Divine Health Care Services

“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 a review of clinical records (CR), home health agency (HHA) policies, home visits/observations, and an interview with the administrator, the HHA failed to assure that the plan of treatment included the visit frequency and duration for occupational and physical therapy for four (4) of seven (7) CR’s reviewed: CR#1, CR#2, CR#6 and CF#7, and included accurate and complete medication orders for five (5) of seven (7) CR’s reviewed: CR#2, CR#3, CR#4, CR#5, and CR#7. Findings include: The HHA’s Policy Establishment of the Plan of Care, Policy No. 3-012.1 reviewed on October 2, 2025 at approximately 1:45 PM reads in part, “...Regardless of the format used, information reported on the plan of care will include but not be limited to the following....Orders for services and treatments/interventions including frequency and duration of visits….and medications.” The HHA’s Policy Occupational Therapy Service, Policy No.3-027.1 reviewed on October 2, 2025 at approximately 2:00 PM states in part, “Information obtained during the initial assessment will be used to assist the physician to develop the plan of care specifying treatment modalities, frequency, and duration...” The HHA’s Policy Physical Therapy Service, Policy No. 3-026.1 reviewed on October 2, 2025 at approximately 2:05 PM reads in part, “Information obtained during the initial assessment will be used to assist the physician to develop the plan of care specifying treatment modalities, frequency, and duration...” The HHA’s Policy Medical Supervision, Policy No. 3-010.1 reviewed on October 2, 2025 at approximately 2:10 PM states in part, “The physician responsible for medical supervision will establish and sign a plan of care that, at minimum, specifies....treatments/interventions including frequency and duration of visits.” Home Visits/Observations were conducted for three (3) patients: CR#2, CR#3, and CR#5 on November 24, 2025 from 10:00 AM to 12:15 PM. A review of CR’s was conducted on September 30, 2025 starting at 2:02 PM, and again on October 2, 2025 starting at 9:27 AM and November 24, 2025 starting at 9:10 AM. The start of care (SOC) and Certification Period (CP) are indicated below. CR#1 SOC 07/02/2025, CP 07/02/2025 to 08/30/2025 found that the plan of care (POC) included physician orders as follows: Occupational Therapy (OT) Evaluate and treat patient for ambulatory dysfunction. The patient was treated by OT on the following dates (2025): 7/8, 7/10, 7/15, 7/18, 7/22, 7/24, 7/29, 7/31, 8/5, 8/7, 8/12, 8/14, 8/19, 8/21, 8/26 and 8/28. Subsequent to the initial orders to evaluate and treat the patient, there were no physician orders to indicate the frequency or duration of occupational therapy visits. CR#2 SOC 07/14/2025, CP 07/14/2025 to 09/11/2025 found that the POC included physician orders as follows: OT Evaluate and treat patient for ambulatory dysfunction. The patient was treated by OT on the following dates (2025): 7/16, 7/18, 7/21, 7/25, 7/29, 7/31, 8/5, 8/7, 8/12, 8/14, 8/19, 8/21, 8/26, 8/28, 9/2, 9/4, 9/9, and 9/11. Subsequent to the initial orders to evaluate and treat the patient, there were no physician orders to indicate the frequency or duration of occupational therapy visits. A review of the POC found medication orders that read, “Lantus Insulin, Inject 30 units at ‘I,’ Route Subcutaneous (Subcut).” There was no order clarification regarding the meaning of ‘I,’ nor when the Lantus insulin was to be administered, i.e., morning, evening or night. The medication profile contained the same information as the physician order. Further, CR#2’s parent, who was administering the Lantus insulin to the patient, stated during the home visit that s/he was administering 60 units of Lantus insulin to CR#2 at night. The POC included medication orders that read, “Regular Insulin, 10 units ‘with,’ Route: Subcut. Comments: Breakfast” and “Regular Insulin, 10 units ‘with,” Route Subcut. Comments: Dinner.” There was no clarification to the insulin order regarding the meaning of the word ‘with’ and there were no parameters ordered for when the insulin should be held based on blood glucose levels. The medication profile contained the same information as the physician’s order. A home visit/observation conducted on 11/24/2025 at approximately 11:00 AM revealed that the patient was documenting and monitoring blood glucose levels via the FreeStyle Libre system, a continuous glucose monitoring (CGM) system applied to the upper arm which streams glucose readings automatically to a smartphone so that glucose levels can be monitored at any time with a quick glance at the smartphone. CR#3 SOC 09/11/2025, CP 09/11/2025 to 11/09/2025 found that the POC contained a medication order for “Acetaminophen (Tylenol) 500 mg (milligrams), 1 tablet, 3 times a day by mouth.” There was no indication for use of the Tylenol nor clarification from the physician indicating if the order was intended to be as needed (prn) instead of routine. The medication profile contained the same information as the physician’s order. A home visit/observation conducted 11/25/2025 at approximately 10:00 AM revealed that the patient was not routinely taking Tylenol. CR#4 SOC 08/18/2025, CP 08/18/2025 to 10/16/2025 found that the POC contained a medication order for Tylenol with frequency noted as “see instruction.” There were no instructions evident nor was the frequency or indication for use present. The medication profile contained the same information as the physician’s order. CR#5 SOC 06/13/2025, CP 08/12/2025 to 10/10/2025 found that the POC contained a medication order for Naloxone, Dosage: 1ml, Frequency: inject every 3 min, Route: IM.” There was no clarification regarding the indications for Naloxone (which is used for opioid overdose in an emergency) nor the method by which it should be administered, if indicated. The medication profile contained the same information as the physician’s orders. Further review of the orders and medication profile found that there were no medication orders for an opioid which is an indication for use of Naloxone. A home visit/observation conducted on 11/24/2025 at approximately 11:45 AM revealed that the patient was not taking an opioid. CR#6 SOC 02/05/2025, CP 04/06/2025 to 06/04/2025 found that the POC included physician orders as follows: Physical Therapy (PT) Evaluate and treat patient for ambulatory dysfunction, and OT Evaluate and treat patients for ambulatory dysfunction. The patient was treated by PT on the following dates (2025) 4/7, 4/14, 4/23, 4/30, 5/7, 5/14, 5/21, 5/28, and 6/4. The patient was treated by OT on the following dates (2025): 4/9, 4/12, 4/16, 4/19, 4/23, 4/26, 4/30, 5/3, 5/7, 5/10, 5/14, 5/17, 5/21, 5/24, 5/28, and 5/31. Subsequent to the initial orders to evaluate and treat the patient, there were no physician orders to indicate the frequency or duration of either physical therapy or occupational therapy visits. CR#7 SOC 02/28/2025, CP 06/28/2025 to 08/26/2025 found that the POC included physician orders as follows: Continue to evaluate and treatment patient for ambulatory dysfunction. The patient was treated by OT on the following dates (2025): 7/1, 7/3, 7/8, 7/10, 7/15, 7/17, 7/22, 7/24, 7/28, and 8/1. Subsequent to the initial orders to evaluate and treat the patient, there were no physician orders to indicate the frequency or duration of occupational therapy visits. A review of the POC found a medication order that read, “Naloxone, 0.4mg/ml only 2 as need; Frequency: 1 as needed; Route: muscle. There was no clarification regarding the indications for Naloxone (which is used for opioid overdose in an emergency), and if indicated, the method by which it should be administered. The medication profile contained the same information as the physician’s orders. Further review of the orders and medication profile found that there were no medication orders for an opioid which is an indication for use of Naloxone. The POC also included an order for Tylenol 325mg, two (2) every 6 hours by mouth. There was no evidence that the order was clarified to indicate if the Tylenol was to be taken as needed (prn) instead of routinely. An interview conducted with the administrator on November 24, 2025 starting at 3:30 PM confirmed the above 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 a review of clinical records (CR), home health agency (HHA) policies, home visits, and an interview with the administrator, the HHA failed to assure that an accurate and complete medication review occurred or five (5) of seven (7) CR’s reviewed: CR#2, CR#3, CR#4, CR#5, and CR#7. Findings include: The HHA’s Policy Medication Profile, Policy No 3-034.1 reviewed on October 1, 2025 at 1:45 PM and again on November 24, 2025 at 2:00 PM states in part, “Upon admission to the Agency, the admitting nurse will initiate a medication review in order to document the current medication regime; The current medication(s) the patient is taking is documented on the Medication Profile. As warranted, conclusions and findings of patient medication use are communicated to the appropriate health team members, including the physician and/or pharmacist; The medication profile is updated as necessary to ensure that it remains current throughout the course of care.” Home Visits/Observations were conducted for three (3) patients: CR#2, CR#3, and CR#5 on November 24, 2025 from 10:00 AM to 12:15 PM. A review of CR’s was conducted on September 30, 2025 starting at 2:02 PM, and again on October 2, 2025 starting at 9:27 AM and November 24, 2025 starting at 9:10 AM. The start of care (SOC) and Certification Period (CP) are indicated below. CR#2 SOC 07/14/2025, CP 07/14/2025 to 09/11/2025 found that the medication profile contained orders that read, “Lantus Insulin, Inject 30 units at ‘I,’ Route Subcutaneous (Subcut).” There was no evidence that the nurse contacted the physician for order clarification regarding the meaning of ‘I,’ nor when the Lantus insulin was to be administered, i.e., morning, evening or night. Further, the medication profile contained medication orders that read, “Regular Insulin, 10 units ‘with,’ Route: Subcut. Comments: Breakfast” and “Regular Insulin, 10 units ‘with,” Route Subcut. Comments: Dinner.” There was no evidence that the nurse contacted the physician for clarification to the insulin order regarding the meaning of the word ‘with’ and there were no parameters ordered for when the insulin should be held based on blood glucose levels. CR#3 SOC 09/11/2025, CP 09/11/2025 to 11/09/2025 found that the medication profile contained a medication order for “Acetaminophen (Tylenol) 500 mg (milligrams), 1 tablet, 3 times a day by mouth.” There was no indication for use of the Tylenol nor was there evidence that the nurse sought clarification from the physician to determine if the Tylenol was intended to be taken as needed (prn) instead of routinely. CR#4 SOC 08/18/2025, CP 08/18/2025 to 10/16/2025 found that the medication profile contained a medication order for “Tylenol” with frequency noted as “see instruction.” There were no instructions evident on the medication profile or in the clinical record, nor was the frequency or indication for use of the Tylenol present. There was no evidence that the nurse sought clarification from the physician regarding the Tylenol order. CR#5 SOC 06/13/2025, CP 08/12/2025 to 10/10/2025 found that the medication profile contained a medication order for “Naloxone, Dosage: 1ml (milliliter), Frequency: inject every 3 min, Route: IM.” There were no orders for an opioid (which is an indication for use of Naloxone in an emergency) and no evidence that the nurse sought clarification from the physician to determine if Naloxone was indeed indicated and if so, obtain appropriate and accurate administration orders. A home visit/observation conducted on 11/24/2025 at approximately 11:45 AM revealed that the patient was not taking an opioid. CR#7 SOC 02/28/2025, CP 06/28/2025 to 08/26/2025 found that the medication profile contained a medication order that read, “Naloxone, 0.4mg/ml only 2 as need; Frequency: 1 as needed; Route: muscle.” There were no orders for an opioid (which is an indication for use of Naloxone in an emergency) and no evidence that the nurse sought clarification from the physician to determine if Naloxone was indeed indicated and if so, obtain appropriate and accurate administration orders. The medication profile also contained an order for Tylenol 325mg, two (2) (tablets) every 6 hours by mouth. There was no evidence indicating that the nurse sought clarification from the physician to determine if the Tylenol was to be taken as needed (prn) instead of routinely. An interview conducted with the administrator on November 24, 2025 starting at 3:30 PM confirmed the above findings.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on a review of personnel files (PF), home health agency (HHA) policy, and an interview with the administrator, the HHA failed to assure that a criminal background check was completed upon hire for one (1) of seven (7) PF’s reviewed: PF#2. Findings include: The HHA’s Policy Criminal History Record Check Policy No.4-005.1 reviewed on October 2, 2025 at approximately 3 PM reads in part, “The agency will complete a criminal history check on all agency employed personnel and contracted professional staff in any position classification. The individual will give signed authorization for the agency to conduct the criminal record check. The administrator will immediately request a criminal background record report directly from the Pennsylvania State Police.” A review of PF’s was conducted on September 30, 2025 starting at approximately 11:05 AM. The date of hire (DOH) is indicated below. PF#2 DOH 11/13/2023 contained a Pennsylvania Access to Criminal History (PATCH) report that was dated 01/03/2025, fourteen (14) months after the DOH. There was no evidence that a criminal history report was obtained at the time of hire. An interview with the administrator on November 24, 2025 starting at 3:30 PM confirmed the above findings.”

“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 a review of clinical records (CR), home health agency (HHA) policy, and an interview with the administrator, the HHA failed to provide evidence that the plan of care (POC) was signed by the physician within thirty (30) days of the receipt of the physician orders for five (5) of seven (7) CR’s reviewed: CR#1, CR#2, CR#5, CR#6 and CR#7. The HHA’s Policy Medical Supervision, Policy No. 3-010.1 reviewed on October 2, 2025 at approximately 2:10 PM states in part, “The physician responsible for medical supervision will establish and sign a plan of care... “ A review of CR’s was conducted on September 30, 2025 starting at approximately 2:02 PM, and again on October 2, 2025 starting at approximately 9:27 AM and November 24, 2025 starting at 9:10 AM. The start of care (SOC) and Certification Period (CP) are indicated below: CR#1 SOC 07/02/2025, CP 07/02/2025 to 08/30/2025 contained a plan of care (POC) that was not signed by the physician until 10/01/2025, three (3) months after the SOC. CR#2 SOC 07/14/2025, CP 07/14/2025 to 09/11/2025 contained a POC that was not signed by the physician until 10/01/2025, almost 3 months after the SOC. CR#5 SOC 06/13/2025, CP 08/12/2025 to 10/10/2025 contained a POC that was neither signed nor dated by the physician. CR#6 SOC 02/05/2025, CP 04/06/2025 to 06/04/2025 contained a POC that was neither signed nor dated by the physician. CR#7 SOC 02/28/2025, CP 06/28/2025 to 08/26/2025 contained a POC that was not signed by the physician until 10/01/2025, 3 months after the start of the CP. An interview with the administrator on November 24, 2025 starting at 3:30 PM confirmed the above findings.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on a review of clinical records (CR), home health agency (HHA) policy, and an interview with the administrator, the HHA failed to provide evidence that a discharge summary was completed and sent to the physician for one (1) of seven (7) CR’s reviewed: CR#6. Findings include: The HHA’s Policy Discharge Summary Policy No.3-053.1 reviewed on October 2, 2025 at 2:30 PM reads in part, “A discharge summary will be completed for each client discharged from the agency. A discharge summary will be sent to the physician>’ A review of CR’s was conducted on September 30, 2025 starting at 2:02 PM, and again on October 2, 2025 starting at 9:27 AM and November 24, 2025 at 9:10 AM. The start of care (SOC) and Discharge Date (DD) are indicated below. CR#6 SOC 02/05/2025, DD 06/04/2025 did not contain evidence that a discharge summary was completed nor sent to the physician. An interview with the administrator conducted on November 24, 2025 starting at 3:30 PM confirmed the above findings.”