Community Home Health, Inc.

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was notified of missed skilled nurse visits for three (Patients #1, 2 and 9) of twenty-one patients. Patient #1 A review of the plan of care dated 01/28/25 to 03/28/25 showed a primary diagnosis of peritoneal abscess with a skilled nurse frequency of four visits per week for one week and three visits per week for six weeks. A review of the clinical record showed the following: Skilled nurse assessments dated 03/24/25 and 03/26/25 and a skilled nurse missed visit note (due to the patient and sister being able to change the incision dressing) dated 03/28/25 for the week of 03/24/25 to 03/28/25. Documentation showed two of three completed visits and no physician notification of the missed frequency. Patient #2 A review of the plan of care dated 01/12/25 to 03/12/25 showed a primary diagnosis of hypertensive heart with heart failure with a skilled nurse frequency of one visit per week for nine weeks. A review of the clinical record showed the following: A skilled nurse missed visit note (due to the patient having enough medications and can wait until next week) dated 02/19/25 for the week of 02/17/25 to 02/23/25. Documentation showed no completed visits for the week and no physician notification of the missed frequency. Patient #9 A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of encounter for change or removal of surgical wound dressing and a skilled nurse frequency of two visits per week for one week, three visits per week for three weeks. A physician’s order dated 02/17/25 ordered continued skilled nurse frequency of three visits per week for three weeks. Skilled nurse assessments dated 01/27/25 and 01/29/25 and a skilled nurse missed visits (due to no answer at the door or phone) dated 01/31/25 for the week of 01/27/25 to 02/02/25 (two of three completed visits). Documentation showed no physician notification of the missed visit. Skilled nurse assessments dated 02/10/25 and 02/12/25 and a skilled nurse missed visits (due to an appointment with surgeon) dated 02/14/25 for the week of 02/10/25 to 02/16/25 (two of three completed visits). Documentation showed no physician notification of the missed visit. Skilled nurse assessments dated 02/17/25 and 02/20/25 and a skilled nurse missed visit (due to inclimate weather, the patient can manage) dated 02/19/25 for the week of 02/17/25 to 02/23/25 (two of three completed visits). Documentation showed no physician notification of the missed visit. On 04/23/25 at 1:30 pm., Staff B stated the physician was not notified of the missed skilled nurse visits for Patients #1, 2 and 9.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nursing services were provided as ordered for three (Patients #1, 2 and 9) of twenty-one patients. Patient #1 A review of the plan of care dated 01/28/25 to 03/28/25 showed a primary diagnosis of peritoneal abscess with a skilled nurse frequency of four visits per week for one week and three visits per week for six weeks. A review of the clinical record showed the following: Skilled nurse assessments dated 03/24/25 and 03/26/25 and a skilled nurse missed visit note (due to the patient and sister being able to change the incision dressing) dated 03/28/25 for the week of 03/24/25 to 03/28/25 (two of three completed visits). Documentation showed no patient refusal, no attempts to reschedule the missed visit and no new orders to change the ordered frequency. Patient #2 A review of the plan of care dated 01/12/25 to 03/12/25 showed a primary diagnosis of hypertensive heart with heart failure with a skilled nurse frequency of one visit per week for nine weeks. A review of the clinical record showed the following: A skilled nurse missed visit (due to the patient having enough medications and can wait until next week) dated 02/19/25 for the week of 02/17/25 to 02/23/25 (no completed visits for the week.). Documentation showed no patient refusal, no attempts to reschedule the missed visit and no new orders to change the ordered frequency. Patient #9 A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of encounter for change or removal of surgical wound dressing, a skilled nurse frequency of two visits per week for one week, three visits per week for three weeks, and a physician’s order dated 02/17/25 for continued skilled nurse frequency of three visits per week for three weeks. Skilled nurse assessments dated 01/27/25 and 01/29/25 and a skilled nurse missed visits (due to no answer at the door or phone) dated 01/31/25 for the week of 01/27/25 to 02/02/25 (two of three completed visits). Documentation showed no patient refusal, no attempts to reschedule the missed visits and no new orders to change the ordered frequency. Skilled nurse assessments dated 02/10/25 and 02/12/25 and a skilled nurse missed visits (due to an appointment with surgeon) dated 02/14/25 for the week of 02/10/25 to 02/16/25 (two of three completed visits). Documentation showed no patient refusal, no attempts to reschedule the missed visits and no new orders to change the ordered frequency. Skilled nurse assessments dated 02/17/25 and 02/20/25 and a skilled nurse missed visit (due to inclimate weather, the patient can manage) dated 02/19/25 for the week of 02/17/25 to 02/23/25 (two of three completed visits). Documentation showed no patient refusal, no attempts to reschedule the missed visit and no new orders to change the ordered frequency. On 04/23/25 at 1:30 pm., Staff B stated the skilled nurse frequencies were not met for Patients #1, 2 and 9.”