Every finding on record at Acadian Home Health Care Services, LLC

Southern Home Health is in compliance with federal emergency preparedness requirements.

Recertification Survey

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's written individualized POC (Plan of Care) was followed as evidenced by the PT (Physical Therapist) failing to record/monitor blood sugar readings for 2 (#7, #16) out of 17 sampled patients. Findings: 1. Patient #7. Review of the patient’s electronic clinical record revealed the start of care date was 12/20/2025. The patient’s diagnoses included diabetes, hypertensive heart disease with heart Failure and hemiplegia following cerebral infarction. The certification period reviewed was 02/18/2026 to 04/18/2026. Review of the patient’s POC (Plan of Care) for certification period 02/18/2026 to 04/18/2026 revealed an order for “PT effective 02/22/2026 1wk8wk, (physical therapy effective the week of 02/22/2026 visit one time a week for eight weeks). Further review of the POC revealed orders for, “…report falling outside the following established parameters… FBS (fasting blood sugar) (greater than) 200 RBS (random blood sugar) 300.” There were no orders for skilled nurse visits. Review of the patient's PT visit notes dated 02/25/2026, 03/04/2026, and 03/11/2026 revealed there was no evidence the PT recorded or monitored the patient’s blood sugar readings. On 03/17/2026 at 1:10 p.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed the patient’s electronic clinical record and confirmed there was no evidence the PT recorded or monitored the patient’s blood sugar readings and should have. 2. Patient #16. Review of the patient’s electronic clinical record revealed the start of care date was 11/14/2025. The patient’s diagnosis included diabetes. The certification period reviewed was 01/13/2026 to 03/13/2026. Review of the patient’s POC (Plan of Care) for certification period 01/13/2026 to 03/13/2026 revealed an order for “PT 1wk8wk, (physical therapy visit one time a week for eight weeks). Further review of the POC revealed orders for, “…report falling outside the following established parameters… FBS 200 RBS 300.” There were no orders for skilled nurse visits. Review of the patient's PT visit notes dated 01/15/2026, 01/23/2026, 01/30/2026, 02/06/2026, 02/10/2026, 02/19/2026, 02/27/2026, and 03/04/2026 revealed there was no evidence the PT recorded or monitored the patient’s blood sugar readings. On 03/17/2026 at 9:23 a.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed the patient’s electronic clinical record and confirmed there was no evidence the PT recorded or monitored the patient’s blood sugar readings and should have.

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 observation, record review, and interview, the agency staff failed to demonstrate that effective coordination of care occurred when the HHA (Home Health Aide) failed to inform the nursing staff of Patient #7’s complaint of exhaustion after straining to have a bowel movement for an hour for 1 (#7) out of 7 patients (#1-#7) seen for home visits out of a total sample of 17 patients. Findings: Review of the agency policy titled, “Coordination of Care, From Admit through Discharge” with a revision date of 12/01/2025 read in part, Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Procedure: Coordination of Care among disciplines and between in-person and virtual clinicians: Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge. This includes: c. Appropriate, timely communication with the patient, caregivers, and staff involved in the patient’s care regarding patient needs, goals, and care as well as changes in these… Significant changes in the patient’s condition (i.e. new or worsening symptoms…) i.e. (in other words). Patient #7. Review of the patient’s electronic clinical record revealed the start of care date was 12/20/2025. The patient’s diagnoses included hypertensive heart disease with heart failure and hemiplegia following cerebral infarction. The certification period reviewed was 02/18/2026 to 04/18/2026. Review of the patient’s POC (Plan of Care) for certification period 02/18/2026 to 04/18/2026 revealed an order for “HHA effective 02/22/2026 1wk4wk, (home health aide effective the week of 02/22/2026 visit one time a week for four weeks). On 03/17/2026 at 11:05 a.m., a home visit was made to Patient #7’s home and S3HHA was present. The patient was observed sitting up in his recliner during the home visit. During the home visit, the patient refused his shower. The patient stated that he was so exhausted from straining to have a bowel movement (BM) prior to S3HHA arrival to his home. The patient stated that he had to manually remove the BM which took an hour. The patient stated that 4 days had passed since his last BM and that it was hard. He stated the stool softeners and Miralax (laxative) did not work. S3HHA stated she would bathe him in the recliner in place of the shower. The patient did not complain of pain during the home visit, but S3HHA was still present with the patient when the surveyor left the home. Review of the patient’s HHA note dated 03/17/2026 at 12:11 p.m. revealed S3HHA documented, “Chair bath. Pt complained of hurting too much.” Review of the patient’s coordination note dated 03/17/2026 with no time and documented by S2PCM (Program Case Manager) revealed, “Received call from (S3HHA) stating patient was having increased generalized pain and didn’t want to get in shower during her visit.” There was no evidence that S3HHA informed S2PCM about the patient not having a BM for 4 days and straining for an hour to have a BM, which exhausted him along with the pain that he was experiencing during his bath. On 03/17/2026 at 3:22 p.m., an interview was conducted with S2PCM. S2PCM stated that S3HHA did call and informed her that Patient #7 was having pain all over when she was changing his position to bathe him in the chair. S2PCM stated that S3HHA did not report the patient was straining to have a bowel movement and had to manually remove it and was too exhausted to get up out of his chair to shower. S2PCM confirmed that S3HHA should have reported it.

Southern Home Health is in compliance with the federal emergency preparedness requirements.

Recertification Survey

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the Skilled Nurse (SN) failing to provide 56 hours of extended care nursing services per week as ordered per the POC for 1 (patient #1) out of 17 sampled patients. Patient #1. Review of the patient's clinical record revealed the start of care date was 8/20/2021. The patient's diagnoses included Congenital Malformation of Brain and Cerebral Palsy. The certification period reviewed was 2/11/2023 to 4/11/2023. Review of the patient's POC for certification period 2/11/2023 to 4/11/2023 revealed an order for LPN… 56 hours weekly for 1 Certification Period(s) starting 2/11/2023. Review of the patient’s skilled nurse visit notes for the week of 2/12/2023 revealed that the patient received 44 hours of extended care nursing for that week. The patient was short 12 hours of extended care nursing services for the week of 2/12/2023. Review of the Missed Visit Note report dated 2/17/2023 revealed that 12 hours of nursing services was not provided due to no nurse available for the week of 2/12/2023 to 2/18/2023. Review of the patient’s skilled nurse visit notes for the week of 2/19/2023 revealed that the patient received 34 hours of extended care nursing for that week. The patient was short 22 hours of extended care nursing services for the week of 2/19/2023. Review of the Missed Visit Note report dated 2/24/2023 revealed that 22 hours of nursing services was not provided due to no nurse available for the week 2/19/2023 to 2/25/2023. Review of the patient’s skilled nurse visit notes for the week of 2/26/2023 revealed that the patient received 33 hours of extended care nursing for that week. The patient was short 23 hours of extended care nursing services for the week of 2/26/2023. Review of the Missed Visit Note report dated 3/2/2023 revealed that 23 hours of nursing services was not provided due to no nurse available for the week of 2/26/2023 to 3/4/2023. On 3/21/2023 at 9:58 a.m., an interview was conducted with S2RNCM (Registered Nurse Case Manager). S2RNCM confirmed the patient was not receiving 56 hours of extended care nursing services per week as ordered due to nurses not being available. .

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 interview, the home health agency staff failed to demonstrate that effective coordination of care occurred when the physical therapist (PT) failed to inform agency staff and the patient’s physician of the patient’s fall on 03/09/2023 in a timely manner for 1 (#12) out of 17 sampled patients. Review of the agency policy titled, “Coordination Of Care, From Admit Through Discharge” read in part, Policy: The agency provides care and services within an integrated continuum of care system. This accomplished by: …Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge. Procedure: ...5. Coordination of care among disciplines: Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge. This includes: …c. Appropriate, timely communication with the patient, caregivers, and staff involved in the patient’s care regarding patient needs, goals and care as well as changes in these. (i.) All clinicians will report within 1 business day to the Patient Care Manager or Clinical Director by fax, telephone, in person at the agency, or coordination notes by synching point of care devices… Patient #12. Review of the patient’s electronic clinical records revealed the start of care date was 01/05/2023. The patient’s diagnoses included Type 2 DM (Diabetes Mellitus), HTN (Hypertension) and History of Falling. The certification period reviewed was 03/06/2023-05/04/2023. Review of the patient’s POC (Plan Of Care) for certification period 03/06/2023-05/04/2023 revealed an order for “SN 1wk9 (skilled nurse visit one time a week for nine weeks), HHA 1wk4 (home health aide visit one time a week for four weeks) and PT 1wk9 (physical therapy visit one time a week for nine weeks) Review of the patient’s physical therapy note dated 03/09/2023 revealed the Physical Therapist documented the patient reported he had fallen since his last skilled visit (03/08/2023). The patient reported bruising to his chest wall. He voiced pain 2 out of 10 on a pain scale of 0 to 10 and soreness due to the fall. Further review of the note revealed the therapist documented a fall notification coordination note was completed. Review of the patient’s record revealed a Client Coordination Note Report titled Fall Notification was not submitted by the physical therapist until 3/16/2023, which was 7 days after the patient reported the fall to the physical therapist. The notification indicated in part, the patient stated he was getting up to go to the bathroom in the early morning on 03/09/2023 and he ran the walker into the bathroom door which caused him to lose his balance and he fell over his walker. The walker tipped over onto him. His wife was able to remove the walker and to get him over to the bathtub to be able to come to stand without calling for help from the neighbors. The patient reported that he was sore from the fall and that he had a bruise on his chest from possibly hitting the walker handle. The patient sustained a skin tear to the right upper arm and a bruise on his chest wall. The patient did not go to the ER or had a follow up appointment with the doctor. Further review of the note revealed that a communication of the fall was reported to S3RNTL and the MD (Medical Doctor) via a MD/SBAR (Medical Doctor/Situation-Background-Assessment Recommendation- a communication between members of the health care team about a patient’s condition). Review of the patient’s record revealed that a MD/SBAR notification was submitted on 3/16/2023 notifying the patient’s physician of his fall. Review of a document titled, “Fax Status Report” revealed that SRNTL faxed the Client Coordination Note Report (MD/SBAR) on 03/16/2023 at 4:31 p.m. notifying the physician of the fall. On 03/22/2023 at 10:00AM, a review of the patient’s electronic record and interview was conducted with S1ED. A review of the physical therapist visit note on 03/09/2023 was reviewed. S1ED confirmed that the patient reported to the therapist that he had sustained a fall early that morning and had soreness and a bruise to his chest related to the fall. She also stated that the fall notification was not synched into the patient’s electronic record until 03/16/2023 and a communication notifying the patient’s physician of the fall was not sent until 03/16/2023. S3RNTL confirmed that the fall notification should have been entered into the patient’s record on 03/09/2023 and the patient’s physician should have been notified on 03/09/2023. On 03/22/2023 at 2:30 P.M., an interview was conducted with S3RNTL. She stated that she could not remember when the physical therapist notified her of Patient #12’s fall. She stated that it was either on 03/09/2023 or 03/10/2023. She stated that she could not notify the patient’s physician until the therapist synched the notification in the patient’s record. She confirmed that the therapist did not synch the notification in the patient’s record until 03/16/2023. She also confirmed that the therapist should have completed it on the day the resident informed her of the fall.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a registered nurse (RN) made an onsite visit for Patient #3 who was receiving home health aide (HHA) services no less frequently than every 14 days for 1 (#3) out of a total of 17 sampled patients. Patient #3. Review of the patient’s electronic clinical record revealed the start of care date was 2/20/2023. The patient’s diagnosis included Rheumatoid Arthritis of Right Hand and Left Hand. The certification period reviewed was 2/20/2023 to 4/20/2023. The patient's POC (Plan of Care) was reviewed and revealed the following orders: HHA 1wk9 (home health aide visit one time a week for nine weeks). Review of the patient's Visit Note Report for the HHA revealed the aide was performing the visits with the patient as ordered. There was no documentation found from 3/1/2023 to 3/21/2023, (20 days) that the RN made a supervised visit for the home health aide between this time frame. On 3/21/2023 at 1:35 p.m., an interview was conducted with S1ED (Executive Director) and after a review of the patient's electronic clinical records, she verified that the RN did not make a supervisory visit for the HHA no less frequently than every 14 days.

Complaint Survey #LA00061767

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate backup skilled nursing care when a nurse did not begin the shift timely causing the HCBS (Home and Community Based Services) staff to stay after their 12 hour shift, for 1 (#1) patient, out of 5 (#1-5) sampled patients receiving extended care nursing services. A review of Patient #1’s PoC (Plan of Care) revealed a start of care date of 3/21/2014. Patient #1’s diagnoses included congenital insufficiency of aortic valve, heart disease, unspecified disorder of psychological development, bowel and bladder incontinence, paralytic ileus, gastrostomy, and UTI (Urinary Tract Infection). Functional limitations included ambulation, endurance, and speech. Patient #1’s orders included skilled nursing by an LPN 84 hours weekly. Further review of the patient’s record revealed a CPOC (Comprehensive Plan of Care) from OCDD (Office for Citizens with Developmental Disabilities) dated 10/21/2021 – 10/20/2022, revealing that he received waiver services and had 24 hour support. The CPOC indicated “Yes” that he received Home Health services for 12 hours from 8AM – 8PM daily, and 12 hours of NOW (New Opportunity Waiver) supports from an HCBS (Home and Community Based Services) provider from 8PM – 8AM. A review of the home health agency’s policy and procedure titled “Staffing and Backup Services” was reviewed and included that all personnel provide patients/ clients served with quality professional services, carrying out their responsibilities and duties with dignity and efficiency… 5. As soon as an employee or contractor knows that they will be unable to provide services, they are instructed to call and notify their immediate supervisor. A review of the home health agency’s policy and procedure titled “Coordination of Care” was reviewed and included that the agency will coordinate patient care among various disciplines to ensure that services are continuous and coordinated, and 6. Coordination of services with other organizations… When the patient receives services from other organizations and/or individuals care is coordinated to ensure that patient’s needs are met efficiently. A review of Patient #1’s Nursing Flow Sheets/visit notes from November 2021 to January 31, 2022 was conducted. S2LPN failed to present to Client #1’s home to provide skilled nursing services at 8:00 AM on 11/3/21, 11/4/21, 11/8/21, 11/10/21, 11/29/21, 12/23/21, 1/3/22, 1/4/22, 1/10/22, 1/11/22, 1/18/22, 1/20/22, 1/24/22, and 1/26/22, with shift start times ranging from 8:04 AM to 8:35 AM. There was no evidence that S2LPN communicated with her supervisors that she would be late, and no evidence that a backup nurse was sent to provide skilled nurse care for Patient #1’s until S2LPN began her shift. A review of complaint forms revealed a complaint dated 11/16/2021 regarding consistent tardiness from S2LPN in regards to Patient #1. The form included that S2LPN acknowledged her tardiness. Further review revealed a complaint date 1/18/2022 regarding S2LPN’s tardiness in regards to Patient #1’s shift. On 1/31/2022 at 12:00 PM, an interview was conducted with S3ED/PEDs. She confirmed that Patient #1’s orders on his PoC were that he receive 12 hours of LPN skilled services daily, followed by 12 hours of NOW waiver supports from an HCBS agency. She stated that on 11/16/21 she received a call from the HCBS agency regarding S2LPN consistently arriving late for the 8:00 AM – 8:00 PM shift. S3ED/PEDs stated that S2LPN being tardy for the 8:00 AM shift had been an ongoing issue. She stated that on 1/18/2022 she received an email from the HCBS provider about the continued tardiness of S2LPN. She confirmed that the tardiness had continued and that the HCBS PCA (Personal Care Attendant) staff could not leave Patient #1 until they were replaced by the home health LPN, as he required 24 hour supervision. She confirmed that the shift times were documented on the daily Nursing Flow Sheet/visit notes, and that S2LPN had documented starting the shift after 8:00 AM on numerous occasions. On 1/31/2022 at 1:20 PM, an interview was conducted with S1DON. She confirmed that the LPN’s 12 hour shift for Patient #1 was to begin at 8:00 AM. She stated that if a nurse was going to be late for the shift, it was expected that they should notify their supervisor. S1DON confirmed that S2LPN had not started Patient #1’s 12 hour shift at 8:00 AM on numerous occasions. On 1/31/2022 at 1:40 PM, an interview was conducted with S3ED/PEDs. She stated that if S2LPN, or any nurse was going to be late for their assigned shift, the agency’s expectation is that they notify their supervisor before they are late so that a backup nurse can be coordinated to provide skilled nursing services until they arrive. S3ED/PEDs stated that S2LPN usually called her after 8:00 AM, when she was already late for her shift, or sometimes before her shift began, but not in time to provide a backup nurse for skilled nurse coverage for the patient until the scheduled LPN would arrive. S3ED/PEDs stated that there was no policy or procedure specifically addressing an appropriate time for the nurse to communicate with a supervisor so that coordination of a backup nurse could occur in a timely manner, ensuring that Patient #1 have a skilled nurse care for 12 hours. S3ED/PEDs confirmed that no coordination within the agency occurred to ensure that Patient #1 had skilled nurse care on the dates that S2LPN did not present at 8:00 AM. She confirmed ineffective coordination with the HCBS agency, when the home health LPN was late arriving, causing the HCBS PCA staff to remain with Patient #1 after their approved 12 hour shift, resulting in the revision of billing by the HCBS agency.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the appropriate provision of services by skilled professionals for 1 (#1) patient out of 5 (#1-5) sampled patients as evidenced by the LPN (Licensed Practical Nurse) failing to begin the scheduled 12 hour shift at the designated time. A review of Patient #1’s PoC (Plan of Care) revealed a start of care date of 3/21/2014. Patient #1’s Diagnoses included congenital insufficiency of aortic valve, Heart Disease, unspecified disorder of psychological development, bowel and bladder incontinence, paralytic ileus, gastrostomy, and UTI (Urinary Tract Infection). Functional limitations included ambulation, endurance, and speech. Patient #1’s orders included skilled nursing by an LPN 84 hours weekly. Further review of the patient’s record revealed a CPOC (Comprehensive Plan of Care) from OCDD (Office for Citizens with Developmental Disabilities) dated 10/21/2021 – 10/20/2022, revealing that he received waiver services and had 24 hour support. The CPOC indicated “Yes” that he received Home Health services from 8AM – 8PM daily, and NOW (New Opportunity Waiver) supports from another provider from 8PM – 8AM. A review of the home health agency’s Policy and Procedure titled, “Staffing and Backup Services” was reviewed and included that all personnel provide patients/ clients served with quality professional services, carrying out their responsibilities and duties with dignity and efficiency. 5. As soon as an employee or contractor knows that they will be unable to provide services, they are instructed to call and notify their immediate supervisor. A review of Patient #1’s Nursing Flow Sheets/visit notes from November 2021 to January 31, 2022 was conducted. S2LPN failed to report to Client #1’s home to provide skilled nursing services at 8:00 AM on 11/3/21, 11/4/21, 11/8/21, 11/10,/21 11/29/21, 12/23/21, 1/3/22, 1/4/22, 1/10 /22, 1/11/22, 1/18/22, 1/20/22, 1/24/22, and 1/26/22. There was no evidence that S2LPN notified her supervisors that she would be late, and no evidence that a backup nurse was sent to provide skilled nursing care until S2LPN arrived at Patient #1’s home. A review of complaint forms revealed a complaint dated 11/16/2021 regarding consistent tardiness from S2LPN in regards to Patient #1. The form included that S2LPN acknowledged her tardiness. Further review revealed a complaint date 1/18/2022 regarding S2LPN’s tardiness in regards to Patient #1’s shift. Both documents had been signed by S3ED/PEDs. On 1/31/2022 at 12:00 PM, an interview was conducted with S3ED/PEDs. She confirmed the complaints dated 11/16/2021 and 1/28/2022, regarding S2LPN’s repeated tardiness regarding starting the shifts for Patient #1. S3ED/PEDs further stated that this has been an ongoing issue with this nurse. S3ED/PEDs confirmed Patient #1’s orders included skilled nursing by an LPN for 12 hours from 8:00 AM to -8:00 PM, and that S2LPN had been late on multiple occasions. On 1/31/2022 at 1:20 PM, an interview was conducted with S1DON. She confirmed that the LPN’s shift for Patient #1 began at 8:00 AM, and further that it is expected that the LPN begin the shift at that time. She confirmed that S2LPN had not started Patient #1’s 12 hour shift at 8:00 AM on numerous occasions. She confirmed that the agency had failed to ensure the appropriate provision of 12 hour skilled nursing for Patient #1.

Recertification Survey A COVID-19 Focused Infection Control Survey was conducted on 7/14/2021. The facility was found to be in compliance with 42 CFR §484.70 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Total Census: 276

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's written individualized plan of care was followed as evidenced by: 1a. No evidence found for Patient #7 that a PT (Physical Therapy) visit was made for the week of 6/27/2021 as ordered per the POC (Plan of Care) and; 1b. No evidence found for Patient #7 that the skilled nurse notified the RN/MD (Registered Nurse/Medical Doctor) for the patient's weight loss and weight gain of over 5 pounds in one week as ordered per the POC for the skilled visits made on 6/23/2021 and 6/30/2021 for 1 (#7) out of 17 sampled patients. Findings: 1a. Patient #7. Review of the patient's electronic clinical record revealed the start of care date was 6/8/2021. The patient's admitting diagnoses included Heart Disease and Diabetes. The certification period reviewed was 6/8/2021 to 8/6/2021. Review of the patient's POC for the certification period 6/8/2021 to 8/6/2021 revealed an order for PT 2wk1, 1wk7 (Physical Therapy visit two times a week for one week, Physical Therapy visit one time a week for seven weeks). Review of the patient's electronic clinical record revealed that there was no evidence that a PT visit was made for the week of 6/27/2021. On 7/14/2021 at 1:27 pm, an interview was conducted with S1Executive Director. S1Executive Director reviewed the patient's electronic clinical record and confirmed that there was no evidence that a PT visit was made for the week of 6/27/2021. 1b. Patient #7. Review of the patient's electronic clinical record revealed the start of care date was 6/8/2021. The patient's admitting diagnoses included Heart Disease and Diabetes. The certification period reviewed was 6/8/2021 to 8/6/2021. Review of the patient's POC for the certification period 6/8/2021 to 8/6/2021 revealed an order for SN 1wk7, 1every2wk2 (Skilled Nurse visit one time a week for seven weeks, skilled nurse visit one every two weeks for two weeks). Further review of the POC revealed an order for "skilled nurse to obtain weight every visit and notify RN/MD of weight gain or loss of 2 lbs overnight or 5 lbs in one week..." Review of the patient's skilled nurse visit notes dated 6/14/2021 revealed that the patient's weight was 204.1 pounds. Review of the patient's skilled nurse visit notes dated 6/23/2021 revealed that the patient's weight was 196.2 pounds, which was a 7.9 pound weight loss in one week. There was no evidence found that the RN/MD (Registered Nurse/Medical Doctor) was notified that the patient had over a 5 pound weight loss in one week. Review of the patient's skilled nurse visit notes dated 6/30/2021 revealed that the patient's weight was 204 pounds, which was a 7.8 pound weight gain in one week from the last weight obtained on 6/23/2021. There was no evidence found that the RN/MD (Registered Nurse/Medical Doctor) was notified that the patient had over a 5 pound weight gain in one week. On 7/14/2021 at 1:38 pm, an interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN confirmed that the patient had changes in her weight. S4LPN stated that she could not remember if she notified the RN that the patient had over a 5 pound weight loss for the skilled nurse visit made on 6/23/2021. Also, S4LPN stated that she could not remember if she notified the RN that the patient had over a 5 pound weight gain for the skilled nurse visit made on 6/30/2021. On 7/14/2021 at 2:05 pm, an interview was conducted with S1Executive Director. S1Executive Director reviewed the patient's electronic clinical record and confirmed that there was no evidence that the S4LPN notified the RN or the MD concerning the patient's weight loss of over 5 pounds for the skilled nurse visit made on 6/23/2021 and the patient's weight gain of over 5 pounds for the skilled nurse visit made on 6/30/2021.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient #7's physician was promptly alerted by the skilled nurse that the patient had a fall on 6/12/2021 for 1 (#7) out of 17 sampled patients. Findings: Review of patient #7's electronic clinical record revealed that she was admitted to the agency on 6/8/2021. The patient's diagnoses included Heart Disease and Diabetes. The certification period reviewed was 6/8/2021 to 8/6/2021. Review of the patient's Plan Of Care (POC) for certification period 6/8/2021 to 8/6/2021 revealed an order for SN 1wk7, 1every2w2 (skill nurse visit one time a week for seven weeks, skill nurse visit one every two weeks for two weeks). Review of the skill nurse visit note dated 6/14/2021 revealed, "...Patient has had recent hospitalization with SOB, weakness, low iron...Patient reports falling this past Saturday night 6/12...Lying in bed when patient turns in bed, both legs ache...Fall notification sent and RN _____ notified." There was no evidence the patient's physician was notified concerning the patient's fall. On 7/14/2021 at 2:05 pm, S1Executive Director reviewed the patient's electronic clinical record and confirmed that there was no evidence the patient's physician was informed of the patient's fall.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled professional made an onsite visit to the patient's home and completed a thorough supervisory visit evaluation no less frequently than every 14 days for Patient #16 whom was receiving home health aide services 1 out of a total of 17 (#1-#17) sampled patients. Findings: Patient #16. The patient was admitted on 6/1/2021 with the diagnoses that included Nondisplaced Intertrochanteric Fracture Right Femur, and History of Falling. The certification period reviewed was 6/1/2021 to 7/30/2021. The patient's plan of care was reviewed and the following order was found - HHA (Home Health Aide) 1wk1 (1 time a week for 1 week), 2wk3 (2 times a week for 3 weeks) and 1wk2 (1 times a week for 2 weeks). Home Health Aide to assist with ADLS (Activities of Daily Living) and personal care needs. The patient's electronic medical records were reviewed and the HHA made a visit to the patient on 6/3/2021. The first documentation found by S3PT (Physical Therapist) of a thorough supervisory visit evaluation for the HHA was dated on 6/21/2021 which was 18 days after the HHA's visit and on 7/6/2021 which was 15 days after the previous evaluation. On 7/14/2021 at 12:53 pm, an interview was conducted with S3PT who was responsible to make the supervisory evaluation on the HHA. S3PT stated she asked the questions to the patient concerning the HHA but verified that the documentation of a thorough supervisory evaluation was documented only on 6/21/2021 and on 7/6/2021 which was late and pass the 14 days. S3PT stated the agency failed to place the supervisory visits on her schedule.