Newmetric Home Health Care Incorporated

“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 and interviews, the agency failed to integrate services 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, in that agency staff failed to integrate services and document communication with an outpatient dialysis provider, Identifier D involved in the care for 1 (Patient #1) of 7 patient records reviewed. The failure to integrate services and document coordination of ongoing care and interventions, potentially would cause the agency staff to be unaware of a change in services provided to the patient. FINDINGS INCLUDE: Patient #1: Record review of a comprehensive assessment completed on 01/12/2026 by the Alternate Administrator/DON, included on page 15, “… Is Patient on Dialysis, (checkmark box) Yes. … Name of Center: (Dialysis provider, Identifier D), … Contact: (Renal (kidney) Physician, Identifier E) ….” Record review revealed a POC dated 01/13/2026 to 03/13/2026 with a SOC date 09/15/2025. The POC included the diagnoses: Hypertensive Heart and Chronic Kidney Disease with Heart Failure (a complex condition where high blood pressure causes severe strain on the heart and kidneys); End Stage Renal Disease (the final, permanent stage of chronic kidney disease that often requires dialysis to filter the blood) and Dependence on Renal Dialysis (a life-sustaining treatment for kidney failure by filtering waste products and excess fluid from the blood). Review of the entire patient’s record revealed no documented coordination of care with the Identifier D. During a home visit with Patient #1 on 03/20/2026 at 9:00 AM, the surveyor asked about dialysis treatments. Patient #1 stated he attended Identifier D on Mondays, Wednesdays and Fridays and there were no issues reported. During an interview with the Alternate Administrator/DON on 03/23/2026 at 1:30 PM, the surveyor reviewed the findings and asked if the agency coordinated care with Identifier D for Patient #1. The Alternate Administrator/DON stated, “we coordinate care when there is a problem. The patient had the shunt (a connection between an artery and a vein that bypasses the capillary bed) placed but didn’t start dialysis immediately.” The surveyor asked if there was any documentation to demonstrate coordination of care with Identifier D. The Alternate Administrator/DON stated, “there is nothing written, I knew about coordination of care with providers, but I thought it was to be used only when there was a problem.” Agency policy, dated 01/01/2026, quoted in part, “Monitoring Patient/Client Care/Coordination of Care … Procedure, … II. … communication will be documented in the medical record. …” Agency policy, dated 04/1/2023, quoted in part, “Monitoring Patient/Client Care/Coordination of Care-Addendum … Procedure: … A. The Agency will ensure the effective exchange of information, reporting, and coordination of patient/client services among: … B. Other providers of health care services involved in the care of a patient/client may include … an outpatient facility … .””

“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 review and interview, 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 #4) of 7 records reviewed, the SN failed to weigh Patient #4. This failure potentially placed patients at risk of not receiving life sustaining interventions when needed to prevent complications from a change in body fluid, weight or a decline in the patients’ health status. FINDINGS INCLUDE: Patient #4: Review of the record revealed a POC dated 12/29/2025 to 02/26/2026 with a SOC date 09/05/2024. The POC included the diagnosis Chronic Diastolic Congestive Heart failure (a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently, causing fluid to back up into the lungs and body). The physician ordered: SN visits twice weekly; SN to assess Acute and chronic respiratory failure, due to Fluid Overload and SN to weigh the patient every visit and report a weight gain of 5 pounds within one week . Record review revealed the DON documented the patient’s weight 286 pounds as reported on 12/27/2025 and 284 pounds as reported on 02/26/2026. Record review revealed LVN A made home visits with Patient #4 and no weight assessment was conducted on the following dates: 01/02/2026; 01/05/2026; 01/08/2026; 01/13/2026; 01/15/2026; 01/20/2026; 01/22/2026; 01/27/2026; 01/29/2026; 02/03/2026; 02/05/2026; 02/10/2026; 02/12/2026; 02/17/2026 and 02/19/2026. In an interview with the DON on 03/23/2026 at approximately 1:45 PM, the surveyor reviewed the findings and asked how she obtained the patient’s weight on 12/27/2025 and 02/26/2026. The DON stated she asked the patient what her weight was when she was last admitted to the hospital and recorded those weights. A phone call was placed to LVN A on 03/23/2026 at 1:50 PM. LVN A stated he was unable to talk at the time as he was making a home visit with a patient. At 1:50 PM, the surveyor asked the DON why LVN A did not follow the POC and assess the patient’s weight during home visits. The DON stated LVN A was unable to assess the patient’s weight because the patient could not stand, but he failed to check the patient’s arm circumference or abdominal girth for fluid retention. Agency Policy, dated 04/01/2025, quoted in part, “Responsibilities of the Supervising Nurse/Clinical Manager, … Procedure: … I. … A. The responsibilities of the Supervising Nurse/Clinical Manager include but are not limited to: … 3. Ensuring that a patient’s/client’s Plan of Care or care plan is executed as written. …” Agency Policy, dated 01/01/2026, quoted in part, “PLAN OF CARE, … Procedure: … V…. Each patient/client must receive the home health services that are written in an individual Plan of Care ….””