1st Precious Home Healthcare Agency

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interview the agency failed to ensure a home health aide was given written patient care instructions prepared by a registered nurse for one (Patient # 1) of five active patient records reviewed. The failure placed the patient’s health and safety at risk if care was not provided as established in the patient’s plan of care. Findings include: Patient # 1: Review of the clinical record for Patient # 1 revealed a POC for Patient # 1 with a SOC date of 11/13/2024. The POC contained a certification period of 01/12/2025 to 03/12/2025 dated and signed by the Admin/DON on 01/08/2025. The POC contained orders for SN visits one time per week for nine weeks and two as needed visits. PT to continue with treatment and hha to assist with personal care and activities of daily living. Continued review of the clinical record for Patient # 1 revealed the Patient’s episodes of care record from 01/12/2025 to 03/12/2025. Review of the patient episodes of care record (visit schedule) revealed that Patient # 1 received home health aide visits three times per week by hha A. Further review of the record revealed a home health aide care plan (written instructions) for the certification periods of 11/13/2024 to 01/11/2025 dated and signed by the Admin/DON on 11/13/2024, and for certification period of 03/13/2025 to 05/11/2025 dated and signed by the Admin/DON on 03/12/2025. The written instructions read in part: “…RN Oriented HHA to POC: 11/27/2027…” Review of hha progress notes dated 01/13, 15, 17, 22, 24, 27, 29, and 31/2025; 02/03, 05, 07, 10, 12, 14, 17, 19, 21, 24, 26, and 28/2025; and 03/03, 05, 07, 10, and 12/2025 revealed that the Admin/DON signed the written instructions for the hha on 11/13/2024 for the episode (certification period) of 11/13/2024 to 01/11/2025. The hha notes were signed by hha A on the date that the notes were completed during the 01/12/2025 to 03/12/2025 episode. Continued review of the record did not reveal that the Admin/DON provided the hha with written patient care instructions specifically for the certification period of 01/12/2025 to 03/12/2025. During an interview with the Admin/DON on 05/06/2025 at 10:08 a.m. the surveyor reviewed the findings and asked why there was no home health aide care plan (written instructions for patient care) for Patient # 1 specifically for the certification period of 01/12/2025 to 03/12/2025. The Admin/DON stated that it was a misunderstanding of the software program. The Admin/DON stated that she thought it had to be updated every 60 days but [the program administrators] stated it had to be updated every 30 days. The surveyor asked how the failure could adversely affect the client. The Admin/DON stated the patient might not receive the needed care, provided by the hha. Review of agency policy titled; “Implementing Care and Treatment” last reviewed 05/02/24 read in part: “Purpose [:] To ensure patient/client care and treatment are provided as identified in the care planning process…V. Home health aides are members of the interdisciplinary team and are assigned to a specific patient/client by a registered nurse (RN)…within a time frame to meet the patient’s/client’s identified needs and per physician and/or non-physician practitioner orders. The home health aide will be provided with written patient/client care instructions prepared by that RN…””

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview a registered nurse failed to conduct an initial assessment visit to determine the immediate care and support needs (medications, fall risk, nutritional needs, etc.) of the patient; and to determine eligibility for the Medicare home health benefit, including homebound status within 48 hours of the referral, in that: for one (Patient # 1) of three active patient records reviewed for timeliness of initial assessments, the agency failed to ensure that an RN conducted the initial assessment within 48 hours of the referral. The failure placed the patient at risk of harm due to immediate care needs not being assessed timely. Findings include: Patient # 1: Review of the clinical record for Patient # 1 revealed a current POC for Patient # 1 with a SOC date of 11/13/2024. The POC contained a certification period of 03/12/2025 to 05/11/2025 dated and signed by the Admin/DON on 03/12/2025. The POC included had diagnoses of type 2 diabetes (a disease where the body does not produce enough or cannot utilize insulin to effectively control the level of glucose in the blood) and hypertension (high blood pressure). The POC contained orders for SN visits one time per week for nine weeks and two as needed visits and hha to assist with personal care and activities of daily living. Continued review of the clinical record for Patient # 1 revealed a “Referral/Intake Form” that was date 11/07/2024. The Admin/DON received the intake on 11/07/2024. The intake form read in part: “… [Skilled Nurse] to assess and admit to home health…” Further review of the record revealed a SOC and initial assessment was completed on 11/13/2024. Continued review of Patient # 1’s clinical records did not reveal any documentation or communication with an explanation of why an initial assessment of the patient was not conducted until 11/13/2024 (more than 100 hours after the referral was received). During an interview with the Admin/DON on 05/06/2025 at 10:08 a.m. the surveyor reviewed the findings and asked why the initial assessment had not been completed within 48 hours of the referral date. The Admin/DON stated that Patient # 1’s family member “kept postponing the visits.” The surveyor asked why the physician was not notified with documentation. The Admin/DON stated, “That’s an oversight for me.” Review of agency policy titled, “Timelines IM.35” dated 10/25/24 read in part: “…Policy The Agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations. Procedure… 1. A. The evaluation visit for admission to Agency is conducted within 48 hours of referral…In instances where the patient/client requests a delay in the start of care date, the Agency will contact the physician and/or non-physician practitioner to request a change in the start of care date and such change will be documented in the medical record…[Addendum] Procedure 1…B. All medical record information will be incorporated into the patient’s/client’s medical record within 14 working days.””

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review, observation, and interview, the agency failed to ensure that treatments were administered only as ordered by a physician, in that: for one (Patient # 3) of two patients, who received foley catheter (a small tube inserted into the urinary bladder to drain urine) care during a home visit, the agency failed to ensure that the foley catheter care was administered as ordered by a physician. The failure placed the client at increased risk for urinary tract infection. Findings Included: Patient # 3: Review of Patient # 3’s clinical records revealed a POC for the certification period 04/28/2025 to 06/26/2025, signed by the Admin/DON and dated 04/23/2025. The POC had a SOC date of 02/27/2025. The POC included the name of physician representative, (Nurse Practitioner, Identifier 100). The POC included a principal diagnosis of urinary tract infection. The POC included orders for SN visits one time per week until the end of the (60 day) episode. Further review of the POC revealed the following: “...Indwelling catheter site care [:] Catheter care…SN to wash hands and [put on] clean gloves. Cleanse around catheter site with NS [normal saline or sodium chloride solution] and 4X 4 gauze [dressing] using aseptic technique [healthcare procedure uses to prevent the spread of germs and infections] …” During a home visit with Patient # 3 on 04/30/2025 at approximately 12:30 p.m., the surveyor observed the Admin/DON administer foley catheter care for Patient # 3. The surveyor observed the Admin/DON use personal care wipes to clean the catheter and around the catheter area. The Admin/DON did not use normal saline, and gauze as ordered in the POC. During an interview with the Admin/DON on 05/06/2025 at 10:15 a.m., the surveyor reviewed the findings and asked why the Admin/DON did not follow the physician’s orders as written in the POC. The Admin/DON stated that she used the wipes because she was cleaning around the catheter area. The surveyor stated that the surveyor observed the Admin/DON clean the catheter with the wipes. The Admin/DON replied, “I believe I will have to change the order to include wipes.” The surveyor asked how the failure could adversely affect the patient. The Admin/DON replied, “Can increase the risk of infection.” Agency policy titled “Plan of Care PC.35” last reviewed 05/02/24 read in part: “…Procedure… VIII. Drugs, services, and treatments are administered only as ordered by a physician and/or nonphysician. practitioner…””