Rebekah Certified Home Health Agency

“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 clinical record reviews, and staff interview, the agency failed to ensure the encoded OASIS (The Outcome and Assessment Information Set) assessments accurately reflect each patient’s status at the time of the assessment. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #14). Failure to ensure the encoded OASIS (The Outcome and Assessment Information Set) accurately reflect the patient’s status at the time of the assessment, has the potential for negative patient outcomes. The Finding Are: 1. Patient # 14 (PAE/Potentially Avoidable Event) has a Start of Care date of 03/07/2024 and discharge date of 03/28/2024 with the following diagnosis “Urinary Tract Infection, Acute Kidney Failure, Hypertensive Heart Disease without Heart Failure,” documented on the Home Health Certification and Plan of Care for the Certification Period 03/07/2024 to 05/05/2024. The Hospital Record documents: “Hospital Course: Date of Admission: 02/28/2024; Date of Discharge: 03/04/2024 ...He was found to have UTI which was treated with 5-day course of Ceftriaxone.” The OASIS (Outcome and Assessment Information Set) Start of Care 03/07/2024 documents: “M1600. Has this patient been treated for a Urinary Tract Infection in the past 14 days? 0 - No Is there any infection in the past 30 days prior to this assessment? a check mark in the box “No” The OASIS (Outcome and Assessment Information Set) Discharge: Visit date:03/28/2024 documents: “M1600. Has this patient been treated for a Urinary Tract Infection in the past 14 days? 1 - Yes.” There is no documented evidence that the OASIS (Outcome and Assessment Information Set) - Start of Care dated 03/07/2025 accurately reflects the patient’s status at the time of assessment. On 01/16/2025 at 02:30 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that all patients receive services as documented in their individualized plan of care. This was evident for five (5) of seventeen (17) clinical records reviewed (Patient: #2, #3, #8, #14, and #15). Failure to ensure that all patients receive services as documented in their individualized plan of care, has the potential for negative patient outcomes. The Findings Are: 2.Patient #3 (HV) has a Start of Care date of 08/13/2024 with diagnoses: Cardiac arrhythmia, Peripheral Vascular Disease, Unspecified, Pressure Ulcer of Unspecified site, unspecified stage, Essential Hypertension, Unspecified Asthma, Uncomplicated… documented on the Home Health Certification and Plan of Care for the Certification Period 12/11/2024 to 02/08/2025. The Home Health Certification and Plan of Care for the Certification Period 12/11/2024 to 02/08/2025 documents: Treatments and Orders for Discipline: Skilled Nurse: Assess/instruct in administration of injectable medications. Skilled Nurse to administer injectable medication as prescribed. On 01/14/2025 at 11:15AM an observational visit was conducted and the patient’s medication in the home were reviewed along with the patient’s medication profile. There is no documented evidence of injectable medications being prescribed for the patient in the plan of care. On 1/16/2025 at 4:00PM the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1.Patient #8 has a Start of Care Date of 11/21/2024 with the following diagnoses “Paroxysmal Atrial Fibrillation, Epilepsy, Essential (primary) Hypertension, Type 2 Diabetes Mellitus without Complications “ documented on the Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025. The Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025 documents: “SN (Skilled Nursing) Frequency: 1W1 (once a week for one week), 2W2 (two times a week for two weeks Starting Week of 11/21/2024. PT (Physical Therapy) Frequency: 1W1 (once a week for one week), 2W3 (two times a week for three weeks) Starting Week 11/21/2024” The clinical record documents Skilled Nursing visits on following dates: 12/19/2024, 12/27/2024, 12/31/2024, 01/03/2025, 01/07/2025 and 01/10/2025. The clinical record documents Physical Therapy visits on following dates: 12/21/2024, 12/27/2024, 12/31/2024, 01/03/2025, 01/07/2025 and 01/09/2025. There is no documented evidence of Physician order for Physical Therapy and Skilled Nursing visits after 12/18/2024. There is no documented evidence of following the Plan of Care as ordered by patient’s physician. On 01/16/2025 at 02:30 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings. 2.Patient #14 has a Start of Care Date of 03/07/2024 and discharge date of 03/28/2024 with the following diagnoses “Urinary Tract Infection, Acute Kidney Failure Essential (primary) Hypertension, Type 2 Diabetes Mellitus without Complications “ documented on the Home Health Certification and Plan of Care for the Certification Period 03/07/2024 to 05/05/2024. The Home Health Certification and Plan of Care for the Certification Period 03/07/2024 to 05/05/2024 documents: “PT (Physical Therapy) Frequency: 1W1 Starting Week of 03/10/2024” The clinical record documents Physical Therapy visits on following dates: 03/11/2024, 03/15/2024, 03/18/2024, 03/22/2024 and 03/25/2024. There is no documented evidence of physician order for Physical Therapy visits on following dates: 03/15/2024, 03/18/2024, 03/22/2024 and 03/25/2024. There is no documented evidence of following the Plan of Care as ordered by patient’s physician. On 01/16/2025 at 02:30 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings. 1.Patient #2 (Home Visit) with a Start of Care date of 1/1/2025 with diagnoses: Unspecified Systolic (Congested) Heart Failure, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Peripheral Vascular Disease, unspecified, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy unspecified, and hyperlipidemia, documented on the Home Health Certification and Plan of Care for the Certification Period 1/1/2025 to 3/1/2025. The Home Health Certification and Plan of Care for the Certification Period 1/1/2025 -3/1/2025 documents: PT (Physical Therapy) 1W1, 2W4 (one time for one week, two times a week for four weeks) starting 1/1/25. HHA (Home health aide) 1 W1, 3W4 x 4 hours (one time for one week, three times a week for four weeks.) SN (Skilled Nurse) to perform fingerstick blood glucose Q (every) visit. The clinical record lacks documented evidence of a Physical Therapy visit for the week starting 1/1/25. There is no documented evidence of communication with the doctor or patient regarding missed physical therapy visit for week of 1/1/25 or home health aide services for the dates 1/10 and 1/13/25. There is no documented evidence of the Skilled Nurse performing fingerstick blood glucose every visit. The clinical record lacks documented evidence of the patient receiving services as written in the plan of care. On 1/16/2025 at 4:00PM the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1.Patient #2 (Home Visit) with a Start of Care date of 1/1/2025 with diagnoses: Unspecified Systolic (Congested) Heart Failure, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Peripheral Vascular Disease, unspecified, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy unspecified, and hyperlipidemia, documented on the Home Health Certification and Plan of Care for the Certification Period 1/1/2025 to 3/1/2025. The Home Health Certification and Plan of Care for the Certification Period 1/1/2025 -3/1/2025 documents: PT (Physical Therapy) 1W1, 2W4 (one time for one week, two times a week for four weeks) starting 1/1/25. HHA (Home health aide) 1 W1, 3W4 x 4 hours (one time for one week, three times a week for four weeks.) SN (Skilled Nurse) to perform fingerstick blood glucose Q (every) visit. The clinical record lacks documented evidence of a Physical Therapy visit for the week starting 1/1/25. There is no documented evidence of communication with the doctor or patient regarding missed physical therapy visit for week of 1/1/25 or home health aide services for the dates 1/10 and 1/13/25. There is no documented evidence of the Skilled Nurse performing fingerstick blood glucose every visit. The clinical record lacks documented evidence of the patient receiving services as written in the plan of care. On 1/16/2025 at 4:00PM the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1.Patient #8 has a Start of Care Date of 11/21/2024 with the following diagnoses “Paroxysmal Atrial Fibrillation, Epilepsy, Essential (primary) Hypertension, Type 2 Diabetes Mellitus without Complications “ documented on the Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025. The Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025 documents: “SN (Skilled Nursing) Frequency: 1W1 (once a week for one week), 2W2 (two times a week for two weeks Starting Week of 11/21/2024. PT (Physical Therapy) Frequency: 1W1 (once a week for one week), 2W3 (two times a week for three weeks) Starting Week 11/21/2024” The clinical record documents Skilled Nursing visits on following dates: 12/19/2024, 12/27/2024, 12/31/2024, 01/03/2025, 01/07/2025 and 01/10/2025. The clinical record documents Physical Therapy visits on following dates: 12/21/2024, 12/27/2024, 12/31/2024, 01/03/2025, 01/07/2025 and 01/09/2025. There is no documented evidence of Physician order for Physical Therapy and Skilled Nursing visits after 12/18/2024. There is no documented evidence of following the Plan of Care as ordered by patient’s physician. On 01/16/2025 at 02:30 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings. 2.Patient #14 has a Start of Care Date of 03/07/2024 and discharge date of 03/28/2024 with the following diagnoses “Urinary Tract Infection, Acute Kidney Failure Essential (primary) Hypertension, Type 2 Diabetes Mellitus without Complications “ documented on the Home Health Certification and Plan of Care for the Certification Period 03/07/2024 to 05/05/2024. The Home Health Certification and Plan of Care for the Certification Period 03/07/2024 to 05/05/2024 documents: “PT (Physical Therapy) Frequency: 1W1 Starting Week of 03/10/2024” The clinical record documents Physical Therapy visits on following dates: 03/11/2024, 03/15/2024, 03/18/2024, 03/22/2024 and 03/25/2024. There is no documented evidence of physician order for Physical Therapy visits on following dates: 03/15/2024, 03/18/2024, 03/22/2024 and 03/25/2024. There is no documented evidence of following the Plan of Care as ordered by patient’s physician. On 01/16/2025 at 02:30 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings. 2.Patient #3 (HV) has a Start of Care date of 08/13/2024 with diagnoses: Cardiac arrhythmia, Peripheral Vascular Disease, Unspecified, Pressure Ulcer of Unspecified site, unspecified stage, Essential Hypertension, Unspecified Asthma, Uncomplicated… documented on the Home Health Certification and Plan of Care for the Certification Period 12/11/2024 to 02/08/2025. The Home Health Certification and Plan of Care for the Certification Period 12/11/2024 to 02/08/2025 documents: Treatments and Orders for Discipline: Skilled Nurse: Assess/instruct in administration of injectable medications. Skilled Nurse to administer injectable medication as prescribed. On 01/14/2025 at 11:15AM an observational visit was conducted and the patient’s medication in the home were reviewed along with the patient’s medication profile. There is no documented evidence of injectable medications being prescribed for the patient in the plan of care. On 1/16/2025 at 4:00PM the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. Patient #15 has a Start of Care Date of 05/28/2024, with the following diagnoses “Transient Cerebral Ischemic Attack, Epilepsy, Essential (primary) Hypertension, Type 2 Diabetes Mellitus without complications “ documented on the Home Health Certification and Plan of Care dated 05/28/2024 to 07/26/2024. The Home Health Certification and Plan of Care dated 05/28/2024 to 07/26/2024 documents: “SN (Skilled Nursing) Frequency: 2W3 (two times a week for three weeks) Starting Week of 05/28/2024.” The clinical record documents Skilled Nursing visits on following dates: 07/09/2024, 07/12/2024, 07/16/2024, and 07/24/2024. There is no documented evidence of physician order for Skilled Nursing visits on following dates: 07/09/2024, 07/12/2024, 07/16/2024, and 07/24/2024. There is no documented evidence of following the Plan of Care as ordered by patient’s physician. On 01/16/2025 at 02:30 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that all healthcare personnel follow standard infection control precautions. This was evident for two (2) of seventeen (17) clinical records reviewed (Patient: #1, and #4). Failure to monitor that all healthcare personnel follow standard infection control precautions, has the potential for negative patient outcomes. The Findings Are: The agency policy documents: Hand Hygiene-CDC Guidelines: Reviewed: 10/24: Procedure: … All staff will use the hand hygiene techniques, as set forth in the following procedure: …After coming in contact with patient’s intact skin, i.e. taking the patient’s blood pressure, pulse, lifting/moving the patient… 2. Patient #4 (Home Visit) with a Start of Care date of 01/01/2025 with diagnoses of: Unspecified Atrial Fibrillation, Pulmonary Hypertension unspecified, abdominal aortic aneurysm ruptured unspecified, and Essential Hypertension documented on the Home Health Certification and Plan of Care for the Certification Period from 01/01/2025 to 03/01/2025. On 01/14/2025 at 1:35PM, a home visit was conducted with the Physical Therapist and the following were observed: Hand Hygiene: During the Physical Therapist session, the therapist did not sanitize hands between touching the patient and the equipment. Bag Technique: The Home Health bag was placed on the floor without a barrier. The equipment for monitoring the patient’s blood pressure, temperature and oxygen level were removed from the bag and placed on the patient’s bed. Upon completion of the assessment, the equipment was returned to the bag without being sanitized. The Physical Therapist failed to follow the agency’s policy and procedure for hand hygiene and failed to follow standard precautions for use of equipment in the home to prevent the transmission of infection. On 1/16/2025 at 3:30PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. The agency policy documents: Hand Hygiene-CDC Guidelines: Reviewed: 10/24: Procedure: … All staff will use the hand hygiene techniques, as set forth in the following procedure: …After coming in contact with patient’s intact skin, i.e. Taking the patient’s blood pressure, pulse, lifting/moving the patient… Dry hands with clean paper towel. (Multiple use towels are not recommended… 1. Patient #1 (Home Visit) has a Start of Care date of 12/27/24 with diagnoses: Attention-deficit hyperactivity disorder, predominately hyperactive type, Tachycardia, Unspecified, Palpitations, Elevated blood-pressure, without diagnosis of hypertension, documented on the Home Health Certification and Plan of Care for the Certification Period 12/27/24 - 01/24/2025. On 01/13/2025 2:00 PM, a home visit was conducted with the Registered Nurse and the following was observed: Hand Hygiene: Upon entering the patient’s home, the Registered Nurse washed hands, removed a cloth from the Home Health bag, dried hands and returned the cloth to the Home Health bag. Bag Technique: The Home Health bag was placed on the floor without a barrier. The equipment for monitoring the patient’s blood pressure, temperature and the patient’s oxygen were removed from the bag. Upon completion of the assessment and the use of the equipment, the equipment was returned to the Home Health bag without being sanitized. The Registered Nurse failed to follow the agency’s policy and procedure for hand hygiene and failed to disinfect equipment after patient use and prior to returning the equipment to the Home Health bag. On 1/16/2025 at 3:30PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure all Home Health Aides receive a complete paraprofessional plan of care. This was evident for five(5) of five (5) clinical records (with Home Health Aides Services) reviewed. (Patient #1, #2, #4, #7, and #17). Failure to ensure all Home Health Aide receive a complete paraprofessional plan of care, has potential for negative patient outcomes. The Findings Are: 1. Patient #2 (Home Visit) with a Start of Care date of 01/01/2025 with diagnoses: Unspecified Systolic (Congested) Heart Failure, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Peripheral Vascular Disease, unspecified, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy unspecified, and hyperlipidemia, documented on the Home Health Certification and Plan of Care for the Certification Period 01/01/2025 to 03/01/2025. The Home Health Certification and Plan of Care for the Certification Period 01/01/2025 - 03/01/2025 documents: HHA (Home health aide) 1 W1, 3W4 x 4 hours (one time for one week, three times a week for four weeks). The Aide Care Plan dated 01/01/2025 documents: The following areas are blank/not checked: Orientation: Patient orientated; Home health aide instructed about: Client’s health condition and how it may affect provision of task: Tasks to be provided, work schedule, and safety and emergency procedure: Report to Care Manager or Clinical Supervisor or designee: Changes in mental status: Falls with or without injury: skin tears: other: Client absence from home or has moved. The clinical record lacks documented evidence that the Skilled Nurse provided a completed written aide’s plan of care with instructions. On 1/16/2025 at 4:00PM the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #4 (Home Visit) with a Start of Care date of 01/01/2025 with diagnoses: Unspecified Atrial Fibrillation, Pulmonary Hypertension unspecified, abdominal aortic aneurysm, ruptured unspecified, Essential Hypertension documented on the Home Health Certification and Plan of Care for the Certification Period from 01/01/2025 to 03/01/2025. The Home Health Certification and Plan of Care for the Certification Period 01/01/2025 - 03/01/2025 documents: HHA (Home health aide) 3W3, 2W1 (three times for three weeks, two times a week for one week) starting 01/05/2025. Client Monthly schedule documented home health aide services for 01/07/2025 9AM-1PM and 01/08/2025 9AM-10AM. There is no documented evidence of the Aide Care Plan and duty sheets. The clinical record lacks documented evidence that the Skilled Nurse provided a complete written aide’s plan of care with instructions. On 01/16/2025 at 02:30 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings. 3. Patient #1 has a Start of Care date of 12/27/24 with diagnoses: Attention-deficit hyperactivity disorder, predominately hyperactive type, Tachycardia, Unspecified, Palpitations, Elevated blood-pressure, without diagnosis of hypertension, documented on the Home Health Certification and Plan of Care for the Certification Period 12/27/24 - 01/24/2025. The Home Health Certification and Plan of Care for the Certification Period 12/24/2024 -02/24/2025documents: Aide Task and Frequency: Activity: Nutrition: Patient Support Activities: Personal Care: Treatment/Special Needs: Frequency: Every Visit- Monday, Thursday, Saturday. The Aide Care Plan dated 12/27/2024 documents: The following areas are blank/ not checked: Orientation: Patient orientated; Home health aide instructed about: Client’s health condition and how it may affect provision of task: Tasks to be provided, work schedule, and safety and emergency procedure: Report to Care Manager or Clinical Supervisor or designee: Changes in mental status: Falls with or without injury: skin tears: other: Client absence from home or has moved. There is no documented evidence of the aide and the client’s signature and the date on the Aides plan of care. The clinical lacks documented evidence of a written plan of care that is complete with instructions prepared by the Registered Nurse. On 1/16/2025 at 3:30PM the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 4. Patient #7 has a start of care date of 04/05/2024 with diagnosis: Urinary Tract Infection, site not specified documented on the Home Health Certification and Plan of Care for the Certification Period 04/05/2024- 06/03/2024. The Home Health Certification and Plan of Care for the Certification Period 1/1/2025 -3/1/2025documents: Aide Frequency: 3W4 (three times a week for four weeks) starting week of 04/07/2024. The Aide Care Plan dated 04/05/02024 documents: The following areas are blank/ not checked: Orientation: Patient orientated; Home health aide instructed about: Client’s health condition and how it may affect provision of task: Tasks to be provided, work schedule, and safety and emergency procedure: Report to Care Manager or Clinical Supervisor or designee: Changes in mental status: Falls with or without injury: skin tears: other: Client absence from home or has moved. There is no documented evidence of the Registered Nurse signature. The clinical record lacks documented evidence that the registered nurse provided a complete written aides’ plan of care with instructions. On 1/16/2025 at 4:00PM the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 5. Patient #17 has a Start of Care Date of 07/12/2024, with the following diagnoses “ Essential (primary) Hypertension, Type 2 Diabetes Mellitus without complications, Hyperglycemia “ documented on the Home Health Certification and Plan of Care dated 07/12/2024 to 09/09/2024. The Home Health Certification and Plan of Care dated 07/12/2024 to 09/09/2024 documents: “AIDE Frequency: 3W4 (three times a week for four weeks) Starting week of 07/14/2024.” The Aide Care Plan dated 07/12/2024 lacks documented evidence of safety precautions for Hypertension, Hypoglycemia and Hyperglycemia. The clinical record lacks documented evidence of a complete paraprofessional plan of care addressing the patient’s needs. On 01/17/2025 at 12:30 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to provide the patient with contact information for other agencies or providers who may be able to provide care. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #16). Failure to ensure that patients receive contact information for other agencies or providers who may be able to provide care, has the potential for negative patient outcomes. The Findings Are: Patient #16 has a Start of Care Date of 12/12/2024, with the following diagnoses “ Cerebral Infarction, Essential (primary) Hypertension, Type 2 Diabetes Mellitus without complications “ documented on the Home Health Certification and Plan of Care dated 12/12/2024 to 02/09/2025. The Face-to-Face Encounter Dated 12/17/2024 documents: “I certify that, based on my findings, the following home health services are medically necessary for this Patient: Nursing, Physical Therapy, Speech Language Pathology, Occupational Therapy, Home Health Aide.” The Home Health Certification and Plan of Care dated 12/12/2024 to 02/09/2025 documents following services: “PT (Physical Therapy) Frequency: 2W4 ( two times a week for four weeks); SN (Skilled Nursing) Frequency: 1W1(once a week for one week), 2W1 (two times a week for one week), 1W1(once a week for one week), 3W1(three times a week for one week), 1W1 (once a week for one week) Starting Week of 12/12/2024.” On 01/16/2025 at 02:30 pm, the Director of Patient Services was interviewed and stated: “The agency does not provide Speech Language Pathology, and Occupational Therapy Services.” The Clinical Record lacks documented evidence of any discussion regarding Speech Language Pathology, and Occupational Therapy Services. There is no documented evidence that the agency provided the patient with contact information for other agencies or providers who may be able to provide care. On 01/16/2025 at 02:30 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on clinical record reviews, and staff interview, the agency failed to ensure all assessments were conducted within the required time frames for all patients. This was evident for one (1) of seventeen (17) clinical records reviewed. (Patient: #1). Failure to ensure all assessments are conducted within the required time frames for all patients, has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #1 (Home Visit) has a Start of Care date of 12/27/24 with diagnoses: Attention-deficit hyperactivity disorder, predominately hyperactive type, Tachycardia, Unspecified, Palpitations, Elevated blood-pressure, without diagnosis of hypertension, documented on the Home Health Certification and Plan of Care for the Certification Period 12/27/24 - 01/24/2025. On 01/02/2025 the clinical record documents OASIS (Outcome and Assessment Information Set)- Transfer to Inpatient Facility. The Inpatient Discharge Summary documents: Admission Date: 01/02/2025- Discharge Date 01/04/2025. The OASIS (Outcome and Assessment Information Set)- Resumption of Care documents visit date 01/09/2025. The clinical record lacks documented evidence of the patient being assessed within 48 hours of the patient’s return home from the hospital. On 01/16/2025 at 3:15PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that the assessment is accurate. This was evident for three (3) of seventeen (17) clinical records reviewed (Patient: #2, #5, and #6). Failure to ensure that the assessment is accurate, has the potential for negative patient outcomes. The Findings Are: 2. Patient #5 has a Start of Care date of 12/18/2024 with diagnoses: Respiratory failure, Unspecified whether with hypoxia or hypercapnia, Hypertensive emergency, Type 2 Diabetes Mellitus without complications … documented on the Home Health Certification and Plan of Care for the Certification Period 12/18/2024 -02/15/2025. The OASIS (Outcome and Assessment Information Set)- Start of Care documents: Cognitive Patterns: C0100: Patient is rarely/ never understood. M1700 Cognitive Functioning: Alert/oriented, able to focus and shift attention, comprehends and recalls tasks directions independently. The clinical record lacks documented evidence of the skilled nurse performing a complete and accurate assessment of the patient’s cognitive status. On 1/16/2025 at 3:30PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #6 has a Start of Care date of 01/03/2025 with diagnoses: Aftercare following surgery for neoplasm, Malignant neoplasm of unspecified part of left bronchus or lung… documented on the Home Health Certification and Plan of Care for the Certification Period 01/03/2025 -03/03/2025. The OASIS (Outcome and Assessment Information Set)- Start of Care documents: Cognitive Patterns: C0100: Patient is rarely/ never understood. M1700 Cognitive Functioning: Alert/oriented, able to focus and shift attention, comprehends and recalls tasks directions independently. The clinical record lacks documented evidence of the skilled nurse performing a complete and accurate assessment of the patient’s cognitive status. On 1/16/2025 at 3:30PM the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1.Patient #2 (Home Visit) with a Start of Care date of 1/1/2025 with diagnoses: Unspecified Systolic (Congested) Heart Failure, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Peripheral Vascular Disease, unspecified, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy unspecified, and hyperlipidemia, documented on the Home Health Certification and Plan of Care for the Certification Period 1/1/2025 to 3/1/2025. The Home Health Certification and Plan of Care for the Certification Period 1/1/2025 to 3/1/2025 documents: SN (Skilled Nurse) 2 W1, 1W 3 (two times a week for one week, one time a week for three weeks) starting week of 01/01/2025. General Disease Processes, skilled assessment of all body systems. The Skilled Nurse Sub sequential Visit dated 1/4, and the Skilled Nurse Routine Visit dated 1/9, and 1/13 documents: Respiratory: Genitourinary: Cardiovascular: Emotional Status: Pain: Skin: Digestive Nutrition: N/A (not applicable). The clinical record lacks documented evidence of the skilled nurse performing a complete and accurate assessment on each visit. On 1/16/2025 at 4:00PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that all medications were reviewed and accurately documented in the patient’s plan of care. This was evident for three (3) of seventeen (17) clinical records reviewed (Patient: #2, #4, and #10). Failure to ensure that all medications are reviewed and accurately documented in the patient’s plan of care, has the potential for negative patient outcomes. The Findings Are: 1.Patient #10 (Home Visit) has a Start of Care Date of 12/26/2024 with the following diagnoses “Cerebral Infarction, Essential (primary) Hypertension, Hyperlipidemia, Malignant Neoplasm of Lower-Inner of Right Female Breast “ documented on the Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025. The Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025 documents: “SN (Skilled Nurse) Frequency: 1W1 (once a week for one week), 2W1 two times a week for one week), 1W2 (once a week for two weeks) Starting Week of 12/26/2024” On 01/14/2025 a home visit was conducted, and the following medications were observed: “Calcium 600 + Vitamin D3 take one (1) tablet up to two times daily; Vitamin B12 500 mg take 1 tablet daily; Vitamin C 500 mg take 1 tablet daily.” The patient was interviewed and stated:” I’ve been taking Vitamin Calcium 600 + Vitamin D3 two times a day for two years, Vitamin C 1 tablet a day and Vitamin B12 one tablet a day about a year.” There is no documented evidence the Plan of Care includes following medication: “Calcium 600 + Vitamin D3 take one (1) tablet up to two times daily; Vitamin B12 500 mg 1 tablet daily; Vitamin C 500 mg 1 tablet daily.” There is no documented evidence of all the medications being reviewed and reconciled. On 01/16/2025 at 02:30 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings. 1.Patient #2 (Home Visit) with a Start of Care date of 1/1/2025 with diagnoses: Unspecified Systolic (Congested) Heart Failure, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Peripheral Vascular Disease, unspecified, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy unspecified, and hyperlipidemia, documented on the Home Health Certification and Plan of Care for the Certification Period 1/1/2025 to 3/1/2025. The Home Health Certification and Plan of Care for the Certification Period 1/1/2025 -3/1/2025 documents: SN (Skilled Nurse) 2 W1, 1W3 (two times a week for one week, one time a week for three weeks) starting week of 01/01/2025. Assess/instruct in use of pill dispenser, prefill medication planner. On 1/13/25 at 1PM a home visit was conducted, the patient’s medication profile documents: Atorvastatin 40mg oral tablet once a day at night and Synthroid 175mcg oral tab once a day. The following medications were observed in the home: Atorvastatin 40mg oral tablet once a day at night. The patient and family said Atorvastatin had expired and showed a bottle of Atorvastatin with a discard date of 12/21/24, Synthroid 75mcg oral tab once a day was documented on the bottle in the patient’s home. On 1/13/25 during the home visit there was no evidence of a pill dispenser or prefill medication planner. The clinical record lacks documented evidence of all medications the patient is currently using. On 1/16/2025 at 4:00PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #4 (Home Visit) with a Start of Care date of 1/1/2025 with diagnoses of: Unspecified Atrial Fibrillation, Pulmonary Hypertension unspecified, abdominal aortic aneurysm ruptured unspecified, and Essential Hypertension documented on the Home Health Certification and Plan of Care for the Certification Period from 1/1/2025 to 3/1/2025. The Home Health Certification and Plan of Care for the Certification Period 1/1/2025 -3/1/2025 document medications: Daptomycin 1000mg/100ml-NaCl 0.9% intravenous solution once daily IV and Torsemide 20mg oral tablets every 12 hours per orem. Assess and instruct in use of pill dispenser, prefilled insulin syringes, prefilled medication planner, clinician to report potentially clinically significant medications issues to physician within 1 calendar day. On 1/14/2025 at 1PM a home visit was conducted, and meds observed in the home were: Daptomycin 650mg (milligrams) in NS (Normal Saline) 13ml (milliliters), infuse over 3-5 minutes Q 24HRS (hours) until 2/5/25. No Torsemide was observed in the home. Family said the medication was not received or taken since hospital discharge. There is no evidence of a pill dispenser, prefill medication planner, prefill insulin syringes. There is no documented evidence of a follow up with physician in 1 calendar day for medication issues. The clinical record lacks documented evidence of all medications the patient is currently using. On 01/16/2025 at 02:30 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey 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 clinical record reviews, and staff interviews, the agency failed to ensure each patient’s individualized plan of care include all the required information. This was evident for eight (8) of seventeen (17) clinical records reviewed (Patients: #2, #5, #6, #8, #11, #15, #16, and #17). Failure to ensure individualized plan of care includes all the required information, has the potential risk for negative patient outcomes. The Findings Are: 1. The Home Health Certification and Plan of Care for following patients: #2, #8, #11, #15, #16, and #17 documents: “SN (Skilled Nursing) to perform finger stick blood sugar Q (every) visit.” The agency lacks documented evidence of CLIA (Clinical Laboratory Improvement Amendments) waiver. On 01/16/2025 at 02:30 pm, the Administrator was interviewed and stated: “We instruct our nurses to educate patients to perform finger stick blood sugar. We are working with the new computer system, and we are working on fixing the issue.” The Home Health Certification and Plan of Care for following patients: #2, #8, #11, #15, #16, and #17 lacks documented evidence of identification who and how often finger stick blood sugar is performed, and parameters to notify physician for abnormal findings. On 01/17/2025 at 12:30 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings. 2. Patient #5 has a Start of Care date of 12/18/2024 with diagnoses: Respiratory failure, Unspecified whether with hypoxia or hypercapnia, Hypertensive emergency, Type 2 Diabetes Mellitus without complications … documented on the Home Health Certification and Plan of Care for the Certification Period 12/18/2024 - 02/15/2025. The Home Health Certification and Plan of Care for the Certification Period 12/18/2024 - 02/15/2025 documents: Treatments and Orders for Disciplines: SN (Skilled Nurse) Frequency 2W1, 1W3 (two times a week for one week, one time a week for three weeks) starting 12/12/2024. Diabetes: SN (Skilled Nurse) to assess and instruct patient/caregiver in the use of glucometer and recording of results. The Plan of Care lacks documented evidence of the frequency for blood glucose monitoring, and parameters for when to notify the physician. On 01/16/2025 at 3:30PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #6 has a Start of Care date of 01/03/2025 with diagnoses: Aftercare following surgery for neoplasm, Malignant neoplasm of unspecified part of left bronchus or lung… documented on the Home Health Certification and Plan of Care for the Certification Period 01/03/2025 - 03/03/2025. The Home Health Certification and Plan of Care for Certification Period 01/03/2025 - 03/03/2025 documents: Treatments and Orders for Disciplines: SN (Skilled Nurse) Frequency: 1W5 (one time a week for five weeks) starting week of 01/03/2025. Wound Care: Patient/Caregiver verbalize/demonstrates knowledge of wound treatment plan by first visit. Instruct patient on signs and symptoms of infection (drainage, fever, redness in the surrounding area and severe pain/ swelling. Assess wound location, size stage, drainage, wound bed, and periwound care every week. Patient/Caregiver will demonstrate independence in wound care by week 3, and symptoms of infection to report by week 2. The clinical record lacks documented evidence of an individualized plan of care that includes physician orders for wound care treatments. On 01/16/2025 at 3:30PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 5. Patient #8 has a Start of Care Date of 11/21/2024 with the following diagnoses “ Paroxysmal Atrial Fibrillation, Type 2 Diabetes Mellitus without Complications, Essential Hypertension” as documented on the Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025. The Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025 documents: “SN (Skilled Nurse) Frequency: 1W1 (once a week for one week), 2W2 (two times a week for two weeks) Starting Week of 11/21/2024. PT (Physical Therapy) Frequency: 1W1 (once a week for one week) 2W3 (two times a week for three weeks) Starting Week of 11/21/2024.” The Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025 documents: “DME (Durable Medical Equipment): No DME/Supplies required.” The OASIS (Outcome and Assessment Information Set) Start of Care dated 11/21/2024 documents: “Mobility: Indicate the type of wheelchair or scooter used. 1- Manual Transportation Assistance Level: a check mark in the box “Wheelchair”” On 1/14/2025 a home visit was conducted, and the following was observed: Patient #8 is utilizing a manual wheelchair and electric scooter. (Patient has right below the knee amputation) There is no documented evidence of the Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025 including “manual wheelchair and motorized scooter.” There is no documented evidence of the established Plan of Care (POC) being individualized and completed to address the patient needs. On 1/17/2025 at 1:30 pm, Administrator and the Director of Patient Services were interviewed and were unable to provide an explanation for the survey findings. 6. Patient #11 has a Start of Care Date of 12/31/2024 with the following diagnoses “Acute Gastritis without Bleeding, Type 2 Diabetes Mellitus without Complications, Human Immunodeficiency Virus Disease” documented on the Home Health Certification and Plan of Care for the Certification Period 12/31/2024 to 02/28/2025. The Home Health Certification and Plan of Care for the Certification Period 12/31/2024 to 02/28/2025 documents: “SN (Skilled Nurse) Frequency: 3W1 (three times a week for one week), 2W2 (two times a week for two weeks), 1W1 (once a week for one week) Starting Week of 12/31/2024” The Home Health Certification and Plan of Care for the Certification Period 12/31/2024 to 02/28/2025 documents: “Wound Care: Wound care instruction: wash with Saline, apply half of Collagen Matrix with ORC (Oxidized Regenerated Cellulose) and Silver dressing and gauze, secure with Kerlix bandage and a Silk tape, do twice a week and as needed.” The Home Health Certification and Plan of Care for the Certification Period 12/31/2024 to 02/28/2025 lacks documented evidence of the wound location and the person responsible for wound care. On 01/17/2025 at 01:00 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings. 1. The Home Health Certification and Plan of Care for following patients: #2, #8, #11, #15, #16, and #17 documents: “SN (Skilled Nursing) to perform finger stick blood sugar Q (every) visit.” The agency lacks documented evidence of a CLIA (Clinical Laboratory Improvement Amendments) waiver. for the On 01/16/2025 at 02:30 PM, the Administrator was interviewed and stated: “We instruct our nurses to educate patients to perform finger stick blood sugar. We are working with the new computer system, and we are working on fixing the issue.” The Home Health Certification and Plan of Care for following patients: #2, #8, #11, #15, #16, and #17 lacks documented evidence of identification who and how often finger stick blood sugar is performed, and parameters to notify physician for abnormal findings. There is no documented evidence that individualized plan of care includes all the required information. On 01/17/2025 at 12:30 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings. 2. Patient #5 has a Start of Care date of 12/18/2024 with diagnoses: Respiratory failure, Unspecified whether with hypoxia or hypercapnia, Hypertensive emergency, Type 2 Diabetes Mellitus without complications … documented on the Home Health Certification and Plan of Care for the Certification Period 12/18/2024 - 02/15/2025. The Home Health Certification and Plan of Care for the Certification Period 12/18/2024 - 02/15/2025 documents: Treatments and Orders for Disciplines: SN (Skilled Nurse) Frequency 2W1, 1W3 (two times a week for one week, one time a week for three weeks) starting 12/12/2024. Diabetes: SN (Skilled Nurse) to assess and instruct patient/caregiver in the use of glucometer and recording of results. The Plan of Care lacks documented evidence of the frequency for blood glucose monitoring, and parameters for when to notify the physician. On 01/16/2025 at 3:30PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #6 has a Start of Care date of 01/03/2025 with diagnoses: Aftercare following surgery for neoplasm, Malignant neoplasm of unspecified part of left bronchus or lung… documented on the Home Health Certification and Plan of Care for the Certification Period 01/03/2025 - 03/03/2025. The Home Health Certification and Plan of Care for Certification Period 01/03/2025 - 03/03/2025 documents: Treatments and Orders for Disciplines: SN (Skilled Nurse) Frequency: 1W5 (one time a week for five weeks) starting week of 01/03/2025. Wound Care: Patient/Caregiver verbalize/demonstrates knowledge of wound treatment plan by first visit. Instruct patient on signs and symptoms of infection (drainage, fever, redness in the surrounding area and severe pain/ swelling. Assess wound location, size stage, drainage, wound bed, and periwound care every week. Patient/Caregiver will demonstrate independence in wound care by week 3, and symptoms of infection to report by week 2. The clinical record lacks documented evidence of an individualized plan of care that includes physician orders for wound care treatments. On 01/16/2025 at 3:30PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 4. Patient #8 has a Start of Care Date of 11/21/2024 with the following diagnoses “ Paroxysmal Atrial Fibrillation, Type 2 Diabetes Mellitus without Complications, Essential Hypertension” as documented on the Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025. The Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025 documents: “SN (Skilled Nurse) Frequency: 1W1 (once a week for one week), 2W2 (two times a week for two weeks) Starting Week of 11/21/2024. PT (Physical Therapy) Frequency: 1W1 (once a week for one week) 2W3 (two times a week for three weeks) Starting Week of 11/21/2024.” The Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025 documents: “DME (Durable Medical Equipment): No DME/Supplies required.” The OASIS (Outcome and Assessment Information Set) Start of Care dated 11/21/2024 documents: “Mobility: Indicate the type of wheelchair or scooter used. 1- Manual Transportation Assistance Level: a check mark in the box “Wheelchair”” On 1/14/2025 a home visit was conducted, and the following was observed: Patient #8 is utilizing a manual wheelchair and electric scooter. (Patient has right below the knee amputation) There is no documented evidence of the Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025 including “manual wheelchair and motorized scooter.” There is no documented evidence of the established Plan of Care (POC) being individualized and completed to address the patient needs. On 1/17/2025 at 1:30 pm, Administrator and the Director of Patient Services were interviewed and were unable to provide an explanation for the survey findings. 5. Patient #11 has a Start of Care Date of 12/31/2024 with the following diagnoses “Acute Gastritis without Bleeding, Type 2 Diabetes Mellitus without Complications, Human Immunodeficiency Virus Disease” documented on the Home Health Certification and Plan of Care for the Certification Period 12/31/2024 to 02/28/2025. The Home Health Certification and Plan of Care for the Certification Period 12/31/2024 to 02/28/2025 documents: “SN (Skilled Nurse) Frequency: 3W1 (three times a week for one week), 2W2 (two times a week for two weeks), 1W1 (once a week for one week) Starting Week of 12/31/2024” The Home Health Certification and Plan of Care for the Certification Period 12/31/2024 to 02/28/2025 documents: “Wound Care: Wound care instruction: wash with Saline, apply half of Collagen Matrix with ORC (Oxidized Regenerated Cellulose) and Silver dressing and gauze, secure with Kerlix bandage and a Silk tape, do twice a week and as needed.” The Home Health Certification and Plan of Care for the Certification Period 12/31/2024 to 02/28/2025 lacks documented evidence of the wound location and the person responsible for wound care. On 01/17/2025 at 01:00 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that treatments are provided as ordered by a physician. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #11). Failure to ensure that treatments are provided as ordered by the physician has the potential for negative patient outcomes. The Findings Are: 1. Patient #11 has a Start of Care Date of 12/31/2024 with the following diagnoses “Acute Gastritis without Bleeding, Type 2 Diabetes Mellitus without Complications, Human Immunodeficiency Virus Disease” documented on the Home Health Certification and Plan of Care for the Certification Period 12/31/2024 to 02/28/2025. The Home Health Certification and Plan of Care for the Certification Period 12/31/2024 to 02/28/2025 documents: “SN (Skilled Nurse) Frequency: 3W1 (three times a week for one week), 2W2 (two times a week for two weeks), 1W1 (once a week for one week) Starting Week of 12/31/2024.” The Physician referral signed on 12/24/2024 documents: “Primary reason for home health care: ...chronic R (right)plantar foot wound, wound care.” The Home Health Certification and Plan of Care for the Certification Period 12/31/2024 to 02/28/2025 documents: “Wound Care: Wound care instruction: wash with Saline, apply half of Collagen Matrix with ORC (Oxidized Regenerated Cellulose) and Silver dressing and gauze, secure with Kerlix bandage and a Silk tape, do twice a week and as needed. Assess wound location, size, stage, drainage, wound bed, and peri wound care every week” The Start of Care OASIS (Outcome and Assessment Information Set) dated 12/31/2024 lacks documented evidence of an assessment of the wound (wound location, size, stage, drainage, wound bed, and peri wound care), and no documented evidence of the wound treatment being provided to the right plantar foot. On 01/16/2025 at 02:30 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure the physician are promptly alerted to any changes in the patient’s condition or needs. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #4). Failure to ensure the physician are promptly alerted to any changes in the patient’s condition or needs, has the potential for negative patient outcomes. The Findings Are: 1. Patient #4 (Home Visit) with a Start of Care date of 01/01/2025 with diagnoses of: Unspecified Atrial Fibrillation, Pulmonary Hypertension unspecified, Abdominal Aortic Aneurysm ruptured unspecified, and Essential Hypertension documented on the Home Health Certification and Plan of Care for the Certification Period from 01/01/2025 to 03/01/2025. SN (Skilled Nurse) 1W1 2W1 1W1 (one time a week for one week, two times a week for one week, one time a week for one week) starting the week of 01/01/2025. PT (Physical Therapy) 1W1 2W4 (one time a week for one week, two times a week for four weeks) starting 01/05/25. The Physical Therapy visits for date 1/3/2025, 1/7/2025 and 1/9 /2025 documents a pain score of 9/10 to lower back. The Physical Therapy Routine visit dated 1/14/2025 documents a pain score of 8/10 to lower back. There is no documented evidence of the Physical Therapist alerting the physician of the patient’s level of pain 9/10, in order for the plan of care to be altered to include pain medication. The License Practical Nurse (LPN) Routine Visit Note dated 01/11/2024 documents: C/o (complains of) abdominal and lower back pain for several days, currently 8/10 pain scale, RN (Registered Nurse) made aware. Not taking anything for pain. Instructed patient and caregiver to give pain reliever to decrease pain. The clinical record lacks documented evidence of an analgesic order for pain management. The clinical record lacks documented evidence of the Skilled Nurse and Physical Therapist alerting the physician to alter the plan of care. On 01/16/2025 at 02:30 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings.”

“Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient’s care and treatments that the HHA will provide, specific to the patient’s care needs. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to provide pertinent instruction related to the patient’s care. This was evident for two (2) of seventeen (17) clinical records reviewed (Patient: #8, and #12). Failure to provide pertinent instruction related to the patient’s care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #8 (Home Visit) has a Start of Care Date of 11/21/2024 with the following diagnoses “Paroxysmal Atrial Fibrillation, Epilepsy, Essential (primary) Hypertension, Type 2 Diabetes Mellitus without Complications “ documented on the Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025. The Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025 documents: “PT (Physical Therapy) Frequency: 1W1 (once a week for one week), 2W3 (two times a week for three weeks) Starting Week 11/21/2024.” The Home Health Certification and Plan of Care for the Certification Period 11/21/2024 to 01/19/2025 documents: “Physical Therapy: Establish Home Exercise Program and Activity Program.” The clinical record documents Physical Therapy visits on the following dates: 11/23/2024, 11/26/2024, 12/05/2024, 12/06/2024, 12/10/2024,12/21/2024, 12/27/2024, 12/31/2024, 01/03/2025, 01/07/2025, and 01/09/2025. The Physical Therapy visits dated 11/26/2024, 12/05/2024, 12/06/2024, 12/10/2024 documents: “Home Exercise follow through between therapy visit: a check mark is documented in the box “Adequate”.” On 01/14/2025, a home visit was conducted. The patient was interviewed and stated the Physical Therapist did not give a Home Exercise Program. The clinical record lacks documented evidence of the Home Exercise Program including the frequency of the repetitions and sets of each exercise, and the pertinent instructions related to the patient’s care and treatment that the HHA (Home Health Agency) will provide, specific to the patient’s care needs before 01/16/2025. On 01/16/2025 at 02:30PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings. 2. Patient #12 has a Start of Care Date of 12/27/2024 with the following diagnoses “ Pneumonia, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Essential (primary) Hypertension” documented on the Home Health Certification and Plan of Care for the Certification Period 12/27/2024 to 02/24/2025. The Home Health Certification and Plan of Care for the Certification Period 01/07/2025 to 01/09/2025 documents: “Physical Therapy: Establish Home Exercise Program and Activity Program.” The clinical record documents Physical Therapy visits on the following dates: 12/31/2024, 01/07/2025, 01/09/2025. The Seated Exercises Rehabilitation Home Program documents: “ Date: blank; Frequency of the repetition: blank” There is no documented evidence of a Seated Exercises Rehabilitation Home Program including frequency of the repetitions and sets of each exercise, and the pertinent instruction related to the patient’s care and treatment that the HHA (Home Health Agency) will provide, specific to the patient’s care needs, and date. On 01/16/2025 at 02:30 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to provide services that are ordered by the physician as indicated in the plan of care. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #16 ). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #16 has a Start of Care Date of 12/12/2024, with the following diagnoses “Cerebral Infarction, Essential (primary) Hypertension, Type 2 Diabetes Mellitus without complications “ documented on the Home Health Certification and Plan of Care dated 12/12/2024 to 02/09/2025. The Home Health Certification and Plan of Care dated 12/12/2024 to 02/09/2025 documents: “SN (Skilled Nursing) Frequency: 1W1(once a week for one week), 2W1 (two times a week for one week), 1W1(once a week for one week), 3W1(three times a week for one week), 1W1 (once a week for one week) Starting Week of 12/12/2024.” The Home Health Certification and Plan of Care dated 12/12/2024 to 02/09/2025 documents: “SN (Skilled Nursing) to perform finger stick blood sugar Q (every) visit. SN (Skilled Nursing) to assess and instruct patient/caregiver in use of glucometer and recording of results.” The SN (Skilled Nursing) Routine Visit dated 12/16/2024, 12/23/2024, 01/01/2025, 01/03/2025 documents: “Glucometer Reading: blank.” The Clinical Record lacks documented evidence of the Skilled Nursing assessing and instructing patient/caregiver in use of glucometer and recording of results as indicated in the plan of care . On 01/16/2025 at 02:30 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that all Home Health Aides receive onsite supervision every 14 days. This was evident for one (1) of five (5) clinical records (with Home Health Aides Services) reviewed. (Patient #17). Failure to ensure that all Home Health Aides receive onsite supervision every 14 days, has the potential for negative patient outcomes. The Findings Are: 1. Patient #17 has a Start of Care Date of 07/12/2024, with the following diagnoses “ Essential (primary) Hypertension, Type 2 Diabetes Mellitus without complications, Hyperglycemia “ documented on the Home Health Certification and Plan of Care dated 07/12/2024 to 09/09/2024. The Home Health Certification and Plan of Care dated 07/12/2024 to 09/09/2024 documents: “AIDE Frequency: 3W4 (three times a week for four weeks) Starting week of 07/14/2024.” The Client Monthly Schedule documents aide services being provided on 07/17/2024, 07/18/2024, 07/19/2024, 07/22/2024, 07/24/2024, 07/26/2024, 07/29/2024, 07/31/2024, 08/02/2024, 08/05/2024, 08/07/2024, and 08/09/2024. The clinical record lacks documented evidence of aide supervision every 14 days. On 01/17/2025 at 12:30 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings.”