Redeemed Health Services

“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 observation, record review and interview, the agency failed to provide the services that were ordered by the physician in the plan of Care (POC) for one of five active patients reviewed (Patient #1), in that: 1. In active patient (Patient #1) the LVN failed to obtain the weight of Patient #1. 2. In active patient (Patient #1) the LVN failed to report any weight gain greater than 5 lbs. to the physician 3. In active patient (Patient #1) the ADON and LVN failed to update medication profile to reflect current medications. This failure could place the agency’s patients at risk of receiving inadequate care and services and could place the patients at risk of negative outcomes. Findings included: 1. Review of Patient #1 clinical record revealed a SOC of 1/23/25, certification period from 7/22/2025 - 9/19/2025 with primary diagnosis of Pressure Ulcer of Right Buttock Stage 2 (bed sore or wound that formed on the underlying tissues due to prolonged pressure and friction with stage of 2 that indicated that the skin loss is not deeper than the middle layer of the right buttocks skin) and other diagnosis included Diabetes Mellitus Type II (body either doesn’t produce enough insulin or it doesn’t use insulin properly); Acute Cystitis (infection of the bladder; Hypertension (force of blood pushing against the walls of blood vessels too highly); Hypertensive Heart Disease (the heart muscle becomes damaged over time due to high blood pressure): Opioid Dependence (physical state where the body adapts to the continuous use of opioids); Osteoarthritis (condition that affects the joints in the body causing pain stiffness and loss of mobility); Spondylosis (natural wear and tear on the spine as people age can cause pain stiffness and lead to other spine problems); Right Side Lumbago with Sciatica (lower back pain that radiates down the right leg, pain is caused by irritation or compression of the sciatic nerve which runs from the lower back through the buttocks and down each leg); Localized Edema (when fluid accumulates in a specific area of the body due to various reasons such as injury, infection or medical conditions); Chronic venous Insufficiency (condition where the valves in the leg veins do not work properly causing blood to pool in the legs); Morbid Obesity (condition characterized by a high Body Mass Index (BMI) of 40 or higher, high BMI indicates more body fat which can be associated with health risk); Bed Confinement (unable to leave the bed due to illness or disability); Muscle Weakness (lack of muscle strength); Gastroesophageal Reflux Disease (stomach acid flows back into the esophagus (tube that is connects the mouth to the stomach) the backflow is known as acid reflux can irritate the esophagus lining); Bilateral Lower Leg Pain (pain in both legs between knees and ankles). RR of the “Recertification” (every 60 day recheck of Patient #1’s condition to determine if home health services are still needed) performed by the ADON dated 05/23/25 and 07/18/25 read in part... Section titled, “Orders for Disciplines and Treatments included SN: 2 times per week for 9 weeks, PT: 2 times per week for 3 weeks and OT: 1 visit every week for 4 weeks. POC revealed Orders and Treatments that included, “SN to obtain Patient #1’s weight every visit and report any weight greater than 5lbs or more to MD/RN” and included “SN to evaluate the Patient #1’s plan of care and report any needed changes to MD/RN.” RR of SN visit notes 7/22/25, 7/25/25, 7/28/25, 8/1/25, 8/4/25, 8/8/25, 8/11/25, 8/15/25, 8/18/25, 8/22/25, 8/25/25, 8/29/25, 8/29/25, 9/1/25, 9/5/25, 9/8/25, 9/12/25 and 9/15/25 revealed weights were not obtained for Patient #1. There was no indication in the clinical record of MD notification that weights were not obtained as ordered in the POC. 2. Interview with ADON on 9/17/25 at 2:40 pm when asked why weights were not obtained and medication list not revised, the ADON stated “It is up to the doctor to update and sometimes they are busy, and we remind them. If we do have that reminder, in the HHA office that means we did not do it” When asked how not following POC to update medication list and report weight gain of 5lbs or more with Client #1’s medical diagnoses could worsen the health status of Client #1. The ADON stated, “I will remind the doctor.” Surveyor asked ADON for the communication to the physician when weights were not obtained or for medication list update request. ADON stated, “If it is not there in the office, we did not do it.” Interview with DON on 9/17/25 at 3:03 pm when asked why weights were not obtained by the SN as written in the POC. DON stated, “That was for a bed scale, it has been broken. We never weighted Patient #1, that order needed to be removed”. Surveyor asked how weight gain of 5lbs or more with Patient #1’s medical diagnoses could affect the health status of Patient #1. The DON did not answer. Surveyor asked DON the discharge from inpatient and referral to HHA date of Patient #1, DON stated “1/21/2025. Surveyor asked DON if IV Ertapenem ever administered by HHA to Client #1. DON stated, “No those were from the hospital and when ADON admitted on 1/23/25 the ADON kept all the same meds.” Surveyor asked DON the HHA’s policy to update POC reflect current medications. DON stated, “We update according to the information from the doctor and asked Patient #1 when we visited”. Surveyor requested communication from HHA to physician regarding medication reconciled for Patient #1. Surveyor asked DON for the communication from the HHA to the physician for weights not obtained, broken scale and medication reconciliation. DON did not provide documentation or response. Interview with LVN on 9/18/25 at 2:45 pm Surveyor asked why weights were not obtained as written in the POC? The LVN stated, “We did not weight Patient #1. Someone in the HHA office will update the plan of care.” Surveyor asked LVN HHA’s policy for medication reconciliation. LVN stated, “When there is a new medication, I write it down and contact the office. Someone in the office will then update” Surveyor asked LVN who is the someone? LVN stated, “The DON or Alt Adm both do the updates when I call.” Surveyor asked why IV Ertapenem and Guaifenesin listed on the current medication profile and Patient # 1 stated those were hospital medications only? LVN stated, “Whatever the hospital meds was the plan of care.” 3. Review of HHA’s policy titled “Professional and Ancillary Services” no date of document, read in part: “Skilled Nursing Services: ...The agency shall provide skilled nursing services by a registered or licensed nurse under the direction of the supervising nurse. Professional nursing services shall be performed in accordance with the attending physician’s Plan of Care and shall include but not limited to: • Development, implementation, review and revision of the Oasis document (standardized data collection tool used by Medicare to measure patient outcomes, quality of care and for reimbursement purposes) and Plan of Care • Notification of the physician and other member of the care team of patient’s progress and needs • Preparation of clinical progress notes summary reports medication profiles discharge summaries and other documentation…” Review of HHA’s policy titled “Physician’s Plan of Care/Change Orders” no date of document, read in part: … “The agency will provide care/services consistent with the Plan of Care.” The Plan of Care shall include but not limited to: …. Medications (needed to treat the patient’s condition) …” Review of HHA’s document titled “Job Description of Director of Nurses/Performance Evaluation,” dated 10/29/01 signed by DON on 10/29/24, read in part: “Essential Functions: …“Assures the development, implementation, and updates of the individualized plan of care... Ensures provision of services as ordered by the physician as indicated in the plan of care... Prepares clinical notes as appropriate... Assume responsibility for continuity, quality, and safety of services delivered in compliance with state and federal regulations…read” Review of agency’s titled “Job Description of Alternate Director of Nurses/Performance Evaluation,” dated 01/01/01 signed by ADON on 4/26/24, read in part: “Essential Functions: …“Assures the development, implementation, and updates of the individualized plan of care... Ensures provision of services as ordered by the physician as indicated in the plan of care... Prepares clinical notes as appropriate... Assume responsibility for continuity, quality, and safety of services delivered in compliance with state and federal regulations...” Review of agency’s titled “Job Description of Licensed Vocational Nurse,” no date, signed by LVN on 04/04/22, read in part: “Responsibilities: …2. Provides skilled nursing as ordered by the physician and assigned by the RN supervisor... 4. Follows the patient’s plan of care.” …”