Ability Home Health

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on interview and record review, it was determined the agency failed to ensure appropriate care planning, coordination of services, and quality of care necessary to meet the needs of the patients. Specifically, the agency failed to demonstrate it was meeting the needs of the patients and that their nursing staff was providing care that followed the standards of practice. On 05/07/2025, a finding of Immediate Jeopardy (IJ), a threat to patient health and safety, was identified. The provider was officially notified in writing of this finding on 05/07/2025. The agency violated §484.60 Condition of participation: Care planning, coordination of services, and quality of care by not following physician orders and not administering medications as ordered. For patient 2, insufficient Diabetes Management resulted in elevated blood glucose levels. For patient 5, a lack of wound assessments and care resulted in the worsening of a pressure wound. The provider alleged IJ removal on 05/08/2025. The provider’s plan for removal of IJ was as follows: -Immediate assessment of patient 2, new medication orders to better control diabetes and a follow up appointment with his primary care physician. -Immediate assessment of patient 5, new wound care orders, and a follow up appointment with her primary care physician. -Immediate training with all nurses for order process for diabetic care and wound care, communication documentation, and appropriate wound care and diabetic visits. -Review and audit of all patients on service receiving diabetic or wound care. On 05/12/2025, surveyors determined the IJ had been removed as of 05/08/2025. The provider was notified of the IJ removal on 05/12/2025. Although the concerns that led to the finding of IJ were removed on 05/08/2025, substantial noncompliance remained in the area of §484.60 Condition of participation: Care planning, coordination of services, and quality of care. Findings include: 1. The agency failed to ensure communication with all physicians or allowed practitioners involved in the plan of care. Refer to tag G 602. 2. The agency failed to ensure drugs, services, and treatments were administered only as ordered by a physician. Refer to tag G 580. 3. The agency failed to ensure each patient’s plan of care contained all the required elements. Refer to tag G 574. 4. The agency failed to ensure all patient care orders, including verbal orders, were recorded in the plan of care. Refer to tag G 576. 5. The survey findings indicated deficiencies in the home health agency’s adherence to established standards of practice in meeting the needs of patients, specifically evidenced through the care provided to Patient 2 and Patient 5. a. Patient 2- Insufficient diabetes management and medication administration, as follows: Patient 2 was admitted to the agency on 08/14/2024 with a diagnosis of Type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood), requiring twice-daily nursing visits for blood glucose monitoring and insulin administration. It was noted that Patient 2 was unable to administer his own insulin due to complications related to his condition, necessitating consistent professional oversight. Review of visit notes for April and May 2025, the patient’s blood glucose levels were recorded at consistently elevated readings above 300, at times reaching up to 500 (normal range: 70-100). There was no documented evidence that the agency communicated these glucose results to the overseeing physician, nor was there any follow-up to ensure appropriate interventions were made. During an interview on 05/06/2025 at 9:56 AM, the allowed practitioner stated she had been attempting to contact the agency’s registered nurse who treated Patient 2 but received no response. The allowed practitioner indicated that she became aware of the patient’s elevated glucose levels through the patient’s family, not from the nursing staff. Additionally, a physician’s order dated 03/14/2025, prescribed an additional diabetes medication to be injected weekly; however, review of the medical records revealed that there was no documented evidence of this medication being administered for at least four weeks, as indicated by a full month’s supply found in the patient’s refrigerator. The registered nurse verbally reported to the Assistant Director of Nursing (ADON) that the medication was administered regularly, which was contradicted by the findings and testimony from the patient’s family. An interview with Patient 2’s daughter on 05/07/2025 at 10:10 AM, confirmed that she had refilled her father’s medications and found the previous month’s supply in the refrigerator. b. Patient 5 - Lack of wound assessment and Care, as follows: Patient 5 was admitted to the agency on 03/03/2025 with a diagnosis of stroke. Surveyors found that physician orders regarding the management of the patient’s skin integrity were not followed. Specifically, a physician order dated 03/24/2025 instructed the assessment of potential sores and swelling on the patient’s body; no documented evidence of this assessment was found in the patient’s medical records. Further, on 04/29/2025, another physician order was issued for a referral to wound care for a Stage 1 sacral wound, requiring daily cleaning and application of Clavaseptin. As of 05/07/2025, there was no documentation indicating that this order had been carried out. [Note: Surveyors researched Clavaseptin with the following results: Clavaseptin is not a topical treatment for wounds. It is an oral antibiotic containing amoxicillin and clavulanic acid, used to treat bacterial infections in cats and dogs.] On 05/06/2025 at 2:15 PM, an interview was conducted with the ADON. The ADON stated that they did not think the wound care order dated 04/29/2025 was for them to treat the patient. She stated they could not bill the insurance for a nursing visit to apply a cream. On 05/07/2025 at 9:35 AM, surveyors conducted an interview with the RN who admitted patient 5. The RN stated she requested the first order dated 03/24/2025 because the family had called and expressed some concerns. The RN further stated the family then called back the next day and reported that the issues had resolved so the visit was not conducted. The RN stated she was not aware of the second order for wound care dated 04/29/2025. On 05/07/2025 at 3:55 PM, and interview was conducted with patient 5’s daughter. Patient 5’s daughter stated the sacral wound had gotten worse over the last few weeks. Conclusion: The agency’s failure to follow established protocols for monitoring critical health conditions and administering prescribed treatments highlights a deficiency in care provision. This placed patients at risk for health complications and contravenes the standards of practice expected of home health nursing.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on interview and medical record review, it was determined that the agency did not ensure a review was completed for all medications the patients were currently using, in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Specifically, 2 out 12 patients did not have a current and accurate medication review. (Patient identifiers: 3 and 12) Findings include: 1. On 04/08/2025, patient 3 provided surveyors with a list of their prescribed medications. Patient 3 was on 6 prescription medications. Surveyors reviewed patient 3’s medication profile in the agency’s electronic medical record dated 03/23/2025, and 3 of the 6 prescribed medications were not listed on patient 3’s medication profile. The agency provided no documented evidence of a complete and current review of patient 3’s medications. 2. On 04/08/2025, patient 12’s daughter provided surveyors with a list of patient 12’s prescribed medications. Patient 12 was on 11 prescribed medications. Surveyors reviewed patient 12’s medication profile in the agency’s electronic medical record dated 04/22/2025, and 7 out of the 11 prescribed medications were not listed on patient 12’s medication profile. The agency provided no documented evidence of a complete and current review of patient 12’s medications. Surveyors reviewed the agency’s medication policy. The policy stated the admitting discipline should check all medications a patient may be taking and document it on the medication profile. On 05/06/2025 at 2:11 PM, surveyors conducted an interview with the assistant director of nursing (ADON). The ADON stated the admitting discipline should be reviewing all medications with the patient. The ADON was asked if the nurse goes off the medications sent to the agency or if they are reviewed with the provider. The ADON stated they only reviewed medications with the provider if there were discrepancies but agreed it should be a part of the process. The ADON further stated if a medication changed it should be updated on the medication profile.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, it was determined the agency did not ensure each patient’s plan of care (POC) contained all the required elements. Specifically, the POC for 4 of 12 sampled patients did not contain all medications and/or diagnoses. (Patient identifiers: 3, 7 and 12.) Findings include: Surveyors reviewed patient 3’s POC dated 03/21/2025 through 05/19/2025. Patient 3’s POC did not include all medications. Surveyors reviewed patient 7’s POC dated 03/03/2025 through 05/01/2025. Patient 7’s POC did not list any medications.Surveyors reviewed patient 12’s POC dated 04/24/2025 through 06/19/2025. Patient 12’s POC did not list any medications. Additionally, patient 12’s POC did not list any diagnoses.On 05/12/2025, surveyors reviewed the agency’s POC policy. The policy matched regulations and stated all medications and treatments, all pertinent diagnoses, and patient specific interventions and goals should be recorded on the POC.On 05/06/2025 at 2:11 PM, surveyors conducted an interview with the agency’s assistant director of nursing (ADON). The elements of a POC were discussed. The ADON agreed, all medications, diagnoses, goals and interventions should be recorded on the POC. The ADON stated she needed to provide some more education for the nurses.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview and record review, it was determined the agency did not ensure all patient care orders, including verbal orders, were recorded in the plan of care (POC). Specifically for 2 of 12 sample patients, updated orders were given and were not included on the POC. (Patient identifiers: 3 and 12) Findings include: 1. On 05/12/2025, surveyors reviewed patient 3’s medical record, the medical record revealed the following: Patient 3 was admitted on 03/21/2025, patient 3 had 2 orders for visit frequency changes documented in their medical record during their current certification period dated 03/21/2025 through 05/19/2025. An order dated 04/29/2025 indicated and increase in physical therapy visits and an order dated 03/24/2025 indicated a decrease in skilled nursing visits. Neither of the orders were updated on patient 3’s POC. 2. On 05/12/2025, surveyors reviewed patient 12’s medical record, the medical record revealed the following: Patient 12 was admitted on 04/21/2025, patient 12 had 5 wound care orders documented in their medical record. None of the wound care orders were documented on patient 12’s current POC dated 04/24/2025 through 06/19/2025. A review of the agency’s POC policy was completed on 05/12/2025. The policy matched regulations and stated all patient care orders, including verbal orders, must be recorded in the POC. On 05/06/2025 at 2:11 PM, an interview was conducted with the agency’s assistant director of nursing (ADON). The ADON was not aware the POC should be updated with all orders.”

“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 interview and record review, it was determined the agency did not ensure drugs, services, and treatments were administered only as ordered by a physician. Specifically, for 2 of 12 sampled patients, physician orders for diabetic medication and wound care were not followed. (Patient identifiers: 2 and 5) Findings include: 1. Surveyors reviewed patient 2’s medical record, the medical record revealed the following: Patient 2 was admitted to the agency on 08/14/2024 with a diagnosis of diabetes mellitus type 2 (DM II) (when the body cannot use insulin correctly and sugar builds up in the blood). Patient 2 was receiving nursing visits twice daily for blood glucose monitoring and insulin administration due to complications related to his condition, necessitating consistent professional oversight. Surveyors reviewed documentation in the nursing visit notes for the previous 3 to 4 weeks. It revealed that patient 2’s blood glucose levels were consistently elevated above 300 and up to 500 at times. (Normal range: 70-100) Surveyors reviewed a physician order dated 03/14/2025 for an additional DM II medication to be injected once weekly. As of 05/07/2025, there was no documented evidence in the medical record that the medication had been administered. On 04/29/2025 at 1:45 PM, an interview was conducted with the assistant director of nursing (ADON). The ADON stated she spoke with the registered nurse (RN) who provided diabetic cares to patient 2. The RN reported to the ADON that he had been administering the medication every Monday. On 05/07/2025 at 10:10 AM, surveyors conducted an interview with patient 2’s daughter. Patient 2’s daughter stated she was the one that refilled her father’s medications. She stated when she went to refill this medication, there was a full month’s worth of doses (4) still in the refrigerator indicating that the medication had not been administered for at least four weeks. 2. Surveyors reviewed patient 5’s medical record, the medical record revealed the following: Patient 5 was admitted to the agency on 03/03/2025 with a diagnosis of stroke. Surveyors reviewed a physician order dated 03/24/2025 to assess for, “possible sore on buttocks, swollen feet and possible blister on leg”. There was no documented evidence in the medical record that an assessment was conducted for the sore, swelling, or blister. Surveyors further reviewed a second physician order dated 04/29/2025, that read, “Referral to wound care: Stage 1 sacral wound – please clean with wound cleanser and apply Clavaseptin (sic) Frequency: once daily as needed.” As of 05/07/2025, there was no documented evidence in the medical record that the order had been followed. NOTE: Surveyors researched Clavaseptin with the following results: Clavaseptin is not a topical treatment for wounds. It is an oral antibiotic containing amoxicillin and clavulanic acid, used to treat bacterial infections in cats and dogs. On 05/06/2025 at 2:15 PM, an interview was conducted with the ADON. The ADON stated that they did not think the wound care order dated 04/29/2025 was for them to treat the patient. She stated they could not bill the insurance for a nursing visit to apply a cream. On 05/07/2025 at 9:35 AM, surveyors conducted an interview with the RN who admitted patient 5. The RN stated she requested the first order dated 03/24/2025 because the family had called and expressed some concerns. The RN further stated the family then called back the next day and reported that the issues had resolved so the visit was not conducted. The RN stated she was not aware of the second order for wound care dated 04/29/2025. On 05/07/2025 at 3:55 PM, and interview was conducted with patient 5’s daughter. Patient 5’s daughter stated the sacral wound had gotten worse over the last few weeks.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review, it was determined the agency did not ensure communication with all physicians or allowed practitioners involved in the plan of care. Specifically, for 1 of 12 sampled patients, elevated blood glucose levels were not reported to the allowed practitioner. Additionally, the registered nurse did not return phone calls from the allowed practitioner who was attempting to inquire about the patient’s blood glucose levels. (Patient identifier: 2) Findings include: Surveyors reviewed patient 2’s medical record and revealed the following: Patient 2 was admitted to the agency on 08/14/2024 with a diagnosis of diabetes mellitus type 2 (when the body cannot use insulin correctly and sugar builds up in the blood). Patient 2 was receiving nursing visits twice daily for blood glucose monitoring and insulin administration due to complications related to his condition, necessitating consistent professional oversight. Surveyors reviewed documentation in the nursing visit notes for the previous 3 to 4 weeks. It revealed that patient 2’s blood glucose levels were consistently elevated above 300 and up to 500 at times. (Normal range: 70-100). There was no documented evidence that the agency had reported the blood glucose results to a physician or allowed practitioner. On 05/06/2025 at 9:56 AM, surveyors conducted an interview with the allowed practitioner for patient 2. The practitioner stated she was aware of the high blood glucose results because patient 2’s family had contacted her. The practitioner stated the agency’s registered nurse had not contacted her regarding the high glucose levels. She stated she had been attempting to get ahold of the agency’s registered nurse who treated patient 2 with no response.”