Geisinger Home Health

“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 CMS (Centers for Medicare/Medicaid Services) wound assessment guidelines and agency policies/procedures and clinical records, home visit observation and based on interview with the Administrator (Employee #9), the agency failed to ensure wound assessment had been completed in accordance with agency policies/procedures for three (3) of six (6) patients whom wound care orders/goals were included on the “Home Health Certification and Plan of Care” and for whom skilled nursing (SN) provided wound care to an open wound. (Patients #1, #4 and #14) Findings include: On April 27, 2026 at approximately 2:25 PM, review of the CMS (Centers for Medicare/Medicaid Services) website ( https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=37166 ) revealed the following: Wound Care…Federal Register References: 42 CFR Part 412, FR Doc No: 2013-18956; Volume 78, No. 160, August 19, 2013. Home Health Agency Prospective Payment System... History/Background and/or General Information…Medicare coverage for wound care on a continuing basis for a given wound in a given patient is contingent upon evidence documented in the patient’s medical record that the wound is improving in response to the wound care being provided. Evidence of improvement may include measurable changes in the following…Wound dimensions (surface measurements, depth)... On April 27, 2026 at approximately 2:27 PM, review of agency policy 2.1.002, titled “Patient Assessment, Initial and Reassessment” revealed the following under “Procedure”: 1. Upon admission and reassessments, the qualified clinician performs the following assessment activities and collects the following data: b. Patient’s...goals...including information that may be used to demonstrate patient’s progress toward achievement of goals identified by patient and measurable outcomes identified by agency... 8. Patients are assessed for continued need and response to care and services... On April 27, 2026 at approximately 4:17 PM, review of agency policy 2.2.001, titled “Wound Assessment, Documentation, and Photography”, revealed the following: PURPOSE: To ensure the accurate and consistent assessment and documentation of wounds. POLICY: Upon initial visit and subsequently as indicated below, all wounds will be assessed with appropriate documentation within the medical record. Wounds will be assessed in person by the Registered Nurse, Physical Therapist, or Occupational Therapist as allowed per licensure board… Wound location and description documentation is completed on all patients with wounds at the time of admit or upon development of a wound. Wound assessment findings will be documented within the Integumentary Command Center by utilizing the Wound Assessment Tool, within HCHB computer system. During routine visits, wound will be documented in the Wound Assessment Tool. Unless otherwise ordered by the physician, the qualified clinician as defined above will assess wounds at least: -Weekly for patient receiving negative pressure wound therapy, receiving daily wound care performed by the agency, have an infected wound, or have stage IV pressure injury with evidence of infection or exposed bone, tendon, or muscle tissue. -Every other week for patients receiving wound care by the agency at a frequency less than daily. -As specified per state requirements if more stringent than above. Reassessments will be documented on the Wound Assessment Tool. The assessment includes measurement of the length, width, and depth, undermining and tunneling… Patient #1: During home visit conducted on April 22, 2026 at approximately 9:00 AM, observation of the wound care procedure revealed a single wound was present on the right lower extremity and that the registered nurse (RN-Employee #1) provided wound care to wound #1. On April 24, 2026 at approximately 9:25 AM, review of the clinical record revealed the start of care (SOC) was 01/09/2026 and that the “Home Care Certification and Plan of Care” for the recertification period of 03/10/2026 through 05/08/2026 included the following diagnoses and SN visit frequency, orders, goals and summary details: -Diagnoses: Venous insufficient-chronic/peripheral (poor circulation), non-pressure chronic ulcer (wound) of right lower leg with fat layer exposed and type-2 diabetes mellitus -SN Visit Frequency: Two (2) times a week for one (1) week, followed by three (3) times a week for seven (7) weeks then two (2) times a week for one (1) week with two (2) as needed (PRN) visits for wound complications -Orders: SN to perform wound care to the right lower extremity wounds every Monday, Wednesday and Friday and SN may perform two (2) PRN mvisits due to wound complication such as change in wound size. -Goals: Patient will demonstrate improved wound status as demonstrated by decrease in wound size. -Summary: Wound in various stage of healing. Review of “Wound Record Report” documentation revealed wound #1 (right mid-pretibial area-front of right lower leg) was re-activated on the SOC (01/09/2026) but the measurements were documented as being “unable” on 01/09/2026. Review of “Wound Record Report” documentation revealed wound #1 measurements revealed the length, width and depth were as follows: 17 centimeters (cm) by 12 cm by 0 cm on 04/08/2026 and 10 cm by 8 cm by 0 cm on 04/17/2026. “Wound Record Report” and SN “Visit Note Report” notes revealed SN provided wound care to wound #1 during the comprehensive SN recertification (reassessment) visit performed on 03/07/2026 and between 03/11/2026 and 04/03/2026. There was no documentation on the “Wound Record Report” and/or SN “Visit Note Report” notes which provided evidence measurements of wound #1 had been obtained during the SOC comprehensive assessment, during the recertification comprehensive re-assessment performed on 03/07/2026 nor during 11 of 11 SN visits performed between 03/11/2026 through 04/03/2026. SN documentation revealed the reasons wound measurements were not obtained were documented as being unable or not due. There was no documentation in the clinical record which provided evidence wound measurements had been obtained in accordance with agency policies/procedures for wound #1. Patient #4: During home visit conducted on April 22, 2026 at approximately 1:25 PM, observation of the wound care procedure revealed a single rectangular shaped wound was present on the left lower extremity (leg), that a wound was present at the base of the left great toe and that the RN (RN-Employee #4) provided wound care to wounds #2 (left leg) and wound #3 (left great toe). On April 24, 2026 at approximately 11”23 AM, review of the clinical record revealed the SOC was 11/08/2024 and that the “Home Care Certification and Plan of Care” for the recertification period of 03/03/2026 through 05/012026 included the following visit diagnoses and SN visit frequency, orders, goals and summary details: -Diagnoses: Lymphedema (chronic condition-tissue swelling cause by accumulation of protein-rich fluid) and cellulitis of left lower limb -SN Visit Frequency: SN-Two (2) times a week for one (1) week followed by three (3) times a week for eight (8) weeks and 2 PRN for wound complications -Orders: SN to perform wound care to the left lower extremity and left toes and SN may perform two (2) PRN visits due to wound complications such as increase in wound size. -Goals: Patient will demonstrate improved wound status as demonstrated by decrease in wound size. -Summary: This patient is considered unstable as evidenced by non-healing wounds. Review of “Wound Record Report” documentation revealed the onset date of wound #2 (left lower extremity) was 08/01/2024 and that the onset date of wound #3 (left great toe) was 07/02/2025. Wound assessment documentation on the “Wound Record Report” revealed the first measurement of wound #2 was obtained on 04/22/2026 (8 cm by 13 cm by 0.2 cm) and that wound #3 measured 1.5 cm by 2 cm by 0.1 cm on 07/02/2025. “Wound Record Report” and SN “Visit Note Report” notes revealed SN provided wound care to wounds #2 and #3 during the comprehensive SN recertification visit performed on 03/02/2026 and between 03/04/2026 and 04/17/2026. There was no documentation on the “Wound Record Report” and/or SN “Visit Note Report” notes which provided evidence measurements of wound #2 and #3 had been obtained during the comprehensive SN recertification visit completed on 03/02/2026 nor during 20 of 20 SN visits performed during 03/04/2026 and 04/17/2026. SN documentation revealed the reasons wound measurements were not obtained was documented as being unable or not due. There was no documentation in the clinical record which provided evidence wound measurements had been obtained in accordance with agency policies/procedures for wounds #2 and #3. Patient #14 (Discharge): On April 27, 2026 at approximately 12:12 PM, review of the clinical record revealed the SOC was 01/13/2026 and that the “Home Care Certification and Plan of Care” for the initial certification period of 01/13/2026 through 03/13/2026 included the following diagnoses, visit frequency, SN orders and goals: -Diagnoses: Pressure ulcer of the sacral region-stage 2 -SN Visit Frequency: One (1) time a week for one (1) week, followed by two (2) times a week for one (1) week then one (1) time a week for seven (7) weeks -Orders: SN to perform wound care to the right buttock every other day and SN may perform two (2) PRN visits due to wound complication such as change in wound size or staging. -Goals: Patient will demonstrate improved wound status as demonstrated by decrease in wound size. Review of the SOC SN “Visit Detail Report” note dated 01/13/2026 revealed the coccyx wound (wound #1) measured 2 cm by 1.5 cm by 0.1 cm. “Wound Record Report” and SN “Visit Note Report” notes revealed SN provided wound care to wound #1 between 01/18/2026 and 01/31/2026. There was no documentation on the “Wound Record Report” and/or SN “Visit Note Report” notes which provided evidence wound #1 was measured during three (3) of three (3) SN visits performed between 01/18/2026 and 01/31/2026. SN documentation revealed the reason wound measurements were not obtained was documented as being not due. There was no documentation in the clinical record which provided evidence wound measurements had been obtained in accordance with agency policies/procedures for wound #1. During interview conducted on April 27, 2026 at approximately 2:45 PM, the Administrator confirmed that there was no documentation in the clinical record which provided evidence wound measurements had been obtained in accordance with agency policies/procedures for the above identified patients.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on review of agency policy/procedure, documentation, clinical records and professional guidance from the National Library of Medicine and based on interview with the Administrator (Employee #9), the agency failed to ensure the clinical notes included documentation of the rationale cardiopulmonary resuscitation (CPR) efforts were not initiated by agency staff for two (2) of two (2) patients for whom emergency services response was requested. (Patients #9 and #10) Findings include: On April 27, 2026 at approximately 2:29 PM, review of agency policy 1.005, titled “Resuscitation Withdrawal of Life Sustaining Care” revealed the following: Policy: The agency staff initiates cardiopulmonary resuscitation on all patients in cardiopulmonary arrest who do not have a Do Not Resuscitate (DNR) order in their chart. On April 27, 2026 at approximately 4:05 PM, review of the National Library of Medicine digital article ( https://www.ncbi.nlm.nih.gov/books/NBK470402/#article-18935.s5 ) titled “Cardiopulmonary Resuscitation” revealed the following under “Contraindications”: Contraindications for CPR arise in situations where resuscitative efforts are considered medically futile or ethically inappropriate. These decisions are primarily guided by clinical judgment and established protocols. CPR should not be performed in cases of irreversible death, such as when there are unmistakable signs like rigor mortis, decapitation, or dependent lividity…In addition, CPR may be deemed nonbeneficial in patients with terminal illnesses or in situations where meaningful recovery is highly unlikely. Patient #9 (Discharge): On April 24, 2026 at approximately 1:32 PM, review of the clinical record revealed the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 04/05/2025 through 06/03/2025: -Start of Care (SOC) date was 02/04/2025; -Primary and secondary diagnoses included hypo-osmolarity (lower than normal levels of electrolytes, proteins, and nutrients in the blood) and hyponatremia (low concentration of sodium in the blood), hyperkalemia (high potassium concentration in the blood), sepsis (serious condition resulting from improper response of the body to an infection), chronic kidney disease-stage 4 (severe), malignant neoplasm (cancer) of the bladder and anemia (low blood count-red blood cells/hemoglobin). -Advance Directive (legal document which outlines a patient’s preferences for medical treatment): Durable power of attorney/surrogate decision maker. Review of the “Visit Note Report” dated 04/29/2025 revealed the reason for agency discharge was Death at Home as documented by the registered nurse (RN-Employee #3). The “Visit Note Report” dated 04/29/2026 did not include details regarding the circumstances of the patient’s death at home. There was no evidence the RN (Employee #3) documented the circumstances regarding the patient’s death on a clinical nor coordination note. On April 21, 2026 at approximately 9:00 AM, review of a report submitted to the Pennsylvania Department of Health Event Reporting System (PA DOH ERS) website on 05/02/2025 revealed the agency included the following details regarding an incident which occurred on 04/29/2025 at 9:45 AM: RN went to do a routine visit with the patient. While RN was outside speaking with the patient’s daughter, prior to entering the home, they were discussing patient’s distended abdomen. Clinician went in to assess the patient and the patient was found recently deceased on the bed. Per clinician, the patient was still warm and must have just expired. Patient also had a brown discharge coming out of his mouth. 911 was contacted and EMS (Emergency Medical Services) and coroner arrived. Patient was pronounced dead at the scene. On April 23, 2026 at approximately 7:11 AM, review of the updated report submitted to the PA DOH ERS website on 04/21/2026 revealed details added to the report included the following: RN did not perform CPR. RN stated patient was expired for some time. 911 called immediately and they (EMS) did not perform CPR. Black blood from mouth, eyes nose and ears. Patient was little warm but not by much. Eyes fixed. Blood was pouring out of his mouth. The nurse did not see fit to initiating CPR. There was no documentation in the clinical record prior to 04/24/2026 which provided evidence the RN (Employee #3) had documented that CPR was not initiated on 04/29/2025 because of the patient assessment findings of fixed eyes (pupils), black blood from mouth, eyes, nose and ears and that the patient had been expired for some time. Patient #10 (Discharge): On April 24, 2026 at approximately 2:05 PM, review of the clinical record revealed the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 07/08/2025 through 09/05/2025: -Start of Care (SOC) date was 07/08/2025; -Primary and secondary diagnoses included Type-2 diabetes mellitus (diabetes), atrial fibrillation (irregular heart rhythm), chronic obstructive pulmonary disease (COPD-chronic respiratory disease), hypertension, fatty liver, history of falling, dependence on supplemental oxygen and long-term use of inhaled steroids. -Advance Directive: None Review of the “Visit Note Report” dated 08/26/2025 revealed the reason for agency discharge was Death at Home as documented by a physical therapist. Review of coordination note documentation dated 08/26/2025 revealed a physical therapy assistant (PTA-Employee #10) documented that PTA was unable to gain entry to the patient’s residence on 08/26/2025 and that maintenance had to gain access to the patient’s residence. The patient was found deceased on the floor with a blanket wrapped around the patient’s head. PTA checked for pulse. No pulse was present. The building business manager contacted 911. the PTA again checked for a pulse, but no pulse was present. Emergency medical services arrived and determined no pulse was present. State police also on scene. On April 21, 2026 at approximately 9:07 AM, review of a report submitted to the PA DOH ERS website on 08/28/2025 revealed the agency included the following details regarding an incident which occurred on 08/26/2025: The physical therapy assistant called patient last evening to schedule and nobody answered. She attempted to call again this morning and there still wasn’t an answer. PTA was concerned as she is familiar with this patient, and this is unlike her. PTA arrived at the home and knocked on the door and there was no answer. PTA consulted the office for assistance. No answer for us here either. Call placed to the patient’s daughter, and daughter asked if the car was there. PTA reported the car was present and she could hear the phone inside ringing. Maintenance contacted and gained access to the apartment. The patient was found deceased on the floor. 911 called. PTA very upset and Patient Care Manager (PCM) went to offer support at the scene. EMS arrived and left. State police arrived on scene. There was no documentation in the clinical record prior to 04/24/2026 which provided evidence the PTA (Employee #10) had documented details regarding the rationale for which CPR was not indicated/indicated on 08/26/2025. During interview conducted on April 27, 2026 at approximately 2:45 PM, the Administrator confirmed the clinical records did not include documentation of the rationale for which CPR was not indicated/initiated for patients #9 and #10.”