema. Patient #6- This 100-year-old patient with diagnoses that include generalized primary osteoarthritis, essential primary hypertension, and atherosclerotic heart disease of native coronary artery without angina pectoris was admitted to the home health agency on 03/27/2025. This record was chosen as a potentially avoidable event: Development of Urinary Tract Infection. A.) Review of the Physical Therapy Progress Note dated 4/10/2025 revealed the Physical Therapist documented the following: Patient has an OTC (over the counter) off-brand topical cream and was applied to L (left) knee to help alleviate pain. Review of the Physical Therapy with Treatment Visit Note dated 4/16/2025 revealed the Physical Therapist documented the following: Lower extremity pain: Location: R (right) Knee Type: Other, chronic Character: intermittent Exacerbated by: walking, prolonged standing Relieved by: Rest, other: Bengay and knee sleeve application Review of the Home Health Certification and Plan of Care for 3/27/2025 to 5/25/2025 lacks an order for a topical analgesic cream. During interview on 8/18/2025 at 12:31 PM, the Physical Therapist confirmed that the patient was using a medicated topical cream for knee pain and was unaware that the medication needed to be added to the plan of care. B.) Review of the Physical Therapy with Treatment Visit Note dated 4/16/2025 revealed the Physical Therapist documented the following: Lower extremity pain: Location: R (right) Knee Type: Other, chronic Character: intermittent Exacerbated by: walking, prolonged standing Relieved by: Rest, other: Bengay and knee sleeve application Review of the Home Health Certification and Plan of Care for certification period 3/27/2025 to 5/25/2025 lacks orders for application of knee sleeve During interview on 8/18/2025 at 12:33 PM, the Physical Therapist confirmed that the patient was using a knee sleeve in the home to assist with knee pain and was unaware that the plan of care needed to be updated to include the medical equipment. Patient #5 – This 82-year-old patient with the diagnoses of fall on same level, unspecified, chronic kidney disease, and unspecified diastolic congestive heart failure was admitted to the home care agency on 7/14/2025. Review of the Skilled Nursing Clinical Notes dated 7/14/2025 revealed the Registered Nurse documented the following: RN (Registered Nurse) reviewed fall prevention, home safety, use of 4 wheeled walker (4ww), use of PERS (personal emergency response system) and emergency plan. Review of the Home Health Certification and Plan of Care for certification period 7/14/2025 to 9/11/2025 reveals the following DME (durable medical equipment) and supplies: Hospital bed, rollator walker, shower bench, toilet seat. The Agency failed to ensure the plan of care included the patient’s personal emergency response system. During interview on 8/18/2025 at 11:37 AM the Director of Patient Services confirmed that the PERS system should be listed in the plan of care under DME/supplies, but it does not. Patient #1- This 64-year-old patient with diagnoses that include type 2 diabetes mellitus, diabetic chronic kidney disease, and unspecified diastolic congestive heart failure was admitted to the agency on 5/1/2025. Review of the Home Health Certification and Plan of Care for certification period 6/30/2025 to 8/28/2025 revealed the following: Principal Diagnosis: N/A Other Pertinent Diagnosis: Type 2 diabetes mellitus with diabetic chronic kidney disease, hypertensive and chronic kidney disease with heart failure and stage 1 through 4 chronic kidney disease, unspecified diastolic heart failure, chronic kidney disease, chronic obstructive pulmonary disease, pulmonary hypertension, acquired immunodeficiency syndrome, chronic respiratory failure with hypoxia, seizure disorder, obstructive sleep apnea. The Agency failed to ensure the plan of care included a principal diagnosis. During interview on 8/18/2025 at 9:43 AM the Director of Patient Services stated that the patient’s previous principal diagnosis in past certifications was discontinued when the patient no longer has leg wound. A new principal diagnosis was never entered but should have been 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 one (1) of seven (7) patients (Patient #1), the agency failed to provide services in accordance with physician orders and the Plan of Care. Failure to ensure patient care is provided in accordance with physician orders and the Plan of Care has the potential for patients to receive poor care and for health care needs to go unmet. The agency failed to ensure services were provided in accordance with physician orders and the Plan of Care as evidenced by: Patient #1- This 64-year-old patient with diagnoses that include type 2 diabetes mellitus, diabetic chronic kidney disease, and unspecified diastolic congestive heart failure was admitted to the agency on 5/1/2025. Review of the Home Health Certification and Plan of Care for certification period 6/30/2025 to 8/28/2025 revealed the following order: “Skilled Nursing to fill oral medications weekly and 2 (two) extra days for patient” Review of the Skilled Nursing Clinical Note Nurse dated 7/11/2025 revealed the following: “Two missing medications that are not in pill box. Discroll (vitamin d) and Lasix 40mg (milligrams). Patient states the medications are delivered to patient and patient expects a delivery this date. Will follow up with patient next business day. Will make PRN (as needed) visit to finish the fill as needed.” Review of the clinical record lacked documented evidence of a follow up visit to ensure all ordered medications were placed in the placed in the mediset. During interview on 8/18/2025 at 1204 PM, the Director of Patient Services (DPS) stated the clinician was unavailable for interview and confirmed that there is nothing documented in the clinical record that the Registered Nurse ever followed up on medication needs or complete medication fill as ordered by the physician and specified within the plan of care.”

“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 seven (7) patients (Patient #s: 1, 2, 4, 6, and 7), the agency failed to document complete and accurate clinical notes. Failure to document complete and accurate clinical and progress notes has a potential for unmet patient needs. Patient #7 – This 84-year-old patient with diagnoses that include chronic atrial fibrillation, unspecified, hypertensive heart disease with heart failure, and congestive heart failure was admitted to the home health agency on 07/23/2024. This record was chosen as a Potentially Avoidable: Discharge to the Community Needing Wound Care or Medication Assistance. Review of the Home Health Certification and Plan of Care for certification period 07/23/2024 to 09/20/2024 revealed the following: Other Pertinent Diagnoses: Acquired absence of right leg below knee SN (Skilled Nursing) SOC (Start of Care) Note: Patient returns home after being hospitalized 7/28-08/04/2023 with a diagnosis of septic shock, secondary to right lower necrotizing infection, and underwent a right BKA (Below Knee Amputation) and subsequently went to rehab for a year. Review of the Occupational Therapy (OASIS E) Routine Visit notes dated 08/01/2024, 08/02/2024, 08/20/2024, 08/27/2024, 08/28/2024, 09/04/2024, and 09/05/2024 revealed the Occupational Therapist documented the following: General Systems/Review/Skin/Amputation Amputation: Assess amputation site and/or prothesis: lower extremity. Lower Extremity – Leg Amputation: Right – above knee. Review of the Occupational Therapy (OASIS E) Initial Visit dated 08/14/2024 revealed the Occupational Therapist documented the following: General - Medical History: … acquired absence of right leg below knee… General Systems Review/Skin/Amputation – Amputation: lower extremity – leg amputation: right above the knee. Review of the Charts/Clinical Notes dated 08/14/2024 revealed the Occupational Therapist documented the following: Patient has a R (Right) AKA (Above the Knee Amputation) with prothesis and is independent with donning in the am (morning) and doffing at bedtime. The Occupational Therapist failed to ensure documentation is consistent. During an interview on 08/14/2025 at 04:03 PM, the Occupational Therapist stated that the patient has a below the knee amputation and that the OT documented incorrectly. Patient #4 – This 72-year-old patient with diagnoses that include chronic obstructive pulmonary disease, type II diabetes with diabetic polyneuropathy was admitted to the home health agency on 01/18/2024. Review of the Occupational Therapy (OASIS E) Routine Visit note dated 07/15/2025 revealed the Occupational Therapist documented the following under General Systems Review/Bladder and Bowel - Bowel: Other: Last BM (Bowel Movement): 07/20/2025. Documentation is inaccurate and does not accurately reflect the date of the patient’s last bowel movement. During an interview on 08/18/2025 at 12:38 PM, the Occupational Therapist stated that the documentation of the patient’s last bowel movement of 07/20/2025 was an error. Patient #1- This 64-year-old patient with diagnoses that include type 2 diabetes mellitus, diabetic chronic kidney disease, and unspecified diastolic congestive heart failure was admitted to the agency on 5/1/2025. Review of the Home Health Certification and Plan of Care for certification period 6/30/2025 to 8/28/2025 revealed the following order: Home Health Aide (HHA) services to continue 3 (three) times a week to assist with personal care, activities of daily living (ADL’s), meal prep. Review of the Skilled Nursing Routine Visit Note dated 7/11/2025 revealed the Registered Nurse documented following: Home Health Aide Supervision: No Home Health Aide Services. Skilled Nursing Clinical Note dated 7/11/2025 revealed the Registered Nurse documented the following: Home visit for skilled assessment and MPF. Patient ambulated to door when writer arrived. PCA present. She receives PCA services three times/week. During interview on 8/18/2025 at 12:02 PM, the Director of Patient Care Services (DPS) stated that the clinician is unavailable for interview but based on review of documentation and the clinical record, the Registered Nurse’s documentation is unclear, and confirmed the patient receives Home Health Aide Services. Patient #2- This 72-year-old patient with diagnoses that include type 2 diabetes, non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin, and non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin was admitted to the agency on 7/25/2025. Review of the Home Health Certification and Plan of Care for certification period 7/25/2025 to 9/22/2025 reveals the following short-term goals: absence of skin breakdown, preservation of skin integrity. Review of the Skilled Nurse Visit Note dated 8/1/2025 revealed the Registered Nurse documented the following: “Vital signs within parameters, afebrile. Patient states she has a blister left calf that opened during the night making a wet area on bedding. Left calf has superficial open area, pink, moist. Cleansed with wound cleanser, pat dry, triple antibiotic ointment, allevyn.” Review of the Visit Record dated 8/1/2025 revealed that the Registered Nurse documented the following: - ST (short-term): absence of skin breakdown + progressing as anticipated - ST (short-term): preservation of skin integrity + progressing as anticipated During interview on 8/18/2025 at 1:44 PM the Registered Nurse stated that documenting the goals as progressing is inaccurate and contradicts the clinical note findings. The Director of Patient Services further stated that there is an EMR (electronic medical record) limitation in which goals can only be documented as the following options: Progressing slowly, progressing as anticipated, rapidly progressing, and met. Patient #6- This 100-year-old patient with diagnoses that include generalized primary osteoarthritis, essential primary hypertension, and atherosclerotic heart disease of native coronary artery without angina pectoris was admitted to the home health agency on 03/27/2025. This record was chosen as a potentially avoidable event: Development of Urinary Tract Infection. Review of the Physical Therapy Routine Visit Note dated 4/24/2025 revealed the Physical Therapist documented following vital sign: 12:17 PM Pulse Oximetry 68.0% (at rest) Oxygen (no) During interview on 8/18/2025 at 12:36 PM, the Physical Therapist stated that the documented pulse oximetry of 68% was a typographical error, and there were no concerns with pulse oximetry reading at time of visit but does not recall what the actual reading was.”