Every finding on record at Fv at Home - Home Health LLC

A partial extended survey for Medicare recertification for the home health provider was completed on 12/03/2025. The provider had 98 current patients. The Emergency Preparedness regulations were also reviewed as part of the Medicare recertification survey completed on 12/03/2025. One standard level deficiency was identified.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of personnel files and interview, the home health provider failed to ensure emergency preparedness (EP) training was completed on hire and/or annually in five of five personnel records reviewed (Employees #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: EMPLOYEE #1: Review of Employee #1’s personnel file showed in part: - The employee’s position was physical therapy assistant; - Orientation in-service training took place on 07/12/2021; and - The personnel file failed to contain evidence that EP training was completed upon hire and every two years. EMPLOYEE #2: Review of Employee #2’s personnel file showed in part: - The employee’s position was occupational therapist; - Orientation in-service training took place on 10/04/2021; and - The personnel file failed to contain evidence that EP training was completed upon hire and every two years. EMPLOYEE #3: Review of Employee #3’s personnel file showed in part: - The employee’s position was registered nurse; - Orientation in-service training took place on 02/08/2024; and - The personnel file failed to contain evidence that EP training was completed upon hire. EMPLOYEE #4: Review of Employee #4’s personnel file showed in part: - The employee’s position was licensed practical nurse; - Orientation in-service training took place on 10/03/2024; and - The personnel file failed to contain evidence that EP training was completed upon hire. EMPLOYEE #5: Review of Employee #5’s personnel file showed in part: - The employee’s position was medical social worker; - Orientation in-service training took place on 10/02/2025; and - The personnel file failed to contain evidence that EP training was completed upon hire. During an interview on 12/03/2025 at 3:20 PM, the business office manager stated that: - They did not have a policy specifically stating that staff would receive EP training upon hire and every two years; - They had an orientation itinerary that contained an EP module; -They expected employees to receive EP training upon hire and every two years; and - They were unable to provide evidence that Employee #1, #2, #3, #4, and #5 had received EP training upon hire or every two years.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the OASIS (Outcome and Assessment Information Set) data accurately reflected the patient’s status at the time of assessment in one of five records reviewed (Record/Patient #3). This deficient practice has the potential to affect the reporting of OASIS data for all the provider’s patients. Findings included: Review of the provider's policy titled, "OASIS Data Transmission," revised 06/2022, showed in part, that the encoded OASIS data must accurately reflect the patient’s status at the time of assessment. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of laceration (cut) of the right hand. The patient had a history of urinary tract infections (UTIs). Review of the OASIS Start of Care comprehensive assessment documentation, dated 11/18/2025, showed in part that: - The clinician completed OASIS items that showed: * Item M1400: When is the patient dyspneic (short of breath) or noticeably short of breath: This was marked as 2 (two) – with moderate exertion; and * Item M1600: Has this patient been treated for a UTI in the past 14 days? This was marked as no; - The visit note failed to contain documentation of a respiratory assessment that included assessment of the patient’s dyspnea; and - The patient had taken Macrobid (an antibiotic) for UTI prophylaxis (prevention) since 08/02/2025. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that: - The clinician reported to him/her that the patient was short of breath during ambulation but had not documented the assessment; and - They had understood question M1600 to be focused on the patient having a UTI at the time of assessment, and had not considered the Macrobid as a prophylactic (preventative) when providing an answer; and - The OASIS answers for M1600 and M1400 were inaccurate.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the comprehensive assessments accurately reflected the patient’s current health, psychosocial, functional, and cognitive status in one of five records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, "Initial and Comprehensive Assessment," revised 06/2022, showed in part, that the initial and comprehensive patient assessment would include a physical assessment, including blood pressure, temperature, pulse, respiration, skin, pain, height/weight, allergies, nutritional status, and other relevant data related to pertinent physical findings. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of laceration (cut) of the right hand. The patient had secondary diagnoses of diabetes (a chronic disease that affects how the body uses sugar for energy), generalized anxiety disorder, hyperlipidemia (elevated fats in the blood), and hypertension (high blood pressure). The patient resided in his/her own home with the assistance of his/her spouse, family members, and private pay caregivers for four hours each morning and four hours each evening. Review of the healthcare practitioner’s progress note, dated 11/12/2025, showed in part that the patient was to start using hydrocortisone cream (a cream used to treat itching) to treat his/her itching; and the patient’s last HGB A1C (glycated hemoglobin, a blood test that measures an individual’s average blood sugar levels over the past two to three months) was abnormal. Review of the referring facility's profile and face sheet, dated 11/13/2025, showed in part that that profile contained orders for: - Monitoring of the patient’s blood sugar reading two times per day; - The use of Vitamin A & D ointment to perineal area three times per day as needed to prevent skin irritation; - Eucerin itch relief lotion twice daily to rash area; - A wound on his/her right shin with dressing changes ordered every three days; and - A wound on his/her coccyx (tail bone) with wound care ordered two times per day. Review of the comprehensive, initial nursing visit documentation, dated 11/18/2025, showed in part that the documentation failed to contain an assessment of: - The patient/caregiver’s competence in performing blood glucose monitoring; and - The patient’s perineal area, rash, or the shin wound. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that the comprehensive assessment failed to include an assessment of the patient's diabetes management, including glucometer use, and failed to include an assessment of the patient's perineal area, the rash, and the shin wound. He/she would expect the comprehensive assessment to accurately reflect the patient's condition.

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, record review, observation, and interview, the home health provider failed to ensure staff performed a review of all medications the patient was currently taking in three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider's policy titled, "Medication Profile," revised 06/2022, showed in part the following: - Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record; and - Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of laceration (cut) of the right hand. The patient had secondary diagnoses of diabetes (a chronic disease that affects how the body uses sugar for energy), generalized anxiety disorder, hyperlipidemia (elevated fats in the blood), and hypertension (high blood pressure). The patient resided in his/her own home with the assistance of his/her spouse, family members, and private pay caregivers for four hours each morning and four hours each evening. Review of the healthcare practitioner’s progress note dated 11/12/2025, showed in part that the patient was to start using hydrocortisone cream (a cream used to treat itching skin) to treat his/her itching skin. Review of the facility profile and face sheet, dated 11/13/2025, showed in part that that profile contained an order for hydrocortisone cream with a start date of 11/13/2025. Review of the providers home health certification and plan of care, dated 11/18/2025, showed in part that the document failed to contain an order for hydrocortisone cream. Review of the provider’s updated medication profile, dated 11/18/2025, showed that the document failed to contain an order for hydrocortisone cream. Observation and interview on 11/12/2025 at 10:45 AM, showed that the patient had hydrocortisone cream in his/her home. The spouse stated that the patient had started using hydrocortisone cream for itch relief before his/her return to their private residence on 11/18/2025. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that: - They would expect the patient’s medication profile to contain all the medications used by the patient; and - They were unable to find an order for hydrocortisone cream on the patient’s medication list. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the skilled nursing facility (SNF) discharge medication list dated 11/14/2025 showed: - Hydrochlorothiazide (used to treat high blood pressure and fluid retention) 12.5 milligrams (mg) every Monday, Wednesday, and Friday; - Cholecalciferol (vitamin D3) (used to treat low vitamin D3 levels and supports healthy bones, muscles and nerves) 50,000 international units (IU) every month; - Ferrous sulfate (iron supplement) 325 mg one table daily; - Probiotic (helps restore good bacteria to the digestive system) one capsule daily; - Zofran (used to treat nausea and vomiting) 4 mg tablet every 6 hours PRN (as needed); and - Docusate sodium (stool softener laxative used to treat constipation) 100 mg capsule once daily. Observation and interview on 12/02/2025 at 10:25 AM showed the following discrepancies between the provider’s medication profile and the patient’s home medications: - The provider’s profile showed hydrochlorothiazide 12.5 mg daily (should be Monday, Wednesday and Friday). The patient stated that he/she took 12.5 mg Monday through Friday and did not take it on Saturday or Sunday; - The provider’s profile showed cholecalciferol 50,000 “UT” (should be IU) every month. The patient stated that he/she took calcium 1200 mg with D3 1000 IU daily; - The provider’s profile showed ferrous sulfate 325 mg one table daily. The patient stated that he/she took one tablet on Monday, Wednesday and Friday; - The provider’s profile showed probiotic one capsule daily. The patient stated that he/she took one capsule twice a day; - The provider’s profile showed Zofran 4 mg every 6 hours PRN (as needed). The patient stated that he/she did not have that medication and did not use it; and - The provider’s profile showed docusate sodium 100 mg one capsule daily. The patient stated that he/she took two capsules daily. The patient had all his/her medications in a basket, used a list that he/she created, and stated that he/she independently took medications and did not use a medication planner. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the skilled nursing facility (SNF) discharge medication list, dated 11/14/2025, showed: - Hydrochlorothiazide (used to treat high blood pressure and fluid retention) 12.5 milligrams (mg) every Monday, Wednesday, and Friday; - Cholecalciferol (vitamin D3) (used to treat low vitamin D3 levels and supports healthy bones, muscles and nerves) 50,000 international units (IU) every month; - Ferrous sulfate (iron supplement) 325 mg one table daily; - Probiotic (helps restore good bacteria to the digestive system) one capsule daily; - Zofran (used to treat nausea and vomiting) 4 mg tablet every 6 hours PRN (as needed); and - Docusate sodium (stool softener laxative used to treat constipation) 100 mg capsule once daily. Observation and interview on 12/02/2025 at 10:25 AM showed the following discrepancies between the provider’s medication profile and the patient’s home medications: - The provider’s profile showed hydrochlorothiazide 12.5 mg daily (should be Monday, Wednesday and Friday). The patient stated that he/she took 12.5 mg Monday through Friday and did not take it on Saturday or Sunday; - The provider’s profile showed cholecalciferol 50,000 “UT” (should be IU) every month. The patient stated that he/she took calcium 1200 mg with D3 1000 IU daily; - The provider’s profile showed ferrous sulfate 325 mg one table daily. The patient stated that he/she took one tablet on Monday, Wednesday and Friday; - The provider’s profile showed probiotic one capsule daily. The patient stated that he/she took one capsule twice a day; - The provider’s profile showed Zofran 4 mg every 6 hours PRN (as needed). The patient stated that he/she did not have that medication and did not use it; and - The provider’s profile showed docusate sodium 100 mg one capsule daily. The patient stated that he/she took two capsules daily. The patient had all his/her medications in a basket, used a list that he/she created, and stated that he/she independently took medications and did not use a medication planner. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 06/01/2025 with a primary diagnosis of chronic peripheral venous insufficiency (a condition in which veins have problems moving blood back to the heart). The patient resided in an assisted living facility (ALF). Observation and interview on 12/02/2025 at 11:00 AM showed the following discrepancies between the provider’s medication profile and the ALF’s medication profile: -The provider’s profile showed the patient took lisinopril (used to treat high blood pressure) 20 milligrams (mg) take one tablet by mouth once daily. The ALF’s profile showed lisinopril 10 mg take one tablet by mouth once daily; -The ALF’s profile showed the patient took cilostazol (used to improve the flow of blood through the vessels) 50 mg take one tablet by mouth two times daily. The provider’s medication profile failed to contain this medication; and -The ALF’s profile showed the patient took gabapentin (used to treat nerve pain) 300 mg capsules, take one capsule by mouth three times a day. The provider’s medication profile failed to contain this medication. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that the cilostazol was a 30-day order and came off the medication profile after the 30 days. He/she also stated that they would expect the medication profile to match what the patient is taking. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of laceration (cut) of the right hand. The patient had secondary diagnoses of diabetes (a chronic disease that affects how the body uses sugar for energy), generalized anxiety disorder, hyperlipidemia (elevated fats in the blood), and hypertension (high blood pressure). The patient resided in his/her own home with the assistance of his/her spouse, family members, and private pay caregivers for four hours each morning and four hours each evening. Review of the healthcare practitioner’s progress note, dated 11/12/2025, showed, in part, that the patient was to start using hydrocortisone cream (a cream used to treat itching) to treat his/her itching skin. Review of the facility profile and face sheet, dated 11/13/2025, showed, in part, that that profile contained an order for hydrocortisone cream with a start date of 11/13/2025. Review of the providers home health certification and plan of care, dated 11/18/2025, showed, in part, that the document failed to contain an order for hydrocortisone cream. Review of the provider’s updated medication profile, dated 11/18/2025, showed that the document failed to contain an order for hydrocortisone cream. Observation and interview on 11/12/2025 at 10:45 AM, showed that the patient had hydrocortisone cream in his/her home. The spouse stated that the patient had started using hydrocortisone cream for itch relief before his/her return to their private residence on 11/18/2025. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that: - They would expect the patient’s medication profile to contain all the medications used by the patient; and - They were unable to find an order for hydrocortisone cream on the patient’s medication list.

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, record review, observation, and interview, the provider failed to ensure the plan of care (POC) included all required treatment orders, and complete/accurate interventions in three of five full records reviewed (Records/Patients #1, #3, and #4). This deficient practice has the potential to affect the provision of care for all the patients served by the provider. Findings included: Review of the provider's policy titled, "Care Planning Process," revised 06/2022, showed in part, based on the assessment and conclusions, the plan of care will include, but will not be limited to; patient specific interventions and education; and specific services and treatments to be provided. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of laceration (cut) of the right hand. The patient had secondary diagnoses of diabetes (a chronic disease that affects how the body uses sugar for energy), generalized anxiety disorder, hyperlipidemia (elevated fats in the blood), and hypertension (high blood pressure). The patient resided in his/her own home with the assistance of his/her spouse, family members, and private pay caregivers for four hours each morning and four hours each evening. Review of the comprehensive, initial nursing visit documentation, dated 11/18/2025, showed in part that the: - The patient had diabetes and was to be on a no concentrated sweets diet; and - Nurse had prefilled the patient’s medication planner during his/her visit. Review of the home health providers certification and plan of care dated 11/18/2025, showed in part that: - The document failed to contain interventions for the nurse to monitor the patient’s diabetes and prefill his/her medication planner; - The document contained and order to treat pain hot/cold packs; and - The document failed to contain individualized instructions for the use of hot/cold packs including, but not limited to, length and frequency of use. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that they would expect the plan of care to: - Contain all medications, interventions, and goals related to the care of the patient; and - He/she was unable to locate orders related to the monitoring of the patient’s diabetes, prefilling of the medication planner, or length and frequency of use for the hot/cold packs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the POC dated 11/17/2025 showed the following: - “Instruct patient nonpharmacologic pain relief measures: hot/cold packs”. The order failed to include the location, frequency, and duration for the use of hot or cold therapy; - “Skilled nurse (SN) to (teach) patient to wear compression therapy to edematous extremity/area”. The order failed to include the location, type, or duration for the application of compression therapy; and - The POC contained blood sugar parameters for fasting and random blood sugar readings for notification to the physician. The POC failed to include orders for the patient or staff to monitor or not to monitor the patient’s blood sugar. Observation and interview on 12/02/2025 at 9:40 AM showed the patient did not take any medications to control blood sugar and the patient stated that his/her hemoglobin A1C (a lab test that monitors control of blood sugar over a period of time) was always good, so he/she did not check his/her blood sugars. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/21/2025 with a primary diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and secondary diagnoses that included pneumonia (infection that involves one or both lungs) and end stage renal disease (kidneys no longer function on their own). The patient lived at home alone, but his/her daughter in law was staying temporarily to assist the patient. Review of the SN start of care assessment dated 10/21/2025 showed the patient received dialysis and had a right central venous catheter ((CVC) a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided into a large vein above the right side of the heart). Review of the POC dated 10/21/2025 showed the following: - “Instruct patient nonpharmacologic pain relief measures: hot/cold packs”. The order failed to include the location, frequency, and duration for the use of hot or cold therapy; - “SN to (teach) patient to wear compression therapy to edematous extremity/area”. The order failed to include the location, type, or duration for the application of compression therapy; and - The POC failed to include orders or instructions related to the right CVC that was used when patient received dialysis. During an interview on 12/03/2025 at 9:20 AM, the clinical manager stated that the hot/cold and compression interventions are already written and they could not be changed, but staff could write other interventions. The POC should include instructions related to the CVC and who managed it. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the POC, dated 11/17/2025, showed the following: - “Instruct patient nonpharmacologic pain relief measures: hot/cold packs”. The order failed to include the location, frequency, and duration for the use of hot or cold therapy; - “Skilled nurse (SN) to (teach) patient to wear compression therapy to edematous extremity/area”. The order failed to include the location, type, or duration for the application of compression therapy; and - The POC contained blood sugar parameters for fasting and random blood sugar readings for notification to the physician. The POC failed to include orders for the patient or staff to monitor or not to monitor the patient’s blood sugar. Observation and interview on 12/02/2025 at 9:40 AM showed the patient did not take any medications to control blood sugar and the patient stated that his/her hemoglobin A1C (a lab test that monitors control of blood sugar over a period of time) was always good, so he/she did not check his/her blood sugars. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of laceration (cut) of the right hand. The patient had secondary diagnoses of diabetes (a chronic disease that affects how the body uses sugar for energy), generalized anxiety disorder, hyperlipidemia (elevated fats in the blood), and hypertension (high blood pressure). The patient resided in his/her own home with the assistance of his/her spouse, family members, and private pay caregivers for four hours each morning and four hours each evening. Review of the comprehensive, initial nursing visit documentation, dated 11/18/2025, showed, in part, that the: - The patient had diabetes and was to be on a no concentrated sweets diet; and - Nurse had prefilled the patient’s medication planner during his/her visit. Review of the home health providers certification and plan of care, dated 11/18/2025, showed, in part, that: - The document failed to contain interventions for the nurse to monitor the patient’s diabetes and prefill his/her medication planner; - The document contained and order to treat pain hot/cold packs; and - The document failed to contain individualized instructions for the use of hot/cold packs including, but not limited to, length and frequency of use. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that they would expect the POC to: - Contain all medications, interventions, and goals related to the care of the patient; and - He/she was unable to locate orders related to the monitoring of the patient’s diabetes, prefilling of the medication planner, or length and frequency of use for the hot/cold packs. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/21/2025 with a primary diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and secondary diagnoses that included pneumonia (infection that involves one or both lungs) and end stage renal disease (kidneys no longer function on their own). The patient lived at home alone, but his/her daughter in law was staying temporarily to assist the patient. Review of the SN start of care assessment, dated 10/21/2025, showed the patient received dialysis and had a right central venous catheter ((CVC) a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided into a large vein above the right side of the heart). Review of the POC dated 10/21/2025 showed the following: - “Instruct patient nonpharmacologic pain relief measures: hot/cold packs”. The order failed to include the location, frequency, and duration for the use of hot or cold therapy; - “SN to (teach) patient to wear compression therapy to edematous extremity/area”. The order failed to include the location, type, or duration for the application of compression therapy; and - The POC failed to include orders or instructions related to the right CVC that was used when patient received dialysis. During an interview on 12/03/2025 at 9:20 AM, the clinical manager stated that the hot/cold and compression interventions are already written and they could not be changed, but staff could write other interventions. The POC should include instructions related to the CVC and who managed it. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 09/08/2025 with a primary diagnosis of dementia with other behavioral disturbances (decline in mental capacity with agitation such as verbal and physical aggression, wandering, and hoarding) and a secondary diagnosis of chronic pain. The patient resided in an assisted living facility (ALF). Review of the plan of care (POC) showed the patient was admitted with a referral for physical therapy and occupational therapy. The POC failed to contain interventions and goals related to the patient’s diagnosis of chronic pain. During an interview on 12/03/2025 at 12:30 PM, the home health clinical manager stated that he/she would expect the POC to contain interventions relating to the patient’s diagnosis and needs.

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 job description review, record review, and interview, the home health provider failed to report symptoms to the physician in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated job description titled, “Home Health RN (Registered Nurse) Case Manager,” showed in part, the RN case manager was to report patient/resident changes, needs, and/or requirements to the appropriate staff. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 06/01/2025 with a primary diagnosis of chronic peripheral venous insufficiency (a condition in which veins have problems moving blood back to the heart). The patient resided in an assisted living facility (ALF). Review of the plan of care (POC) dated 09/29/2025 to 11/27/2025 and the POC dated 11/28/2025 to 01/06/2026 showed an intervention for the skilled nurse (SN) to report to physician if patient experiences pain level not acceptable to patient, pain level greater than 5 (five) (numeric pain scale rating where 0 (zero) is no pain and 10 is the worst pain), or pain affecting ability to perform patient’s normal daily activities. Review of the RN skilled nursing visit notes dated 10/21/2025, 10/24/2025,10/28/2025, 11/11/2025, and 11/14/2025, showed a pain rating of a 7 (seven) out of 10. The provider failed to document communication to the physician regarding the high pain level. During an interview on 12/03/2025 at 12:30 PM, the clinical manager stated that the clinician did contact the physician on 10/28/2025 and the physician chose not to change the medication order for pain, but the clinician did not document this conversation. He/she then stated that they would expect all physician contact to be documented.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on personnel file review and interview, the home health provider failed to ensure infection control training was completed on hire and annually in two of five employee records reviewed (Employees #2 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: EMPLOYEE #2: Review of Employee #2’s personnel file showed in part that: - The employee’s position was physical therapy assistant; - Orientation in-service training took place on 07/12/2021; and - The personnel file failed to contain evidence that infection control training was completed upon hire or annually. EMPLOYEE #3: Review of Employee #3’s personnel file showed in part that: - The employee’s position was occupational therapist; - Orientation in-service training took place on 10/04/2021; and - The personnel file failed to contain evidence that infection control training was completed upon hire or annually. During an interview on 12/03/2025 at 3:20 PM, the business office manager stated that: - They did not have a policy specifically stating that staff would receive infection control training upon hire and annually; - They had an orientation itinerary that contained an infection control for home-based care providers; -They expected employees to receive initial and annual training on infection control; and - They were unable to provide evidence that Employee #2 and #3 had received initial and annual training on infection control.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure complete pain assessments were completed on clinician visits in three of five full records reviewed (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Initial and Comprehensive Assessment,” dated 06/2022, showed in part, during the comprehensive assessment, all data and other relevant information will be documented in the patient’s clinical record, including a physical assessment, including blood pressure, temperature, pulse, respiration, skin, pain status, height/weight, allergies, nutritional status, and other relevant data related to pertinent physical findings of common symptoms. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the plan of care (POC) dated 11/17/2025 showed a goal for patient to report effective pain control: will report pain less than 3 (numeric pain scale rating where 0 is no pain and 10 is the worst pain). Review of the physical therapy assistant (PTA) note dated 11/24/2025 showed the PTA documented that the patient had bilateral knee pain and back pain that was increased by "chronic pain, walking", relieved by "sitting", and interferes with "comfort". The PTA failed to document a pre-therapy and post-therapy rating of the pain. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/21/2025 with a primary diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and secondarydiagnoses that included pneumonia (infection that involves one or both lungs) and end stage renal disease (kidneys no longer function on their own). The patient lived at home alone, but his/her daughter in law was staying temporarily to assist the patient. Review of the plan of care (POC) dated 10/21/2025 showed a goal for patient to report effective pain control: will report pain less than 3 (numeric pain scale rating where 0 is no pain and 10 is the worst pain). Review of the physical therapy notes showed the physical therapist (PT) or PTA failed to document a complete pain assessment in the following notes: - The PTA noted dated 11/06/2025 showed the patient had left hip/groin pain that was increased by “activity- aware but not painful”, relieved by “avoidance, lying down and resting”, and interferes with “comfort”. The PTA failed to document a pre-therapy and post-therapy rating of the pain; - The PTA noted dated 11/13/2025 showed the patient had left hip/groin pain that was increased by “activity- aware but not painful weather change”, relieved by “avoidance, lying down and resting”, and interferes with “comfort”. The PTA failed to document a pre-therapy and post-therapy rating of the pain; - The PT re-evaluation note dated 11/18/2025 showed the patient had left hip pain that was increased by “activity”, relieved by “avoidance”, and interferes with “upright activity”. The PT failed to document a pre-therapy and post-therapy rating of the pain; - The PTA note dated 11/20/2025 showed the patient had left hip pain that was increased by “activity”, relieved by “avoidance”, and interferes with “upright activity”. The PTA failed to document a pre-therapy and post-therapy rating of the pain; and - The PTA note dated 11/24/2025 showed the patient had left hip/groin pain that was increased by “initially standing and taking the first few steps”, relieved by “avoidance”, and interferes with “upright activity”. The PTA failed to document a pre-therapy and post-therapy rating of the pain. Review of the occupational therapy (OT) visit notes showed OT failed to document a complete pain assessment in the following notes: - The OT note dated 11/13/2025, showed the patient had left knee pain that was increased by “baseline”, relieved by was not completed, and interferes with was not completed. The OT failed to document a pre-therapy and post-therapy rating of the pain; - The OT note dated 11/18/2025, showed the patient had left knee pain that was increased by “increases with prolonged activity”, relieved by was not completed, and interferes with was not completed. The OT failed to document a pre-therapy and post-therapy rating of the pain; and - The OT note dated 11/24/2025, showed the patient had left knee pain that was increased by “baseline – patient reports increased pain when ambulating/standing”, relieved by “Tylenol” (pain reliever), and interferes with was not completed. The OT failed to document a pre-therapy and post-therapy rating of the pain. During an interview on 12/03/2025 at 9:40 AM, the clinical manager stated that the staff should document the patient’s report of pain before and after treatment and if patient has high levels of pain, they should recommend medication before treatments. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the plan of care (POC) dated 11/17/2025 showed a goal for patient to report effective pain control: will report pain less than 3 (numeric pain scale rating where 0 is no pain and 10 is the worst pain). Review of the physical therapy assistant (PTA) note dated 11/24/2025 showed the PTA documented that the patient had bilateral knee pain and back pain that was increased by "chronic pain, walking", relieved by "sitting", and interferes with "comfort". The PTA failed to document a pre-therapy and post-therapy rating of the pain. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 06/01/2025 with a primary diagnosis of chronic peripheral venous insufficiency (a condition in which veins have problems moving blood back to the heart). The patient resided in an assisted living facility (ALF). Review of the PTA visit, dated 11/21/2025, showed patient had pain to the left leg that was "increased by walking", "relieved by elevation and rest", and "interferes with walking speed. The clinician failed to document a pain level pre therapy and post therapy. Review of the PTA visit, dated 11/26/2025, showed patient had pain to the left leg that was increased by walking, relieved by elevation and rest, and interferes with walking speed. The clinician failed to document a pain level pre therapy and post therapy. During an interview on 12/03/2025 at 12:30 PM, the home health clinical manager stated that he/she expected full pain assessments to be completed on every visit. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/21/2025 with a primary diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and secondary diagnoses that included pneumonia (infection that involves one or both lungs) and end stage renal disease (kidneys no longer function on their own). The patient lived at home alone, but his/her daughter in law was staying temporarily to assist the patient. Review of the POC, dated 10/21/2025, showed a goal for patient to report effective pain control: will report pain less than 3 (numeric pain scale rating where 0 is no pain and 10 is the worst pain). Review of the physical therapy notes showed the physical therapist (PT) or PTA failed to document a complete pain assessment in the following notes: - The PTA note, dated 11/06/2025, showed the patient had left hip/groin pain that was increased by “activity- aware but not painful”, relieved by “avoidance, lying down and resting”, and interferes with “comfort”. The PTA failed to document a pre-therapy and post-therapy rating of the pain; - The PTA note, dated 11/13/2025, showed the patient had left hip/groin pain that was increased by “activity- aware but not painful weather change”, relieved by “avoidance, lying down and resting”, and interferes with “comfort”. The PTA failed to document a pre-therapy and post-therapy rating of the pain; - The PT re-evaluation note, dated 11/18/2025, showed the patient had left hip pain that was increased by “activity”, relieved by “avoidance”, and interferes with “upright activity”. The PT failed to document a pre-therapy and post-therapy rating of the pain; - The PTA note, dated 11/20/2025, showed the patient had left hip pain that was increased by “activity”, relieved by “avoidance”, and interferes with “upright activity”. The PTA failed to document a pre-therapy and post-therapy rating of the pain; and - The PTA note, dated 11/24/2025, showed the patient had left hip/groin pain that was increased by “initially standing and taking the first few steps”, relieved by “avoidance”, and interferes with “upright activity”. The PTA failed to document a pre-therapy and post-therapy rating of the pain. Review of the occupational therapy (OT) visit notes showed OT failed to document a complete pain assessment in the following notes: - The OT note, dated 11/13/2025, showed the patient had left knee pain that was increased by “baseline”, relieved by was not completed, and interferes with was not completed. The OT failed to document a pre-therapy and post-therapy rating of the pain; - The OT note, dated 11/18/2025, showed the patient had left knee pain that was increased by “increases with prolonged activity”, relieved by was not completed, and interferes with was not completed. The OT failed to document a pre-therapy and post-therapy rating of the pain; and - The OT note, dated 11/24/2025, showed the patient had left knee pain that was increased by “baseline – patient reports increased pain when ambulating/standing”, relieved by “Tylenol” (pain reliever), and interferes with was not completed. The OT failed to document a pre-therapy and post-therapy rating of the pain. During an interview on 12/03/2025 at 9:40 AM, the clinical manager stated that the staff should document the patient’s report of pain before and after treatment and if patient has high levels of pain, they should recommend medication before treatments.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on job description review, record review, and interview, the home health provider failed to ensure the staff documented clearly and completely in two of five full records reviewed (Records/Patients #1, and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the “LPN (licensed practical nurse) Job Description,” showed in part, the nurse will accurately and timely complete required documentation. Review of the “RN (registered nurse) Case Manager (job description),” showed in part, the nurse will accurately and timely document patients/residents progress toward goals and other observations. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/17/2025 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the stomach and intestines) and secondary diagnoses that included pleural effusion (buildup of excess fluid in the area between the lungs and chest wall), hypertension (high blood pressure), type 2 (two) diabetes mellitus (DM) without complications (a chronic disease that affects how the body uses sugar for energy), and venous insufficiency (accumulation of blood or fluid that occurs due to poor blood flow usually in the lower extremities). The patient resided in an apartment alone in an independent care facility. Review of the registered nurse (RN) start of care (SOC) assessment, dated 11/17/2025, showed the RN documented the patient had an active diagnosis of DM in the Outcome and Assessment Information Set (OASIS- a data collection tool) section (M1028) and documented no DM in the endocrine assessment section. The rest of the endocrine DM section was not completed since the nurse documented the patient did not have DM. (The nurse’s documentation was unclear and incomplete since the patient had a diagnosis of type 2 DM.) RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/21/2025 with a primary diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and secondary diagnoses that included pneumonia (infection that involves one or both lungs) and end stage renal disease (kidneys no longer function on their own). The patient lived at home alone, but his/her daughter in law was staying temporarily to assist the patient. Review of the LPN visit note, dated 10/28/2025, showed a comment in the medication change since last visit section; “Daughter in law sets up medications in planner. Lexapro (an antidepressant) decreased. Renee (this should be Remeron (an antidepressant)) on start for weight loss”. This unclear note carried over to the LPN visits on 10/30/2025, 11/04/2025, and 11/06/2025. During an interview on 12/03/2025 at 9:20 AM, the clinical manager stated that he/she was unsure why the endocrine section was completed incorrectly, or why the medication note carried over to multiple visits.

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 12/07/2022. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare recertification for the home health provider was completed on 12/07/2022. The agency had 120 current patients. The COVID-19 Health Care Staff Vaccination regulation was reviewed as part of the Medicare recertification survey. During the survey it was determined the agency was in compliance with the regulation.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Review of agency policy, clinical record review, and interview, showed the agency failed to ensure encoded OASIS (Outcome and Assessment Information Set) data accurately reflected the patient's status in two (Records/Patients #1 and #5) of five applicable records reviewed. This deficient practice has the potential to affect the accuracy of OASIS data collection for the agency's patients. Findings included: Review of the agency’s policy titled, “Reassessment/Recertification,” dated June 2022 showed that: - A comprehensive assessment, including all required OASIS data elements, must be performed to measure patient progress towards outcomes; and - Documentation in the clinical record should support the assessment as well as the actions taken in response. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/23/2022 with a primary diagnosis of weakness. The patient resided in their own apartment within an assistive living facility. Review of the initial, comprehensive assessment dated 11/23/2022 showed that: - The intensity of the patient’s pain was “0”, on a 0-10 high scale, and the pain relief rating of pain was “0”, on a 0-10 high scale; and - The assessment failed to contain documentation identifying any pain; and - The OASIS question (M1242) Frequency of Pain Interfering with patient’s activity or movement was answered as “(2) – Less often than daily”. The documentation failed to support this answer as the documentation failed to support that the patient had any pain. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 05/10/2022 with a primary diagnosis of gastrointestinal hemorrhage (bleeding from the stomach and/or intestines). The patient resided in their own apartment with the continuous assistance of their adult child. Review of the initial, comprehensive assessment dated 05/10/2022 showed that: - The intensity of the patient’s pain was “3”, on a 0-10 high scale, and the pain relief rating of pain was “0”, on a 0-10 high scale; and - The assessment failed to contain documentation identifying continuous pain affecting the patient’s activity or movement; and - The OASIS question (M1242) Frequency of Pain Interfering with patient’s activity or movement was answered as “(4) – All of the time”. The documentation failed to support this answer as the documentation failed to support that the patient had continuous pain. During an interview on 12/06/2022, at 4:15 PM, the executive director stated that they would expect the assessment documentation to support the OASIS data collection elements.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s status, to include the patient’s medical, nursing, rehabilitative, social, and discharge planning needs in one (Record/Patient #2) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Initial and Comprehensive Assessment,” dated 2009, showed: - The assessment will be patient-specific and comprehensive to include the patient’s needs for home care, rehabilitative care, social, and discharge planning needs; and - During the initial and comprehensive patient assessment, all baseline data to be used in measuring the patient’s progress towards goals and other relevant information will be documented in the patient’s clinical record, including a physical assessment of the skin. Review of the agency’s policy titled, “Prevention and Treatment of Skin Breakdown Policy,” dated 08/2019, showed: - It is the policy to properly identify and assess patients whose clinical conditions increase the risk for impaired skin integrity and pressure injuries; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care; and - Skin will be observed weekly with care by the nurse. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the agency on 11/16/2022 with diagnoses of second degree burns of the abdomen and right thigh (the patient also had burns on the left thigh), type one diabetes mellitus (a chronic condition in which the pancreas produces little or no insulin, it typically appears in childhood or adolescence), and spina bifida (a congenital defect of the spine often causing paralysis of the lower limbs). The patient and his/her spouse reside in an independent living facility. Review of the hospital referral information, dated 11/14/2022, showed: - The patient had deep second and third degree burns to the lower abdomen and the right and left thighs; and - A small amount of redness around the lateral edge of the left thigh burn that was not considered cellulitis and the rest of the wound was without infection. Review of the comprehensive assessment, dated 11/16/2022, showed: - The abdominal burn wound was identified as “Wound 1” and no measurements were documented; - The right thigh burn wound was identified as “Wound 2” and no measurements were documented; and - The left thigh burn wound was not identified or assessed on the comprehensive assessment. During an interview on 12/06/2022 at 2 PM, the executive director stated that he/she would expect all wounds to be identified and assessed during the comprehensive assessment and weekly thereafter.

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, clinical record review, home visit observation, and interview the agency failed to ensure a review of all medications the patients were currently using were documented 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 in three (Records/Patients #1, #2, and #5) of five applicable records reviewed. This deficient practice has the potential to affect the medication review of all the agency's patients. RECORD/PATIENT #2: Review of the agency-provided medication list showed the patient was taking the following medications: - Ventolin inhaler (used to treat or prevent bronchospasms) 108 mcg/act (micrograms per actuation), two puffs every four hours as needed for wheezing. The start date on the medication is 05/21/2020 and the patient’s spouse stated that this is not a current medication; and - Zaditor Ophthalmic (used to treat itching of the eyes caused by allergies) 0.025% / 5 ml (milliliters), one drop every eight hours (does not specify which eye). The start date on the medication is 05/21/2020 and the patient’s spouse stated that this is not a current medication. Medication review and interview conducted at during a home visit on 12/05/2022 at 1:00 PM, showed: - The patient takes Anoro Elipta (used to treat chronic bronchitis and emphysema) 625 mcg / 25 mcg inhaler, one inhalation daily (this medication was not on agency’s medication list); - The patient does not take the Ventolin inhaler or the Zaditor eye drops; and - The patient’s spouse stated that they have told the agency that he/she does not take the medications any more but they are still on the list. During an interview immediately following the home visit, the registered nurse stated that he/she could not explain the medication discrepancies because this is the first time he/she has ever seen the patient. During an interview on 12/06/2022 at 4:17 PM, the executive director stated that he/she would expect the agency’s medication list to accurately reflect the medications the patient is currently taking. Review of the agency's policy titled, "Medication Profile," revised June 2022 showed that a drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will be performed by qualified personnel and will identify drug/food interactions, potential adverse effects, and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/23/2022 with a primary diagnosis of weakness. The patient resided in their own apartment within an assistive living facility. Observation on 12/05/2022 at 12:05 PM, medication reconciliation performed by LPNA during the patient’s home visit, showed the patient had: - Cipro 500mg tablets in the home with a start date of 11/22/2022; - Bupropion tablets in the home with a start date of 11/22/2022; and - Ocean nasal spray; and None of the medications listed above were on the agency medication profile. Review of the patient's medication profile, with date range of 11/23/2022 to 01/21/2023, showed that the document failed contain Cipro and bupropion. During an interview on 12/05/2022 at 12:30 PM, LPNA stated that they had made a home visit last week and that they do not remember the medication being at the patient’s home. During an interview on 12/05/2022 at 12:30 PM, the patient stated that the pharmacy brought the medications to their home, and that they have not taken any of the medications. During an interview on 12/06/2022 at 4:15 PM, the executive director stated that they would expect all of the patient’s medications to be listed on the agency medication profile.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and interview, the agency failed to ensure the plan of care contained, but not limited to, the types of services, supplies, and equipment required; nutritional requirements; all medications and treatments; and patient-specific interventions in three (Records/Patients #2, #3, and #5) of five full records reviewed. This deficient practice has the potential to affect the care planning for all of the agency's patients. RECORD/PATIENT#2: Review of the clinical record showed the patient was admitted to the agency on 11/16/2022 with diagnoses of second degree burns of the abdomen and right thigh (the patient also had burns on the left thigh), type one diabetes mellitus (a chronic condition in which the pancreas produces little or no insulin, it typically appears in childhood or adolescence), and spina bifida (a congenital defect of the spine often causing paralysis of the lower limbs). The patient was admitted to the hospital on 11/28/2022 to 12/02/2022 for skin grafting of the burned areas and the agency resumed care on 12/03/2022. The patient and his/her spouse reside in an independent living facility. Review of the hospital referral information, dated 11/14/2022, showed: - The patient had deep second and third degree burns to the lower abdomen and the right and left thighs; and - A small amount of redness around the lateral edge of the left thigh burn that was not considered cellulitis and the rest of the wound was without infection. Review of the comprehensive assessment, dated 11/16/2022 showed: - Other retention of urine is entered as “other diagnosis” on M1023; - The patient required intermittent urinary catheterization (a soft, thin tube used to empty urine from the body); - The patient rated their pain as a “5” on a scale of 0 to 10 (zero being no pain and 10 being the worst possible pain); - The patient answered “dressing change” to the question, “What makes pain worse?”; - The abdominal burn wound was identified as “Wound 1” and no measurements were documented; - The right thigh burn wound was identified as “Wound 2” and no measurements were documented; and - The left thigh burn wound was not identified or assessed on the comprehensive assessment. Review of the plan of care (POC), dated 11/16/2022 to 01/14/2023, showed: - Skilled nurse (SN) to perform/teach wound care to the abdomen and right thigh, daily and as needed; * Cleanse/irrigate with Hibiclens (an antiseptic skin cleanser); * Allow to air dry or pat dry with gauze; * Apply Xeroform (a medicated petroleum dressing) and Mupirocin (a topical antibiotic ointment); * Cover with ABD (a thick dressing) pad; * Secure with tape; - The patient’s goal is that wounds will heal without complication by 01/14/2023; - The POC failed to contain an assessment of the patient and spouse’s comprehension of /response to the wound care education; - The POC failed to contain directions or guidance to measure the burn wounds weekly; - The POC failed to contain any directions for the assessment and treatment of the left thigh burn wound; - The POC failed to contain directions or guidance to ensure the patient pre-medicates with their narcotic pain reliever prior to the dressing change; and - The POC failed to contain information/orders regarding intermittent urinary catheterization. During an interview on 12/06/2022 at 4:17 PM, the executive director stated that he/she would expect all wounds to be assessed at each visit, measured weekly, and treatments to include all wounds. He/she would expect to see documentation that the patient and spouse verbalized an understanding or returned demonstration of wound care teaching. The POC should have contained the order for the intermittent urinary catheterization, including frequency and who was performing the procedure. He/she would also expect instruction for the nurse to ensure the patient had taken their pain medication prior to performing the dressing change. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the agency on 11/08/2022 with diagnoses of fractured fourth and fifth right metatarsal (foot) bones, a history of falls, dementia, atherosclerotic heart disease (a build-up of fat in the artery walls), hypertensive heart disease (heart problems that occur because of high blood pressure), and hypothyroidism (abnormally low activity of the thyroid gland). The patient lives alone in an independent living facility. Review of the hospital emergency room visit note showed: - Radiology findings of fourth and fifth metatarsal fractures of the right foot; and - A controlled ankle movement (CAM) walker boot was placed to the right foot. Review of the start of care assessment, dated 11/08/2022, showed diagnoses of displaced fractures of the fourth and fifth metatarsal bones of the left foot (the fractures were on the right foot). Review of the SN visit note dated 11/22/2022, showed: - The patient was wearing the CAM boot on his/her right foot; - The patient is forgetful; and - The SN encouraged the patient to use the boot at all times. Review of the SN visit note dated 12/01/2022 showed the licensed practical nurse (LPN) documented the patient stated that there were no skin issues. Review of the physical therapy visit notes, with dates ranging from 11/21/2022 to 11/28/2022, showed the patient: - Had fractures to the fourth and fifth metatarsal bones on the right foot; - Was not consistently wearing his/her CAM boot when therapist arrived for visits; - Complained of right foot pain; and - Was educated on importance of wearing CAM boot since the patient used feet to propel self in wheelchair. Review of the occupational therapy visit notes, with dates ranging from 11/11/2022 to 11/30/2022 showed the patient: - Had fractures of the fourth and fifth metatarsal bones on the left foot (fractures were on the right foot); - Complained of right foot pain; - Was not consistently wearing the CAM boot when therapist arrived for visits; - Was partially wearing CAM boot but the straps were not fastened; and - Required maximum assistance to don the boot appropriately. Review of the plan of care (POC) dated, 11/08/2022 to 01/06/2023, showed: - A primary diagnosis of a displaced fracture of the fourth metatarsal bones of the left foot (the fractures were on the right foot); - A secondary diagnosis of a displaced fracture of the fifth metatarsal bones of the left foot (the fractures were on the right foot); and - The POC failed to contain guidance or instructions on the placement of the CAM boot, how long it should be worn, and assessment for skin breakdown under the CAM boot. During an interview on 12/07/2022 at 10:20 AM, the executive director stated that he/she would expect the diagnoses on the POC to correctly reflect that the metatarsal fractures were on the right foot. He/she would expect the CAM boot to be on the POC and orders that specified to check for placement on the right foot, when to wear, how long to wear, and to inspect the skin of the right foot for breakdown from wearing the boot. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 05/10/2022 with a primary diagnosis of gastrointestinal hemorrhage (bleeding from the stomach and/or intestines), and secondary diagnoses of diabetes (a condition in which the body fails to metabolize sugars to meet the bodies metabolic needs), and gastrostomy (placement of a tube in the stomach for medication administration. The patient resided in their own apartment with the continuous assistance of their adult child. Review of the initial, comprehensive assessment dated 05/10/2022 showed that the patient: - Was a diabetic and the caregiver was not taking glucose levels regularly; and - Had a gastrostomy used for medications, and ate meals two to three times per day. Review of the plan of care dated 11/23/2022 to 01/21/2023 showed the document failed to contain interventions for: - The management of diabetes to include monitoring of the patient’s blood sugar readings; and - The management of the gastrostomy including, but not limited to, daily site care and medication administration. During an interview on 12/06/2022 at 4:20 PM, the executive director stated that they would expect the plan of care to contain interventions for the management of the patient’s diabetes and gastrostomy.

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, home visit observation, and interview, the agency failed to ensure that drugs, services and treatments were administered only as ordered by a physician or allowed practitioner in three (Records/Patients #1, #2, and #4) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Physician Participation in Plan of Care,” dated/revised 06/2022, showed: - A physician will direct the care of every home health care patient admitted for service; - The physician will participate in the care planning process by initiating, reviewing, and revising the plan of care (therapeutic and diagnostic orders); - The care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards and practice; and - Physician orders will be individualized and based on the patient’s needs. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the agency on 11/16/2022 with diagnoses of second degree burns of the abdomen and right thigh (the patient also had burns on the left thigh), type one diabetes mellitus (a chronic condition in which the pancreas produces little or no insulin, it typically appears in childhood or adolescence), and spina bifida (a congenital defect of the spine often causing paralysis of the lower limbs). The patient was admitted to the hospital on 11/28/2022 to 12/02/2022 for skin grafting of the burned areas and the agency resumed care on 12/03/2022. The patient and his/her spouse reside in an independent living facility. Review of the post-hospital resumption of care (ROC) orders, dated 12/03/2022 showed: - Skilled nurse to perform/teach wound care to upper thighs and upper abdomen; * Use washcloth to remove scabs/crusts/debris on wounds; * Apply xeroform (a medicated petroleum dressing)/bacitracin (an antibiotic ointment) and gauze daily to healing grafts on abdomen and both thighs; and * Apply bacitracin ointment to xeroform dressing on right lateral (outer side) thigh donor site daily, trim loose xeroform until it lifts up, do not remove xeroform from donor site until wound has healed. Observation during a home visit on 12/05/2022 at 12:45 pm, showed the registered nurse was observed performing wound care and dressing changes to the patient’s abdomen and both the right and the left thigh. The nurse also treated the donor site on the right lateral thigh. Review of the skilled nurse (SN) visit note, dated 12/05/2022, showed the nurse documented wound care to the abdomen, the right thigh, and the lateral right thigh. The nurse failed to document the wound care and dressing change performed on the left inner thigh. During an interview on 12/06/2022 at 4:17 PM, the executive director stated that he/she would expect the nurse to document the care and treatment of all of the patient’s wounds. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency on 11/15/2022 with diagnoses of sepsis (a potentially life threatening complication of an infection resulting from the presence of harmful microorganisms in the blood), urinary tract infection (UTI), and encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition). The patient lives at home with his/her daughter, who is the primary caregiver. Review of the physician’s orders showed: An order for an urinalysis with an urine culture dated 11/18/2022 and dated received on 11/29/2022; and An order for an urinalysis with an urine culture, CBC (complete blood count) and BMP (basic metabolic panel) dated 11/28/2022 and dated received on 12/02/2022. Review of the SN visit note, dated 11/25/2022, showed “SN attempted to collect urine via straight cath [catherization - process of inserting a sterile tube into bladder to obtain urine sample]. Attempt unsuccessful.” Review of the SN visit note, dated 11/29/2022, showed “This nurse straight cathed patient with a 16FR (French) catheter and obtained cloudy, yellow urine with a moderate amount of sediment in it.” Review of the POC, dated 11/15/2022 to 01/13/2023, showed: - The patient’s goal is to have fewer UTIs; and - The POC did not contain orders to perform intermittent or straight catheterization on the patient to collect a urine sample. During an interview on 12/07/2022 at 10:30 AM, the executive director stated that he/she would expect there to be orders to use a straight catheter for urine collection before the nurse performed the procedure.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, home visit observation, and interview, the agency failed to ensure that the clinicians provided services that are ordered by the physician or allowed practitioner as indicated in the plan of care in one (Record/Patient #1) of three applicable records. This deficient practice has the potential to affect the provision of care for all the agency's patients. Findings included: Review of the agency's undated policy titled, "Job Description LPN (Licensed Practical Nurse)," showed that: - The LPN performs direct patient care under the supervision of a Registered Nurse. The incumbent performs nursing assessments, follows the plan of care in accordance with physician’s plan of treatment, provides nursing services in accordance with current nursing practice, and evaluates resident’s/patient’s response to treatment; and - Provides direct patient care in home setting based on a specific plan of care and physicians’ orders. Review of the agency’s undated policy titled, “Home Health RN (Registered Nurse) Case Manager,” showed that the RN Case Manager effectively and timely provides for the comfort and well-being of patients by assessing conditions, processing physicians’ orders, providing treatment, and administering prescribed drugs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/23/2022 with a primary diagnosis of weakness. The patient resided in their own apartment within an assistive living facility. Review of the plan of care with the date range of 11/23/2022 to 01/21/2023 showed they were to assess the patient filling medication box to determine if the patient was preparing it correctly. The RN comprehensive assessment dated 11/23/2022: - Failed to contain documentation that the nurse assessed the patient filling the medication box during the visit; - Showed the patient had no immediate family that lived near; and - That they had a friend who checked on them at times and brought them “stuff”. The RN visit completed on 11/28/2022 failed to contain documentation that the nurse assessed the patient filling the medication box during the visit. The LPN visit completed on 11/29/2022: - Failed to contain documentation that the nurse assessed the patient filling the medication box during the visit; and - Contained documentation that the patient’s child “sets up medications and ensures compliance”. During an interview on 12/05/2022 at 12:30 PM, LPNA stated that a friend of the daughter fills the medication planner, and that he/she had never watched the patient fill the medication planner. During an interview on 12/06/2022 at 4:30 PM, the executive director stated that they would expect the nurse to follow the orders on the plan of care, including assessing the patient’s accuracy in filling his/her medication planner.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on policy review, review of governing body minutes, and interview, the agency failed to ensure a qualified, pre-designated person is authorized in writing by the administrator and the governing body to assume the responsibilities and obligations of the administrator when the administrator is not available. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Position Description, Position Title: Administrator,” dated 09/25/2019, showed: - The administrator designated by the governing body shall be responsible for the overall management of the agency; - The administrator shall designate in writing a qualified person who shall act in his/her absence; and - The policy failed to contain the requirement that the qualified person acting in the administrator’s absence must be appointed by the agency’s governing body. Review of the agency’s document titled, “Authorization of Agency Responsibility,” signed/dated 05/11/2022 and 05/12/2022, showed: - The administrator designated an employee to assume the responsibilities of the administrator position, according to agency policy and procedures; - The authorization was in effect from 05/11/2022 to 12/31/2022; - The document was signed by the administrator on 05/12/2022 and by the designated employee on 05/11/2022; and - The document failed to include evidence that the employee was appointed by the governing body. Review of the agency’s governing body minutes, with dates ranging from 03/23/2022 to 11/07/2022, showed the agency failed to ensure the employee designated to act in the administrator’s absence was appointed by the governing body. During an interview on 12/05/2022 at 12:00 PM, the office manager stated that he/she was unable to find the appointment of the alternate administrator in the agency’s governing body minutes.