People Home Health Svs Chha

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on review of clinical records and interviews, for one (1) of five (5) patients (Patient #3) requiring updates to the comprehensive assessment, the agency failed to ensure the assessments were of sufficient scope to identify current patient needs. Failure to ensure comprehensive assessments contain complete and accurate information has the potential for unmet patient needs. The agency failed to ensure the assessments were of sufficient scope to identify current patients needs as evidenced by: Patient #3 – This 40-year-old patient with diagnoses that include other cerebral palsy, atelectasis, and unspecified asthma, uncomplicated was admitted to the home care agency on 01/22/2025. Review of the Physical Therapy with Treatment (OASIS E1) v24.4 (PT w treatment) Routine Visit on 01/29/2025 revealed the Physical Therapist documented the following: - Pulse Oximetry: Time 08:40 AM – 85% Activity (At Rest) Oxygen (Yes – At night). - Respiratory: Respiratory: Patient offers no complaints. - Breath Sounds Detailed: General Lung Sounds and Color: + (positive) Crackles bilateral all lobes. - Description of Respiratory Status: No signs or symptoms of distress. - Left Lungs Sounds: Upper Lobe, Lower Lobe – Coarse crackles. - Right Lung Sounds: Upper Lobe, Middle Lobe, and Lower Lobe – Coarse Crackles. - Frequency of Oxygen Use: At night. - Method of Oxygen Delivery: Cannula. - Liter Flow Per Minute: Continuous 2L (liters). Review of the Chart/Clinical Notes dated 01/29/2025 revealed the Physical Therapist documented the following: SPO2 levels noted to fluctuating in between 85% - 89% … Upon auscultation noted coarse crackles bilaterally in all lobes of lungs. Registered Nurse at patient’s doctor’s office contacted at 08:51 AM and notified of all obtained vitals and also noted coarse crackles bilaterally in all lobes. The registered nurse updated the patient’s doctor and called back at 11:45 AM notifying doctor would like a chest x-ray for patient and that they would send the script for the same to patient’s group home. Called staff at group home at 11:47 AM and updated on doctor wanting chest x-ray for patient and that they would receive script for the same from the doctor’s office and that the doctor would like patient to be monitored for other symptoms. The group home staff verbalized understanding. Care team notified and updated on patient’s status. Review of the Physical Therapy with Treatment (OASIS E1) v24.4 (PT w treatment) Routine Visit – on – 02/05/2025 revealed the Physical Therapist documented the following: - Pulse Oximetry: Time 08:41 AM – 92% Activity (At Rest) Oxygen (No). - Respiratory: Respiratory: Patient offers no complaints. - Breath Sounds Detailed: General Lung Sounds and Color: Other: Crackles. - Description of Respiratory Status: No signs or symptoms of distress. - Left Lungs Sounds: Upper Lobe, Lower Lobe – Coarse crackles. - Right Lung Sounds: Upper Lobe, Middle Lobe, and Lower Lobe – Coarse Crackles. - Frequency of Oxygen Use: At night. - Method of Oxygen Delivery: Cannula. - Liter Flow Per Minute: Continuous 2L (liters). Review of the Charts/Clinical Notes dated 02/05/2025 revealed the Physical Therapist documented the following: Upon auscultation, continued noting of coarse crackles bilaterally in all lobes of lungs. No S/S (signs and symptoms) of respiratory distress noted. Staff reports no falls or changes in medications since last visit. Review of the clinical record from 01/22/2025 to 04/07/2025 lacked documented evidence that the Physical Therapist followed up with the staff from the group home to see if the patient had received the chest x-ray. During an interview on 04/09/2025 at 11:18 AM, the Physical Therapist stated, “I don’t know if the patient had the chest x-ray and that I did not follow up and check with the group home staff to see if the patient had a chest x-ray.” During an interview on 04/09/2025 at 11:19 AM, the Administrator stated that the physical therapist should have followed up with the staff from the group home to see if the patient received a chest x-ray.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on review of clinical records and interviews with staff, for one (1) of five (5) patients, (Patient #4), the agency failed to ensure that a comprehensive assessment consistent with the patient’s needs was performed within five (5) calendar days after the start of care. Failure to ensure a comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. The agency failed to ensure that a comprehensive assessment consistent with the patient’s needs was performed within five (5) calendar days after the start of care as evidenced by: Patient #4- This 83- year- old patient with diagnoses that include pressure ulcer of sacral region, stage 4, pressure ulcer of right heel, stage 2, and acute posthemorrhagic anemia was admitted to the home care agency on 3/11/2025. A. Review of the Home Health Certification and Plan of Care dated 3/11/2025 to 5/9/2025 revealed orders for Physical Therapy 1xweek x1week. Review of the clinical record reveals a Physical Therapy with Treatment initial visit dated 3/21/2025, ten (10) days after the start of care. During interview on 4/9/2025 at 10:08 AM, the Administrator stated that there was no documented evidence indicating why the Physical Therapy initial assessment was completed more than five (5) days following the start of care. B. Review of the Home Health Certification and Plan of Care dated 3/11/2025 to 5/9/2025 revealed orders for Occupational Therapy 1xweek x1week. Review of the clinical record reveals an Occupational Therapy with Treatment initial visit dated 3/20/2025, nine (9) days after the start of care. During interview on 4/9/2025 at 10:08 AM, the Administrator stated that there was no documented evidence indicating why the Occupational Therapy initial assessment was completed more than five (5) days following the start of care.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on review of clinical records and interviews with staff for one (1) of five (5) patients (Patient #5), the agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest the plan of care may need to be altered. Failure to promptly notify the physician to changes in the patient’s condition or needs that may suggest that outcomes are not being achieved and/or the plan of care should be altered has the potential to result in unmet patient needs and negative patient outcomes. The agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest the plan of care may need to be altered as evidenced by: Patient #5 – This 61-year-old patient with the diagnoses of pressure ulcer of sacral region, stage 2, epilepsy, unspecified, not intractable, without status epilepticus, and cerebral palsy, unspecified, was admitted to the home care agency on 10/08/2024. Review of the Home Health Certification and Plan of Care for 10/8/2024 to 12/6/2024 revealed “Assess wound location, size stage, drainage, wound bed and peri wound care.” A. Review of the Chart/Clinical Note dated 10/28/2024 revealed “Skilled Nursing completed wound care per order, tolerated well. No signs or symptoms. Wound is healed, no open areas, no drainage.” Review of the clinical record lacks documented evidence of notification to the physician regarding the change in the status of patient’s wound. During interview on 04/09/2025 at 10:56 AM, the Administrator stated there is no documentation stating the physician was promptly notified following the 10/28/2024 visit, however, the nurse did document notification of wound status to physician at next visit on 10/30/2024. B. Review of Chart/Clinical Note dated 11/08/2024 revealed “Skilled Nursing visit for wound care to sacral/coccyx wound. SN completed wound care per order, tolerated well. No signs or symptoms. Small area has reopened.” Review of the clinical record lacks documented evidence of notification to the physician regarding the change in the status of patient’s wound. During interview on 04/09/2025 at 10:59 AM, the Administrator confirmed there is no documentation stating the physician was notified regarding the reopening of the wound from 11/08/2024 visit. C. Review of the Skilled Nursing Routine Visit Note dated 11/20/2024 revealed “Skilled nursing visit for wound care to coccyx pressure ulcer wound, patient lying in bed upon arrival. Lungs clear bilaterally, vital signs within normal limits. Skilled nursing performed wound care per medical doctor orders, patient tolerated well. No signs or symptoms of infection noted, wound is healed.” Review of the clinical record lacks documented evidence of notification to the physician regarding the change in the status of patient’s wound. During interview on 04/09/2025 at 09:12 AM, the Registered Nurse confirmed there is no documentation stating the physician was notified regarding the healing of the wound from 11/20/2024 visit, Registered Nurse stated, “can’t recall whether physician was notified.””

“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 and Assessment Information Set submissions, clinical records, and interviews with agency staff for two (2) of seven (7) patients (Patient #s: 6 and 7), the agency failed to ensure Outcome and Assessment Information Set data accurately reflects the patient’s status at the time of the initial and discharge assessment. Failure to ensure accurate documentation of Outcome and Assessment Information Set data has the potential for negative outcomes. Patient #7 - This 26-year-old patient with diagnoses that include cerebral palsy, anxiety, and unspecified pruritus was admitted to the home health agency on 03/16/2023. This record was chosen as a potentially avoidable event: Substantial Decline in Management of Oral Medications. This is a Physical Therapy only case. Review of the Physical Therapy with Treatment Outcome and Assessment Information Set Start of Care dated 03/16/2023 revealed the Physical Therapist documented the patient is able to independently take the correct oral medication(s) and proper dosage(s) at the correct times. Review of the Physical Therapy with Treatment Outcome and Assessment Information Set Recertification Reassessments dated 05/11/2023, 07/12/2023, 09/08/2023, and 11/08/2023 and the Physical Therapy with Treatment Routine Visits dated 03/23/2023, 03/30/2023, 04/13/2023, 04/20/2023, 04/25/2023, 05/03/2023, 05/18/2023, 05/25/2023, 06/08/2023, 06/15/2023, 06/29/2023 07/06/2023, 07/20/2023, 07/26/2023, 08/02/2023, 08/09/2023, 08/16/2023, 08/23/2023, 08/30/2023, 09/13/2023, 09/20/2023, 09/27/2023, 10/11/2023, 10/18/2023, 10/25/2023, 11/01/2023, 11/29/2023, 12/06/2023, and 12/19/2023 revealed the Physical Therapist documented the patient has abnormal muscle tone, spastic extremities, and/or hypertonicity. Review of the Occupational Therapy Initial Visit dated 03/23/2023 and Occupational Therapy Routine Visits dated 03/30/2023, 04/06/2023, 04/13/2023, 04/20/2023, 04/27/2023, 05/04/2023, 05/11/2023, 05/18/2023, 05/25/2023, 06/08/2023, 06/15/2023, 06/22/2023, 06/29/2023, 07/13/2023, 07/18/2023, 07/27/2023, 08/10/2023, 08/17/2023, 08/24/2023, 09/06/2023, 09/13/2023, 09/20/2023, 09/27/2023, 10/04/2023, 10/11/2023, 10/18/2023, 10/25/2023, 11/01/2023, 11/08/2023, 11/15/2023, 11/22/2023, 11/29/2023, 12/06/2023, 12/13/2023, and 12/20/2023 revealed the Occupational Therapist documented the patient has abnormal muscle tone and/or spastic upper extremities, needs minimal assistance at times with dressing and bathing, and needs minimal assistance at times with left upper extremity activities of daily living. Review of the Charts/Clinical Notes effective 03/23/2023, 03/30/2023, 04/06/2023, 04/13/2023, 04/21/2023, 04/27/2023, 05/04/2023, 05/11/2023, 05/18/2023, 05/25/2023, 06/08/2023, 07/13/2023, 07/18/2023, 09/06/2023, and 11/08/2023 revealed the Occupational Therapist documented the patient has moderate to maximum difficulty with fine motor skills with the left hand. Review of the Outcome and Assessment Information Set Discharge from agency dated 01/04/2024 revealed the Occupational Therapist documented the patient is unable to take medication unless it is administered by another person. During interview on 07/16/2024 at 10:00 AM, the Occupational Therapist stated the patient is right hand dominant. The Occupational Therapist stated that an assessment of fine motor skills consists of the nine-hole peg test, the use of a sock holder, and the ability to pick items up and not drop them. The Occupational Therapist stated it would make sense that the patient would need assistance with medication administration because of the patient’s lack of dexterity. The agency failed to ensure the Physical Therapy with Treatment Outcome and Assessment Information Set Start of Care accurately reflects the patient’s status at the time of assessment. During interview on 07/16/2024 at 10:20 AM, the Administrator stated that the Physical Therapist responsible for the 03/16/2023 start of care is no longer employed by the agency, but based on the documentation throughout the record it would appear as though the Physical Therapist scored the patient’s ability to manage medications incorrectly at the start of care. Patient #6 – This 61-year-old patient with diagnoses that include displaced fracture of lateral malleolus of left fibula, subsequent encounter for closed fracture with routine healing, non-pressure chronic ulcer of other part of right foot with unspecified severity, and type 2 diabetes with foot ulcer was admitted to the home care agency on 02/08/2024. This record was chosen as a potentially avoidable event: Increase in Number of Pressure Ulcers. This is a therapy only case. Review of the Physical Therapy with Treatment OASIS E Start of Care visit dated 02/08/2024 revealed the Physical Therapist documented the following: Non-pressure chronic ulcer of other part of right foot with unspecified severity, M1306. Does this patient at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure ulcers/injuries): 0 – No M1322. Current Number of Stage 1 Pressure Injuries: Intact Skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.: 0 M1324. Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable: (Excludes pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar, or deep tissue injury.): NA – Patient had no pressure ulcer/injuries or no stageable pressure ulcer/injuries. M1330. Does this patient have a stasis ulcer?: 0 – No. M1340. Does this patient have a surgical wound?: - No. Skin: Skin Integrity: Non-surgical wound. See Incision/Wound Assessment. Indicate number of Incision/Wound Sites: 1. Plantar surface of R (right) foot: Site location: Specify location: Plantar surface of R foot, Present on SOC (Start of Care). Type: Diabetic neuropathic ulcer. Healing: Healing by secondary intent. Wound Measurement: Not measured. Incision/Wound Tissue Observed: Not able to visualize due to non-removable dressing placed by a RN (Registered Nurse) and patient is to attend wound clinic beginning next week. Surrounding tissue: Other: Unable to visualize, foot is wrapped entirely in non-removable dressing. Wound margins: not evaluated. Drain site and type: None. Dressing Change this Visit: No. Review of the Physical Therapy with Treatment OASIS E Discharge from Agency visit dated 02/22/2024 revealed the Physical Therapist documented the following: M1306. Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure ulcers/injuries): 1 – Yes. M1307. The Oldest Stage 2 Pressure that is present at discharge: (Excludes healed Stage 2 Pressure Ulcers): 1 – Was present at the most recent SOC (Start of Care)/ROC (Resumption of Care) assessment. M1324. Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable: (Excludes pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar, or deep tissue injury.): NA – Patient has no pressure ulcers/injuries or no stageable pressure ulcer/injuries. M1311. Unhealed Pressure Ulcer/Injuries at Each Stage or Unstageable. (M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage\A1. Stage 2: 0 (M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage\B1. Stage 3: 0 (M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage\C1. Stage 4: 0 (M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage\D1. Unstageable: Non-Removable dressing: 1 (M1311) Current number of Unhealed Pressure Ulcers/Injuries at Each Stage\D2. Number of these unstageable pressure ulcer/injuries that were present at the moat recent SOC/ROC: 1. (M1311) Current number of Unhealed Pressure Ulcers/Injuries at Each Stage\E1. Unstageable: Slough and/or eschar: 0. (M1311) Current number of Unhealed Pressure Ulcers/Injuries at Each Stage\F1. Unstageable: Deep tissue injury: 0. M1330. Does this patient have a Stasis Ulcer?: 0 – No. M1340. Does this patient have a Surgical Wound?: 0 -No. Skin Integrity: Non-surgical wound Skin Character: Normal See Incision/Wound Assessment: Indicate number of Incision/Wound Sites: 1. General Systems Review/Skin/Incision/Wound: Plantar surface of R (Right) foot: Site Location: Specify location: plantar surface of R (Right) foot, present at SOC (Start of Care). Type: Diabetic neuropathic ulcer. Healing: Healing by secondary intent. Wound measurement: Not measured. Incision/Wound Tissue Observed: Other: Not visualized due to non-removable dressing. Surrounding Tissue: Intact. Wound Margins: Not evaluated. Drain Site and Type: None. Drainage: None. Dressing changed this visit: No. The agency failed to ensure Physical Therapy with Treatment (OASIS E) – Discharge from Agency accurately reflects the patient’s status at the time of the assessment. During an interview on 07/16/2024 at 01:27 PM, the Physical Therapist stated that the wrong button was probably clicked and that the patient did not have a pressure ulcer.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on review of patient care records, agency policy and procedure, and interview with agency staff for one (1) of seven (7) patient records (Patient #5), the agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs. Specifically, the Physical Therapist failed to perform a complete assessment of the patient’s palliative care needs. Failure to ensure the initial comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. Patient #5 – This 52-year-old patient with diagnoses that include orthostatic hypotension, Down syndrome, unspecified and profound intellectual disabilities was admitted to the home health agency on 04/03/2023 and discharged on 04/14/2023. This record was chosen as a potentially avoidable event: Development of a Urinary Tract Infection. This is a Physical Therapy only case. Review of the agency policy entitled “Facilitating Access to Palliative Care Information and Counseling” last revised 07/2024 revealed the following: “1. At the time of the initial assessment and on an ongoing basis all clinicians should assess the patients need for access to palliative care…” Review of the Physical Therapy with Treatment Outcome and Assessment Information Set Start of Care dated 04/03/2024 lacked documented evidence the Physical Therapist assessed the patient’s palliative care needs. Review of the clinical record from 04/03/2023 to 04/14/2023 lacked documented evidence that the patient’s palliative care needs were assessed. The agency failed to ensure that the patient’s palliative care needs were assessed. During interview on 07/14/2024 at 12:25 PM, the Administrator stated that the assessment of the palliative care needs may have fallen off because there had been an update to NetSmart around this time. The Administrator stated that an assessment of a patient’s palliative care needs is an expectation, and it should have been done.”

“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 review, agency policy and procedure, and interview with agency staff, for three (3) of seven (7) patients (Patient #s: 2, 3, and 5), the clinical record lacked documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns. The issues are: - The clinical records lack documented evidence the Registered Nurse was involved in the medication review process for therapy-only cases. - The clinician failed to follow up on a major drug interaction identified during the drug regimen review process. Failure to conduct a complete medication review has the potential for the patient to experience medication side effects or to receive incorrect medication dosages. Review of the agency policy entitled, “Patient Assessments Drug Regimen Review” last revised 07/2024 revealed the following, “It shall be the responsibility of the Therapist to 2. Will notify the Registered Nurse Case Manager/Director of Patient Services of any changes/adverse effects. It shall be the responsibility of the Registered Nurse Case Manager/Designee to 1. Review the completed Medication Record with the therapist and will note any changes in medications since the last certification and review all medications on new admissions… 6. Will contact the patient’s physician with any identified problems. 7. Will document the date and time that the medication review was completed and any discussions with the therapist, pharmacists and or physician in the electronic medical record.” Patient #2 – This 42-year-old patient with diagnoses that include spastic quadriplegic cerebral palsy, essential (primary) hypertension, and chronic pain syndrome was admitted to the home health agency on 04/16/2024. This is a Physical Therapy only case. A. Review of the Wellness Visit note dated 02/02/2024 and faxed to agency on 04/15/2024 revealed the patient was taking the following medications at the time of the wellness visit: - Amlodipine Besylate 10 milligram tablet, take 1 tablet by mouth daily for hypertension; - Flonase Allergy Relief 50 micrograms/Act, inhale 2 sprays into each nostril daily for nose inflammation; - Medical marijuana as directed; - Melatonin ER 5 milligrams, 1 tablet by mouth nightly as needed; - Methocarbamol 500 milligrams, 1 tablet four times a day as needed; - Metoprolol Succinate ER 50 milligrams, take 1 tablet by mouth once daily for high blood pressure; - One Adult Multivitamin by mouth daily; - Naproxen 250 milligrams, 1 tablet by mouth twice daily as needed; - Neosporin + Pain/Itch/Scar 1%, apply topically every day as needed; - Omeprazole 20 milligrams, take 1 capsule by mouth once daily; - Pepto-Bismol 262 milligrams/15 milliliters, 2 tablespoons every 30 minutes – 1 hour as needed; - Sertraline HCL 50 milligrams, take 1 tablet by mouth once daily; - Simvastatin 20 milligrams, alternate 1 tablet with 1.5 tablets every other day; - Systane 0.4-0.3%, 1 drop per eye, 1-3 times per day for dry eyes; - Vitamin C 500 milligrams over the counter chew and swallow, 1 tablet by mouth daily for Vitamin C deficiency; and - Vitamin D -3 1000 units by mouth every day. Review of the Home Health Certification and Plan of Care for certification period 04/16/2024 – 06/14/2024 revealed orders for the following medications: - Metoprolol Succinate ER 50 milligrams, take 1 tablet by mouth once daily for high blood pressure; - Systane 0.4-0.3%, 1 drop per eye, 1-3 times per day for dry eyes; - Sertraline HCL 50 milligrams, take 1 tablet by mouth once daily for anxiety/depression; - Omeprazole 20 milligrams, take 1 capsule by mouth once daily for gastroesophageal reflux; - Naproxen 250 milligrams, 1 tablet by mouth as needed for chronic pain syndrome, maximum daily dose 1,100 milligrams; - Methocarbamol 500 milligrams, 1 tablet as needed for chronic pain syndrome; - Melatonin 5 milligrams, 1 tablet by mouth as needed; - Vitamin C 500 milligrams, 1 tablet by mouth daily for; - Vitamin D - 3 25 micrograms, 2 capsules by mouth daily - Simvastatin 20 milligrams, 1 tablet by mouth daily, 1.5 every other day for hypertension; - Amlodipine Besylate 10 milligram tablet, take 1 tablet by mouth daily for hypertension; and - Flonase Allergy Relief 50 micrograms/Act, inhale 2 sprays into each nostril daily for allergies. There are no orders for Multivitamin, Neosporin, or Pepto-Bismol. Review of the patient care record from 04/16/2024 to 07/09/2024 lacked documented evidence the Physical Therapist contacted the physician regarding the discrepancies identified between the medications included in the Wellness Visit note and what the patient was taking in the home. Additionally, there is a lack of documented evidence the Physical Therapist notified the Registered Nurse of the need to complete a drug review of all medications. Furthermore, there is no evidence that medication orders were verified with the physician. During interview on 07/16/2024 at 11:39 AM, the Administrator stated that there is a note that was written by the Physical Therapist dated 04/16/2024 which says that the Physical Therapist completed a medication reconciliation with a Registered Nurse at the doctor’s office; however, it does not specifically address the drugs that were omitted. The Administrator and the Registered Nurse/Director of Patient Services could not say if the patient should or should not be taking the omitted medications. B. Review of the Existing Drug/Drug Interactions completed on 04/16/2024 revealed the following: - Minor reaction between Metoprolol Succinate ER and Simvastatin; - Moderate reaction between Metoprolol Succinate ER and Naproxen; - Moderate reaction between Metoprolol Succinate ER and Sertraline HCl; - Moderate reaction between Amlodipine Besylate and Simvastatin; and - Major reaction between Naproxen and Sertraline HCl. Review of the Charts/Clinical Note effective 04/16/2024 revealed the Physical Therapist documented a drug-to-drug screen was run with a major interaction found between Sertraline and Naproxen and the Registered Nurse at the doctor’s office was notified. Review of the patient care record from 04/16/2024 to 07/09/2024 lacked documented evidence the Physical Therapist or the agency’s Registered Nurse followed up with the physician regarding the major drug interaction between Metoprolol Succinate ER and Sertraline HCl. Additionally, there is a lack of documented evidence the Physical Therapist or the agency’s Registered Nurse followed up with the physician regarding the minor reaction between Metoprolol Succinate ER and Simvastatin, moderate reaction between Metoprolol Succinate ER and Naproxen, moderate reaction between Metoprolol Succinate ER and Sertraline HCl, and moderate reaction between Amlodipine Besylate and Simvastatin. During interview on 07/16/2024 at 11:39 AM, the Registered Nurse/Director of Patient Services stated the clinician has been dealing with the doctor’s office directly and taking medication recommendations from the patient’s physician; the Registered Nurse/Director of Patient Services stated “I have not been involved in these discussions.” Lastly, the Registered Nurse/Director of Patient Services stated that how the therapists are completing the drug regimen review is not in line with the agency’s policy. Patient #5 – This 52-year-old patient with diagnoses that include orthostatic hypotension, Down Syndrome, unspecified and profound intellectual disabilities was admitted to the home health agency on 04/03/2023 and discharged on 04/14/2023. This record was chosen as a potentially avoidable event: Development of a Urinary Tract Infection. This is a Physical Therapy only case. Review of the Annual/New Patient Visit dated 10/27/2022 and faxed to the agency on 03/31/2023 revealed the patient was taking the following medications at the time of the Annual/New Patient Visit: - Vitamin B-12 1,000 micrograms, 1 tablet by mouth daily; - Loratadine – D 24 hour 10-240 milligrams, take 1 tablet by mouth once a day; - Mometasone Furoate 0.1%, apply to scalp every night at bedtime; - Benzoyl Peroxide-Erythromycin 5-3%, apply to affected area on face, neck, and anterior chest twice daily; - Diazepam 5 milligrams by mouth, 1 hour prior to dental procedure; - Docusate Sodium 100 milligrams, 1 capsule by mouth daily; - Diazepam 10 milligrams, take 1 tablet 30 minutes prior to CT scan; - Levothyroxine Sodium 50 micrograms, take 1 tablet by mouth daily; - Vitamin D3 5, take 1 capsule by mouth daily; - Petroleum, apply a thin layer topically to cracked hands at bedtime; - Head 1%; use twice weekly on Tuesday and Saturday; - Fish, take 1 capsule by mouth daily; - Atorvastatin Calcium 10 milligrams, take 1 tablet by mouth at bedtime; - Aveeno Moisturizing 1.2, apply topically to dry skin twice daily; - Prozac 20 milligrams, take 1 capsule by mouth daily; - Pseudoephedrine HCl 30 milligrams, take 1 tablet by mouth every 6 hours as needed; - Triple Antibiotic 3.5-400-5000, apply to affected area 3 times a day as needed to cuts, scratches and abrasions – clean area first; - Triamcinolone Acetonide 55 micrograms/act, 1 spray in each nostril daily; - Acetaminophen 325 milligrams as needed; - Tamsulosin HCL 0.4 milligrams, take 1 capsule by mouth twice daily with breakfast; - Polyethylene Glycol 3350 17 grams daily by mouth per the hospital; - GNP Miconazorb AF 2%, apply between all toes twice daily; - Ketoconazole 2%, apply to affected area 2-3 times per day; - Guaifenesin-DM 100-10 milligrams/5 milliliters every 6 hours as needed for cough; and - Levothyroxine 75 micrograms (no frequency or route specified. Review of the Home Health Certification and Plan of Care for certification period 04/03/2023 – 06/01/2023 revealed orders for the following medications: - Acetaminophen 325 milligrams, take 2 tablets by mouth every 4 hours as needed for pain and temperature greater than 101; - Lacosamide 50 milligrams, take 1 tablet by mouth twice a day for seizures; - Vitamin D3 50 micrograms, by mouth daily, supplement - Mometasone Furoate 0.1%, apply to scalp at bedtime for inflammation; - Finasteride 5 milligrams, take 1 tablet by mouth daily for urinary retention; - Triamcinolone Acetonide External Cream 0.025 %, 1 amount 3 times weekly (Monday, Wednesday, and Friday) to both ear canals for inflammation; - Altarussin DM 110-10 milligrams/5 milliliters, take 20 milliliters by mouth every 12 hours as needed for cough; - Benzoyl Peroxide-Erythromycin 5-3%, apply to affected area on face, neck, and anterior chest twice daily; - Ketoconazole 2%, apply one amount 3 times weekly (Monday, Wednesday, and Friday) to bottom of feet for fungus; - Triple Antibiotic 3.5-400-5000, 1 amount every 8 hours as needed for minor cuts and scrapes; - SudoGest 30 milligrams, take 2 tablets by mouth every 6 hours for cold and allergy symptom; - Triamcinolone Acetonide 55 micrograms/act, 1 spray in each nostril daily; - Petroleum jelly 1 amount at bedtime to cracked skins; - Allergy relief D-24 10-240 milligrams, take 1 tablet by mouth daily for allergies; - Levothyroxine Sodium 75 micrograms, take 1 tablet by mouth daily for hypothyroidism; - Fish Oil 1000 milligrams, take 1 capsule by mouth daily for supplement; - Docusate Sodium 100 milligrams, take 1 capsule by mouth daily for constipation; - Aveeno Active Naturals External Lotion 1.2 %, apply to dry skin twice daily; - Atorvastatin Calcium 10 milligrams, take 1 tablet by mouth at bedtime for cholesterol; and Fluoxetine HCl 40 milligrams, take half a capsule by mouth daily for urinary retention. A. There are no orders for Diazepam 5 milligrams or 10 milligrams, Levothyroxine Sodium 50 micrograms, Polyethylene Glycol, or Tamsulosin. B. The following medications are on the plan of care but are not on the Annual/New Patient note: Lacosamide and Finasteride. Review of the patient care record from 04/03/2023 to 04/14/2023 lacked documented evidence the Physical Therapist notified the Registered Nurse of the need to complete a drug review of all medications. Additionally, there is no evidence that the physician was contacted regarding the discrepancies identified between the medications included in the Annual/New Patient Visit note and what the patient was taking in the home. Furthermore, there is a lack of documented evidence that a complete review of all medications was done, and medication orders were verified with the physician. During interview on 07/14/2024 at 12:24 PM, the Administrator stated that the Physical Therapist responsible for completing the start of care is no longer employed by the agency. The Administrator stated that because the Annual/New Patient note was a year prior to the patient’s admission to the agency, that possibly the Physical Therapist used the medication and treatment record from the group home to help reconcile medications, but could not be certain. Patient #3 – This 58-year-old patient with diagnoses that include essential (primary hypertension) schizophrenia, and Down Syndrome, unspecified was admitted to the home health agency on 06/21/2024. This is a Physical Therapy only case. A. Review of the Facility Discharge Summary dated 06/18/2024 revealed the patient was discharged home on the following medications: - Lantus 20 units subcutaneous daily; - Vitamin D 1000 units, 1 tablet by mouth daily; - Haldol 5 milligrams, take 1.5 tablets by mouth every 12 hours; - Omeprazole 20 milligrams, take 1 capsule by mouth early morning; - Ziprasidone 80 milligrams, take 2 capsules by mouth at bedtime; - Tizanidine 4 milligrams, take 1 tablet by mouth every 6 hours as needed; - Sodium Chloride 1 gram, take 1 tablet by mouth 3 times daily at 10:00 AM, 02:00 PM, and 09:00 PM; - Januvia 50 milligrams, 1 tablet by mouth daily; - Oxcarbazepine 150 milligrams, take 1 tablet by mouth twice a day at 10:00 AM and 09:00 PM; - Metoprolol Succinate ER 50 milligrams, 1 tablet by mouth daily; - Metformin HCl 1000 milligrams, 1 tablet by mouth twice daily; - Lamotrigine 200 milligrams, 2 tablets by mouth at bedtime; - Zetia 10 milligrams, 1 tablet by mouth daily; - Docusate Sodium 100 milligrams, 1 tablet by mouth every 12 hours; - Bupropion HCl ER 150 milligrams, 1 tablet by mouth daily; - Benztropine Mesylate 1 milligram, 1 tablet by mouth daily; - Baclofen 10 milligrams, 1 tablet by mouth every 12 hours; and - Ammonium Lactate 12%, apply to both ankles daily. Review of the Home Health Certification and Plan of Care for certification period 06/21/2024 – 08/19/2024 revealed orders for the following medications: - Sodium Chloride 1 gram, 1 tablet by mouth every 8 hours for fluid balance; - Oxcarbazepine 150 milligrams, take 1 tablet by mouth twice for Schizophrenia; - Glumetza ER 1000 milligrams, 1 tablet by mouth twice daily for Type II diabetes; - Lamictal 200 milligrams, 2 tablets by mouth at bedtime for Schizophrenia; - Januvia 50 milligrams, 1 tablet by mouth daily in the morning for Type II diabetes; - Haldol 5 milligrams, take 1.5 tablets by mouth twice a day for pre-split Schizoaffective Disorder; - Ezetimibe 10 milligrams, 1 tablet by mouth daily for hypercholesterolemia; - Esomeprazole Magnesium 20 milligrams, take 1 capsule by mouth daily in the morning; - Drysol External Solution 20%, 1 amount externally nightly for hyperhidrosis; - Docusate Sodium 100 milligrams, 1 tablet by mouth twice a day for constipation; - Bupropion HCl ER 150 milligrams, 1 tablet by mouth daily for Schizophrenia; - Benztropine Mesylate 1 milligram, 1 tablet by mouth daily to prevent side effects from psych medications; - Baclofen 10 milligrams, 1 tablet by mouth twice a day for left lower foot drop/spasticity; and - Ammonium Lactate 12%, apply to both ankles daily for dry skin. There are no orders for Vitamin D, Ziprasidone, Tizanidine, or Metoprolol Succinate ER. Review of the patient care record from 06/21/2024 to 07/11/2024 lacked documented evidence the Physical Therapist notified the Registered Nurse of the need to complete a drug review of all medications. Additionally, there is no evidence that the physician was contacted regarding the discrepancies identified between the medications included in the facility discharge and what the patient was taking in the home. Furthermore, there is a lack of documented evidence that a complete review of all medications was done, and medication orders were verified with the physician. During interview on 07/16/2024 at 11:46 AM, the Administrator stated the Physical Therapist would be contacted and asked what the Physical Therapist reconciled the medications to The Administrator stated the Physical Therapist may have used more information for the reconciliation such as the medication administration and treatment records in the group home. As of exit, no further information was provided to refute the findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on review of clinical records and staff interviews for three (3) of seven (7) patients (Patient #s: 1, 2, and 4) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients. The issues are: The Plan of Care lacked a complete order for the administration of Melatonin. The Plan of Care lacked an order for Durable Medical Equipment. The Plan of Care lacked an order for the patient’s use of CPAP (Continuous Positive Airway Pressure) and settings. The Plan of Care lacked an order for blood glucose monitoring/A1C checks. The Plan of Care lacked an accurate diet order. The Plan of Care lacked an order for Boost. The Plan of Care lacked an order for a gel overlay or APP (alternating pressure) mattress. The Plan of Care lacked an order for oxygen 2 liters nasal cannula. Failure to develop a complete and accurate plan of care that is comprehensive and addresses patient needs has the potential to result in patient harm. Patient #2 – This 42-year-old patient with diagnoses that include spastic quadriplegic cerebral palsy, essential (primary) hypertension, and chronic pain syndrome was admitted to the home health agency on 04/16/2024. This is a Physical Therapy only case A. Review of the Home Health Certification and Plan of Care for certification period 04/16/2024 to 06/14/2024 revealed the order “Melatonin 5 milligrams, take one tablet by mouth as needed.” The order is incomplete and does not specify the frequency or the indication. During interview on 07/12/2023 at 12:30 PM, the Physical Therapist stated “It was an amateur mistake on my part. I know that now and it’s an error.” B. Review of the Physical Therapy Physical with Treatment Outcome and Assessment Information Set Start of Care dated 04/16/2024 revealed the Physical Therapist documented the patient has a device to call for help. Review of the Occupation Therapy Initial Visit dated 04/24/2023 revealed the Occupational Therapist documented the patient has a device to call for help. Review of the Home Health Certification and Plan of Care for certification period 04/16/2024 to 06/14/2024 lacked documented evidence of a safety device to call for help. The agency failed to ensure a comprehensive plan of care to include all durable medical equipment and supplies. During interview on 07/12/2024 at 12:57 PM, the Physical Therapist stated the patient has a life alert, and it is not on the plan of care. During interview on 07/16/2024 at 09:42 AM, the Occupational Therapist stated the device that the patient has is connected by the bedside, the Occupational Therapist is not certain what the device is, and the Occupational Therapist does not typically include these things on patient’s plans of care. Patient #1 – This 46-year-old patient with diagnoses that include unspecified open wound, right lower leg, subsequent encounter, unspecified intellectual disabilities, and prediabetes was admitted to the home care agency on 05/28/2024. A. Review of the SN (Skilled Nurse) – Nursing (OASIS E) Routine visit dated 07/03/2024 and 07/05/2024 revealed the Registered Nurse (RN) documented the following: Respiratory: General Lung Sounds and Color: Lung Sounds – clear all lobes. Description of Respiratory Status: No signs or symptoms of distress. Frequency of Oxygen Use: Patient does not use oxygen. Additional Detail: Positive Airway Pressure. Positive Airway Pressure System: CPAP. During an observational home visit on 07/10/2024 at 02:30 PM, the surveyor observed the patient to have a CPAP machine on the patient’s nightstand near the patient’s head of the bed. Review of the Home Health Certification and Plan of Care for certification period from 05/28/2024 to 07/26/2024 lacked an order for the patient’s use of CPAP and settings. During an interview on 07/11/2023 at 09:40 AM, the Administrator stated I do not see CPAP on the patient’s Plan of Care, will check with the Registered Nurse (RN)/Director of Patient Services (DPS) to see if the CPAP is listed on the Plan of Care and that if the patient is using CPAP, then the CPAP should be listed on the patient’s Plan of Care. During an interview on 07/11/2023 at 02:40 PM, the Administrator stated the RN/DPS did not see CPAP on the patient’s Plan of Care and that the CPAP should be listed on the patient’s Plan of Care. B. Review of the SN (Skilled Nurse) – Nursing (OASIS E) Routine visit dated 07/03/2024 and 07/05/2024 revealed the Registered Nurse (RN) documented the following: Respiratory: General Lung Sounds and Color: Lung Sounds – clear all lobes. Description of Respiratory Status: No signs or symptoms of distress. Frequency of Oxygen Use: Patient does not use oxygen. Additional Detail: Positive Airway Pressure. Positive Airway Pressure System: CPAP. During an observational home visit on 07/10/2024 at 02:30 PM, the surveyor observed the patient to have a CPAP machine on his nightstand near the patient’s head of the bed. Review of the Home Health Certification and Plan of Care for certification period from 05/28/2024 to 07/26/2024 revealed the following DME (Durable Medical Equipment) and Supplies: grab bars, four (4) layer wraps, wound cleanser, four (4) x fours (4s), and ABD (abdominal pad). There is a lack of documented evidence of orders for DME to include CPAP. During an interview on 07/11/2023 at 09:40 AM, the Administrator stated that I do not see CPAP on the patient’s Plan of Care, will check with the Registered Nurse (RN)/Director of Patient Services (DPS) to see if the CPAP is listed on the Plan of Care and that if the patient is using CPAP, then the CPAP should be listed on the patient’s Plan of Care. During an interview on 07/11/2023 at 02:40 PM, the Administrator stated the RN/DPS did not see CPAP on the patient’s Plan of Care and that the CPAP should be listed on the patient’s Plan of Care. C. Review of the Home Health Certification and Plan of Care for certification period from 05/28/2024 to 07/26/2024 revealed the following: - Prediabetes. - NCS (No concentrated sweets). - Metformin HCL by mouth solution 500 mg (milligrams)/5ml (milliliters) daily PO (by mouth). There is a lack of documented evidence of an order for blood glucose monitoring/A1C Checks. During an interview on 07/16/2024 at 10:11 AM, the Registered Nurse (RN)/Director of Patient Services (DPS) stated that when placing a phone call to the patient’s doctor and confirming the diagnosis of prediabetes and that the patient’s doctor checks the patient’s A1C at the patient’s appointments. The RN/DPS continued to state that the doctor checking the patient’s A1C at appointments should be listed as an order on the patient’s Plan of Care. Patient #4 – This 73-year-old patient with diagnoses that include type 2 diabetes with diabetic polyneuropathy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and chronic obstructive pulmonary disease, unspecified was admitted to the home care agency on 06/07/2024. This is a therapy only case. A. Review of Patient Referral from the physician’s office dated 06/03/2024 faxed on 06/04/2024 revealed a referral for physical therapy effective date 06/05/2024. Review of the History and Physical dated 05/31/2024 faxed from the patient’s physician on 06/03/2024 revealed the following: Patient was seen in her home today for f/u (follow up) care. Patient’s husband was present. Patient c/o (complaints of) decreased appetite attributing to missing teeth and issues with swallowing, also states “nothing tastes good.” … patient was advised small amount but frequent meals, average of 1600 calories a day. Patient drinks Boost two (2) bottles per day equivalent to 500 calories total. Patient is requesting for a home PT (Physical Therapist). Care Plan: Type 2 diabetes mellitus with unspecified complications: cw (unknown abbreviation) Glimepiride 4 mg (milligrams) BID (two (2) times a day), Ozempic (one (1) mg/dose) four (4) mg/three (3) ml one (1) mg injection once weekly, pioglitazone thirty (30) mg daily, diabetic diet, managed by endocrinology. Essential (primary) hypertension: bp (blood pressure) stable, monitor cw (unknown abbreviation) metoprolol tartrate fifty (50) mg BID, isosorbide mononitrate twenty (20) BID, low salt diet, monitor. Obesity: Counselled to lose weight, low cholesterol diet. Review of the Home Health Certification and Plan of Care for certification period 06/07/2024 to 08/05/2024 revealed an order for a Regular diet. Review of the clinical record from 06/07/2024 to 07/08/2024 (date of survey) lacked documented evidence of communication with the physician to clarify what diet the patient should be following. During an interview on 07/17/2024 at 10:58 AM, the Physical Therapist stated that the patient was asked about what diet the patient followed, and the patient stated that the patient does not follow a specific diet. The Physical Therapist continued to state that there was not a discussion with the physician regarding the diet the patient should be following but that there should have a discussion. B. Review of Patient Referral from the physician’s office dated 06/03/2024 faxed on 06/04/2024 revealed a referral for physical therapy effective date 06/05/2024. Review of the History and Physical dated 05/31/2024 faxed from the patient’s physician on 06/03/2024 revealed the following: Patient was seen in the patient’s home today for f/u (follow up) care. Patient’s husband was present. Patient c/o (complaints of) decreased appetite attributing to missing teeth and issues with swallowing, also states “nothing tastes good.” … patient was advised small amount but frequent meals, average of 1600 calories a day. Patient drinks Boost two (2) bottles per day equivalent to 500 calories total. Patient is requesting for a home PT (Physical Therapist). Review of the Home Health Certification and Plan of Care for certification period 06/07/2024 to 08/05/2024 lacked documented evidence of an order for the Boost two (2) bottle per day. Review of the clinical record from 06/07/2024 to 07/08/2024 (date of survey) lacks documented evidence of communication with the physician to clarify whether the patient should be drinking Boost two (2) bottles per day. During an interview on 07/17/2024 at 11:00 AM, the Physical Therapist stated that the patient did not mention about drinking two (2) bottles of Boost per day, and I did not reconcile the Boost with the physician as the Boost was not on the patient’s medication list. Review of the clinical record from 06/07/2024 to 07/08/2024 (date of survey) lacks documented evidence of communication with the physician to clarify whether the patient should be drinking Boost two (2) bottles per day. During an interview on 07/17/2024 at 11:00 AM, the Physical Therapist stated that the patient did not mention about drinking two (2) bottles of Boost per day, and I did not reconcile the Boost with the physician as the Boost was not on the patient’s medication list. C. Review of Patient Referral from the physician’s office dated 06/03/2024 faxed on 06/04/2024 revealed a referral for physical therapy effective date 06/05/2024. Review of the History and Physical dated 05/31/2024 faxed from the patient’s physician on 06/03/2024 revealed the following: Patient was seen in the patient’s home today for f/u (follow up) care. Care Plan: Plan: Patient’s husband was present. Patient needs gel overlay (on top of mattress) or an APP (alternating pressure) mattress. As mattress delivered is extremely hard. Mattress for the patient’s bariatric bed. Review of the Home Health Certification and Plan of Care for certification period 06/07/2024 to 08/05/2024 lacked documented evidence of an order for a gel overlay (on top of mattress) or an APP (alternating pressure) mattress or a mattress for the patient’s bariatric bed. Review of the clinical record from 06/07/2024 to 07/08/2024 (date of survey) lacked documented evidence of communication with the physician to clarify whether the patient should have a gel overlay (on top of mattress) or APP (alternating pressure) mattress or a mattress for the patient’s bariatric bed. During an interview on 07/17/2024 at 11:10 AM, the Physical Therapist stated that the patient did not have an APP mattress or gel overlay and that During an interview on 07/17/2024 at 11:14 AM, the Administrator stated the gel overlap and APP mattress were not part of the patient’s referral. During an interview on 07/17/2024 at 11:14 AM, the Physical Therapist stated that there was no need for a gel overlay or APP mattress because the gel overlay, and APP mattress were not part of the referral. D. Review of Patient Referral from the physician’s office dated 06/03/2024 faxed on 06/04/2024 revealed a referral for physical therapy effective date 06/05/2024. Review of the History and Physical dated 05/31/2024 faxed from the patient’s physician on 06/03/2024 revealed the following: Patient was seen in her home today for f/u (follow up) care. Care Plan: Plan: COPD (Chronic Obstructive Pulmonary Disease), history of COPD, not in acute exacerbation, albuterol inhalation every four (4) hours PRN (as needed), cw (unknown abbreviation) Trelegy Ellipta, 02 (oxygen) 2L (two (2) liters) NC (Nasal Cannula), O2 sat (oxygen saturation) remains at 92%, monitor. Review of the Home Health Certification and Plan of Care for certification period 06/07/2024 to 08/05/2024 lacked documented evidence of an order for the patient’s use of oxygen. Review of the clinical record from 06/07/2024 to 07/08/2024 (date of survey) lacked documented evidence of communication with the physician to clarify whether the patient should be utilizing oxygen. During an interview on 07/17/2024 at 11:15 AM, the Physical Therapist stated that the patient was not on oxygen when she did the initial visit.”

“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 two (2) of seven (7) patients (Patient #s: 2 and 6), the agency failed to ensure drugs, services, and treatments are administered in accordance with the orders of a physician or allowed practitioner that establishes and periodically reviews the plan of care. Issues are: The Physical Therapist failed to follow the Plan of Care and notify the physician for blood pressure outside of parameters. The agency failed to provide Physical Therapy Services in accordance with physician orders and the Plan of Care. Failure to ensure drugs, services, and treatments are administered in accordance with the orders of a physician or allowed practitioner that establishes and periodically reviews the plan of care has the potential for patients to receive poor care and for health care needs to go unmet. Patient #2 – This 42-year-old patient with diagnoses that include spastic quadriplegic cerebral palsy, essential (primary) hypertension, and chronic pain syndrome was admitted to the home health agency on 04/16/2024. This is a Physical Therapy only case. Review of the Home Health Certification and Plan of Care for certification period 04/16/2024 to 06/14/2024 revealed the following order: Physical Therapist to notify physician if blood pressure is outside of the range of 90/120-60/80. Review of the Physical Therapy with Treatment Routine Visit dated 05/03/2024 revealed the Physical Therapist documented the patient’s blood pressure was 128/82. Review of the Charts/Clinical Note effective 05/03/2024 revealed the Physical Therapist documented that Occupational Therapy received a verbal order from the medical doctor on 05/01/2024 to increase the blood pressure parameters to greater than 140/100 and less than 90/50. Review of the Physical Therapy with Treatment Routine Visit dated 05/07/2024 revealed the Physical Therapist documented the patient’s blood pressure was 130/88. Review of the Charts/Clinical Note effective 05/07/2024 revealed the Physical Therapist documented that the blood pressure parameters were changed to greater than 140/100 and less than 90/50. Review of the clinical record from 05/03/2024 through 07/09/2024 lacked documented evidence that the physician was notified when the patient’s blood pressure was outside of the range of 90/120-60/80. The Physical Therapist failed to ensure drugs, services, and treatments are administered in accordance with the orders of a physician or allowed practitioner that establishes and periodically reviews the plan of care. During interview on 07/12/2024 at 01:00 PM, the Administrator stated the Occupational Therapist obtained an order to increase the blood pressure parameters and changed the Occupational Therapy Plan of Care. The Administrator stated that the Physical Therapist did not obtain an order to increase the blood pressure parameters and update the Physical Therapy Plan of Care and should have. During interview on 07/16/2023 at 11:23 AM, the Occupational Therapist stated no supplemental order was generated for an increase to the blood pressure parameters because the Physical Therapist did not click the send order box. Patient #6 – This 61-year-old patient with diagnoses that include displaced fracture of lateral malleolus of left fibula, subsequent encounter for closed fracture with routine healing, non-pressure chronic ulcer of other part of right foot with unspecified severity, and type 2 diabetes with foot ulcer was admitted to the home care agency on 02/08/2024. This record was chosen as a potentially avoidable event: Increase in Number of Pressure Ulcers. This is a therapy only case. Review of the Home Health Certification and Home Health Certification and Plan of Care for certification period from 02/08/2024 to 04/07/2024 revealed the following orders: PT (Physical Therapy) one (1) time a week times one (1) week then two (2) times a week times two (2) weeks. Review of the clinical record from 02/11/2024 to 02/17/2024 revealed the PT services were provided on 02/15/2024. There is a lack of documented evidence of a second physical therapy visit for the week of 02/11/2024 to 02/172024. The agency failed to ensure Physical Therapy services were provided in accordance with physician orders and the Plan of Care. During an interview on 07/16/2024 at 01:22 PM, the Physical Therapist stated that there was a missed visit for the week of 02/11/2024 to 02/17/2024 and that there is documentation in an e-mail of the missed visit but no documentation in the clinical record of the missed visit.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Review of clinical records and interviews with staff for two (2) of seven (7) patients (Patient #s: 2 and 3), the agency failed to ensure the Plan of Care is reviewed and revised to reflect the patient’s current status. The issues are: The plan of care lacked an order for compression stockings to include when they should be donned and doffed and who was responsible for managing their application and removal. The plan of care lacked an order for wound care to include type, frequency, and who was responsible for performing it. The plan of care lacked an order for durable medical equipment, specifically a gait belt. Failure to ensure the plan of care is updated and revised has the potential to result in negative patient outcomes. Patient #3 – This 58-year-old patient with diagnoses that include essential (primary hypertension) schizophrenia, and Down Syndrome, unspecified was admitted to the home health agency on 06/21/2024. This is a Physical Therapy only case. A. Review of the Charts/Clinical Note effective 07/03/2024 revealed the Physical Therapist documented that compression stockings were measured and ordered for the patient to help with bilateral lower extremity edema. Review of the Charts/Clinical Note effective 07/04/2024 revealed the Occupational Therapist documented that the patient was noted to be wearing new compression stockings which were donned by staff. Review of the patient care record from 07/03/2024 to 07/11/2024 lacked documented evidence the plan of care was updated to include an order for compression stockings to include when they should be donned and doffed and who was responsible for managing their application and removal. The agency failed to ensure the Plan of Care is reviewed and revised to reflect the patient’s current status. During interview on 07/12/2024 at 12:40 PM, the Physical Therapist stated that the stockings were not there yet, there was a possible delay, and once they arrived at the group home a supplemental order would be added. During interview on 07/16/2024 at 11:00 AM, the Occupational Therapist stated the patient had the stockings on during the visit on 07/04/2024 and the group home staff had applied them. The Occupational Therapist stated a supplemental order could be placed; however, the Occupational Therapist stated, “I have never put in an order for compression stockings and I will have to learn.” B. Review of the Charts/Clinical Note effective 07/01/2024 revealed the Physical Therapist documented the following: “Upon inspection, therapist observed right medial ankle wound that was open with slight yellow slough present. Therapist measured wound at 7 centimeters wide and 1 centimeter tall. Group home staff denied request to have nursing come in and inspect as they will have their own group home nurse help with the wound. Group home staff to clean and cover wound for primary intent healing.” Review of the Charts/Clinical Note effective 07/03/2024 revealed the Physical Therapist documented the following: “Group home staff to clean and cover wound for primary intent healing. Staff instructed to cover and clean wound this visit secondary to wound not covered…Group home staff instructed to cover wound on right medial ankle with Band-Aid.” Review of the patient care record from 07/01/2024 to 07/11/2024 lacked documented evidence the plan of care was updated to include an order for wound care to include type, frequency, and who was responsible for performing it. The agency failed to ensure the Plan of Care is reviewed and revised to reflect the patient’s current status. During interview on 07/12/2024 at 12:33 PM, the Physical Therapist stated there are no wound care orders, the medical ankle wound is now closed, and “I have not directly spoken to the nurse at the group home.” Patient #2 – This 42-year-old patient with diagnoses that include spastic quadriplegic cerebral palsy, essential (primary) hypertension, and chronic pain syndrome was admitted to the home health agency on 04/16/2024. Review of the Occupational Therapy Initial Visit dated 06/20/2024 revealed the patient has a gait belt. Review of the patient care record from 06/20/2024 to 07/09/2024 lacked documented evidence the plan of care was updated to include an order for a gait belt. The agency failed to ensure the Plan of Care is reviewed and revised to reflect the patient’s current status. During interview on 07/16/2024 at 10:48 AM, the Administrator stated the gait belt should be on the plan of care if the patient is using it.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on review of clinical records, agency policy and procedure, and interviews with agency staff, for two (2) of seven (7) clinical records (Patient #s: 3 and 5), the agency failed to ensure there is ongoing interdisciplinary assessments and communication for patients receiving nursing and rehabilitation services. Issues are: Physical Therapy and Skilled Nurse failed to communicate regarding the patient’s wounds. Physical Therapy and Skilled nursing failed to communicate regarding the patient’s hypotension. Physical Therapy and Skilled Nursing failed to communicate regarding the patient’s development of a urinary tract infection. Failure to ensure there is ongoing interdisciplinary assessments and communication has the potential for negative patient outcomes. Patient #5 – This 52-year-old patient with diagnoses that include orthostatic hypotension, Down Syndrome, and unspecified and profound intellectual disabilities was admitted to the home health agency on 04/03/2023 and discharged on 04/14/2023. This record was chosen as a potentially avoidable event: Development of a Urinary Tract Infection. This is a Physical Therapy only case. Review of the Home Health Certification and Plan of Care for certification period 04/03/2023 revealed the following orders: - Amlodipine Besylate 2.5 milligrams, take one tablet by mouth daily for hypertension, and - Notify physician if blood pressure is outside of the range of greater than 140/90 or less than 100/70. Review of the Physical Therapy with Treatment Outcome and Assessment Information Set Start of Care dated 04/03/2023 revealed the Physical Therapist documented the patient’s blood pressure was 90/50, physician notified. Review of the Physical Therapy with Treatment Routine Visit dated 04/13/2023 revealed the Physical Therapist documented the patient’s bold pressure was 86/56, physician notified. Review of the Charts/Clinical Note dated 04/13/2023 revealed the Physical Therapist documented the following: “Staff reports patient was in the emergency room on Tuesday due to low blood pressure and urinary tract infection. New medication: Cefpodoxime 200 milligrams every 12 hours and discharged medication Amlodipine Besylate. His blood pressure today was 86/56, notified doctor. Attempted to get patient to participate in therapeutic exercise, manual therapy, and functional therapy. Multiple attempts made and patient continued to refuse and not participate. He is nonverbal and has difficulty following commands…Will attempt one more visit and then discharge if not cooperative.” Review of the Charts/Clinical Note dated 04/14/2023 revealed the Physical Therapist documented the following: “Patient discharged from physical therapy and home services effective 04/14/2023 due to noncompliance…blood pressure was 80/50 today, notified doctor and group home staff…” Review of the clinical record lacked documented evidence of ongoing interdisciplinary assessments and communication between the skilled professionals regarding the patient’s hypotension, medication changes, and development of a urinary tract infection. During interview on 07/17/2024 at 12:42 PM, the Administrator stated there was room for a nursing referral due to the changes. The Administrator stated the agency should not have discharged the patient when they did. Lastly, the Administrator stated that there should have been at least one nursing visit to follow up on the medication changes, the hypotension, and the status of the urinary tract infection. Patient #3 – This 58-year-old patient with diagnoses that include essential (primary hypertension) schizophrenia, and Down Syndrome, unspecified was admitted to the home health agency on 06/21/2024. This was a Physical Therapy only case Review of the Physical Therapy with Treatment Outcome and Assessment Information Set Start of Care dated 06/21/2024 revealed the Physical Therapist documented the patient’s skin is intact and there are no pressure ulcers, stasis ulcers, or surgical wounds. Review of the Charts/Clinical Note effective 07/01/2024 revealed the Physical Therapist documented the following: “Upon inspection, therapist observed right medial ankle wound that was open with slight yellow slough present. Therapist measured wound at 7 centimeters wide and 1 centimeter tall. Group home staff denied request to have nursing come in and inspect as they will have their own group home nurse help with the wound. Group home staff to clean and cover wound for primary intent healing...Agency staff notified…” It is unclear what the Physical Therapist communicated to agency staff. Review of the Charts/Clinical Note effective 07/03/2024 revealed the Physical Therapist documented the following: “Group home staff to clean and cover wound for primary intent healing. Staff instructed to cover and clean wound this visit secondary to wound not covered…Group home staff instructed to cover wound on right medial ankle with Band-Aid.” There is a lack of documented evidence of communication between the Physical Therapist and Skilled Nursing regrading the wound status and group home staff non-compliance with recommended wound care. Review of the clinical record lacked documented evidence of ongoing interdisciplinary assessments and communication between the skilled professionals regarding the patient’s wound. During interview on 07/12/2024 at 12:38 PM, the Physical Therapist stated, “I have not directly spoken to a Registered Nurse at the group home. During interview on 07/12/2024 at 12:40 PM, the Registered Nurse/Director of Patient Services stated’ I was not aware of the patient’s wounds.””

“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, 3, 4 and 6), the agency failed to document and complete and accurate clinical notes. Failure to document complete and accurate clinical and progress notes has the potential for unmet patient needs. Patient #3 – This 58-year-old patient with diagnoses that include essential (primary hypertension) schizophrenia, and Down Syndrome, unspecified was admitted to the home health agency on 06/21/2024. This patient is a Physical Therapy only case. A. Review of the Physical Therapy with Treatment Routine Visit note dated 07/01/2024 revealed the Physical Therapist documented no contact with the physician was required/made. Review of the Charts/Clinical Note effective 07/01/2024 revealed the Physical Therapist documented that an attempt was made to contact the doctor’s office, but the doctor was unreachable. Additionally, the Physical Therapist documented an attempt to contact the physician on the next business day would be made. Documentation regarding the physician contact is inconsistent. During interview on 07/12/2024 at 12:24 PM, the Physical Therapist stated it was a mis-click/human error on the part of the Physical Therapist and contact with the physician was attempted as per the note. B. Review of the facility discharge summary revealed the patient had allergies to the following: Statins, Atorvastatin, Accupril, and Lipitor. Review of the Home Health Certification and Plan of Care for certification period 06/21/2024 to 08/19/2024 revealed the patient has allergies to antihypertensives and antihyperlipidemics (only drug classifications were listed, not specific medications). The documentation is inaccurate and does not accurately reflect the patient’s drug allergies. During interview on 07/12/2024 at 11:59 AM, the Physical Therapist stated this information was what was provided by patient’s doctor at the start of care. The Physical Therapist stated the doctor’s office stated that the patient had allergies to antihypertensives and antihyperlipidemics so that is what was written. Patient #2 – This 42-year-old patient with diagnoses that include spastic quadriplegic cerebral palsy, essential (primary) hypertension, and chronic pain syndrome was admitted to the home health agency on 04/16/2024. This is a Physical Therapy only case. A. Review of the Home Health Certification and Plan of Care for certification period 04/16/2024 to 06/14/2024 revealed the Physical Therapist documented the patient completed medication management himself without assistance and is independent. Review of the Physical Therapy with Treatment Outcome and Assessment Information Set Start of Care dated 04/16/2024 revealed the Physical Therapist documented the patient is unable to take medication unless administered by another person. The documentation regarding the patient’s ability to manage medications is inconsistent. During interview on 07/12/2024 at 12:52 PM, the Physical Therapist stated that the patient can self administer medications, does not need reminders, does not need help, and does it independently. The Physical Therapist stated that the reason the patient was scored as dependent in the Outcome and Assessment Information Set is because the patient needs to use a wheelchair to access the medications, and the Physical Therapist thought that because of this the Outcome and Assessment Information Set needed to be scored as dependent. B. Review of the Physical Therapy with Treatment Outcome and Assessment Information Set Start of Care dated 06/13/2024 revealed the Physical Therapist documented the patient has an electric hospital bed. Review of the Occupational Therapy Initial Visit dated 06/20/2024 revealed the Occupational Therapist documented the patient has a non-electric hospital bed. The documentation regarding the patient’s hospital bed is inconsistent. During interview on 07/16/2024 at 10:48 AM, the Administrator stated the type of bed the patient has is unknow, but if the patient is using an electric hospital bed it should be listed on the patient’s plan of care. Patient #1 – This 46-year-old patient with diagnoses that include unspecified open wound, right lower leg, subsequent encounter, unspecified intellectual disabilities, and prediabetes was admitted to the home care agency on 05/28/2024. Review of the Home Health Certification and Plan of Care for certification period from 05/28/2024 to 07/26/2024 revealed the following orders: - SN (Skilled Nurse) two (2) times a week times one (1) week, three (3) PRN (as needed): for wound complications, and three (3) times a week times eight (8) weeks. - Wound care to be provided by SN (Skilled Nurse) three (3) times a week. - Assess wound location, size, stage, drainage, wound bed and peri-wound care. - Measure wound first dressing change of the week. - SN (Skilled Nurse) to perform wound care to Wound #1 Right Anterior Lower Extremity – remove old dressing, cleanse with wound cleaner, pat dry, xeroform gauze to wound bed, clobetasol cream to peri-wound, cover ABD (Abdominal Pad), secure with four (4) layer wrap. May use three (3) layer if four (4) layer is unavailable. Review of the SN – Nursing (OASIS E) Start of Care visit note dated 05/28/2024 revealed the Registered Nurse documented the following: Skin: Skin Integrity: Intact Skin Character: Normal Skin Color and Warmth – Extremities: Lower – no abnormalities noted, Upper – Ashen See Detailed Skin Assessment: Skin/Wound Education Instructed On: other: Instructed to leave dressing intact. Review of the Charts/Clinical Notes dated 05/28/2024 revealed the RN (Registered Nurse) documented the following: SN (Skilled Nurse) SOC (Start of Care). Home Visit for initiation of home care services for unspecified wound on right shin. Wound measures 6.0 cm x 4.2 cm x 0.1 cm. No drainage noted because dressing had been removed. The wound appears dry, pink without evidence of infection. Wound care to be provided to by SN (Skilled Nurse) 3xw (three (3) times a week). Wound care consists of cleanse with soap and water or wound cleanser, clobetasol 0.05% to skin surrounding the wound, Vaseline gauze to wound bed, ABD (abdominal pad) and apply 4 layer compression. There is a lack of documented evidence that wound care was provided. The agency failed to ensure documentation is complete. During an interview on 07/16/2024 at 10:31 AM, the Registered Nurse (RN)/Director of Patient Services (DPS) stated that the dressing was changed at this visit but cannot find the documentation that the dressing was changed. Patient #4 – This 73-year-old patient with diagnoses that include type 2 diabetes with diabetic polyneuropathy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and chronic obstructive pulmonary disease, unspecified was admitted to the home care agency on 06/07/2024. This is a therapy only case. A. Review of the Physical Therapy with Treatment (OASIS E) Routine Visit note dated 06/12/2024 revealed the PTA (Physical Therapy Assistant) documented the following: Care Management/Care Coordination – Physician contact: No contact required/made. Case Coordination: Communicated with the following: None. Review of the Charts/Clinical Notes dated 06/12/2024 revealed the Physical Therapy Assistant (PTA) documented the following: MD (medical doctor) and a different certified home health agency team notified regarding date of last BM (bowel movement) and elevated BP (Blood Pressure). Documentation regarding notification to the MD is inconsistent. During an interview on 07/16/2024 at 02:17 PM, the Physical Therapy Assistant (PTA) stated that contact with the patient’s MD regarding the date of the patient’s last bowel movement and elevated blood pressure was made. B. Review of the Charts/Clinical Notes dated 06/12/2024 revealed the Physical Therapy Assistant (PTA) documented the following: Patient states that the patient woke up at 11:30 AM and this writer arrived approximately at 3:40 PM. Patient educated on taking pills/checking blood glucose upon getting up in the morning. As a result of not taking medications, BP (blood pressure) was outside parameters at 140/70. Last BM (bowel movement) reported on 06/08/2024. Patient states, “I don’t eat much so not much comes out,” and states that it’s normal for me to not have a bowel movement for several days. MD (medical doctor) and a name of a different certified home health agency notified regarding date of last BM (bowel movement) and elevated BP (Blood Pressure). Review of the Charts/Clinical Notes dated 06/14/2024 revealed the Physical Therapy Assistant (PTA) documented the following: Blood pressure elevated outside parameters. Patient states I have not taken my medication despite it being approximately 03:00 PM at the time of the PT (Physical Therapy) treatment; this occurred at the last visit as well. Patient also admitted to not yet checking blood glucose today, also for the second consecutive visit. Education provided on the importance of taking medications on time as well as monitoring blood sugar. Name of a different certified home health agency and MD (medical doctor) notified of elevated BP (Blood Pressure) and patient not checking blood glucose. Documentation is inaccurate regarding what certified home health agency was notified. During an interview on 07/16/2024 at 02:17 PM, the Physical Therapy Assistant (PTA) stated that notification was provided to this certified home health agency (name of the certified home health agency) and not the certified home health agency that was documented in the charts/clinical notes. C. Review of the referral from the patient’s physician dated 05/31/2024 revealed the following: house visit for f/u (follow up) care. Patient was seen in the patient’s home today for f/u (follow up) care. Patient’s husband (name) was present. Review of the Physical Therapy with Treatment (OASIS E) Start of Care Visit note dated 06/07/2024 revealed the Physical Therapist documented the following: Caregiver: (M1100) Patient living situation: Patient lives with other person(s) in the home: around the clock. Type of Assistance: f. Supervision and safety: f. no assistance needed – patient is independent or does not have needs in this area. Evaluate: Identify Caregiver(s) Caregiver Identification: Spouse – The PCG (Primary Caregiver) is, Spouse – Present during the visit, Spouse – Spouse’s name is a different name than what is documented on the history and physical from the physician. Documentation is inaccurate and does not reflect the patient’s caregiver/spouse’s correct name. During an interview on 07/17/2024 at 11:17 AM, the Physical Therapist stated that patient’s caregiver/spouse’s name is what the history and physical from the physician states and that she must have made a typographical error. Patient #6 – This 61-year-old patient with diagnoses that include displaced fracture of lateral malleolus of left fibula, subsequent encounter for closed fracture with routine healing, non-pressure chronic ulcer of other part of right foot with unspecified severity, and type 2 diabetes with foot ulcer was admitted to the home care agency on 02/08/2024. This record was chosen as a potentially avoidable event: Increase in Number of Pressure Ulcers. Review of the Home Health Certification and Plan of Care for certification period 02/08/2024 to 04/07/2024 revealed the following: - Under DME (Durable Medical Equipment) and Supplies that the patient uses a 4WW (four (4) wheeled walker). Review of the Charts/Clinical Notes dated 02/08/204 revealed the Physical Therapist documented that the patient requires supervision at highest level of assist for ambulation with 2WW (two (2) wheeled walker) due to impulsivity and has ROM (Range of Motion) WNL (Within Normal Limits) …. And Patient to be seen one (1) week one (1), two (2) week two (2) for PT (Physical Therapy) in order to educate patient on donning CAM (Controlled Ankle Movement) boots so he can independently perform, ambulate with Mod I (Modified Independent) and adhere to safety precautions with 2WW (two (2) wheeled walker), improve strength to WFL (within functional limits) grossly in B LE (bilateral lower extremities, and is agreeable to the POC (Plan of Care). Review of the Physical Therapy with Treatment (OASIS E) visit note dated 02/08/2024 and 02/22/2024 revealed the Physical Therapist documented the following: patient uses a front wheeled walker. Review of the Physical Therapy with Treatment (OASIS E) visit note dated 02/15/2024 and 02/19/2024 revealed the Physical Therapist documented the following: the patient is gait training with a rolling walker. Review of the Charts/Clinical Notes dated 02/15/2024 revealed the Physical Therapist documented the following: … ambulated with supervision with 2WW (two (2) Wheeled Walker). Review of the Charts/Clinical Notes dated 02/19/2024 revealed the Physical Therapist documented the following: …. and ambulated with Mod I (Modified Independent) with 2WW (2 wheeled walker). Documentation regarding patient type of walker the patient uses is inconsistent. During an interview on 07/16/2024 at 01:24 PM, the Physical Therapist stated that the patient has a 4 wheeled walker and that a 2 wheeled walker would not need to be listed under durable medical equipment (DME) as the patient does not have a 2 wheeled walker.”

“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 patient care record review and interview with agency staff, for one (1) of three (3) patients with wounds (Patient # 3), the agency failed to follow current clinical practice guidelines and accepted professional standards when providing services. Specifically, the agency failed to develop and implement a comprehensive wound policy. Failure to develop and implement policies and procedures that adhere to accepted professional standards has the potential to result in unmet patient needs and inadequate care. Patient #3 – This 58-year-old patient with diagnoses that include essential (primary hypertension) schizophrenia, and Down Syndrome, unspecified was admitted to the home health agency on 06/21/2024. This is a Physical Therapy Only case. Review of the Physical Therapy Routine Visit dated 07/01/2024 revealed the Physical Therapist documented the patient has a Stage 1 pressure ulcer on his right medial ankle that measures 7 centimeters long by 1 centimeter wide. There is a lack of documented evidence of a wound depth. On 07/12/2024 at 02:30 PM, the wound care policy was requested. On 07/15/2024 at 09:15 AM the Administrator stated the agency does not really have a wound care policy, but that they follow best practice guidelines. On 07/15/2024 at 11:00 AM, the Administrator provided a policy entitled “Wound Management Policy and Procedure” last revised 12/01/2023. Review of the agency’s policy lacked a procedure for wound care to include wound measurements and wound assessment. The agency failed to develop and implement policies and procedures that adhere to accepted professional standards.”