Every finding on record at Divinity Home Health Services, LLC

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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 observation, interviews, and record reviews, the agency failed to ensure an accurate review of all medications that were prescribed for 1 (Patient #7) of 7 sampled patients observed for medication reconciliation during home visits. Findings: Review of Patient #7’s Resumption of Care Orders dated 12/18/2025 revealed Patient #7 was to receive skilled nursing services once a week for four weeks. Review of Patient #7’s record revealed Patient #7 received skilled nursing services on 12/18/2025, 12/26/2025, and 01/07/2026. Review of Patient #7’s medication profile, presented by S1Administrator/Director of Nursing (DON) as the most current copy of Patient #7’s medication, revealed Patient #7 was documented as receiving, in part, Metoprolol Succinate Extended Release (medication used to treat high blood pressure) 25 milligrams, one tablet by mouth twice a day with a start date of 12/18/2025; and, no evidence of Trazadone (medication used to treat depression) 50 milligrams one tablet by mouth at bedtime was listed as a current medication. Observation on 01/13/2026 at 9:15AM revealed the following medications were presented as current medications, in part, Metoprolol Succinate Extended Release 25 milligrams, administer one half of a tablet twice a day with a prescription filled date of 12/17/2025; and, Trazadone 50 milligrams one tablet by mouth at bedtime with a prescription filled date of 12/18/2025. In an interview on 01/13/2026 at 9:15AM, Patient #7 and Patient #7’s caregiver confirmed Patient #7 was currently taking Metoprolol Succinate Extended Release 25 milligrams administer one half of a tablet twice a day; and, Trazadone 50 milligrams one tablet by mouth at bedtime. Review of Patient #7’s Discharge Summary Report dated 12/17/2025 revealed, in part, Patient #7 was ordered Metoprolol Tartrate 25 milligrams administer 12.5 milligrams by mouth twice a day. Review of Patient #7’s Nurse Report Communication dated 12/18/2025 revealed, in part, Patient #7 had requested a prescription of Trazadone, which was given to Patient #7 in the hospital. Further review revealed Patient #7’s physician office was notified and a prescription was sent to the pharmacy. In an interview on 01/14/2026 at 12:07PM, S1Administrator/Director of Nursing indicated the skilled nurse should have identified the above mentioned medications and incorporated the medication changes into the medication profile.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure the agency maintained a coordinated program for the surveillance and identification of infections for 5 (Patient #2, Patient #5, Patient #8, Patient #12, Patient #15) of 12 sampled patients reviewed for infection control investigations. Patient #2 Review of Patient #2’s Patient Medication Record revealed in part, Patient #2 received metronidazole (antibiotic used to treat stomach/intestinal infections) 500 milligrams (mg) one tablet by mouth twice a day for seven days, with a start date of 12/18/2025. Patient #5 Review of Patient #5’s Patient Medication Record revealed in part, Patient #5 received Zithromax (antibiotic, used to treat respiratory infections) 500 mg one tablet by mouth twice a day for 5 days for cough and congestion, with a start date of 11/18/2025. Patient #8 Review of Patient #8’s Patient Medication Record, revealed in part, Patient #8 received Macrobid (antibiotic, used to treat infections) 100 mg one capsule by mouth twice a day for five days, with a start date of 09/02/2025; Bactrim Double Strength (antibiotic, used to treat infections) 800-160 mg by mouth daily for 10 days, with a start date of 11/22/2025; and, Cephalexin (antibiotic, used to treat infections) 500 mg one capsule by mouth three times a day, with a start date of 11/24/2025. Patient #12 Review of Patient #12’s Patient Medication Record revealed, in part, Patient #12 received Cephalexin 500 mg one capsule twice a day with a start date of 03/31/2025; and, Cephalexin 500 mg one capsule every 6 hours for 10 days, with a start date of 10/29/2025. Patient #15 Review of Patient #15’s Patient Medication Records revealed, in part, Patient #15 received Ampicillin (antibiotic, used to treat infections) 500 mg one capsule twice a day for 7 days, with a start date of 08/18/2025; and, Fosfomycin Tromethamine (antibiotic, used to treat infections) 3 grams one packet daily for 5 days, with a start date of 08/18/2025. In an interview on 01/14/2026 at 10:55AM, S1Administrator/Director of Nursing (DON) indicated once a skilled nurse or clinician identifies signs and symptoms of an infection and/or a new antibiotic in the home, used to treat an infection, the clinician was to initiate an infection control report for the patient within the note. S1Administrator/DON further indicated the infection control report then would be automatically be sent to myself (S1Administrator/DON) and S2Case Manager for any reviews. S1Administrator/DON further indicated the agency then would use the infection control reports to create a log which would be used to track and trend all patient infections and/or contagious disease, and look for trends which would require intervention by the agency. Review of agency’s Infection Control Log for 01/01/2025 thorough 12/31/2025 revealed, in part, the above mentioned infections/antibiotic usage was not captured on the infection control log. In an interview on 01/14/2026 at 10:57AM, S3Regional Clinical Director of Operations indicated all infections and antibiotic usage, unless used for prophylaxis, should be captured on the infection control log. In an interview on 01/14/2026 at 11:27AM, S1Administrator/DON indicated she had reviewed the above mentioned antibiotic usage/infections and had no further evidence to present that the above mentioned infections/antibiotic usage was captured on the agency’s infection control log; therefore, the agency had no evidence the above mentioned infections were used to trend and identify infections, as required.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on interview and record reviews, the agency failed to ensure the registered nurse measured a patient’s wound weekly to assess for wound healing status for 1 (Patient #12) of 15 sampled patients reviewed for weekly wound care assessments. Findings: Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed the assessment and documentation of wound status included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment included: dimensions and depth, presence, location and depth of any sinus tracts or undermining areas, status and characteristics of the wound bed, volume, color, and odor of exudates, and evidence of infection in surrounding tissues. Further review revealed when recorded over time, this information can be used to track the progress of wound healing. Review of Patient #12’s physician order dated 12/05/2025 revealed, in part, the skilled nurse was to evaluate and assess Patient #12’s wounds at each dressing change and as needed, and notify the physician if any signs and symptoms of infection were noted. Review of Patient #12’s Registered Nurse (RN) Skilled Nursing Visit dated 12/05/2025, 12/09/2025, and 12/18/2025 and revealed the following wounds, in part: -left buttock stage 1 pressure injury (a red non-blanchable skin, condition when skin is intact, red and does not turn white when pressure applied) with no documentation of the size of the wound; -left lower leg venous ulcer (wound caused by poor circulation) with a minimal amount of serous (clear fluid coming from the wound) drainage, with 100 percent pink/red wound tissue, with no documentation of the size of the wound; and, -right lower leg venous ulcer with a minimal amount of serous drainage, with 100 percent pink/red tissues, with no documentation of the size of the wound. Review of Patient #12’s RN Skilled Nursing Visit dated 01/05/2026 revealed the following wounds, in part: -left buttock stage 1 pressure injury with no documentation of the size of the wound; -left lower leg venous ulcer with a minimal amount of serous drainage, with 100 percent pink/red wound tissue, with no documentation of the size of the wound; and, -right lower leg venous ulcer with a moderate amount of serous drainage, with 100 percent pink/red tissues, with no documentation of the size of the wound. Review of Patient #12’s RN Skilled Nursing Visit dated 01/12/2026 revealed the following wounds, in part: -left buttock stage 1 pressure injury with no documentation of the size of the wound; -left lower leg venous ulcer with a moderate amount of serous drainage, with 100 percent pink/red wound tissue, with no documentation of the size of the wound; and, -right lower leg venous ulcer with a moderate amount of serous drainage, with 100 percent pink/red tissues, with no documentation of the size of the wound. In an interview on 01/14/2026 at 12:53PM, S1Administrator/Director of Nursing (DON) indicated the skilled nurse should have measured the open areas on Patient #12’s bilateral lower legs, and should have measured the red non-blanch able area to Patient #12’s left buttock.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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 record review and interview, the agency failed to reconcile medications at every skilled nurse visit to maintain an accurate record of patients’ medications. This deficient practice was identified for 2 (Patient #1 and Patient #2) of 13 patients sampled for accurate medication records in a total sample of 13. Findings: Review of the agency’s Medication Management/Medication Profile Policy and Procedure revealed, in part, patients receiving medications will have a current and accurate medication profile in the clinical record. Further review revealed medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Review of Patient #1’s current home medications revealed the following medications not listed on the Medication Profile List: Lumigan 0.01% eye drops (a medication for glaucoma); and, Aspirin 81 milligrams (mg) (medication to prevent blood clots). Review of Patient #2’s current medications taken at Patient #2’s home revealed the following medications not listed on the Medication Profile List: Symbicort 160 mg/14.5 micrograms (mcg) (medication for asthma). Further review revealed the following medications were listed on the Medication Profile List but not currently being taken by Patient #2: Protonix 40 mg (medication for reflux); Culturelle Digestive Health Capsule (probiotic); Mucinex DM 30-600 mg (cough medication); Vitamin D3 25 mcg; and, Lyumjev Injection 100 units/milliliter (ml) (antidiabetic). In an interview on 01/30/2023 at 3:58 p.m., S4Physical Therapist (PT) stated she asked the patients at every visit if they have had any changes but she did not go through all the patients’ current medications. In an interview on 01/31/2023 at 11:20 a.m., S3Registered Nurse (RN) stated he asked the patients at every visit if they have had any medication changes and makes any updates to the medication list. S3RN further stated Patient #1’s eye drops were new and he was unsure why he did not have the Aspirin on the medication list. In an interview on 01/31/2023 at 2:56 p.m., S1Administrator/Director of Nurses (DON) confirmed all nurses should do a full medication reconciliation to be able to note any changes in patients’ medications. S1Administrator/DON further confirmed if a patient was not currently receiving skilled nursing services, the therapist should complete a full medication reconciliation to make sure the medications in the medical record are accurate.

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 record review, observation, and interview the agency failed to only administer treatments as ordered in the Plan of Care by the physician. This deficient practice was identified for 2 (Patient #1 and Patient #13) of 13 sampled patients reviewed. Findings: Review of the agency’s Provision of Care, Treatment, and Services Ongoing Assessments Policy and Procedure revealed, in part, the physician will be notified to verify any changes in care, treatment, or services that require physician approval. Patient #1 Review of Patient #1’s Home Health Certification and Plan of Care, with a certification period of 01/11/2023 through 03/11/2023, revealed, in part, an order for staff to clean left leg with normal saline, pat dry, and apply Unna Boot followed by Coban starting above the toes and ending below the knee twice a week. Review of Patient #1’s visit note dated, 01/12/2023, revealed, in part, Patient #1 called skilled nurse to report that he had to remove his Unna Boot last night due to itching. Further review revealed Patient #1 requests to start using Unna Boot with Calamine (a medication used for itching). Review also revealed documentation that S3Registered Nurse (RN) visited Patient #1 and reapplied his Unna Boot with Calamine. Review of Patient #1’s orders for the certification period of 01/11/2023 through 03/11/2023 did not reveal, nor did the agency provide documented evidence of an order for the treatment of Patient #1’s left leg wound with Unna Boots with Calamine. Review of Patient #1’s medical record revealed, in part, an order dated 01/26/2023 to clean Patient #1’s medial ankle with normal saline, pat dry, cover with bordered gauze and wrap from just above the toes to just below the knee with Coban and kerlix twice a week. Observation on 01/31/2023 at 9:08a.m. of an in home visit with Patient #1, S3Registered Nurse (RN) noted the wound to Patient #1’s left leg had worsened and due to the worsening S3RN explained to Patient #1 that he would perform the wound care with previous wound care orders. Further observation revealed S3RN performed wound care to Patient #1’s left leg as follows: cleaned with normal saline, patted dry, applied Unna Boot with Calamine Gauze and wrapped with Coban. In an interview on 01/31/2023 at 11:20 a.m., S3RN stated he did not request or receive a new order for Patient #1 left leg wound care to be completed with Unna Boot with Calamine. S3RN further stated he did not get a new wound care order from the physician prior to changing Patient #1’s wound care treatment at the home visit on 01/31/2023. In an interview on 01/31/2023 at 3:01 p.m., S1Administrator/Director of Nurses (DON) confirmed S3RN should have contacted the physician prior to performing new wound care on Patient #1. Patient #13 Review of Patient #13’s Visit Note, dated 07/26/2022, revealed, in part, documentation that Patient #13’s right 4th toe surgical wound was cleaned with wound cleanser, patted dry, and left open to air. Review of Patient #13’s Visit note dated 08/02/2022 revealed, in part, revealed, in part, documentation that Patient #13’s right 4th toe surgical wound was cleaned with wound cleanser, patted dry, and left open to air. Review of Patient #13’s Visit Note dated 08/09/2022 revealed, in part, revealed, in part, documentation that Patient #13’s right 4th toe surgical wound was cleaned with wound cleanser, patted dry, and left open to air. Review of Patient #13’s Home Health Certification and Plan of Care, with a certification period of 07/15/2022 through 09/12/2022, did not reveal, nor did the agency provide any documented evidence of wound care orders for patient #13’s right 4th toe surgical site. In an interview on 02/01/2023 at 10:32 a.m., S2Case Manager (CM) confirmed there was no order to perform wound care to Patient #13’s right 4th toe surgical site. S2CM further confirmed nurses should have not performed wound care without an order.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of changes in a patient’s condition. This deficient practice was identified for 2 (Patient #1 and Patient #10) of 13 patients sampled for record review in a total sample of 13. Findings: Review of the agency’s Provision of Care, Treatment, and Service Care Coordination Policy and Procedure revealed, in part, coordinate communication with all physicians involved in the plan of care. Patient #1 Review of Patient #1’s Home Health Certification and Plan of Care, with a certification period of 01/11/2023 through 03/11/2023, revealed, in part, a physician’s order to clean left leg with normal saline, pat dry, and apply Unna Boot followed by Coban starting above the toes and ending below the knee twice a week. Review of Patient #1’s visit note, dated 01/12/2023, revealed, in part, Patient #1 called skilled nurse to report that he had to remove his Unna Boot last night due to itching. Further review revealed Patient #1 requested Unna Boot with Calamine (a medication for itching). Review of Patient #1’s record revealed no documented evidence and the agency did not present any documented evidence that Patient #1’s physician was notified of a change in Patient #1’s status or request for treatment change. In an interview on 01/31/2023 at 11:20 a.m., S3Registered Nurse (RN) stated he did not notify the physician of Patient #1’s itching with the Unna Boot or the request to apply Unna Boot with Calamine. In an interview on 01/31/2023 at 3:01 p.m., S1Administrator/Director of Nurses (DON) confirmed S3RN should have contacted the physician to report a change in Patient #1’s status and Patient #1’s request to change wound treatment. Patient #10 Review of Patient #10’s Home Health Certification and Plan of Care, with a certification period of 05/07/2022 through 07/05/2022, revealed, in part, and order for staff to notify the physician of fasting and/or random blood sugar readings greater than 300 milligrams per deciliter (mg/dl) or less than 60mg/dl. Review of Patient #10’s visit note, dated 05/26/2022, revealed, in part, Patient #10’s blood sugar was assessed and had a reading of “high” on the glucometer. Further review did not reveal nor did the agency provide any documented evidence of physician notification of change. In an interview on 02/01/2023 at 9:22 a.m., S2Case Manager (CM) confirmed the nurse should have called the physician regarding Patient #10’s blood sugar reading.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on record review, observation, and interview the facility failed to prevent the spread of infections by failing to have a nurse change contaminated gloves and perform hand hygiene prior to dressing a clean wound for 1 (Patient #1) of 5 patients sampled for home visits. Findings: In an observation on 01/31/2023 at 9:08a.m. of an in home visit with Patient #1, S3Registered Nurse (RN) put on clean gloves to remove dirty dressings from Patient #1’s left lower leg. After removing the dirty dressing the surveyor did not see the nurse remove dirty gloves and perform hand hygiene. Further observation revealed S3RN to clean the wound with normal saline and gauze. Further observation did not reveal S3RN to change his gloves after cleaning the wound or perform hand hygiene. Further observation revealed S3RN to apply Unna boot gauze to the patient’s right leg from right above the toes to right below the knee and secure with Coban. In an interview on 01/31/2023 at 11:20 a.m., S3RN stated he should complete hand hygiene before starting wound care and putting on his gloves before starting and don gloves. S3RN further stated he usually changed gloves and hand sanitized before putting on new gloves and then removed gloves and washed his hands after he was finished with wound care. S3RN further stated he did not need to change them again after cleaning the dirty wound. In an interview on 01/31/2023 at 3:01p.m., S1Administrator/Director of Nurses confirmed S3RN should have changed his gloves after cleaning Patient #1’s wound because his gloves were contaminated.