Every finding on record at C & P Home Health, LLC

A recertification survey was conducted from 12/29/25 to 12/31/25 at Community Home Health. The agency was found to be in substantial compliance with the Emergency Preparedness Conditions of Participation for Home Health Agencies.

A recertification survey was conducted at Community Home Health from 12/29/25 to 12/31/25. Standard Level deficiencies were cited and will require an acceptable plan of correction.

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 medical record review, agency policy and procedure, observation, and interviews with staff, it was determined the agency failed to ensure physician's orders for Peripherally Inserted Central Cather (PICC) line care were followed. This deficient practice affected one of one patients with a PICC line including Home Visit (HV) # 2 and had the potential to affect all patients with PICC lines admitted to this agency. Findings include: Agency Policy: Plan of Care - CMS (Centers for Medicare & Medicaid Services) # 485 and Physician Orders Policy Number: 9.10.1 Revised: January 2025 Policy: Skilled nursing and other home health services will be in accordance with a Plan of Care ... Procedure: ... 20. Care and services provided will be provided according to physician/practitioner orders... 1. HV # 2 was admitted on 12/3/25 with diagnoses of Reaction due to Implanted Electrical Neurostimulator of Spinal Cord and Disruption of External Operation (Surgical) Wound. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 12/3/25 revealed physician's orders for Skilled Nurse (SN) one visit per week for nine weeks to obtain blood sample for laboratory testing weekly via PICC line. SN to obtain specimen then flush with 20 milliliters (ml) of Normal Saline (NS) followed by 5 ml of Heparin 10 units/ml. Review of the SN Visit Note, Infusion Notes, dated 12/3/25, 12/8/25, 12/15/25, 12/22/25, and 12/29/25, revealed blood was withdrawn from the PICC line on each visit and the port was flushed with 10 ml of NS after the blood sample was removed. The staff failed to follow the physician's orders to flush the PICC line with 20 ml of NS after each blood sample was withdrawn. Review of the Communication Note dated 12/11/25 revealed the SN documented HV # 2 reported the PICC line was not flushing and he/she was going to the hospital Emergency Room. HV # 2 was then scheduled for a PICC line replacement 12/12/25. A HV was conducted on 12/29/25 at 12:55 PM to observe care provided by Employee Identifier (EI) # 3, Registered Nurse (RN). The surveyor observed EI # 3 withdraw a blood sample from the PICC line port and flush the port with 10 ml NS and 5 ml of Heparin. An interview was conducted on 12/29/25 at 3:05 PM with EI # 3 who confirmed he/she flushed the PICC line with 10 ml of NS. An interview was conducted on 12/31/25 at 12:14 PM with EI # 2, RN, Director, who confirmed the agency failed to ensure physician's orders for flushing the PICC line were followed.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure the hand hygiene policy was followed. This deficient practice affected one of one observation of Peripherally Inserted Central Catheter (PICC) line care including Home Visit (HV) # 2 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: PICC Line Dressing Change Policy Number: I-260 Date Revised: Not Listed Purpose: To prevent infection ... Special Considerations: PICC line dressing changes will use sterile technique... Procedure: ... Wash hands... 6. Don non-sterile gloves... 10. Discard old dressing, remove non-sterile gloves... 11. Don sterile gloves. 12. Clean exit site... Agency Policy: Hand Hygiene Policy and Compliance Program. Policy Number: 5.7.1 Revised: March 2018 Policy: Hand hygiene will be done by all employees to reduce the transfer of microbes to patients and to prevent the growth of microorganisms... Purpose: To prevent transfer of germs and transmission of infections to patients and caregivers... Procedure: ...7. The Agency will follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene: Recommendations: After removing gloves. Before handling invasive device... 1. HV # 2 was admitted on 12/3/25 with diagnoses of Reaction due to Implanted Electrical Neurostimulator of Spinal Cord and Disruption of External Operation (Surgical) Wound. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 12/3/25 revealed physician's orders for Skilled Nurse (SN) one visit per week for nine weeks to perform Vascular Access Device (VAD) care to right upper arm PICC line weekly. A HV was conducted on 12/29/25 at 12:55 PM to observe PICC line care provided by Employee Identifier (EI) # 3, Registered Nurse (RN). EI # 3 donned non-sterile gloves, removed the dressing from the PICC line, removed the non-sterile gloves, donned sterile gloves, and cleaned the PICC line insertion site. EI # 3 failed to perform hand hygiene after removing the non-sterile gloves and donning the sterile gloves. An interview was conducted on 12/29/25 at 3:05 PM with EI # 3, who confirmed he/she failed to perform hand hygiene between glove changes. An interview was conducted on 12/31/25 at 12:14 PM with EI # 2, RN, Director, who confirmed the agency failed to ensure the staff followed agency policy for hand hygiene.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure Visit Note (VN) documentation was completed per agency policy. This deficient practice did affect six of 10 MRs reviewed including MR # 6, MR # 4, Home Visit (HV) # 2 MR # 2, HV # 1, MR # 5, and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Timely Submission of Patient Documentation Policy Number: 11.5.1 Revised: October 2017 Policy: The agency will ensure the timely and proper submission of patient documentation... Procedure: ...2. Itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding five (5) business days. All patient visit reports from contract personnel must be submitted within five (5) business days from the date of the visit... 4. MR # 2 was admitted on 11/17/25 with diagnoses including Parkinson's, and Dementia in Other Disease Classified Elsewhere With Mood Disturbance. Review of the HHC and POC dated 11/17/25 revealed physician's orders for SN one visit per week for nine weeks, and two visits pro re nata (PRN). Review of the SN VN dated 11/17/25 revealed the note was signed by the SN on 12/3/25, which was 12 business days after the visit. Review of the SN VN dated 11/18/25 revealed the note was signed by the SN on 12/4/25, which was 12 business days after the visit. An interview was conducted on 12/31/25 at 12:35 PM with EI # 2, who confirmed the agency failed to ensure the SN VNs were completed and signed per agency policy. 5. HV # 1 was admitted on 12/1/25 with diagnoses including Acute Kidney Failure, Chronic Kidney Failure, and Chronic Obstructive Pulmonary Disease. Review of the HHC and POC dated 12/1/25 revealed physician's orders for SN one visit per week for nine weeks, and two visits PRN. Review of the SN VN dated 12/1/25 revealed the note was signed by the SN on 12/17/25, which was 12 business days after the visit. Review of the SN VN dated 12/4/25 revealed the note was signed by the SN on 12/17/25 which was nine business days after the visit. Review of the SN VN dated 12/10/25 revealed the note was signed by the SN on 12/23/25 which was nine business days after the visit. An interview was conducted on 12/31/25 at 12:35 PM with EI # 2, who confirmed the agency failed to ensure the SN VNs were completed and signed per agency policy. 6. MR # 5 was admitted on 6/17/25 with diagnoses including Type 2 Diabetes with Other Skin Ulcer, Non-pressure Ulcer of Right Heel and Mid Foot Necrosed Muscle, and Pressure Ulcer Sacral Region. Review of the HHC and POC dated 6/17/25 revealed physician's orders for SN three visits per week for eight weeks, one visit per week for one week, and two visits PRN. Review of the SN VN dated 7/21/25 revealed the note was signed by the SN on 8/13/25, which was 17 business days after the visit. Review of the SN VN dated 7/23/25 revealed the note was signed by the SN on 8/13/25 which was 15 business days after the visit. Review of the SN VN dated 7/25/25 revealed the note was signed by the SN on 8/13/25 which was 13 business days after the visit. Review of the SN VN dated 7/28/25 revealed the note was signed by the SN on 8/13/25, which was 12 business days after the visit. Review of the SN VN dated 7/30/25 revealed the note was signed by the SN on 8/13/25 which was 10 business days after the visit. Review of the SN VN dated 8/1/25 revealed the note was signed by the SN on 8/13/25 which was 8 business days after the visit. Review of the SN VN dated 8/4/25 revealed the note was signed by the SN on 8/13/25 which was 7 business days after the visit. An interview was conducted on 12/31/25 at 12:35 PM with EI # 2, who confirmed the agency failed to ensure the SN VNs were completed and signed per agency policy. 1. MR # 6 was admitted on 4/11/25 with diagnoses including Aftercare Following Surgery for Neoplasm, Other Acute Procedural Pain, and Unspecified Asthma. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/11/25 revealed physician's orders for Skilled Nurse (SN) one visit per week for one week, two visits per week for three weeks, then one visit per week for five weeks. Review of the Skilled Nurse SN VN dated 4/11/25 revealed the note was signed by the SN on 4/30/25, which was 14 business days after the visit. Review of the SN VN dated 4/22/25 revealed the note was signed by the SN on 5/4/25, which was eight business days after the visit. Review of the SN VN dated 4/24/25 revealed the note was signed by the SN on 5/5/25, which was seven business days after the visit. Review of the SN VN dated 5/1/25 revealed the note was signed by the SN on 5/13/25, which was eight business days after the visit. Review of the SN VN dated 5/6/25 revealed the note was signed by the SN on 5/15/25 which was seven business days after the visit. Review of the SN VN dated 5/7/25 revealed the note was signed by the SN on 5/22/25 which was 11 business days after the visit. Review of the SN VN dated 5/20/25 revealed the note was signed by the SN on 6/2/25 which was nine business days after the visit. Review of the SN VN dated 6/3/25 revealed the note was signed by the SN on 7/1/25 which was 20 business days after the visit. An interview was conducted on 12/31/25 at 12:35 PM with Employee Identifier (EI) # 2, Registered Nurse (RN), Director, who confirmed the agency failed to ensure the SN VNs were completed and signed per agency policy. 2. MR # 4 was admitted on 9/4/24 and recertified from 3/3/35 to 5/1/25 with diagnoses including Essential (Primary) Hypertension, Hypotension, and Type 2 Diabetes Mellitus with Hyperglycemia. Review of the HHC and POC dated 3/3/25 revealed physician's orders for SN one visit per week for nine weeks. Review of the SN VN dated 4/9/25 revealed the SN signed the note on 4/25/25, which was 12 business days after the visit. An interview was conducted on 12/31/25 at 12:35 PM with EI # 2, who confirmed the agency failed to ensure the SN VNs were completed and signed per agency policy. 3. HV # 2 was admitted on 12/3/25 with diagnoses including Reaction due to Implanted Electrical Neurostimulator of Spinal Cord and Disruption of External Operation (Surgical) Wound. Review of the HHC and POC dated 12/3/25 revealed physician's orders for SN one visit per week for nine weeks. Review of the SN VN dated 12/3/25 revealed the SN signed the note on 12/19/25, which was 12 business days after the visit. Review of the SN VN dated 12/8/25 revealed the SN signed the note on 12/30/25, which was 16 business days after the visit. Review of the SN VN dated 12/15/25 revealed the SN signed the note on 12/30/25, which was 11 business days after the visit. An interview was conducted on 12/31/25 at 12:14 PM with EI # 2, who confirmed the agency failed to ensure the SN VNs were completed and signed per agency policy.

A recertification survey was conducted on 1/3/23 to 1/5/23, and Community Home Health was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted at Community Home Health on 1/3/23 through 1/5/23, standard level deficiencies were cited and will require a plan of correction.

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 review of agency policy and procedure, observations, medical records (MR), and interviews with staff, it was determined the agency failed to maintain an accurate medication profile for each patient. This deficient practice affected one of three home visits (HV) including HV # 1 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Medication Reconciliation Date: None Policy: ... will reconcile patient's medications at time of admission and on an ongoing basis. Purpose: To define the medication reconciliation process. Procedure: At time of admission, the admitting RN (registered nurse), PT (physical therapist), or SLP (speech language pathologist) will create and document a complete list of medications that patient is taking at home... Any discrepancies will be reconciled by a RN with the patient's physician. Discrepancies include ...omissions, changes... 1. HV # 1 was admitted to the agency 11/20/22 and certified for care 11/20/22 to 1/18/23 with diagnoses including Nondisplaced Fracture of Medial Malleolus of Left Tibia and Unspecified Fracture of Shaft of Left Tibia, Subsequent Encounter for Closed Fracture with Routine Healing. A review of the Home Health Certification and Plan of Care (POC) revealed skilled nurse (SN) visits two times a week for week one and one time a week for eight weeks. A HV was conducted on 1/4/23 at 7:45 AM to observe care provided by Employee Identifier (EI) # 2 Home Health Aide (HHA). Medication reconciliation was performed with the patient using the the agency Medication Summary (MS) and medications found in the home. The following medications were found in the home, verified by the patient and not documented on the agency MS. a. Lisinopril 40 milligram (mg) tablet take one a day for high blood pressure. Filled 11/25/22. The patient stated "I have taken that for several months or years." b. Meloxicam 7.5 mg take one tablet daily. Filled 7/19/22. The patient stated he/she takes that for arthritis pain. "I don't take it like I should." An interview conducted on 1/5/23 at 2:10 PM with EI # 1, Administrator confirmed the staff failed to maintain an accurate medication profile for each patient.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, KCI (Kinetic Concepts Incorporated) Clinical Guidelines: VAC Therapy (Vacuum Assisted Closure) and interview with the staff, it was determined the agency failed to ensure the nurse documented the number of foam pieces removed and placed to the wound during wound care dressing changes per physician orders. This deficient practice affected one of three patients with wounds and did affect Home Visit (HV) # 3 and had the potential to negatively affect all patients served by the agency with wounds. Findings include: Agency Policy: Plan of Care and Physician Orders Policy number: 9.10.1 Revised date: 10/17 Policy: Skilled nursing and other home health services will be in accordance with a plan of care based on the patient's diagnosis and assessment of immediate and long range needs and resources. Purpose: To describe the contents of the plan of care Procedure: ...2. 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... ...4. The individualized plan of care must include the following: All patient care orders...must be recorded in the plan of care... ...20. Care and services provided will be provided according to physicians orders. KCI Clinical Guidelines: VAC Therapy Clinical Guidelines Revised Date: 3/2011 Points to Remember When Using VAC Wound Therapy: Accurately record the number of foam pieces used in the patient's chart and on a readily visualized place on the drape... When dressing is removed, count the number of foam pieces removed, correlate the count with the number of pieces previously placed in the wound... 1. HV # 3 was admitted to agency on 12/13/2022 and certified for care 12/13/22 to 2/10/23 with diagnoses including Cellulitis of Right Upper Limb and Superficial Foreign Body of Right Forearm. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 12/13/22 revealed the skilled nurse (SN) was to visit two times a week for one week and then three times a week for eight weeks. Further review of the HHC and POC dated 12/13/22 revealed the following orders for wound care: SN to perform wound care (wound VAC therapy) to right forearm cellulitis wound: three times a week and PRN (as needed) dislodgement/soilage. Clean the wound with saline, apply skin prep to periwound, hydroferra blue foam to denuded skin, then window pane with clear drape, gently fill wound bed with foam, cover with drape, cut quarter size hole in clear drape and apply suction pad, connect to NPWT (Negative Pressure Wound Therapy) machine at 125 mmHg (millimeters per mercury) continuous...and document the number of foam pieces removed and placed. Review of ten of ten SN visit notes dated 12/13/22 through 1/4/23 revealed no documentation of the number of foam pieces that were removed and placed in the wound. An interview was conducted on 1/5/23 at 1:55 PM with Employee Identifier (EI) # 1 Administrator, who confirmed the SN failed to document the number of foam pieces removed and placed in the wound per physician's orders and agency policy.