Glorious Home Health Care Inc.

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review, observation and interview, the agency failed to integrate services to ensure agency staff documented communication with the medical supplies provider, Identifier B, regarding suprapubic catheter supplies for 1 (Patient #2) of 2 active patients records reviewed. The failure to integrate services and document coordination of care regarding suprapubic catheter supplies procurement, potentially placed the patient at risk of infection, unnecessary scheduling and travel to a hospital clinic, Identifier C. FINDINGS INCLUDE: Patient #2: Record review revealed a POC dated 07/31/2025 to 09/28/2025 with a SOC date 07/31/2025. The POC included, “… Diagnosis: Quadriplegia (loss of movement and/or feeling in both arms and legs) C1-C4 (cervical spine at vertebras 1-4) ... Frequency: 2WK9 (twice a week for nine weeks)… Orders For Discipline And Treatments, SN to change suprapubic catheter (a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen) every month and PRN dislodgement or leakage… .” A SOC comprehensive assessment completed by the Administrator/DON on 07/31/2025 included on page 4, “… PAST MEDICAL HISTORY, … Genitourinary (system of organs/functions of the urinary system)- Suprapubic catheter, …” Review of the patient record revealed LVN A provided SN visits on the following dates: 08/01/2025; 08/05/2025; 08/08/2025; 08/12/2025; 08/15/2025; 08/19/2025; 08/22/2025; 08/26/2025; 08/29/2026; 09/02/2025; 09/05/2025; 09/09/2025; 09/12/2025; and 09/16/2025. LVN A did not change the suprapubic catheter during any SN visit. During a home visit with Patient #2 on 09/30/2025 at 9:30 AM, the surveyor observed the patient had a suprapubic catheter. The surveyor asked about care/services provided by the agency and when the suprapubic catheter was last changed. Patient #2 stated LVN A was working on getting the supplies needed to change the suprapubic catheter from Identifier B. The last time the suprapubic catheter was changed was 09/02/2025 at Identifier C. Patient #2 stated he was scheduled for an appointment at Identifier C on 10/06/2025 for the next suprapubic catheter change. Review of the entire patient record revealed no documented coordination of care with Identifier B, regarding suprapubic catheter supplies. In an interview with the Administrator/DON on 09/30/2025 at approximately 2:00 PM, the surveyor reviewed the findings and asked about the medical supplies for the suprapubic catheter and the monthly change ordered by the physician. The Administrator/DON stated the patient had been instructed to request a doctor’s order from the PCP for the catheter supplies and he was not aware if the patient had received an order yet. In an interview with LVN A on 09/30/2025 at approximately 2:30 PM, the surveyor reviewed the findings and asked about the suprapubic supplies and the monthly change ordered by the physician. LVN A stated he had called Identifier B and spoke with them about the supplies needed for the Patient’s suprapubic catheter change. LVN A stated they (the agency) were just waiting on the insurance now to approve everything, then the supplies will be sent to the patient’s home. The surveyor asked who was responsible to follow up on the coordination of supplies. LVN A stated he or the RN (Administrator/DON) would follow up. The surveyor asked if LVN A had documented any coordination of care with Identifier B. LVN A stated he did not document the coordination of care with Identifier B. Agency policy, undated, quoted in part, “Policy 4.18: COORDINATION OF SERVICES, POLICY: All skilled clinicians and unskilled personnel furnishing care maintain liaison to ensure that client services are coordinated effectively and in accordance with the objectives outlined in the plan of care. PROCEDURE: … 10. Case conference service as a means for effective interchange, reporting and coordination of client care. Case conference is documented as minutes, case conference forms and communication notes and accomplished through the following: … b. Documented telephone communication to clinicians involved in care and appropriate staff. c. Fax communication to clinicians involved in care and appropriate staff. …””

“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 record reviews, observation and interviews, the agency failed to ensure skilled professionals provided services to patients as ordered by the physician and included in the plan of care. In 1 (Patient #1) of 2 active patient records reviewed, the SN failed to assess/monitor the patients’ weight. This failure placed the patient at risk of not receiving interventions when needed to prevent complications and a decline in the patients’ health status due to possible fluid imbalance. FINDINGS INCLUDE: Patient #1: Review of the patient record revealed a POC dated 08/08/2025 to 10/06/2025 with a SOC 06/09/2025. The POC included the diagnoses: Arthritis (swelling and tenderness of one or more joints); Hypertension (high blood pressure); Chronic obstructive pulmonary disease (causes airflow obstruction and breathing problems) and Vertigo (sensation of spinning, where the person or their surroundings seem to be moving). The physician ordered SN visits once a week for nine weeks and instructed, “SN assessment and observation of all body systems, … Report abnormal parameter or pertinent findings to RN/MD and notify MD of weight gain or loss greater than 4 lbs (pounds) in a week, …” A comprehensive reassessment completed by the Administrator/DON on 08/07/2025 included on page 3, “… Vital signs, … weight: 163 pounds. … “ SN visit notes dated: 08/13/2025; 08/20/2025; 08/27/2025; 09/03/2025; 09/10/2025; and 09/17/2025 were completed by the Administrator/DON and did not include monitoring or an assessment of the patient’s weight. During a home visit interview with the patient on 09/30/2025 at approximately 11:30 AM, the surveyor observed Patient #1 was ambulatory without an assistive device. The surveyor conducted the home visit interview with the assistance of the patient’s family member as interpreter and asked about the care and services provided by the agency. The patient stated the nurse visited every week and checked his vital signs and blood pressure. The surveyor asked if the nurse weighed him. The patient said, “no, he doesn’t weigh me.” The surveyor reviewed the patient’s home folder and found a log of recorded vital signs that included: date (of SN visit); temperature; pulse; respirations; blood pressure and the clinicians’ initials. No weights were recorded during the SN visits. In an interview with the Administrator/DON and LVN D on 09/30/2025 at approximately 2:00 PM, the surveyor reviewed the findings and asked why the plan of care was not followed and the patient’s weight not assessed during SN visits. The Administrator/DON stated he did not know what happened or why the patient’s weight was not assessed and stated, “it was an oversight.” The surveyor asked how this failure could affect the patient. LVN D stated, “weight gain could be fluid overload and make the COPD worse.” Agency policy, undated, quoted in part, “Policy 4.16: IMPLEMENTING CARE AND TREATMENT, … PURPOSE: To ensure patient/client care and treatment are provided as identified in the care planning process. … PROCEDURE: The Agency is responsible for patient/client care, and must conduct and provide, either directly or under arrangement, all services rendered to patients/clients. …””