West Wynde Health Services

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on record reviews and interviews, the Administrator failed to be responsible for all day-to-day operations of the Agency in that the Administrator failed to ensure that 2 of 2 discharged Patients (Patients #6 and #7) were provided with written notice of discharge prior to being discharged from the agency. This failure could place the Patients at risk of poor health outcome due to the Patient and/or Patients’ family not having advanced notice of an impending discharge and ample time to effectively plan for continuation of care delivery after discharge from the agency. Findings include: Patient #6 Review of agency’s discharge list revealed that Patient #6 was discharged from the agency on 09/12/2025 because the Patient’s health care goals were met. Review of Patient #6’s clinical records revealed Patient’s plan of care (POC) for certification period from 07/25/2025 to 09/22/2025 which showed Patient’s start of care date as 07/25/2025. Review of the Patient’s POC revealed pertinent information regarding Patient #6 such as: Patient’s medical diagnoses which included External surgical wound(a clinically acquired wound as a result of surgical operation), Cutaneous abscess of abdominal wall (is a small, pus-filled lump that forms in the skin and the tissues just under the skin on the front or side of the stomach.), Anemia (A blood disorder that occurs as a result of low red blood cells in the body or when the red blood cells do not have enough oxygen carrying agent known as hemoglobin in the body), Major depressive disorder(a mood disorder that causes a persistent feeling of sadness and loss of interest). The review of the Patient’s POC also revealed that Patient was to be seen by a skilled Nurse once during the first week of the episode and then two to three times weekly for 8 weeks to provide wound care services to the Patient. Continued review of Patient 6’s clinical record contained no record that agency provided any written notification to the Patient or the Patient’s responsible party to notify them of the agency’s intent to discharge the Patient before the Patient was discharged from the agency on 09/12/2025. During interview with the Nurse (LVN A) that was assigned to provide care to Patient #6 on 06/19/2026 at 3:23pm, LVN A stated that she did not provide a written notification of agency’s intent to discharge Patient 6 before the patient was discharged but did verbally inform Patient 6 that she would be discharged from that agency as her wound had healed. LVN A was asked where she documented that she notified Patient #6 that the Patient would be discharged from the agency. LVN A stated that she documented it in the visit note a week before the Patient was discharged. Review of all of Patient #6’s visit notes had no record that LVN A verbally notified Patient #6 of agency’s intent to discharge the Patient from service. When asked what agency’s policy was regarding Patients’ discharge notification, LVN A stated that the agency’s discharge policy was for agency’s staff to notify the Patients that they would be discharged from the agency before the date of the actual discharge. LVN A was then asked if she was aware that agencies’ Patients are to be provided with written discharge notification by state regulation at least five (5) days before the actual discharge. LVN A replied that she had never provided the agency’s Patients with any written notice of discharge that it was the responsibility of the registered Nurse to provide the agency’s Patients with written discharge notice. Patient #7 Review of agency’s discharge list revealed that Patient #7 was discharged from agency on 08/27/2025 due to Patient’s set health care goals were met. Review of Patient #7’s clinical records revealed a plan of care for the certification period from 06/29/2025 – 08/27/2025 which revealed the Patient’s start of care date as 04/30/2025. Review of the Patient’s POC revealed pertinent information about the Patient such as the Patient’s diagnoses which included: Diabetes Type 2(Also known as high blood sugar - is when the body’s cells become resistant to insulin - a hormone that helps move sugar (glucose) from your blood into your cells for energy production. when sugar stays in the blood and do not get moved into the cells, over time, it can cause serious health issues), Anemia (A blood disorder that occurs as a result of low red blood cells in the body or when the red blood cells do not have enough oxygen carrying agent known as hemoglobin in the body), and Hypertension(commonly known as high blood pressure – a high ongoing pressure exerted on body’s blood vessels that can silently harm your health if not controlled). Continued review of Patient #7’s POC also revealed that the Patient was to be seen by a Nurse once a week for 9 weeks and 1-3 more times as needed for changes in the Patient health condition. The Patient was also to be seen and evaluated and treated by a Physical Therapist and an Occupational Therapist. Further review of Patient 7’s clinical record contained no record that agency provided any written notification to the Patient or the Patient’s responsible party to notify them of the agency’s intent to discharge the Patient before the Patient was discharged from the agency on 08/27/2025. During interview with Agency’s Administrator/Supervising Nurse who happened to be Patient #7’s assigned Nurse on 06/19/2026 at 3:37pm, the Administrator stated that she did not provide Patient 7 or the Patient’s responsible party with a written notice of agency’s intent to discharge the Patient before the Patient was discharged from the agency, but she notified the Patient’s Physician that Patient was going to be discharged from the agency and then added “is that not okay”? Surveyor asked the Administrator what agency policy on discharge was and requested to see agency’s policy on discharge. The Administrator stated agency’s discharge policy was for agency’s staff to provide the Patients and/or the Patients’ responsible parties with a written notice of its intent to discharge the Patient five (5) days before the actual date of discharge. The Administrator was asked who was responsible for providing Patient #7 and/ or family with written notice of agency’s intent to discharge Patient from the agency. The Administrator stated that all clinical staff were responsible for ensuring that Agency’s Patients and their responsible parties are provided with written notice of agency’s intent to discharge Patient five days before the actual date of patients’ discharged from the agency. The Administrator was then asked why she did not provide Patient #7 with a written notice of agency’s intent to discharge the Patient before discharging the Patient from the agency. The Administrator stated that she notified the Patient’s attending Physician about agency’s intent to discharge patient #7 and then asked Surveyor if that was not enough. The Administrator read out the agency policy and then said, You are right I messed up…” Review of agency’s undated administrative policy titled, “Patient Discharge” reads in part, “…To establish a consistent and effective process to provide continuity of care to patients when their services are transferred between agency offices or when patient is discharged from services. Except in emergency, Agency must notify the Patient, or the Patient’s parents, family, spouse, significant other, or legal representative, and the Patient attending physician (if applicable) five days (5 days) before the date on which the Patient will be transferred…” Review of agency’s Adminitrator policy titled, “Job Description – Administrator” last revised March 2018 reads in part, “…The Administrator ensures quality and safe delivery of Home Health Care Services that reflects Agency’s Philosophy and standard of care…and responsible for all day-to-day operations of the agency…””