Every finding on record at Cooperative Home Care, Inc

A complaint investigation #2673439 was completed on 12/22/2025 at the home health provider. The provider had 95 current patients. The complaint was substantiated. One or more of the allegations reported were verified and condition-level deficiencies were cited that were related to the allegations that were investigated. Two condition-level deficiencies were identified during this survey. Condition-level deficiencies are identified at: - §484.50 Condition of Participation: Patient Rights; and - §484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care.

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider violated the patient’s rights when the provider failed to ensure that the patients received all services outlined in the plan of care (G0436). The cumulative effect of this deficient practice has the potential to affect all the patients on service.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation and interview, the home health provider failed to ensure that the patients received all services outlined in the plan of care in three of three records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients on service. Findings included: Review of the provider’s policy titled, "Patient Bill of Rights and Responsibilities,” revised February 2024, showed in part: - The patient has the right to be admitted by the agency (provider) only if it has the resources needed to provide the care safely and at the required level of intensity, as determined by a professional assessment; - The agency with less then optimal resources may nevertheless admit the patient if a more appropriate provider is not available, but only after fully informing the patient of the agency's limitations and the lack of suitable alternative arrangements; and - The patient has the right to receive all services in the plan of care. RECORD/PATIENT #1: Review of the clinical record showed, in part, the patient was admitted to home health services on 11/05/2025 with a primary diagnosis of fracture of neck of left femur, subsequent encounter for closed fracture with routine healing (a break in the upper part of the thigh bone near the hip joint). The patient resided at home alone. Review of the home health referral orders, dated 10/31/2025, showed in part: - Discharge (DC) home with home health; and - Home health physical therapy (PT), occupational therapy (OT), and registered nurse (RN). Review of the plan of care, dated 11/05/2025 to 01/03/2026, showed in part: - OT evaluate (eval) visit, one (1) visit weekly for 1 week starting 11/10/2025; - PT eval visit, 1 visit weekly for 1 week starting 11/10/2025; - RN start of care (SOC) outcome and assessment information set (OASIS - a standardized data collection tool), 1 visit weekly for 1 week starting 11/05/2025; and - Skilled nurse (SN) visit, 1 visit weekly for eight (8) weeks starting 11/10/2025. Review of the SOC OASIS, dated 11/05/2025, showed in part: - The patient had a high risk diagnosis of altered gait; - Barrier to independent self-management included functional; - Physical limitations included deconditioning, frailty, and physical limitations impaired the patient’s ability to participate in their own care; and - Recommended services included PT and OT to eval and treat (tx). Review of SN visit note, dated 11/14/2025, showed in part, the musculoskeletal system assessment included balance, unsteady gait, endurance, weakness to the left (L) leg from hip surgery, limited movement, assistive device of a walker, and the patient had pain to the L hip. Review of SN visit note, dated 11/17/2025, showed in part: - The musculoskeletal system assessment included balance, unsteady gait, endurance, weakness to the L leg from hip surgery, limited movement, assistive device of a walker, the patient had pain to the L hip and fractures of recent L hip; and - Problems, interventions, and goals showed, “Pt (patient) hasn’t had therapy and hasn’t made much process (progress). (He/she) is hopeful to be up and moving by the holidays.” Review of the complaint log, dated 11/19/2025, showed: - The director of clinical services (back-up administrator) returned a call to a friend of the patient with the patient in the background; - He/she was updated regarding the unforeseen therapy circumstances and were working diligently to resolve; and - He/she requested the contact information to the administrator and it was provided to him/her. Review of the complaint log, dated 11/21/2025, showed: - The director of clinical services went to visit the patient; - The patient reported that he/she was going to have “brain surgery” on 12/01/2025 and he/she had gotten better with the walker but wanted to make sure that he/she would have therapy visits when returning home after surgery; and - The director of clinical services explained how therapy and visits worked and stated that they (home health provider) would have therapy when the patient returned from his/her brain surgery. Review of the clinical record showed that the home health provided violated the patient’s right to receive all services outlined in the plan of care when the provided failed to provide the patient with therapy services. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 07/03/2025 with a primary diagnosis of intervertebral disc disorders with myelopathy, lumbar region (a damaged lower back disc that is compressing the spinal cord, and can cause symptoms like leg weakness, balance issues, numbness, tingling, and potential bladder and bowel dysfunction). The patient lived at home with his/her spouse. Review of the recertification follow-up assessment, dated 10/30/2025, showed in part: - Activities permitted included transfer bed/chair, exercise prescribed, wheelchair, and walker; - Homebound status showed chairfast and unable to wheel self, unable to negotiate stairs leading to outside, and ambulation was unsteady and unsafe; - The patient had a history of falls; - Barrier to independent self-management included functional; - Physical limitations included deconditioning, frailty, and physical limitations impaired the patient’s ability to participate in their own care; and - Discharge and rehab showed rehabilitation potential was good and discharge would be under the supervision of the primary care provider (PCP) and caregiver (CG) when goals are met and max (maximum) potential was reached. Review of the plan of care, dated 10/31/2025 to 12/29/2025, showed in part: - PT eval visit, 1 visit weekly for 1 week starting 11/03/2025; and - SN visit, 1 visit weekly for nine (9) weeks starting 10/31/2025. Review of the complaint log, dated 11/24/2025, showed: - The director of clinical services called the patients spouse back after the spouse had left a message; - The patient’s spouse asked when therapy would be able to come back out to see the patient; - “OT had just DC pt per notes on 10/22;” - “Discussed with wife that it will hopefully be about 2-3 (two to three) weeks or so before a therapist will be able to come out;” - “Pt and wife had been made aware of unforeseen therapy circumstances;” and - The patient’s wife stated that she would be waiting for therapy’s return. Review of the clinical record showed that the home health provided violated the patient’s right to receive all services outlined in the plan of care when the provided failed to provide the patient with therapy services as written in the plan of care. Observation on 12/16/2025, beginning at 8:00 AM showed: - A physical therapist with the new therapy company evaluated the patient and developed a treatment plan with the patient and spouse (caregiver); - The patient was going to start receiving therapy twice a week; - The spouse reported that the previous therapy company was working with the patient on transferring with a walker at the end of October but it took three people to assist; - The spouse continued to assist the patient with the exercises that he/she could but the patient had not worked on transferring with a walker since the previous therapy company quit; - The patient went from the end of October until 12/16/2025 without therapy services; - The patient and spouse were eager for therapy services to resume; and - The spouse reported that he/she was impressed with the new therapist and was looking forward to the patient receiving therapy again. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/07/2025 with a primary diagnosis of aftercare following joint replacement surgery (following joint replacement, focusing on rehabilitation, physical therapy, and follow-ups to monitor for healing, signs of complications, and rehabilitation for full recovery) and presence of right artificial knee joint (the replacement of damaged knee parts with metal or plastic implants to relieve pain and restore function). The patient lived at home with a family member. Review of the home health referral orders, dated 10/24/2025, showed in part: - The patient was to discharge home on 10/29/2025 with home care; and - PT, OT, and nursing for medication management. Review of the SOC OASIS, dated 11/07/2025, showed in part: - Musculoskeletal status included right total knee replacement; - Functional limitations included endurance, ambulation, pain, dyspnea with moderate exertion, and total knee arthroplasty (TKA) precautions; - Physical limitations included deconditioning, frailty, and physical limitations impaired the patient’s ability to participate in their own care; and - Recommended services included SN for general assessment, wound assessment, pain control, PT and OT to eval and tx. Review of the plan of care, dated 11/07/2025 to 01/05/2026, showed in part: - PT eval visit, 1 visit weekly for 1 week starting 11/10/2025; - RN SOC OASIS 1 visit weekly for 1 week starting 11/07/2025; - SN visit, 1 visit weekly for 8 weeks starting 11/07/2025; and - The plan of care failed to show OT as ordered in the referral and identified as a needed service during the initial comprehensive assessment. Review of SN visit note, dated 11/13/2025, showed in part: - Ambulation is unsteady and unsafe even with assistance; - Dyspnea when ambulating, must stop and rest after so many feet; and - Musculoskeletal system assessment showed balance, unsteady gait, endurance, weakness, knee pain and swelling, and assistive device of a walker. Review of the complaint log, dated 11/17/2025, showed: - The author of the entry was the clinical manager; - The patient called to inquire about therapy services and when they would start; - The patient was informed that therapy services would be available within the next several weeks as the agency was undergoing therapy company transition; - The patient was instructed to continue therapy exercises that were sent upon discharge from acute rehab; - The patient was instructed if any concerns regarding exercises, the skilled nurse could assist with demonstration at the next SN visit; - The patient was informed that he/she would be informed as soon as therapy was available; and - The patient voiced understanding. Review of a SN missed visit note, dated 11/24/2025, showed in part: - The patient refused the visit; and - The patient refused nursing services until he/she was able to work with PT/OT. Review of the complaint log, dated 11/24/2025, showed: - The author of the entry was the clinical manager; - The patient’s case manager informed the director of nursing that the patient refused further services until therapy was available; - The patient reported that he/she no longer needed nursing as the incision was healed and pain was controlled; - The patient requested to be discharged from the agency so that he/she could start outpatient therapy; - The patient was informed that therapy services for home health are subject to start in the next 2-3 weeks; and - The patient stated that he/she did not wish to wait and would be starting outpatient services. Review of the discharge note, dated 11/25/2025, showed in part: - The patient declined (nursing) services and wanted to discharge; - The patient refused all care until the patient was able to work with PT; - The patient didn’t see the need for an RN’s care; - (The SN) explained the importance and our (nursing’s) role that we (the nurses) provide in patient care; and - The patient still refused. Review of the clinical record showed that the home health provided violated the patient’s right to receive all services outlined in the plan of care when the provided failed to provide the patient with therapy services. During an interview on 12/15/2025, at 3:45 PM, the back-up administrator stated that: - They (the home health provider) had two contract companies for therapy with one being the primary and the second company being a back-up; - The primary therapy contract company gave notice at the end of October that the company was closing; - The back-up company was contacted to provide therapy services until a new company could be found; - The back-up company was only able to pick-up a few patient’s for therapy and then they ended up giving notice that they were closing as well; - The new contract company started a week ago but had to get trained in our (the home health provider) system; - The patient’s went without therapy while waiting for the new company to start; and - The physician’s were not notified but the patient’s were informed that it would be 2-3 weeks before therapy could start.

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 policy review, record review, observation, and interview, the home health provider failed to: - Ensure that each patient received the home health services that were written in the individualized plan of care (G0572); and - Assure communication with all physicians or allowed practitioners involved in the plan of care (G0602). The cumulative effect of these deficient practices has the potential to affect all the patients on service.

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 policy review, record review, observation, and interview, the home health provider failed to ensure that each patient received the home health services that were written in the individualized plan of care, in three of three records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients on service. Findings included: Review of the provider’s policy titled, "Plan of Care and Physician/Practitioners Orders,” revised February 2024, showed in part: - Patients are accepted for treatment on the reasonable expectation that the agency can meet the patient’s medical, nursing, rehabilitative and social needs in his or her place of residence; and - 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 (every 60 days or more frequently when indicated by changes in the patient's condition) and signed by a physician or authorized practitioner acting with the scope of his or her state license, certification or registration. RECORD/PATIENT #1: Review of the clinical record showed, in part, the patient was admitted to home health services on 11/05/2025 with a primary diagnosis of fracture of neck of left femur, subsequent encounter for closed fracture with routine healing (a break in the upper part of the thigh bone near the hip joint). The patient resided at home alone. Review of the home health referral orders, dated 10/31/2025, showed in part: - Discharge (DC) home with home health; and - Home health physical therapy (PT), occupational therapy (OT), and registered nurse (RN). Review of the plan of care, dated 11/05/2025 to 01/03/2026, showed in part: - OT evaluate (eval) visit, one (1) visit weekly for 1 week starting 11/10/2025; - PT eval visit, 1 visit weekly for 1 week starting 11/10/2025; - RN start of care (SOC) outcome and assessment information set (OASIS - a standardized data collection tool), 1 visit weekly for 1 week starting 11/05/2025; and - Skilled nurse (SN) visit, 1 visit weekly for eight (8) weeks starting 11/10/2025. Review of the SOC OASIS, dated 11/05/2025, showed in part: - The patient had a high risk diagnosis of altered gait; - Barrier to independent self-management included functional; - Physical limitations included deconditioning, frailty, and physical limitations impaired the patient’s ability to participate in their own care; and - Recommended services included PT and OT to eval and treat (tx). Review of SN visit note, dated 11/14/2025, showed in part, the musculoskeletal system assessment included balance, unsteady gait, endurance, weakness to the left (L) leg from hip surgery, limited movement, assistive device of a walker, and the patient had pain to the L hip. Review of SN visit note, dated 11/17/2025, showed in part: - The musculoskeletal system assessment included balance, unsteady gait, endurance, weakness to the L leg from hip surgery, limited movement, assistive device of a walker, the patient had pain to the L hip and fractures of recent L hip; and - Problems, interventions, and goals showed, “Pt (patient) hasn’t had therapy and hasn’t made much process (progress). (He/she) is hopeful to be up and moving by the holidays.” Review of the complaint log, dated 11/19/2025, showed: - The director of clinical services (back-up administrator), returned a call to a friend of the patient with the patient in the background; - He/she was updated regarding the unforeseen therapy circumstances and were working diligently to resolve; and - He/she requested the contact information to the administrator and it was provided to him/her. Review of the complaint log, dated 11/21/2025, showed: - The director of clinical services, went to visit the patient; - The patient reported that he/she was going to have “brain surgery” on 12/01/2025 and he/she had gotten better with the walker but wanted to make sure that he/she would have therapy visits when returning home after surgery; and - The director of clinical services explained how therapy and visits worked and stated that they (home health provider) would have therapy when the patient returned from his/her brain surgery. Review of the clinical record showed that the home health provided failed to ensure that the patient received the therapy services that were written in the individualized plan of care. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 07/03/2025 with a primary diagnosis of intervertebral disc disorders with myelopathy, lumbar region (a damaged lower back disc that is compressing the spinal cord, and can cause symptoms like leg weakness, balance issues, numbness, tingling, and potential bladder and bowel dysfunction). The patient lived at home with his/her spouse. Review of the recertification follow-up assessment, dated 10/30/2025, showed in part: - Activities permitted included transfer bed/chair, exercise prescribed, wheelchair, and walker; - Homebound status showed chairfast and unable to wheel self, unable to negotiate stairs leading to outside, and ambulation was unsteady and unsafe; - The patient had a history of falls; - Barrier to independent self-management included functional; - Physical limitations included deconditioning, frailty, and physical limitations impaired the patient’s ability to participate in their own care; and - Discharge and rehab showed rehabilitation potential was good and discharge would be under the supervision of the primary care provider (PCP) and caregiver (CG) when goals are met and max (maximum) potential was reached. Review of the plan of care, dated 10/31/2025 to 12/29/2025, showed in part: - PT eval visit, 1 visit weekly for 1 week starting 11/03/2025; and - SN visit, 1 visit weekly for nine (9) weeks starting 10/31/2025. Review of the complaint log, dated 11/24/2025, showed: - The director of clinical services called the patients spouse back after the spouse had left a message; - The patient’s spouse asked when therapy would be able to come back out to see the patient; - “OT had just DC pt per notes on 10/22;” - “Discussed with wife that it will hopefully be about 2-3 (two to three) weeks or so before a therapist will be able to come out;” - “Pt and wife had been made aware of unforeseen therapy circumstances;” and - The patient’s wife stated that she would be waiting for therapy’s return. Review of the clinical record showed that the home health provided failed to ensure that the patient received the therapy services that were written in the individualized plan of care. Observation on 12/16/2025, beginning at 8:00 AM showed: - A physical therapist with the new therapy company evaluated the patient and developed a treatment plan with the patient and spouse (caregiver); - The patient was going to start receiving therapy twice a week; - The spouse reported that the previous therapy company was working with the patient on transferring with a walker at the end of October but it took three people to assist; - The spouse continued to assist the patient with the exercises that he/she could but the patient had not worked on transferring with a walker since the previous therapy company quit; - The patient went from the end of October until 12/16/2025 without therapy services; - The patient and spouse were eager for therapy services to resume; and - The spouse reported that he/she was impressed with the new therapist and was looking forward to the patient receiving therapy again. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/07/2025 with a primary diagnosis of aftercare following joint replacement surgery (following joint replacement, focusing on rehabilitation, physical therapy, and follow-ups to monitor for healing, signs of complications, and rehabilitation for full recovery) and presence of right artificial knee joint (the replacement of damaged knee parts with metal or plastic implants to relieve pain and restore function). The patient lived at home with a family member. Review of the home health referral orders, dated 10/24/2025, showed in part: - The patient was to discharge home on 10/29/2025 with home care; and - PT, OT, and nursing for medication management. Review of the SOC OASIS, dated 11/07/2025, showed in part: - Musculoskeletal status included right total knee replacement; - Functional limitations included endurance, ambulation, pain, dyspnea with moderate exertion, and total knee arthroplasty (TKA) precautions; - Physical limitations included deconditioning, frailty, and physical limitations impaired the patient’s ability to participate in their own care; and - Recommended services included SN for general assessment, wound assessment, pain control, PT and OT to eval and tx. Review of the plan of care, dated 11/07/2025 to 01/05/2026, showed in part: - PT eval visit, 1 visit weekly for 1 week starting 11/10/2025; - RN SOC OASIS 1 visit weekly for 1 week starting 11/07/2025; - SN visit, 1 visit weekly for 8 weeks starting 11/07/2025; and - The plan of care failed to show OT as ordered in the referral and identified as a needed service during the initial comprehensive assessment. Review of SN visit note, dated 11/13/2025, showed in part: - Ambulation is unsteady and unsafe even with assistance; - Dyspnea when ambulating, must stop and rest after so many feet; and - Musculoskeletal system assessment showed balance, unsteady gait, endurance, weakness, knee pain and swelling, and assistive device of a walker. Review of the complaint log, dated 11/17/2025, showed: - The author of the entry was the clinical manager; - The patient called to inquire about therapy services and when they would start; - The patient was informed that therapy services would be available within the next several weeks as the agency was undergoing therapy company transition; - The patient was instructed to continue therapy exercises that were sent upon discharge from acute rehab; - The patient was instructed if any concerns regarding exercises, the skilled nurse could assist with demonstration at the next SN visit; - The patient was informed that he/she would be informed as soon as therapy was available; and - The patient voiced understanding. Review of a SN missed visit note, dated 11/24/2025, showed in part: - The patient refused the visit; and - The patient refused nursing services until he/she was able to work with PT/OT. Review of the complaint log, dated 11/24/2025, showed: - The author of the entry was the clinical manager; - The patient’s case manager informed the director of nursing that the patient refused further services until therapy was available; - The patient reported that he/she no longer needed nursing as the incision was healed and pain was controlled; - The patient requested to be discharged from the agency so that he/she could start outpatient therapy; - The patient was informed that therapy services for home health are subject to start in the next 2-3 weeks; and - The patient stated that he/she did not wish to wait and would be starting outpatient services. Review of the discharge note, dated 11/25/2025, showed in part: - The patient declined (nursing) services and wanted to discharge; - The patient refused all care until the patient was able to work with PT; - The patient didn’t see the need for an RN’s care; - (The SN) explained the importance and our (nursing’s) role that we (the nurses) provide in patient care; and - The patient still refused. Review of the clinical record showed that the home health provided failed to ensure that the patient received the therapy services that were written in the individualized plan of care. During an interview on 12/15/2025, at 3:45 PM, the back-up administrator stated that: - They (the home health provider) had two contract companies for therapy with one being the primary and the second company being a back-up; - The primary therapy contract company gave notice at the end of October that the company was closing; - The back-up company was contacted to provide therapy services until a new company could be found; - The back-up company was only able to pick-up a few patient’s for therapy and then they ended up giving notice that they were closing as well; - The new contract company started a week ago but had to get trained in our (the home health provider) system; - The patient’s went without therapy while waiting for the new company to start; and - The physician’s were not notified but the patient’s were informed that it would be 2-3 weeks before therapy could start.

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 policy review, record review, and interview, the home health provider failed to assure communication with all physicians or allowed practitioners involved in the plan of care, in three of three records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients on service. Findings included: Review of the provider’s policy titled, "Coordination of Patient Care,” revised February 2024, showed in part, that the agency (provider) must: - Assure communication with all physicians/practitioners involved in the plan of care; - Integrate orders from all physicians/practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient; and - Integrate services, weather 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. RECORD/PATIENT #1: Review of the clinical record, showed, in part: The patient was admitted to home health services on 11/05/2025 with a primary diagnosis of fracture of neck of left femur, subsequent encounter for closed fracture with routine healing (a break in the upper part of the thigh bone near the hip joint). The patient resided at home alone. Review of the home health referral orders, dated 10/31/2025, showed in part: - Discharge home with home health; and - Home health physical therapy (PT), occupational therapy (OT), and registered nurse (RN). Review of the plan of care, dated 11/05/2025 to 01/03/2026, showed in part: - OT evaluate (eval) visit, one (1) visit weekly for 1 week starting 11/10/2025; and - PT eval visit, 1 visit weekly for 1 week starting 11/10/2025. Review of the complaint log, dated 11/19/2025, showed: - The director of clinical services (back-up administrator), returned a call to a friend of the patient with the patient in the background; - He/she was updated regarding the unforeseen therapy circumstances and were working diligently to resolve; and - He/she requested the contact information to the administrator and it was provided to him/her. Review of the complaint log, dated 11/21/2025, showed: - The director of clinical services went to visit the patient; - The patient reported that he/she was going to have “brain surgery” on 12/01/2025 and he/she had gotten better with the walker but wanted to make sure that he/she would have therapy visits when returning home after surgery; and - The director of clinical services explained how therapy and visits worked and stated that they (home health provider) would have therapy when the patient returned from his/her brain surgery. Review of the clinical record showed that the home health provider failed to provide therapy services as ordered and failed to notify the physician regarding the provider’s inability to provide therapy services. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 07/03/2025 with a primary diagnosis of intervertebral disc disorders with myelopathy, lumbar region (a damaged lower back disc that is compressing the spinal cord, and can cause symptoms like leg weakness, balance issues, numbness, tingling, and potential bladder and bowel dysfunction). The patient lived at home with his/her spouse. Review of the plan of care, dated 10/31/2025 to 12/29/2025, showed in part: - PT eval visit, 1 visit weekly for 1 week starting 11/03/2025; and - SN visit, 1 visit weekly for nine (9) weeks starting 10/31/2025. Review of the complaint log, dated 11/24/2025, showed: - The director of clinical services called the patients spouse back after the spouse had left a message; - The patient’s spouse asked when therapy would be able to come back out to see the patient; - “OT had just DC (discharged) pt per notes on 10/22;” - “Discussed with wife that it will hopefully be about 2-3 weeks or so before a therapist will be able to come out;” - “Pt and wife had been made aware of unforeseen therapy circumstances;” and - The patient’s wife stated that she would be waiting for therapy’s return. Review of the clinical record showed that the home health provider failed to provide therapy services as ordered and failed to notify the physician regarding the provider’s inability to provide therapy services until a new therapy contract company started. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/07/2025 with a primary diagnosis of aftercare following joint replacement surgery (following joint replacement, focusing on rehabilitation, physical therapy, and follow-ups to monitor for healing, signs of complications, and rehabilitation for full recovery) and presence of right artificial knee joint (the replacement of damaged knee parts with metal or plastic implants to relieve pain and restore function). The patient lived at home with a family member. Review of the home health referral orders, dated 10/24/2025, showed in part: - The patient was to discharge home on 10/29/2025 with home care; and - PT, OT, and nursing for medication management. Review of the plan of care, dated 11/07/2025 to 01/05/2026, showed in part: - PT eval visit, 1 visit weekly for 1 week starting 11/10/2025; - The plan of care failed to show OT as ordered in the referral; and - The clinical record failed to show documentation that the physician was notified regarding therapy and failed to show an order to discontinue the OT eval. Review of the complaint log, dated 11/17/2025, showed: - The author of the entry was the clinical manager; - The patient called to inquire about therapy services and when they would start; - The patient was informed that therapy services would be available within the next several weeks as the agency was undergoing therapy company transition; - The patient was instructed to continue therapy exercises that were sent upon discharge from acute rehab; - The patient was instructed if any concerns regarding exercises, the skilled nurse could assist with demonstration at the next SN visit; - The patient was informed that he/she would be informed as soon as therapy was available; and - The patient voiced understanding. Review of the complaint log, dated 11/24/2025, showed: - The author of the entry was the clinical manager; - The patient’s case manager informed the director of nursing that the patient refused further services until therapy was available; - The patient reported that he/she no longer needed nursing as the incision was healed and pain was controlled; - The patient requested to be discharged from the agency so that he/she could start outpatient therapy; - The patient was informed that therapy services for home health are subject to start in the next 2-3 weeks; and - The patient stated that he/she did not wish to wait and would be starting outpatient services. Review of the discharge note, dated 11/25/2025, showed in part: - The patient declined (nursing) services and wanted discharged; - The patient refused all care until the patient was able to work with PT; - The patient didn’t see the need for an RN’s care; - (The SN) explained the importance and our (nursing’s) role that we (the nurses) provide in patient care; and - The patient still refused. Review of the clinical record showed that the home health provider failed to provide therapy services as ordered and failed to notify the physician regarding the provider’s inability to provide therapy services. During an interview on 12/15/2025, at 3:45 PM, the back-up administrator stated that: - They (the home health provider) had two contract companies for therapy with one being the primary and the second company being a back-up; - The primary therapy contract company gave notice at the end of October that the company was closing; - The back-up company was contacted to provide therapy services until a new company could be found; - The back-up company was only able to pick-up a few patient’s for therapy and then they ended up giving notice that they were closing as well; - The new contract company started a week ago but had to get trained in our (the home health provider) system; - The patient’s went without therapy while waiting for the new company to start; and - The physician’s were not notified but the patient’s were informed that it would be 2-3 weeks before therapy could start.

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 12/18/2024. During the survey it was determined that the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 12/18/2024. The provider had 59 current patients.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure that criteria were met to facilitate a transfer or discharge from care in one of two discharge records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Discharge Criteria and Planning,” revised February 2024, showed in part, that: The patient will be discharged from services as follows: - Discharge is necessary for the patient’s welfare because the agency (provider) and the physician/practitioner who is responsible for the home health plan of care agree that the agency can no longer meet the patient’s needs, based on the patient’s acuity; - The patient or payor will no longer pay for the services provided by the agency; - The discharge is appropriate because the physician/practitioner who is responsible for the home health plan of care and the agency agree that measurable outcomes and goals set forth in the plan of care have been achieved and the agency and physician/practitioner responsible for the home health plan of care agree that the patient no longer needs the agency’s services; - The patient refuses services or elects discharge; - The patient/family requests discharge; - The patient’s (or other persons in the patient’s home) behavior is disruptive, abusive or uncooperative to the extent that delivery of care to the patient or the ability of the agency to operate effectively is seriously impaired. The agency will do the following before it discharges a patient for cause: * Advise the patient, representative (if any), the physician(s)/practitioner(s) issuing orders for the home health plan of care and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services of the patient after discharge from the agency (if any) that a discharge for cause is being considered; * Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home or situation; * Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; * Document the problem(s), behaviors and circumstances that warranted discharge for cause and efforts made to resolve the problem(s) and enter documentation into its clinical record; * The medical record will reflect: * Identification of the problems encountered; * Assessment of the situation; * Communication among the agency management, caregiver, legal representative and the physician/practitioner responsible for the plan of care; * A plan to resolve the issue; and * Results of the plan implementation. * Only in extreme situations when there is a serious imminent threat of physical harm to agency staff, the agency may take immediate action to discharge or transfer the patient without first making efforts to resolve the underlying issue; * Evidence in the record will be documented that the agency provided the patient and his or her representative (if any) with information including contact numbers for other community resources and names of other agencies or providers that may be able to provide services to the patient; and - The patient refuses to follow physician’s/practitioner’s prescribed plan of care/treatment (physician/practitioner will be notified). RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted to home health services on 09/03/2024, with a diagnosis of nondisplaced fracture of the medial condyle of the right tibia (a fracture of the tibia bone in the right leg) and secondary diagnoses of acute osteomyelitis (an infection in the bone) of the right tibia and fibula, and encounter for change and removal of surgical wound dressing. Review of the initial assessment, dated 09/03/2024, showed: - The patient was alert and oriented to person, place, time, date, and situation; - The patient showed no cognitive, behavioral, or psychiatric symptoms (reported or observed); - The patient showed no disruptive behavior symptoms such as physical, verbal, or other disruptive/dangerous symptoms that were injurious to self or others or jeopardized personal safety (observed or reported); - The patient’s environment was documented as safe for the patient and safe for the employee; and - The patient/caregiver had the desire and ability to participate in care and work towards mutually agreed upon goals. Review of the plan of care, dated 09/03/2024, showed the patient was alert and cooperative and discharge plans were “when wound heals.” Review of a skilled nurse (SN) note, dated 09/09/2024, showed: - The patient had a physician visit at the wound care clinic on “Friday” (09/06/2024) with no changes to the plan of care; - The patient was alert and oriented to person, place, date/time, and situation; - Treatments were completed to wound number one and wound number two as ordered by the physician; and - No behaviors or refusals of care were documented. Review of a SN note, dated 09/16/2024, showed: - The patient had a physician visit prior to the visit; - The patient was alert and oriented to person, place, date/time, and situation, and agitated; - Treatments were completed to wound number one and wound number two as ordered by the physician; and - The nurse note stated that patient appeared “flustered and uninterested in SN visit.” Review of a SN note, dated 09/18/2024, showed: - The patient was alert and oriented to person, place, date/time, and situation; - Treatments were completed to wound number one and wound number two as ordered by the physician; and - The nurse note stated that the patient “answered the door and immediately began to light his/her cigarette. I asked him/her if he/she could please wait to smoke after the visit which would take about 30 minutes. He/She immediately became upset and stated, “What?! No! You’re not gonna come here and tell me I can’t smoke in my own house?! I can’t even smoke in my own house?!” I explained to him I had visits with other patients who have respiratory issues, and the smoke from the cigarettes would linger on my clothing and that would present other issues for those patients. He/She scoffed and put the cigarette out. And kept mumbling curse words under his/her breath;” and - The incident was reported to the director of clinical services for “patient belligerence towards this SN.” Review of a discharge from the home health provider assessment, dated 09/19/2024, showed: - The patient showed no cognitive, behavioral, or psychiatric symptoms (reported or observed); - The patient showed no disruptive behavior symptoms such as physical, verbal, or other disruptive/dangerous symptoms that were injurious to self or others or jeopardized personal safety (observed or reported); - The treatments were completed to wound number one and wound number two as ordered by the physician, however, the patient refused to have wound number one covered; - The patient was to follow-up with the wound care clinic at discharge; and - The primary reason for discharge was listed as “no longer meets admission criteria-environment unsafe for employees.” Review of a client logging report, dated 09/19/2024, showed that the director of clinical services documented that the patient was notified via phone that he/she was being discharged from the home health provider due to inappropriate behavior with staff and that the payor source had been notified and was in agreement. The provider failed to make efforts to resolve any problems with the patient’s behavior, failed to document the efforts made to resolve the problems, and failed to show that the patient’s behavior was disruptive, abusive, and uncooperative to the extent that delivery of care to the patient or the ability of the provider to operate effectively was seriously impaired. During an interview on 12/18/2024 beginning at 1:40 PM, the administrator stated that patient #5 was a worker’s compensation patient and that the representative from worker’s compensation had been notified of the patient’s behavior and had decided to stop his/her care with the home health provider. He/She further stated that he/she would expect the documentation to reflect the patient and their behavior.

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 policy review, clinical record review, home visit observation, and interview, the home health provider failed to ensure a complete and accurate medication list was maintained in, but not limited to, two of three home visit observations (Record/Patient #2, and #3). This deficient practice has the potential to affect the provider’s ability to ensure safe and effective use of medications for all patient’s served by the provider. Findings included: Review of the provider’s policy titled, 8.15.1 “Medication Reconciliation,” revised February 2024, showed in part: - The provider will reconcile patient’s medications at time of admission and on an ongoing basis in order to identify any potential adverse effects and drug reactions; - At time of admission, the admitting registered nurse (RN) will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency; * Any concerns or discrepancies will be reconciled by a RN with the patient's physician/practitioner; * Discrepancies include duplications, omissions, changes, contraindications and/or unclear information; and - Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/02/2024 with a primary diagnosis of aftercare following surgery for neoplasm (abnormal mass of tissue that forms when cells grow and divide more than they should or do not die when they should) and malignant (cancer) neoplasm of ascending colon (first part of the large intestine). The patient resided in his/her home with an adult child as the caregiver. Observation and interview on 12/17/2024 at 11:33 AM, showed the following discrepancies: - The medication profile showed the patient used Bacitracin external ointment (antibiotic to treat external skin infections) 500 unit/gram (GM) small dose applied three times a day to incision on left lower quadrant surgical wound. The patient and caregiver stated he/she had not used since 12/05/2024; - The medication profile showed the patient took Farxiga (oral medication to improve blood sugar control) 10 milligrams (mg) once a day. The patient and caregiver stated he/she had not used since 12/04/2024; - The medication profile showed the patient took Lipitor (oral medication to control cholesterol) 20 mg at bedtime. The medication bottle showed the patient took 40 mg one by mouth daily. The patient and caregiver stated he/she took 40 mg at bedtime and had been since 12/04/2024; - The medication profile showed the patient took oxycodone (narcotic analgesic for moderate to severe pain) oral capsule 5 mg as needed (PRN) every four hours for pain. The patient and caregiver stated he/she had not used since 12/04/2024; - The medication bottle showed the patient took Lasix (diuretic) 20 mg one by mouth daily. The patient and caregiver stated he/she had been taking since 12/04/2024. The medication failed to be on the provider’s list; - The medication bottle showed the patient took Jardiance (used to treat type 2 diabetes)10 mg one by mouth daily. The patient and caregiver stated he/she had been taking since 12/04/2024. The medication failed to be on the provider’s list; - The medication bottle showed the patient took Senna S (stool softener) 50 mg/8.6 mg one by mouth daily. The patient and caregiver stated he/she had been taking since 12/04/2024. The medication failed to be on the provider’s list; - The medication bottle showed the patient took oxycodone/acetaminophen (narcotic analgesic) 10/325 mg one by mouth PRN/pain. The patient and caregiver stated he/she took one at bedtime and three PRN and had been taking since 12/04/2024. The medication failed to be on the provider’s list; and - The medication bottle showed the patient took Eliquis (blood thinner) 2.5 mg one by mouth twice a day. The patient and caregiver stated he/she had been taking since 12/04/2024. The medication failed to be on the provider’s list. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/21/2024 with a primary diagnosis of aftercare following joint replacement surgery, presence of left artificial hip joint and hypertension (elevated blood pressure). The patient resided in his/her own apartment. Observation and interview on 12/17/2024 at 9:25 AM, showed the following discrepancies: - The medication profile showed the patient took acetaminophen (mild analgesic) eight-hour tablet extended release 650 mg twice a day for arthritic pain. The patient stated he/she had been taking one at bedtime; - The medication profile showed the patient took aspirin 81 mg chewable tablet once a day for blood clot prevention. The patient stated he/she had not been taking for a couple of years; - The medication profile showed the patient took Celebrex (nonsteroidal anti-inflammatory) 200 mg two times a day for arthritis. The patient stated he/she had been taking100 mg twice a day; - The medication profile showed the patient took Vitamin D3 (supplement) oral tablet chewable 25 micrograms (1000 UT) once a day. The patient stated he/she had been taking 50 mcg three times daily; - The medication profile showed the patient took levothyroxine sodium (thyroid medication) capsule 112 mcg once a day. The patient stated he/she had been taking 88 mcg daily; - The medication profile showed the patient took Vitamin B complex (supplement) capsule one a day. The patient stated he/she did not take anymore, and it had been a while since he/she took it; - The medication profile showed the patient took ibuprofen (mild to moderate pain) tablet 200 mg PRN every six hours as needed for pain. The patient stated he/she was told not to take since returning home; - The medication profile showed the patient took Percocet (narcotic analgesic) tablet 5-325 mg PRN every four hours for post-op pain. The patient stated he/she was not taking and never took after returning home; - The medication profile showed the patient took tramadol (narcotic analgesic) tablet 50 mg PRN every six hours as needed for post-op pain. The patient stated he/she did not take tramadol; - The medication bottle showed the patient took glucosamine chondroitin (supplement) triple strength 1500 mg/120 mg one tablet twice a day. The patient stated he/she had been taking one twice a day and had been taking since 12/04/2024. The medication failed to be on the provider’s list; and - The medication bottle showed the patient took ropinirole (dopamine to treat restless leg syndrome) 1 mg one by mouth at bedtime. The patient stated he/she had been taking since 12/09/2024. The medication failed to be on the provider’s list. During an interview on 12/18/2024 starting at 1:44 PM, the director of clinical services stated that he/she expects medications to be reviewed every visit and reconciled with start of care, resumption of care and with new medications and discontinued medications.

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 policy review, record review, and interview the home health provider failed to ensure that wounds were measured in three of five full records reviewed (Records/Patients #1, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: A policy for wound measurements was requested but not provided by survey exit. RECORD/PATIENT #1: Review of the clinical record showed that the patient was re-admitted to home health services on 12/13/2024, with a diagnosis of an unstageable pressure area (tissue damage to the skin that is caused by unrelieved pressure and cannot be accurately evaluated because it is covered by a layer of dead tissue) to the sacral region and a diagnosis of an unstageable pressure ulcer of the right heel. Review of the resumption of care assessment, dated 12/13/2024, showed: - A wound assessment that noted wound number one on the posterior right heel of the wound location sheet that was described as: “unstageable, observable, no drainage, no odor, peri wound skin (the skin surrounding the wound) intact, N/A (not applicable) edema, thickened wound edges, located on the bottom, wound care completed;” - A wound assessment that noted wound number two on the sacral area of the wound location sheet that was described as: “stage II, observable, small amount of drainage, serosanguinous in color (drainage of a wound that is usually light pink to red in color), thin consistency, no odor, peri wound skin intact, N/A edema, appearance of the wound bed red, wound edges intact, wound care completed;” and - The provider failed to ensure that measurements were completed of both wounds. Review of the recertification assessment, dated 12/17/2024, showed: - A wound assessment that noted wound number one on the posterior right heel of the wound location sheet that was described as: “unstageable, observable, no drainage, no odor, peri wound skin intact, N/A edema, appearance of wound bed brown, wound edges intact, located on the bottom, wound care completed;” - A wound assessment that noted wound number two on the sacral area to the wound location sheet that was described as: “stage II, observable, small amount of drainage, serosanguinous in color, thin consistency, no odor, peri wound intact, appearance of wound bed red, wound care completed;” and - The provider failed to ensure that measurements were completed of both wounds. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to home health services on 11/06/2024, with a diagnosis of Type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood) with a foot ulcer (an open sore on the foot). Review of the plan of care dated, 11/06/2024, showed in part that, the wound to the left fifth toe was to be assessed, measured, and described on visits. Review of a skilled nursing visit note, dated 11/11/2024, showed: - A wound assessment that noted a wound on the anterior left fifth toe of the wound location sheet that was described as: “arterial, observable, N/A drainage, N/A odor, N/A peri wound skin, N/A edema, N/A wound edges, wound care done;” and - The provider failed to ensure that wound measurements were completed. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted to home health services on 09/03/2024, with a diagnosis of nondisplaced fracture of the medial condyle of the right tibia (a fracture of the tibia bone in the right leg) and secondary diagnoses of acute osteomyelitis (an infection in the bone) of the right tibia and fibula, and encounter for change and removal of surgical wound dressing. Review of the plan of care dated, 09/03/2024, showed in part that, wound number two to the left lower medial leg was to be assessed, measured, and described on visits. Review of the initial assessment, dated 09/03/2024, showed: - The skin assessment area showed two wounds to the left lower extremity; - A wound assessment that noted wound number one on the anterior outside of the upper part of the left leg of the wound location sheet that was described as: “surgical wound, observable, small amount of drainage, serosanguinous in color, thin consistency, tunneling (a channel or tract that extends from the surface of a wound deeper into the underlying tissue)/undermining (the edges of the wound have separated from the surrounding healthy tissue creating a dead space beneath the skin) ½ centimeter (cm), no odor, peri wound skin intact, N/A edema, N/A wound edges, wound care completed;” - A wound assessment that noted wound number two on the anterior inside of the lower part of the left leg of the wound location sheet that was described as: “surgical wound, observable, large amount of drainage, serosanguinous in color, thin consistency, no odor, N/A peri wound skin, N/A edema, wound edges intact, wound care done;” and - The provider failed to ensure that measurements were completed of both wounds. Review of a skilled nursing visit, dated 09/09/2024, showed: - A wound assessment that noted wound number one on the anterior outside of the upper part of the left leg of the wound location sheet that was described as: “surgical wound, not healing, observable, large amount of drainage, clear color, thin consistency, tunneling/undermining 5 cm at 11 o’clock, no odor, peri wound intact, N/A edema, wound edges intact, wound care completed;” - A wound assessment that noted wound number two on the anterior inside of the lower part of the left leg of the wound location sheet that was described as: “surgical wound, early/partial granulation (soft, pink, new healthy tissue in a healing wound), observable, large amount of drainage, serosanguinous in color, thin consistency, no odor, peri wound erythematous (reddened or showing redness), N/A edema, red wound bed, wound edges intact, wound care completed;” and - The provider failed to ensure that measurements were completed of both wounds. Review of a skilled nursing visit, dated 09/16/2024, showed no assessment of the patient’s wounds. Review of a skilled nursing visit, dated 09/18/2024, showed no assessment of the patient’s wounds. During an interview on 12/18/2024 at 12:30 PM, the director of quality assurance nurse stated that staff have been instructed to measure wounds weekly, with a start of care (initial assessment), and with any signs of deterioration and notify the physician if there are changes. He/she further stated the provider did not currently have a written policy for this and that measurements should be obtained for all kinds of wounds. During an interview on 12/18/2024 at 1:40 PM, the director of clinical services stated that he/she would expect wounds to be measured weekly, with a start of care, and when there was a change in the wound.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 02/16/2022. During the survey it was determined Cooperative Home Care, Inc. is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

An extended survey for Medicare certification for Cooperative Home Care, Inc. was completed on 02/16/2022. The parent agency had eight current patients. The branch location, at 107 Lanaghan Drive, Fairview Heights, Illinois, had no patients.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to include the rights of the patient and representative (if any) regarding contact information for the home health agency administrator to receive complaints. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all agency patients/representatives. Findings included: The Director of Nursing (DON) provided an admission packet for review on 02/14/2022. The agency notice of patient rights and other information given to a patient during the initial visit contained no current administrator name for which to receive patient complaints. The current administrator was appointed in November of 2021. During an interview on 02/16/2022, at 10:30 AM, the administrator stated that the name of the new administrator was sent to the state office on 11/30/21. He/she stated that the agency was waiting for confirmation from the state office before changing the patient admission information.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on record review, current patient rights, and interview, the agency failed to ensure the patient was advised orally of the extent to which payment for services may be expected from Medicare, Medicaid, or any other federally-funded aid program, the charges of services that may not be covered for five full records reviewed. This deficient practice has the potential to adversely affect the patient's ability to pay for services for all the agency's patients. Findings included: Review of the agency's policy titled "Bill of Rights and Responsibilities/Transfer & Discharge Criteria", dated February 2021 showed that the patients have the right to be advised of the extent to which payment for services may be expected from Medicare, Medicaid or any other federally funded or federal aid program known to the agency. The patient bill of rights failed to include that the patient will be informed both orally and in writing. The findings were presented to the director of nursing on 02/15/2022 and he/she concurred with the findings.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to include the name, address and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the current patient rights information failed to include: - The current QIO organization; and - The agency failed to list the current complete QIO information for: * Livanta LLC BFCC-QIO Program 10820 Guilford Road, Suite 202 Annapolis Junction, MD 20701-1105 Phone No 1-888-755-5580 TTY: 1-888-985-9295 The findings were reviewed with the director of nursing (DON) on 02/15/2022 at 2:40 PM. The DON concurred with the findings.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services at no cost to the individual and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations. The deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Bill of Rights & Responsibilities/Transfer & Discharge Criteria," dated 2021 showed that patients have a right to be informed of the right to access auxiliary aids and language services and how to access these services. The rights failed to list web sites for persons with disabilities and services at no cost to the patient, in accordance with the Americans with disabilities act. During an interview on 02/15/2022 at 2:40 PM, the director of nursing concurred with the findings.

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 agency policy review, clinical record review, home visit observation, and interviews, the agency failed to ensure/maintain an accurate and complete review of all medications the patient was currently using in, but not limited to, one (Record/Patient # 3) of five full records reviewed. This deficient practice has the potential to adversely affect the accuracy and safety of medication administration for all the agency's patients. Findings included: Review of the agency's policy titled, "Medication Reconciliation," dated 2018, showed, in part, the following: - At the time of admission, the admitting registered nurse (RN), physical therapist (PT), or speech language pathologist (SLP) will create and document a complete list of medications that the patient is taking at home, including dose, strength, route, and frequency; - Any concerns or discrepancies will be reconciled by a RN with the patient's physician; - The Agency provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route and frequency as well as which medications will be administered by the Agency staff and staff acting on behalf of the agency; and - Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The medication list in the home will be updated. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted on 01/26/2022 and the current plan of care was dated 01/26/2022 through 03/26/2022. Observation on 02/15/2022 at 8:30 AM, during the patient's home visit, showed the agency's medication listed Norvasc (treats high blood pressure) five (5) milligrams (mg) daily. Home medication showed losartan (treats high blood pressure) 50 mg daily. Review of the losartan medication bottle showed fill date 12/29/2021. Per interview conducted during observation, the patient's spouse stated that the patient's physician had changed the medication from Norvasc to losartan due to patient's reaction to the Norvasc. Spouse stated that the patient had "swelling" after taking the medication. Per interview conducted during observation, the occupational therapy assistant (COTA) stated that the patient usually tells him/her of any changes with his/her medication. The COTA failed to ask the patient related to patient medications.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to provide a discharge summary that included all necessary components was sent to the primary care physician after discharge within five business days of the patient's discharge in one (Record/Patient #4) of one discharge records reviewed. This deficient practice has the potential to adversely affect the post discharge care of all patients served by the agency. Findings included: Review of the agency's policy, titled, "Discharge Summary," revised March, 2018, showed in part the following: - A Discharge Summary form will be completed by the Skilled Nurse (SN), Medical Social Worker (MSW) and/or Therapist. The Discharge Summary will include, but is not limited to: * Laboratory data; * Patient's discharge condition; * Types of services provided and frequency of services; * Patient's outcomes in meeting goals in the plan of care; * Patient/family post discharge instructions; and * Medications at time of discharge. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to the agency on 11/15/2021 with a diagnosis of infection and inflammatory reaction due to internal right knee prosthesis (replacement of a body part). On 11/20/2021 the physician called the agency and requested discharge to another agency. Review of the discharge summary, dated/sent 11/24/2021 failed to show: * Laboratory data; * Patient's discharge condition; * Types of services provided and frequency of services; * Patient's outcomes in meeting goals in the plan of care; * Patient/family post discharge instructions; and * Medications at time of discharge. During an interview on 02/16/2022 at 11:00 AM, the director of nursing (DON) concurred with the findings. The DON agreed that the agency failed to provide ongoing information related to the patient's needs.

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 policy review, clinical record review, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all the required elements, in but not limited to, one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect the care of all patients served by the agency. Findings included: Review of the agency's policy titled, "Care Planning Process," dated March 2018 showed: - The POC developed and implemented with the physician. Demonstrates problems and interventions through physician orders and long range goals identified; - Initial Assessment: description of problems and changes. Demonstrates identified problems, interventions and goals at time of admission; and - Visit Notes: documents modifications to care/service, current problems, interventions and short term goals; individualized. Will be revised as problems are identified. Review and revision will be ongoing with each home visit and will be based on patient's health status, environment and relevant baseline data from assessments to determine current needs, problems, interventions and goals. Will reflect goal evaluation/goal resolution. RECORD/PATIENT #5: Review of the comprehensive start of care assessment dated 11/12/2021 showed the following; - Patient admitted post abdominal surgery, for wound care; - Patient has a Peripherally inserted central catheter (PICC) line. POC failed to include interventions of care needed, no assessment of PICC line site needed; and - Patient has pain, POC failed to list pain parameters and/or patient interventions for pain. During an interview on 02/15/2022 at 2:10 PM, the director of nursing (DON)stated that the PICC line should have been included in the POC to assess the line site, and he/she stated that the physician did not give orders for pain and that she would contact him for them.

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 policy review, clinical record review, observation, and interview, the agency failed to provide drugs, services and treatments only as ordered by a physician in, but not limited to, two (Records/Patients #3 and #5) out of five full records reviewed. This deficient practice has the potential to adversely affect the care and services provided to all the agency's patients. Findings included: Review of the agency's policy, titled, "Coordination of Patient Care," revised March, 2019, showed in part the following: The agency must: - Assure communication with all physicians involved in the plan of care (POC); - Integrate orders from all physicians involved in the POC to assure the coordination of all services and interventions provided to the patient; and - Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any) and caregiver(s), where applicable, receives ongoing education and training provided by the Agency, as appropriate, regarding the care and services identified in the POC. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted on 01/26/2022 and the current POC was dated 01/26/2022 through 03/26/2022. Observation on 02/15/2022 at 8:30 AM, during the patient's home visit, the patient was observed with oxygen at 2.5 L (liters, measurement of oxygen delivery system). The POC ordered oxygen at 4L. Per interview during the home visit, the patient's spouse stated that the patient's physician was "trying to wean the patient off of oxygen by the end of the month". Per interview during the home visit, occupational therapist assistant (COTA) stated that the patient was on 3L of oxygen when he/she first started seeing the patient. During an interview with the director of nursing (DON) on 02/15/2022 at 1:35 PM, the DON stated that there should have been an order to wean the patient's oxygen down, he/she stated unaware of the oxygen changes. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted on 11/12/2021 and the current plan of care was dated 11/12/2021 through 01/10/2022. POC showed patient admitted due to surgical wound dressing care. Record review also showed patient receiving antibiotics through a peripherally inserted central catheter (PICC) . POC failed to provide care parameters for the PICC line, how to manage and/or care for the line. During an interview with the DON on 02/15/2022 at 2:10 PM, the DON concurred that the POC should have parameters for care for the PICC line.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on policy review, record review and interview the agency failed to ensure staff provided the patient/caregiver with ongoing education and training in, but not limited to, two (Records/Patients #1 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the home health agency. Findings included: Review of the agency's policy titled, "Coordination of Patient Care", updated March, 2019 showed that the agency must ensure that each patient, and his or her caregiver(s), where applicable, receives ongoing education and training provided by the Agency, as appropriate, regarding the care and services identified in the plan of care (POC). The Agency must provide training, as necessary, to ensure a timely discharge. RECORD/PATIENT #1: Review of the clinical record showed: - The agency admitted the patient for home health services on 01/26/2022 with diagnoses of pressure ulcer (damage to the skin, as a result of long-term pressure); - POC also documented intermittent catheter (medical device inserted in the body); and - POC also stated patient at risk for urinary tract infections (UTI). POC and record review failed to show patient teaching related to UTI prevention and intermittent catheter insertion process. During an interview on 02/15/2022 at 1:15 PM, the director of nursing (DON) stated that he/she could not find any education on UTI prevention on any of the patient's nursing visits. RECORD/PATIENT #3: Review of the clinical record showed: - The agency admitted the patient on 01/26/2022 with a diagnoses of COVID-19 (coronavirus disease, infection of the lungs) and diabetes mellitus (body unable to handle all the sugars eaten); and - The POC listed glucometer (medical device for determining the appropriate concentration of glucose (sugar) in the blood. POC and record review failed to show patient teaching related to use of the glucometer. During an interview with DON on 02/15/2022 at 1:35 PM, the DON stated that he/she was not sure why glucometer was on the POC. The DON also stated that the staff should also be checking for diabetic neuropathy (pain, tingling, numbness in patient's feet) for this patient.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to include the rights of the patient and representative (if any) regarding the name and the contact information for the home health agency clinical manager. This deficient practice has the potential to affect the rights and responsibilities for all agency patients/representatives to discuss the services provided to the patient by agency staff. Findings included: The Director of Nursing (DON) provided an admission packet for review on 02/14/2022. The agency notice of patient rights and other information given to a patient during the initial visit failed to contain the current clinical manager's name. The current clinical manager was appointed in November of 2021. During an interview on 02/16/2022, at 10:30 AM, the administrator stated that the name of the new clinical manager was sent to the state office on 11/30/21. He/she stated that the agency was waiting for confirmation from the state office before changing the patient admission information.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure a complete, comprehensive transfer summary containing relevant information was sent to the other health care facility the patient was receiving care at within two business days of the agency becoming aware of the patient's transfer for one (Record/Patient #5) of one transfer record reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Transfer/Referral Criteria," revised March, 2019, showed in part: - Patients are transferred or referred to alternative care situations when the following conditions exist: - Transfer is necessary for the patient's welfare because the Agency and the physician who is responsible for the home health plan of care agree that the Agency can no longer meet the patient's needs, based on the patient's acuity. The Agency will arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the Agency's capabilities/ - A written Transfer Summary concerning the agency's involvement with the patient, e.g., patient condition at transfer, lab data, patient outcomes in meeting goals in the plan of care, instructions/referrals provided to the patient, current reconciled medication list (with an explanation of how to obtain clarification), advance directives, any continuing symptom management needs, e.g., pain, nausea or dyspnea (shortness of breath), and reasons for transfer or referral will be completed. Transfer Summary will be provided: - Within two business days of becoming aware of an planned transfer, if the patient's care will be immediately continued in a health care facility; or - Within two business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time the Agency becomes aware of the transfer. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to the agency on 11/12/2021 for post surgical dressing care. The record showed patient transferred to a hospital on 12/02/2021. The record failed to show facility transfer summary was sent to the hospital. During an interview on 02/14/2022 at 1:00 PM the director of nursing (DON) stated that no transfer summary was done. The DON stated that transfer summaries had not been done, but that he/she was making sure that they were being done now.

A complaint investigation, #61037, was completed on 10/20/2021 at Cooperative Home Care, Inc. The agency had 17 current patients. The complaint is substantiated. One or more of the allegations reported are verified and deficiencies were cited that are related to the allegations being investigated.

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 policy review, clinical record review, and interview, the agency failed to ensure on-call staff attended to patient’s calls for assistance with malfunctioning wound vac (vacuum-assisted closure of a wound is a type of therapy to help wounds heal) machine and wound vac dressing changes during after-hours and did not follow the agency's policy which affected two (Record/Patient #1 and #3) of three clinical records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, “After Hours Accessibility,” dated March, 2018 showed: - Policy: At the time of admission, each patient will receive written information about the hours that care and services are available (normal business hours) and how to obtain care after hours; - Purpose: To provide care to patients requiring immediate care; and - Agency office hours are 8:00 AM to 5:00 PM Monday through Friday; - A registered nurse (RN) is available 24 hours per day, seven (7) days per week; - Contact can be made by telephone through the on-call system; - At time of admission, patients will be informed of the on-call system; - The RN on-call is available at all times by telephone; - If a visit is made, a skilled nursing visit report is completed; and - The director of clinical services and/or clinical manager is on call 24 hours per day on a rotating weekly basis. RECORD/PATIENT #1: Review of the initial comprehensive assessment dated 09/09/2021 at 3:50 PM showed: - Registered nurse (RN A) admitted the patient; - Surgical abdominal wound with wound vac (vacuum-assisted closure of a wound is a type of therapy to help wounds heal) in place; - Wound vac dressing changed and patient and caregiver instructed on actions to take if wound vac malfunctions; RN A provided instructions to remove dressing and lightly pack wound with a normal saline wet to dry gauze and secure with tape and call the RN; and - Abdominal surgical wound measured 7 centimeters (cm) long x 21 cm wide x 1.5 cm deep; moderate serosanguinous drainage, no odor, wound bed pink, wound edges intact, RN A removed old dressing and provided wound care/wound vac appliance as ordered; 3 cm area on each side of the open wound that has sutures; wound vac set at 125 mm/Hg. Review of the plan of care dated 09/09/2021 through 11/07/2021 documented by RN A showed: - Diagnoses included but not limited to: Disruption of external surgical operation (opening/dehiscence of surgical wound), surgical procedure, anxiety, and chronic pain syndrome; - Skilled nurse (SN) visits: 2 w 1 (2 times per week for 1 week) starting 09/9/2021 and SN visits 3 w 1 starting 09/13/2021 through the certification period(s) starting 09/13/2021; - Wound care: Wound care location abdomen, cleanse/irrigate wound with wound cleanser, pack/fill wound with black foam, cover with transparent dressing, and apply wound vac machine to run at 125 milliliters (ml)/Hg (mercury, a unit of measure using pressure); - Patient lives alone at home and has intermittent assistance in the home; - Poor historian and remains silent when questions asked; - SN to see patient for wound care and wound vac maintenance; - Patient complained of pain and went back to the ER early this AM for pain control; - While in the ER, the wound vac started to alarm (beep) and the dressing was dripping when RN A arrived at the home; and - Goals and discharge plans: Patient demonstrates proper wound care procedures, when to report, wound will be resolved when goals met and skilled services no longer needed or the patient no longer qualifies for skilled services. Review of all 14 skilled nursing visit notes dated 09/11/2021 through 10/15/2021 showed: - RN A instructed the patient and a caregiver in protocol for wound care/dressing change when the wound vac malfunctioned (remove dressing and lightly pack wound with a normal saline wet to dry gauze and secure with tape and call the RN). Case Communication Note dated 10/18/2021 at 5:57 AM completed by RN A showed: - At 9:05 PM on 10/16/2021, the patient text messaged RN A that the wound vac machine kept beeping and showed the wound vac dressing was leaking (air leaking, dressing not fully intact with the skin); - Patient stated that the wound vac machine had been beeping since 5:00 AM; - RN A instructed the patient to remove the wound vac dressing and to apply a wet to dry dressing as previously instructed and also instructed on risks of infection by leaving the dressing in place when the machine did not work properly (SN failed to provide a visit or follow up to ensure the patient removed the malfunctioning wound vac and applied a wet to dry dressing); - At 10:30 AM on 10/17/2021 RN Director of Nursing (DON) notified RN A that the patient called the DON about the wound vac beeping; - The patient refused to remove the wound vac and dressing and refused to apply a wet to dry dressing as instructed; - The on call RN B, was then contacted and asked to see the patient on 10/17/2021: - At 4:08 PM, RN A spoke to RN B, and RN B stated the patient refused a skilled nurse visit; and - RN B reported the patient stated he/she had a neighbor apply tape to the dressing and refused a visit by RN B. Case communication note dated 10/19/2021 at 4:08 PM completed by RN B, showed: - On 10/17/2021, received a text from supervisor, RN A, about a leaking wound vac and instructed to make a visit to the patient; - Patient agreed to a visit by RN B without insurance authorization and a payment of $150.00 needed to be made; - RN B called the patient at 1:30 PM to schedule a time for the visit; - Patient reported beeping stopped after a neighbor placed tape over the dressing and asked RN B to call back in 20 minutes; - RN B called back at 1:55 PM and the patient requested RN B to not make a visit, the machine stopped beeping; - The patient reported he/she would be contacting the insurance company the next morning (concerned about number of visits); and - RN B notified the nurse supervisor/RN A. During an interview on 10/20/2021 at 8:55 AM, the quality assurance RN stated that: - The patient’s case was opened 09/09/2021 and the insurance company had authorized 15 visits to use from 09/08/2021 through 03/08/2022; - The physician ordered the dressing to be changed three times per week throughout the certification period(s) starting 09/13/2021; - All 15 visits were made prior to the patient's after hours call the the on-call system and no other visits were authorized until Monday 10/18/2021; staff had requested more visits from the insurance agency on 10/16/2021; - The insurance agency sent another nine authorized visits to the agency on 10/18/2021; and - RN A explained to the patient that the 15 visits were used up and no insurance visits were available when he/she called for the on-call nurse to make a visit. He/she would need to pay $150.00 for the nurse to make the extra visit. During an interview on 10/20/2021 at 10:20 AM, RN A stated that: - He/she was the patient’s assigned skilled nurse; - He/she was out of state on 10/16/2021 when the patient reported by text messaging at 9:05 PM that the wound vac machine was beeping and the dressing needed to be changed; - The wound vac had been beeping since 5:00 AM on 10/16/2021; - RN B was the on-call nurse for the weekend; - RN A called and instructed the patient to have his/her son (caregiver) to remove old dressing and wound vac and apply a wet to dry dressing and tape in place; - RN A instructed the patient in infection potential if old dressing not removed and a clean dressing applied; - The patient had four different people at different times as his/her caregiver, the last one being his/her son; - The patient had applied oil and ointments under the transparent tape holding the dressing in place on the abdomen at different times; - The patient picked at the tape frequently and loosened the air tight seal made by the tape which caused an air leak and malfunctioning (beeping) of the wound vac; - The patient was not compliant with changing the dressing when needed and with his/her medications; - He/she went to the ER on several occasions seeking high powered narcotics for chronic pain; - His/her primary care physician and the ER physicians refused to order anymore narcotics for him/her and that upset the patient; - The DON contacted RN A at 10:03 AM on 10/17/2021 that the patient had called regarding the beeping wound vac, and that the patient refused to remove the dressing and wound vac and did not apply a clean dressing as instructed; - RN A then contacted the on-all nurse, RN B, and instructed him/her to make a SN visit; - At 4:08 PM on 10/17/2021, RN A spoke with RN B and RN B reported that the patient had refused a SN visit and that the patient had his/her neighbor apply tape to the old dressing; - The insurance company had originally authorized 15 SN visits but all had been used and the agency was waiting for further authorization for more visits; - The patient was told if a SN visit was made on 10/17/2021 he/she would need to pay $150.00 for the visit because the insurance company had not authorized more SN visits; and - The patient had plenty of dressing supplies in the bedroom for dressing changes that were provided by the agency. During an interview on 10/20/2021 at 11:45 AM, RN B stated that; - He/she was the on-call nurse on 10/16/2021 and 10/17/2021 but he/she did not become involved with the patient until the DON/supervising nurse (RN A) contacted him/her on 10/17/2021 by text and email; - He/she called the patient and the patient said the beeping had stopped, a neighbor had placed tape over the old dressing, and asked the patient if he/she needed to make a SN visit; - The patient asked RN B to call back in 20 minutes to see if the wound vac was beeping; - RN B called back and the patient said the machine was not beeping and to not make a SN visit; - RN B told the patient there were no authorized insurance visits and if he/she made the visit, the patient would need to pay $150.00 for the visit; the patient probably did not have the money to pay for the visit; - RN B stated he/she did not tell the patient he/she could not see patients in Missouri; and - RN B has a license to practice nursing in the State of Missouri and he/she only visits Missouri patients. RECORD/PATIENT #3: Review of the Request for Skilled Home Health Services dated 10/14/2021 showed: - Referral date 10/14/2021; and - Insurance authorized 15 SN visits form 10/14/2021 through 04/14/2021. Review of the POC dated 10/16/2021 through 12/14/2021 documented by RN B showed: - Diagnoses included but not limited to: Surgical procedure, non-pressure chronic ulcer of the left foot, and diabetes mellitus (abnormal blood sugar levels often treated with oral medications or insulin); - SN visits 1 w 1 starting 10/16/2021, SN visits 3 w 4 starting 10/18/2021, and SN visits 2 w 1 starting 11/15/2021; - Change and instruct patient/caregiver/family in wound dressing as ordered; - Found wound vac malfunctioning, client/caregiver should remove the wound vac dressing and lightly pack the wound with normal saline wet to dry gauze dressing and secure with tape; then call the agency to inform them of the wound vac status; - Left foot surgical incision and drainage (I & D) to left foot after infection from stepping on a nail; - Instructed on dressing change if wound vac should malfunction without resolve; and - Patient verbalized understanding of instructions. Review of the initial start of care (SOC) assessment dated 10/16/2021 documented by RN B showed: - Surgical wound to left foot; - Wound measured: 6 cm long x 1.3 cm width x 1/8 cm depth; and - Moderate serosanguinous (yellow liquid or bloody serum) drainage, no odor, skin around wound macerated (occurs when skin is in contact with moisture for too long), wound bed pink, wound care done, cleaned with wound cleanser, wound packed with black foam, skin protectant applied around wound, covered with transparent film, application of wound vac set at 125 mm/Hg. Review of SN visit note dated 10/18/2021 at 9:35 AM documented by RN B showed: - Patient instructed in dressing change if wound vac should malfunction without resolve and wound care performed; apply wet to dry dressing and notify the SN, instructed in signs and symptoms of infection fever, increased redness, odor, increased swelling, and no signs and symptoms of infections noted. Review of a communication note dated 10/19/2021 documented by RN B showed: - SN changed wound vac during SN visit on 10/18/2021 in the AM; - Received phone call from patient on 10/18/2021 at 4:30 PM reporting the wound vac was leaking and beeping; - Instructed in trouble shooting tactics and the leaking stopped; - Patient also reported that machine was not staying charged; - RN B informed patient to call the wound vac company for problems with the machine; - RN B received another call from the patient at 7:15 PM reported leaking and beeping again; - Also patient called the wound vac company and was placed on hold; - Instructed to remove wound vac and dressing and place a wet to dry dressing to wound and RN B would make a visit in the AM; - Patient state he/she had no one to remove the wound vac and dressing and his/her caregiver could not remove it; - Patient did not inform SN that caregiver would not do dressing change at SN visit this AM; - Informed patient that he/she could go to the ER or Urgent Care; patient hinting he/she wanted SN to make a SN visit to change the dressing; - Informed the patient, “we are 24/7 for questions and concerns, not an ER;” - He/she told RN B that he/she had a willing and able caregiver during the AM visit; - RN B informed the patient that the agency was available for questions and concerns 24/7, but they were not an ER; - Informed patient that this was explained to him/her at the start of care visit at the SOC and he/she told RN B he/she had a willing caregiver who was his/her spouse; - Informed patient that SN was there to assist and teach so he can stay at home and out of the hospital; and; - Patient stated he/she “would figure something out.” During an interview on 10/20/2021 at 10:30 AM, the DON stated that: - Nurses teach protocol for wound vac malfunction issues, removal of old dressing and wound vac and applying wet to dry dressing, cover with transparent tape; - If a patient called after hours, we ideally try to assist the patient over the phone and see the patient the next day; - The patient called his/her insurance company at 6:30 PM on 10/18/2021 about the wound vac issue and reported that the wound was red and swollen; - The insurance person instructed the patient to go to the ER for treatment; - The patient went to the ER and later informed the insurance company he/she did not want the agency to return to his/her home; - He/she had 15 insurance authorized SN visits but the agency did not know if they could see a patient more than one time per day; - RN B reported that the patient did not tell him/her the caregiver was not able to care for the wound; and - RN B should not have said the agency is not an ER and 24/7 service was for questions and concerns. During an interview on 10/20/2021 at 11:30 AM, RN B stated that: - He/she admitted the patient on 10/16/2021 and instructed the patient and caregiver in the care of the wound vac, dressing change, and protocol if the machine malfunctioned; - He/she saw the patient the AM of 10/18/2021 and provided wound care and instruction; - The patient called RN B at 4:30 PM on 10/18/2021 and wanted a SN visit to correct the beeping machine and change the dressing if needed; - RN B told the patient to follow the protocol he/she instructed to him/her and caregiver or go to the ER; - The patient did not indicate the caregiver was not able to provide care for the wound during admission on 10/16/2021 or during SN visit in the AM of 10/18/2021; - RN B was told that two SN visits could not be made on the same day; - The patient did not report redness or swelling of the foot/wound to him/her during the call and he/she did not see redness or swelling of the foot during the SN visit; - The wound was in a difficult place on the bottom of the foot and between toes so the dressing was difficult to stay in place; and - He/she probably should not have made the comment about the agency not being an ER. During an interview on 10/20/2021 at 12:00 PM, the director of operations stated that: - The agency provided care 24/7 to patients, and staff should make visits after hours if patients call and have any kind of difficulty or situation; - He/she expected on-call staff to make a visit if there are problems no matter the time, whether it is 9:00 PM or 1:00 AM; and - If there were 15 authorized visits, a second visit could have been made on 10/28/2021 by RN B since the patient was just admitted on 10/16/2021.