Every finding on record at Jennifer's Home Health Agency Inc

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 03/25/2026. 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 Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 03/25/2026. The provider had three current patients.

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 an accurate medication review and/or update of the patient medications was completed, in two of two home visits conducted (Records/Patients #1 and #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider's undated policy titled, "Medication Profile and Medication Reconciliation," showed in part the following: - At time of admission, the admitting registered nurse (RN), physical therapist (PT) or speech language pathologist (SLP) will create and document a complete list of medications that the patient is taking at home, including dose, strength, route and frequency; - Any discrepancies we will be reconciled by an RN with the patient’s physician; - The agency (provider) provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route and frequency as well as which medications will be administered by agency staff and staff acting on behalf of the agency; and - Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient's medication list in the home will also be updated. Review of the provider’s policy titled, “Policy for Drug Regimen Education For Patient,” dated reviewed “01/17/2024”, showed in part the following: - Medication management services include: * Assistance in developing a medication schedule; * Review of medication regimen; * Create a complete list of the patient's prescribed and over the counter medicines; * Communicate with patient's doctor for optimum outcome; - RN or PT will review and have an interactive and informative discussion with patient on dose, time, amount and frequency of their medications; and - Medication review will be done upon admission and discharge, and as new medications are found. RECORD/PATIENT #1 Review of the clinical record showed the patient was admitted to home health services on 01/28/2026 with a primary diagnosis of urinary tract infection (bacterial infection of the urinary system) and gastrointestinal hemorrhage (bleeding in the digestive tract). The patient resided with his/her adult child. Observation on 02/23/2026 at 11:00 AM, with RN A and interview with the patient, and review of the nurses’ notes showed the following discrepancies between the provider’s current medication profile printed 03/23/2026, and the patient’s home medication bottles: - The provider’s current medication profile showed the patient was to use Benzonate (non-narcotic medication used to relieve coughs) 200 milligrams (mg) one by mouth three times a day. The patient stated he/she did not take and never picked up from the pharmacy; - The provider’s current medication profile showed the patient was to take Carvedilol (beta blocker to treat high blood pressure, heart failure, and improve survival after heart attacks) 25 mg one tablet two times a day. The patient and RN stated he/she took 12.5 everyday and BID (twice a day) if blood pressure > 120/80 or elevated heart rate (HR); - The provider’s current medication profile showed the patient was to take cefdinir (antibiotic used to treat bacterial infections like pneumonia) 300 mg one capsule every 12 hours. RN A and the patient stated he/she had finished that and did not take it anymore; - The provider’s current medication profile showed the patient was to take cholecalciferol (supplement vitamin D-3) 50 micrograms (mcg) every 12 hours. Review of the bottle showed 125 mcg and the patient stated he/she took one in the AM; - The patient had spironolactone (potassium-sparing diuretic to treat high blood pressure, heart failure and edema) 25 mg by mouth every day, (bottle showed filled 03/05/2026). The medication list failed to include spironolactone; - The patient had potassium chloride (potassium supplement) 20 milliequivalent (mEq) /15 milliliters (ml) daily. The patient stated he/she took it as needed (PRN) that it taste awful. The medication list failed to include potassium chloride; - The patient had oxygen (supplemental oxygen) continuous via nasal cannula (NC) @ 2-5 liters (L). 5 L when he/she was up with activity (usually showers). The medication list failed to include oxygen; - The patient had a bubbler humidifier (add moisture to dry oxygen) he/she used with the oxygen daily. (order date 01/24/2025). The medication list failed to include bubbler humidifier; - The patient had Boost (nutritional drink that provides extra calories, protein, and vitamins due to poor appetite and weight loss) drink 1-3 daily PRN when he/she cannot eat. The medication list failed to include Boost; and - The patient had Triad hydrophilic (sterile, zinc oxide-based paste designed for managing light-to-moderate wound exudate) apply to buttocks PRN. The medication list failed to include Triad hydrophilic. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she would expect medications to match the providers medication list, and staff should reconcile medications at the first visit and every week, and anytime needed after that visit. Medications should be reconciled any time there is a new medication. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 10/30/2025 with a primary diagnosis of presence of a left artificial shoulder joint (a surgical procedure that replaces the shoulder joint) and the patient was receiving physical therapy services. Observation on 03/24/2026 beginning at 8:30 AM, during the patient’s residential care facility (RCF) home visit, showed that physical therapist (PT)-B asked the patient and the RCF staff if the patient had any recent medication changes, and both confirmed that the patient had no new medications. Review of the provider’s plan of care (POC) dated 02/27/2026 to 04/27/2026 and the RCF’s list of current medications as of 03/24/2026, showed the following discrepancies in medication orders: - The provider’s POC showed orders for Acetaminophen (a mild pain medication) 500 mg one tablet three times per day and Acetaminophen 650 mg one tablet three times per day and the RCF medication list showed Acetaminophen 1000 mg three times per day to be given with Tramadol (a medication used for moderate to severe pain); - The provider’s POC showed an order for Atorvastatin (a medication used for high cholesterol) 80 mg one tablet daily at bedtime and the RCF medication list showed Atorvastatin 20 mg one tablet in the evening with Atorvastatin 40 mg one tablet in the evening to equal 60 mg daily; - The provider’s POC showed an order for Biotin (a medication used as a supplement) 1000 mg one tablet daily and the RCF’s medication list showed Biotin 10,000 mg one tablet daily; - The provider’s POC showed an order for Colace Clear (a medication for constipation) 50 mg one capsule twice a day and the RCF’s medication list showed Docusate Sodium (another name for Colace) 100 mg one capsule two times a day; - The provider’s POC showed an order for Duloxetine (a medication for depression) 30 mg one tablet daily and the RCF’s medication list showed Duloxetine DR (delayed release) 60 mg one capsule every day; - The provider’s POC showed an order for Famotidine (a medication used for heart burn) 20 mg one tablet at bedtime and the RCF’s medication list failed to include Famotidine; - The provider’s POC showed an order for Fish oil (a medication used as a supplement) 1000 mg one tablet daily and the RCF’s medication list failed to include Fish oil; - The provider’s POC showed an order for Lisinopril (a medication used for elevated blood pressure) 10 mg one tablet daily and the RCF’s medication list showed Lisinopril 20 mg one tablet daily; - The provider’s POC showed an order for Meloxicam (a medication used for pain and inflammation) 15 mg one tablet daily and the RCF’s medication failed to include Meloxicam; - The provider’s POC showed an order for Metformin (a medication for elevated blood sugar) 1000mg one tablet twice per day and the RCF’s medication list showed Metformin 500 mg one tablet two times per day; - The provider’s POC showed an order for Tramadol (a medication used for moderate to severe pain) 50 mg one tablet four times per day and the RCF’s medication list showed Tramadol 50 mg one tablet two times per day; - The provider’s POC showed an order for Trazodone (a medication used for depression and sleep) 150 mg one tablet at bedtime and the RCF’s medication list failed to include Trazodone; - The provider’s POC showed an order for Trulicity (an injectable medication used for elevated blood sugar) 3 mg per 0.5 milliliters (mL) subcutaneous (SQ) weekly on Fridays and the RCF’s medication list failed to include Trulicity; - The provider’s POC showed an order for Hydroxyzine (a medication used for anxiety) 25 mg one tablet three times per day PRN (pro re nata- as needed) and the RCF’s medication list showed Hydroxyzine 25 mg give one or two tablets three times daily PRN; - The provider’s POC showed an order for Senna (a medication for constipation) 8.6 mg one tablet daily PRN and the RCF’s medication list showed Senna 8.6 mg one tablet two times per day; - The RCF’s medication list showed an order for Atenolol (a medication used for elevated blood pressure) 50 mg one tablet daily and the provider’s POC failed to include Atenolol; - The RCF’s medication list showed an order for Clonazepam (a medication used for anxiety) 0.5 mg and give ½-tablet two times daily and the provider’s POC failed to include Clonazepam; - The RCF’s medication list showed an order for Fenofibrate (a medication used for high cholesterol) 48 mg one tablet in the evening and the provider’s POC failed to include Fenofibrate; - The RCF’s medication list showed an order for Fiber-lax (a medication used for constipation) 625 mg one tablet one time daily and the provider’s POC failed to include Fiber-lax; - The RCF’s medication list showed an order for Memantine (a medication used for Alzheimer’s Disease) 5 mg one tablet two times per day and the provider’s POC failed to include Memantine; and - The RCF’s medication list showed an order for Mounjaro (an injectable medication used for elevated blood sugar) 2.5 mg SQ and 5 mg SQ one time weekly on Monday and the provider’s POC failed to include Mounjaro. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she would expect medications to match what the facility is giving the patient, medications should be reconciled with each certification, and that staff should be asking about any new medications on all visits.

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, and interview, the home health provider failed to ensure that all pertinent diagnoses, medications, and treatments were included in the plan of care (POC) in two of six records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider's policy titled, "Plan of Care," dated 06/13/2018, showed in part the POC must: -Be individualized; -Specify the care and services necessary to meet patient needs; -Include the following: * All medications and treatments; * Safety measures to protect against injury; * Any other additional items the HHA (home health agency)/physician may choose; and * Orders. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 10/30/2025 with a primary diagnosis of presence of a left artificial shoulder joint (a surgical procedure that replaces the shoulder joint) and the patient was receiving physical therapy services. Review of the POC dated 02/27/2026 to 04/27/2026, showed secondary diagnoses included: - Type 2 diabetes mellitus without complications (a group of diseases that results in too much sugar in the blood); - Gastro-esophageal reflux disease with esophagitis, without bleed (GERD-a chronic condition that causes inflammation, irritation, and damage to the lining of the esophagus); - Vitamin deficiency; - Pain due to an internal orthopedic prosthetic (artificial joint); and - Schizoaffective disorder, bipolar type (a mental health illness that can cause hallucinations, delusions, and mood disorders). Review of the residential care facility (RCF) physician’s orders dated 03/24/2026, showed the following additional diagnoses and medications that were not included on the provider’s POC: - PTSD (Post Traumatic Stress Disorder- a mental health illness triggered by experiencing or witnessing terrifying events); - Tobacco use (the use of tobacco products such as smoking); - Nicotine dependence (the physical and psychological need to use nicotine); - Mild intellectual disabilities (a condition with minor limitations in cognitive, social, and practical daily skills); - Essential (primary) hypertension (chronic high blood pressure); -The patient received Atenolol (a medication for elevated blood pressure) 50 milligrams (mg) one tablet daily and Lisinopril (a medication for elevated blood pressure) 20 mg one tablet daily; and - The provider’s POC failed to include all diagnoses that were related to the care of the patient. During an interview with patient #2 on 03/24/2026 beginning at 8:30 AM, during the patient's RCF home visit, the patient stated that he/she checks his/her blood sugar every morning with the help of the staff at the RCF and that he/she takes insulin and the provider’s POC failed to include any orders for checking or monitoring the patient’s blood sugars. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she would expect the plan of care to include blood sugar checks and that diagnoses should match the medications that were ordered for the patient. RECORD/PATIENT #1 Review of the clinical record showed the patient was admitted to home health services on 01/28/2026 with a primary diagnosis of urinary tract infection (bacterial infection of the urinary system) and secondary diagnoses of gastrointestinal hemorrhage (bleeding in the digestive tract), chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), aphagia (the complete loss of the ability to swallow or a total refusal to eat), peripheral vascular disease (PVD; narrowed or blocked blood vessels outside the heart and brain). The patient resided with his/her adult child. Review of the POC dated 02/27/2026 to 04/27/2026, showed the following medications listed with no diagnoses included on the POC: - Atorvastatin (cholesterol) 40 milligrams (mg) at bedtime. The POC failed to include a hyperlipidemia diagnosis; - Carvedilol (hypertension) 12.5 mg daily and 25 mg if blood pressure > 120/80 or heart rate elevated. The POC failed to include a hypertension diagnosis; - Levothyroxine (treat hypothyroidism – thyroid gland does not produce enough thyroid hormone) 50 mg by mouth daily. The POC failed to include a hypothyroidism diagnosis; and - Hydrocodone-Acetaminophen 5-325 mg one tab twice a day as needed for pain. The POC failed to include a pain diagnosis. - The provider’s POC failed to include all diagnoses that were related to the care of the patient.

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, record review, observation, and interview, the home health provider failed to ensure that the plan of care (POC) was followed in four of six records reviewed (Records/Patients #1, #2, #4, and #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 06/13/2018, showed in part, the POC must: - Specify the care and services necessary to meet the patient needs; - Be reviewed and signed by a physician; - Include the following: * All medications and treatments; * Safety measures to protect against injury; and * Orders. Review of the provider’s undated policy titled, “Physical Therapist Job Description,” showed in part the following: - Provide therapy services within the scope and limitations set forth in the physician’s POC; and - Physical therapy (PT) services performed will be designated by a physician’s order. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 10/30/2025 with a primary diagnosis of presence of a left artificial shoulder joint (a surgical procedure that replaces the shoulder joint) and the patient was receiving physical therapy services. Review of the POC dated 02/27/2026 to 04/27/2026, showed that PT (physical therapy) was to obtain vital signs and “SPO2” (the patient’s oxygen saturation) pre, during, and post (exercise) every visit and notify the clinical manager or MD (physician) if not within normal limits for the patient. Observation on 03/24/2026 beginning at 8:30 AM, during the patient’s residential care facility (RCF) home visit, showed that physical therapist (PT)-B had the patient complete exercises on the hand bike and then obtained the patient’s vital signs to include temperature, pulse, respirations, blood pressure, and oxygen saturation. PT-B then had the patient complete various other exercises and ended the visit at approximately 9:20 AM. PT-B failed to obtain vital signs on the patient before and after completing the prescribed exercises. Review of the PT visit notes dated 02/27/2026, 03/03/2026, 03/06/2026, 03/10/2026, 03/13/2026, 03/17/2026, and 03/20/2026, failed to include three sets of vitals signs. The sets of vital signs that were included on the visits failed to show if they were completed pre, during, or post exercise. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/30/2025 with a primary diagnosis of presence of a right artificial knee joint (a surgical procedure that replaces the knee joint) and the patient was receiving physical therapy. Review of the POC dated 05/30/2025 to 07/28/2025, showed that PT was to obtain vital signs and “SPO2” pre, during, and post (exercise) every visit and notify the clinical manager or MD if not within normal limits for the patient. Review of the physical therapy assistant (PTA) visit notes dated 05/31/2025, 06/02/2025, 06/04/2025, 06/06/2025, 06/10/2025, 06/12/2025, 06/14/2025, 06/16/2025, 06/20/2025, 06/23/2025, 07/01/2025, 07/03/2025, 07/10/2025, 07/12/2025, and 07/17/2025, failed to include three sets of vital signs. The sets of vital signs that were included on the visits failed to show if they were completed pre, during, or post exercise. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 10/03/2025 with a primary diagnosis of atherosclerosis of the coronary artery bypass graft (CABG), unspecified, with unstable angina pectoris (plaque build-up in the previous blood vessels that were used for the CABG procedure with unstable chest pain) and the patient was receiving physical therapy. Review of the POC dated 10/03/2025 to 12/01/2025, showed that PT was to obtain vital signs and “SPO2” pre, during, and post (exercise) every visit and notify the clinical manager or MD if not within normal limits for the patient. Review of the PT visit notes dated 10/07/2025, 10/10/2025, 10/14/2025, 10/17/2025, 10/21/2025, 10/24/2025, 10/28/2025, 10/31/2025, 11/04/2025, 11/07/2025, 11/11/2025, 11/18/2025, 11/21/2025, and 11/25/2025, failed to include three sets of vital signs. The sets of vital signs that were included on the visits failed to show if they were completed pre, during, or post exercise. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she would expect the plan of care to be followed by all disciplines. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 01/28/2026 with a primary diagnosis of urinary tract infection (bacterial infection of the urinary system) and gastrointestinal hemorrhage (bleeding in the digestive tract) and the patient was receiving physical therapy services. The patient resided with his/her adult child. Review of the provider’s POC dated 01/28/2026 to 03/28/2026, showed that PT (physical therapy) was to obtain vital signs and “SPO2” (the patient’s oxygen saturation) pre, during, and post (exercise) every visit and notify the clinical manager or MD (physician) if not within normal limits for the patient. Review of the PT visit notes dated 02/12/2026, 02/16/2026, 02/20/2026, 02/23/2026, 02/26/2026, 03/02/2026, and 03/06/2026, failed to include three sets of vital signs. The sets of vital signs that were included on the visits were incomplete and failed to state if they were completed pre, during, or post exercise.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that wound measurements and assessments were completed in one of six records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Wound Assessment and Documentation Policy,” showed in part the following: - A comprehensive wound assessment will be completed by a licensed nurse upon admission and at regular intervals thereafter for all patients with wounds; - A licensed nurse will perform and document a wound assessment at start of care, resumption of care, recertification, when a new wound is identified, and with any significant change in condition; - The wound assessment will include location, wound type, measurements (length, width, depth in centimeters), wound bed description, drainage, odor, condition of surrounding skin, signs and symptoms of infection, and pain level; - Wounds will be assessed and measured at least weekly or per physician order; - The nurse will obtain and follow physician orders for wound care; and - All wound care will be documented in the clinical record each visit. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/30/2025 with a primary diagnosis of presence of a right artificial knee joint (a surgical procedure that replaces the knee joint) and the patient was receiving physical therapy (PT). Review of the initial start of care assessment dated 05/30/2025, showed that the patient had a surgical wound to the right knee that PT was “unable to assess covered with a non-removable dressing.” Review of the plan of care dated 05/30/2025 to 07/28/2025, showed an order for standard infection control and safety precautions. Review of the physical therapy assistant (PTA) visits dated 05/31/2025, 06/02/2025, 06/06/2025, 06/10/2025, 06/12/2025, 06/14/2025, 06/16/2025, 06/20/2025, and 06/23/2025 showed “no skin deficit” under the skin assessment section. Review of the PT functional assessment dated 06/27/2025, showed “incision 20 centimeters (cm) covered with tape” and no other assessment of the surgical incision. Review of the PTA visits dated 07/01/2025, 07/03/2025, 07/10/2025, 07/12/2025, and 07/17/2025 showed “no skin deficit” under the skin assessment section. Review of the discharge assessment dated 07/25/2025, showed no wounds, incision healed. The provider failed to obtain any orders for the licensed nurse to conduct a visit to assess the patient’s wound and failed to complete measurements or assessments of the wound. During an interview on 03/25/2025 beginning at 11:50 AM, the administrator stated that he/she would expect an incision or wound to be measured and assessed on each visit.

Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that care was supervised by the physical therapist (PT) in one of six records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Supervision of Physical Therapist Assistant (PTA),” showed in part the following: - The supervising PT is responsible for the supervision of the PTA; - The supervising PT will review the plan of care and PTA documentation on an ongoing basis and will perform a supervisory visit with the patient and PTA at least once every 30 days; and - The PTA will provide services only as delegated by the supervising PT and within the established plan of care (POC). Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed in part the staff communicates with each other to discuss changes in the following: - The patient’s condition; - The POC; and - The physician’s orders. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/30/2025 with a primary diagnosis of presence of a right artificial knee joint (a surgical procedure that replaces the knee joint) and the patient was receiving PT. Review of the initial start of care assessment dated 05/30/2025, showed the patient had pain and swelling in the right knee. Review of the POC dated 05/30/2025 to 07/28/2025, showed the following: - PT to instruct and educate patient on disease process and notify PT or MD (physician) if changes; - PT to monitor for S/S (signs and symptoms) and intervention for pain; and - PT to supervise PTA every month. Review of a PTA visit note dated 06/04/2025, showed the patient stated that his/her posterior (the back) calf (lower leg) was sore, and the PTA failed to coordinate care with the PT. Review of a PTA visit note dated 06/10/2025, showed the patient stated that he/she was sore and fatigued due to not sleeping well, and the PTA failed to coordinate care with the PT. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she would expect the PTA to notify the PT of any changes in the patient’s condition and to follow the plan of care. He/she further stated that he/she would have assumed that if the PT was told of the changes he/she would have documented it and that nothing was found in the clinical record.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to ensure a completed comprehensive discharge summary was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the home health provider/services within five business days of the patient’s discharge in three of three discharge records reviewed (Records/Patients #4, #5, and #6). This deficient practice has the potential to affect the post-discharge care of all patients served by the home health provider. Findings included: Review of the provider's undated policy titled, "Discharge or Transfer Policy," showed in part that the provider may only discharge or transfer you from this agency (provider) if: - Your physician, who is responsible for your home health plan of care, and our agency agrees that the measurable outcomes and goals of your plan of care have been achieved, and you no longer need home health services; and - Following your discharge or transfer, we will send a discharge or transfer summary within the timeframes specified by federal law and regulations to your primary care practitioner or other health care professional who will be providing care and services to you after discharge or transfer from our agency. The summary may include, but will not be limited to, a list of your current medications and information, necessary for your continued care, including pain management. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/30/2025 with a primary diagnosis of presence of a right artificial knee joint (a surgical procedure that replaces the knee joint) and the patient was receiving physical therapy. The patient was discharged from services on 07/25/2025. Review of the discharge summary completed by the physical therapist (PT) dated 07/25/2025, showed that the patient was discharged due to meeting his/her goals and the provider failed to send the completed discharge summary to the physician within five days of discharge. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 10/03/2025 with a primary diagnosis of atherosclerosis of the coronary artery bypass graft (CABG), unspecified, with unstable angina pectoris (plaque build-up in the previous blood vessels that were used for the CABG procedure with unstable chest pain) and the patient was receiving physical therapy. The patient was discharged from services on 12/01/2025. Review of the physical therapy discharge dated 11/28/2025, showed that the patient was discharged due to meeting his/her goals and the provider failed to send the completed discharge summary to the physician within five days of discharge. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she is responsible for sending the discharge summary to the physician and that it is mailed to the providers. He/she would expect that if the summary had been sent to the provider there would be a notation that it was mailed on the back page of the summary. Also stated that a medication list is sent with the discharge summary. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/30/2025 with a primary diagnosis of presence of a right artificial knee joint (a surgical procedure that replaces the knee joint) and the patient was receiving physical therapy. The patient was discharged from services on 07/25/2025. Review of the discharge summary completed by the physical therapist (PT) dated 07/25/2025, showed that the patient was discharged due to meeting his/her goals and the provider failed to send the completed discharge summary to the physician within five days of discharge. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 10/03/2025 with a primary diagnosis of atherosclerosis of the coronary artery bypass graft (CABG), unspecified, with unstable angina pectoris (plaque build-up in the previous blood vessels that were used for the CABG procedure with unstable chest pain) and the patient was receiving physical therapy. The patient was discharged from services on 12/01/2025. Review of the physical therapy discharge dated 11/28/2025, showed that the patient was discharged due to meeting his/her goals and the provider failed to send the completed discharge summary to the physician within five days of discharge. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to home health services on 02/05/2026 with a primary diagnosis of type 2 diabetes mellitus with diabetic neuropathy and active primary progressive multiple sclerosis (MS). The patient was discharged from services on 03/15/2026. Review of the discharge summary completed by the registered nurse (RN) dated 03/15/2026, showed that the patient was discharged due to meeting his/her goals and the provider failed to send the completed discharge summary to the physician within five days of discharge. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she is responsible for sending the discharge summary to the physician and that it is mailed to the providers. He/she would expect that if the summary had been sent to the provider there would be a notation that it was mailed on the back page of the summary. Also stated that a medication list is sent with the discharge summary.

The Emergency Preparedness regulations were reviewed as part of the Medicare re-certification survey completed on 03/23/2023. 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 03/23/2023. The agency had 7 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 home health provider 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: Based on record review and interview the agency failed to ensure that the OASIS (Outcome and Assessment Information Set, a federally mandated assessment) data accurately reflected the patient's status at the time of the assessment in two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: RECORD/PATIENT #2: Review of the initial comprehensive assessment dated 01/02/2023, completed by the physical therapist (PT) showed OASIS question M2001 (Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?) showed the clinician answered no issues found during review. Review of the drug interaction report dated 01/02/2023 and signed by the physician 01/10/2023 showed 23 potential drug interactions with two being major interactions (this would indicate potentially clinically significant issues were found). RECORD/PATIENT #4: Review of the initial comprehensive assessment dated 02/25/2023 completed by the PT, showed OASIS question M2001 (Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?) showed the clinician answered no issues found during review. Review of the drug interaction report dated 02/25/2023 and signed by the physician on 03/10/2023 showed 111 potential interactions with 11 being major interactions (this would indicate potentially clinically significant issues were found). During an interview on 03/22/2023 beginning at 1:50 PM, the administrator stated that they send major interactions to the physician. He/she also had staff call the physician if there were major interactions. The clinical manager stated that he/she would expect staff to document issues found on the drug regimen review of the OASIS if major interactions were indicated.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the agency failed to ensure one (Record/Patient #4) patient was admitted within 48 hours of referral of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Checklist for Comprehensive Assessment," showed in part that the registered nurse (RN) must conduct the initial assessment within 48 hours. Therapy may complete the assessment if it is the only service ordered. RECORD/PATIENT #4: Review of the referral showed it was sent to the home health provider on 02/22/2021 (the referral had a typo, should have been 02/22/2023). Review of the record showed the initial assessment completed by the physical therapist (PT) on 02/25/2023, showed the date of referral was 02/22/2023. The assessment was not completed within 48 hours of the referral. During an interview on 03/22/2023 beginning at 1:50 PM, the administrator stated that the patients should be admitted within 48 hours of the referral.

Content of the comprehensive assessment CFR(s): 484.55(c) 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: This STANDARD is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure a comprehensive assessment was completed to accurately reflect the patient's status in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: Review of the home health provider's undated policy titled, "Checklist for Comprehensive Assessment," showed in part that the comprehensive assessment must include current health status. RECORD/PATIENT #1: Review of the initial comprehensive assessment dated 03/01/2023 showed: - Date of referral to home health was blank; - The safety measures triage/risk assessment code was blank (used to determine needs priority in the event of an emergency); - The fall risk assessment was not completed; - The risk for hospitalization showed a history of falls and the patient currently took five or more medications; - The patient was a potential fall risk due to age and immobility; - The pain assessment was not completed; and - The nutritional status assessment requirements were not completed; Review of the plan of care (POC) dated 03/01/2023, showed the patient was a fall risk, safety measures included fall precautions, skilled nurse implement fall prevention interventions, the patient stated his/her pain was in control, medication regime was working for the patient, and the patient was on a regular diet. During an interview on 03/22/2023 beginning at 1:50 PM, the administrator stated that he/she expected staff to complete all of the comprehensive assessment.

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 agency failed to maintain an accurate/updated medication profile in three of three home visit observations (Records/Patients #1, #2, and #3). The provider failed to ensure a complete drug regimen review was completed in, but not limited to, two of five full records reviewed (Records/Patients #1 and #2), and failed to ensure a nurse reviewed medications in one of one record reviewed that only received therapy services (Record/Patient #4). This deficient practice has the potential to affect the accuracy and safety of the medication regimen for all patients served by the home health provider. Findings included: Review of the home health provider's policy titled, "Medication Profile and Medication Reconciliation," revised 06/13/2018, showed in part the following: - At the time of admission, the admitting RN (registered nurse), PT (physical therapist) or SLP (speech language pathologist) will create and document a complete list of medications that the patient is taking at home; - Any discrepancies will be reconciled by an RN with the patient’s physician; - Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated; - The medication review must include effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy currently associated with laboratory monitoring; and - The source for medication review is drugs.com. Review of the agency’s undated policy titled, “Drug Regimen Review/Education,” showed in part the following: - The documentation by the reviewer must include content of the review (must include effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy currently associated with laboratory monitoring), date sent to the reviewer, person that performed the review with complete name and credentials, names of medications reviewed, date the review was done, communication between staff and reviewer related to the review, and verification the review was completed. - If no problem found, a blanket statement will be entered that identifies that a review was completed for the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy currently associated with laboratory monitoring for all the patient’s medications; and - If a problem is found during the review, then there must be documentation of communication between the reviewer, staff member and physician with outcome and a plan developed. RECORD/PATIENT #1: Review of the initial comprehensive assessment dated 03/01/2023 showed: - The nurse documented issues were found during the drug regimen review. The comment section to describe the problems found during the review was left blank; - The physician was contacted in response to the potentially clinically significant medication issues. No documentation regarding what significant issues were identified; and Review of the patient’s undated medication profile showed no information regarding a drug regimen review. Review of a drug interaction report dated 03/01/2023 presented as the drug regimen review failed to include documentation of review for the effectiveness of drug therapy, drug side effects, duplicate drug therapy, drug therapy currently associated with laboratory monitoring, noncompliance with drug therapy, potential adverse effects and drug reactions. Observation on 03/20/2023 beginning at 4:30 PM, during the patient’s home visit, showed the following discrepancies with the home health provider's medication profile for the patient: - After the nurse finished his/her visit, the surveyor requested to review the patient’s medications; - The patient took docusate sodium (stool softener) 100 milligrams (mg) once a day. The medication profile showed the patient took this twice a day. The patient’s family member stated that the patient had taken it once a day for a "long time"; - The patient took simethicone (used for gas relief) 12 mg once a day. The medication profile showed the patient took this every six hours at meals and at bedtime. The family member stated that the patient had taken it once a day for a "long time"; - The patient took cranberry (supplement usually used for urinary tract health) tablets 500 mg once a day. The medication profile showed one tablet twice a day. The family member stated that the patient had taken it once a day for a "long time"; and - The patient took iron (supplement) 150 mg one capsule daily. The family member stated that the patient had taken this for a "long time". This medication was not included on the home health provider's medication profile for the patient. RECORD/PATIENT #2: Review of the undated medication profile and drug interaction report failed to include documentation of review for the effectiveness of drug therapy, drug side effects, duplicate drug therapy, drug therapy currently associated with laboratory monitoring, noncompliance with drug therapy, potential adverse effects and drug interactions. Observation on 03/21/2023, beginning at 8:00 AM, during the patient's home visit, showed the following discrepancies with the home health provider's medication profile for the patient: - The patient took caffeine 200 mg if his/her blood pressure was low. The patient stated that he/she seldom took this but had taken it that day; - The patient took docusate sodium 100 mg (a stool softener) if he/she did not have a bowel movement for three days; - The patient took gas relief tablets as needed; and - These medications were not included on the provider's medication profile for the patient. RECORD/PATIENT #3: Observation on 03/23/2023 beginning at 10:00 AM, during the patient's home visit, showed the following medication discrepancies with the home health provider's medication profile for the patient: - The patient used clonidine (for high blood pressure) 0.1 mg/24 hours one patch topically every seven days. The medication box was dated 02/24/2023. The home health provider's medication profile for the patient incorrectly showed that clonidine 0.1 mg one tablet was to be taken as needed (PRN) if the patient's blood pressure was above 150/90; and - The patient used a Breztri inhaler (used to treat chronic lung problems) two puffs in the morning and two puffs at night, Thie medication was not included on the the home health provider's medication profile for the patient. The patient stated that he/she had been on the medication for "about 90 days". During an interview on 03/22/2023 beginning at 1:50 PM, the administrator stated that they do all the components of the drug regimen review. He/she thought the interaction report included duplicate medications. If staff discover a medication discrepancy they would notify the physician and send an order to the physician. The clinical manager stated that staff should look at the medications every visit. RECORD/PATIENT #4: Review of the plan of care dated 02/25/2023 showed an order for physical therapy (PT) two times a week for nine weeks. Review of the initial comprehensive assessment completed by the PT dated 02/25/2023 showed no issues were found during the drug regimen review. There was no documentation that the patient's medications had a drug regimen review completed by a nurse or physician. During an interview on 03/21/2023, at 10:30 AM, the administrator stated that they report major drug interactions to the physician and also has staff call the physician. During an interview on 03/21/2023, at 2:45 PM, the administrator stated that when PT does the start of care, the PT calls the administrator to run the interactions check on drugs.com. The nurse reviews the medications within the first couple of days, but probably does not document it. The comprehensive assessment should include what issues were found during the drug regimen review. During an interview on 03/22/2023 at 3:05 PM, the clinical manager stated that a nurse reviews the medications in therapy only cases. If he/she knows the therapist has a new case he/she reviewed the medications, but he/she did not review the medications for this patient.

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, and interview the home health provider failed to ensure that clinical staff developed a complete plan of care (POC) in, but not limited to, two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: Review of the home health provider's policy titled, “Plan of Care,” dated 06/13/2018, showed in part that the POC must be individualized, specify the care and services necessary to meet patient needs, contain measurable goals and outcomes, include all treatments, and information related to advance directives. Orders for therapy service include the specific modalities to be used and the amount, frequency, and duration. Review of the home health provider's policy titled, “Documentation Needed by Therapists,” dated 2014, showed in part that all treatments must have a physician order, any treatment ordered must include location, frequency, duration (examples included cold therapy and moist heat). RECORD/PATIENT #2: Review of the initial comprehensive assessment completed by the physical therapist (PT) dated 01/02/2023, showed the patient was a DNR (do not resuscitate). Review of the POC dated 01/02/2023 showed no information related to advance directives, or specify the patient's DNR status. Review of the recertification comprehensive assessment completed by the PT dated 02/28/2023, showed: - No changes made to advance directive since the previous assessment; and - Pain interventions included use of ice/heat, the POC failed to specify frequency and the application duration of the ice/heat. Review of the POC dated 03/03/2023 showed: - No information related to advance directives; and - No orders for use of ice/heat for pain. RECORD/PATIENT #4: Review of the patient acknowledgements and consents, dated 02/25/2023, showed the description of the content of the advance directive was that the patient was a full code (to be resuscitated). Review of the initial comprehensive assessment completed by the PT dated 02/25/2023 showed: - The patient was not a DNR; and - Pain interventions included use of ice/heat (specify frequency and application duration); Review of the POC dated 02/25/2023 showed: - PT to do interventions to monitor and mitigate pain but no PT goals related to pain interventions; - No orders for use of ice/heat; and - Showed no information related to advance directives, or specify the patient's full code status. During an interview on 03/22/2023 beginning at 1:50 PM, the administrator stated that the POC should include whether the patient is a DNR or full code. During an interview on 03/22/2023 at 3:05 PM, the administrator stated the POC should include goals for pain interventions and orders for ice and heat.

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 nationally-recognized standards, policy review, home visit observation, and interview, the he home health provider failed to ensure staff followed acceptable standards of practice for infection control in two of three home visit observations (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: Review of McGoldrick, M. (2015). Home Care Infection Prevention and Control Program. Saint Simons Island, GA: Home Health Systems, Inc., showed in part that bag technique included: - Perform hand hygiene; and - Remove supplies from the bag and place on a clean, dry surface or a surface barrier as needed. Review of undated forms presented as the provider's infection control policy titled, "Infection Control Program," showed in part the following: - Upon entering the home place the nursing bag on a clean barrier; - Remove items from bag and place on a clean barrier; - Hand hygiene should occur after removing gloves, between each glove change, after contact with non-intact skin and would dressings, and when moving from a contaminated body site to a clean site during care; - Change or remove gloves when moving from a dirty to clean patient site; and - Wash hands between each glove change, when changing dressings, when handling soiled items and contaminated surfaces or items. RECORD/PATIENT #1: Observation on 03/20/2023, beginning at 4:30 PM, during the patient’s home visit, showed: - The nurse provided wound care to the patient's left arm. The nurse removed the old dressing and wrap, removed his/her gloves then without using hand sanitizer, placed a glove on his/her right hand and proceeded to clean the wound. After cleaning the wound, the nurse removed the glove from the right hand but failed to use hand sanitizer before applying new gloves and completed the wound care; - After applying the new dressing, he/she reached into the patient’s clean supply bag to obtain tape without changing his/her gloves or using hand sanitizer; - The nurse then removed an old dressing from the right lower leg, then without changing gloves or using hand sanitizer proceeded to clean the wound. After cleaning the wound, removed the left hand glove but failed to use hand sanitizer then provided wound care with the gloved right hand. The nurse then removed the glove but failed to use hand sanitizer before applying new gloves. The nurse then placed a dressing on the wound, removed the left hand glove and without using hand sanitizer wrapped the dressing; - The nurse then removed an old dressing from the right arm, then without changing gloves or using hand sanitizer proceeded to clean the wound. After completing the wound care, the nurse removed his/her gloves but failed to use hand sanitizer then applied tape to the dressing. During an interview on 03/22/2023 beginning at 1:50 PM, the clinical manager stated that he/she would expect staff to wash their hands or use hand sanitizer after removing gloves and would expect staff to change their gloves and use hand sanitizer after removing an old dressing. RECORD/PATIENT #3: Observation on 03/23/2023, beginning at 10:10 AM, during the patient’s home visit, showed the nurse removed vital sign equipment from his/her nursing bag, cleaned the equipment with an antibacterial wipe, then without establishing a clean surface or placing a barrier, placed the equipment on the patient’s kitchen counter. During an interview on 03/23/2023, at 12:20 PM, the administrator stated that staff should sit their equipment on a barrier. During an interview on 03/23/2023, at approximately 1:00 PM, the clinical manager stated that he/she liked for staff to place their equipment on barriers.

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, observation, and interview the home health provider failed to document complete/accurate wound assessments in one of five full records reviewed and failed to consistently document complete pain assessments in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: Review of the home health provider's undated policy titled, “Wound Assessments and Care,” showed in part the following: - Documentation of complete wound assessments should include location, if multiple sites, use consistent and correct anatomical terminology in identifying each wound; - Documentation of wound assessment at each visit should include at a minimum location, appearance, odor, drainage, and pain; - The specific treatment done to each wound including the cleaning agent used, products applied, and type of dressing applied; and - If your agency documents “wound care per order” you must specify the date of the order you are following. Review of the home health provider's undated policy titled, “Pain Assessments and Management,” showed in part the documentation for all pain assessments should include: - The rating of pain using a standardized pain scale, either verbal or non-verbal; - The location, type, and quality of pain; - Document the history of pain – this may be a 24 hour recall or pain since the last nursing or therapy visit. If you document “no pain at present time” still document a history to determine if the patient truly has no pain or if the patient’s pain is well controlled with the prescribed regimen; - Document specific medication or medications taken by the patient and how often the patient used each medication and the effectiveness; and - Consistently assess and document if the patient is satisfied with the level of pain control. RECORD/PATIENT #1: Review of the comprehensive assessment dated 03/01/2023 showed the patient had a wound to the left arm. Review of a physician order dated 03/06/2023 showed an order for new wounds to the patient's right elbow and wrist. Review of the nursing visits from 03/01/2023 through 03/20/2023 showed staff documented they completed wound care as ordered but failed to indicate the date of the orders they followed. Review of the nursing visits showed: - On 03/06/2023 no nurse assessment of the patient's right elbow and wrist; - On 03/08/2023 no nurse assessment of the patient's right elbow, wound #2 showed the right arm; and - On 03/13/2023 no nurse assessment of the patient's right elbow, wound #2 showed left arm (previous assessment labeled this wound as wound #1). Review of a physician order dated 03/16/2023 included an treatment order for the patient's right elbow and wrist. Review of a nursing visit dated 03/17/2023 showed no assessment of the patient's right elbow. Observation on 03/20/2023 beginning at 4:30 PM, during the patient’s home visit, showed the nurse provided wound care to the left lower arm, right lower arm and right lower leg. The nurse stated that these were the patient’s only wounds. The left arm measured 1.7 centimeters (cm) x 0.5 cm with undermining that measured 1.8 cm, the right arm measured 4.0 x 4.0 cm with undermining that measured 3.7 cm, and the right anterior leg measured 2.2 x 0.4 cm. Review of the nursing visit note dated 03/20/2023 showed that the nurse documented the left arm undermining measured 2.0 cm (during the visit the nurse measured 1.8 cm), the right arm undermining measured 3.0 cm (during the visit the nurse measured 3.7 cm), and the right leg measured 2.2 x 0.8 (during the visit the nurse measured 2.2 x 0.4 cm). During an interview on 03/22/2023 beginning at 1:50 PM, the administrator stated that he/she would expect the documentation to be accurate. The clinical manger stated that he/she would expect the nurse to document an assessment or whether an area had healed on all wounds. The patient went to a wound clinic on Mondays and thought the wound clinic probably changed the patient's dressings on 03/06/2023. He/she did not know why the nurse would have seen the patient if the patient had been to the wound clinic on 03/06/2023. He/she would expect the documentation to be accurate. During an interview on 03/23/2023 at 1:45 PM, the clinical manager stated that the nurse did not see the patient on 03/06/2023. The date on the visit was wrong. The date should have been 03/10/2023. The patient went to a doctor visit on 03/06/2023. RECORD/PATIENT #2: Review of the nursing visit records showed: - On 01/14/2023, the patient had aching pain at a level of four (pain is rated on a scale of 0-10 with 0 meaning no pain and 10 meaning the worst pain) in the joints daily, but not constantly. The nurse documentation showed no assessment of the patient’s history of pain levels, current pain management and effectiveness and the patient’s pain goal; - On 02/10/2023 the patient had pain at a level of two in the joints daily, but not constantly. The nurse documentation showed no assessment of the history of pain levels, current pain management and effectiveness; and the patient’s pain goal. During an interview on 03/22/2023 beginning at 1:50 PM, the administrator stated that he/she would expect a full pain assessment including the patient's history of pain levels.

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 policy review, record review, and interview, the he home health provider failed to ensure staff followed the physician ordered plan of care (POC) in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the the home health provider. Findings included: Review of the home health provider's policy titled, "Plan of Care," dated 06/13/2018, showed in part to integrate services to assure the identification of patient needs/factors that could affect patient safety and treatment effectiveness and coordination of care by all disciplines. Review of the home health provider's undated policy titled, " Coordination of Patient Care", showed in part that the staff communicates with each other to discuss changes in the patient's condition, POC, and physician orders. RECORD/PATIENT #1: Review of the POC dated 03/01/2023, showed an order to weigh the patient weekly and notify the physician if not within normal limits for the patient. Review of the nursing visits from 03/03/2023 through 03/20/2023 showed no weights documented for the patient. During an interview on 03/22/2023 beginning at 1:50 PM, the administrator stated that he/she expected staff to follow the POC. During an interview on 03/23/2023, at 1:45 PM, the clinical manager stated that the nurse said that the patient did not want to be weighed, but that was not documented. RECORD/PATIENT #2 Review of the POC dated 01/02/2023, showed an order to notify the physician if the patient's blood pressure was greater than 160/90. Review of the nursing visits showed: - On 01/28/2023, the patient's blood pressure was 180/100. The patient's blood pressure had increased that morning and his/her anxiety had increased. Blood pressure while the patient was standing upright was 176/94. There was no documentation the physician was notified of the blood pressure. There was no documentation of follow-up with the patient regarding his/her blood pressure until 02/04/2023; - On 02/04/2023, the patient's blood pressure was 176/103 and 166/100. The patient stated that he/she had taken his/her medications and felt fine. The nurse cautioned the patient on the need to recheck his/her blood pressure at 2:00 PM after the next dose of blood pressure medication. The physician was contacted regarding that the patient was to recheck his/her blood pressure and call the nurse and/or physician if elevated. No order changes. There was no documentation of follow-up with the patient regarding his/her blood pressure until 02/10/2023; - On 02/24/2023, the patient's blood pressure was 188/98 and 184/88. The patient reported he/she had a blood pressure exacerbation (worsening) with chest tightness. The patient expressed increased anxiety. The physician was contacted. The patient has a physician appointment scheduled on Monday (02/27/2023). No order changes. No documentation of follow-up with the patient regarding his/her blood pressure or anxiety until 03/03/2023; and - On 03/03/2023, blood pressure 180/100 and 174/94. The patient saw the physician and the dose of his/her pyridostigmine (cholinergic) was increased. The physician was contacted regarding muscle weakness and the medication change order. No documentation of follow-up with the patient by the home health provider until 03/10/2023. Review of the aide care plan assigned by the nurse, dated 01/02/2023, showed the patient's blood pressure varied with sitting to standing and to notify the nurse if the patient was dizzy. Review of the aide progress note (The certified occupational therapy assistant provided the patient's aide visits) dated 01/23/2023 showed the patient's blood pressure was 98/52 while sitting. The COTA rechecked the patient's blood pressure and it was 134/76. The patient had low blood pressure and took two salt tablets to increase his/her blood pressure. The COTA instructed the patient to continue to monitor. The patient was "too dizzy" to check the blood pressure while standing. There was no documentation the COTA notified the nurse of the patient's blood pressure or dizziness. During an interview on 03/22/2023, beginning at 1:50 PM, the clinical manager stated that the nurse should report vital signs out of the parameters to the physician. He/she would expect the nurse to have followed up with the patient's blood pressure the same day. He/she thought the nurse probably did follow up, but did not document it. The COTA should have reported the patient's dizziness to the nurse. During an interview on 03/23/2023, at 2:05 PM, the clinical manager stated that the nurse said there was a period of time where the patient's blood pressure was up and down. He/she did call the physician but did not document it.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure the RN (registered nurse) performed an adequate aide supervisory visit in one of one record reviewed that received aide services (Record/Patient #2). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: Review of the the home health provider's undated policy titled, "Home Health Aide Supervisory Visits," showed in part that the RN makes a supervisory visit to the patient's residence at least every two weeks to assure services are being rendered in accordance with the written plan of treatment. Review of the the home health provider's undated policy titled, “Coordination of Patient Care,” showed in part the following: -The staff communicates with each other to discuss changes in patient condition; and -If nursing and therapy are involved in the patient’s care, nursing must take responsibility for the aide, plan of care (POC) and supervision. RECORD/PATIENT #2: Review of the aide care plan dated 01/02/2023 showed the patient's blood pressure varied with sitting to standing and to notify the nurse if the patient was dizzy. Review of the aide progress note (The certified occupational therapy assistant provided the patient's aide visits) dated 01/23/2023 showed the patient's blood pressure was 98/52 while sitting. The COTA rechecked the patient's blood pressure and it was 134/76. The patient had low blood pressure and took two salt tablets to increase his/her blood pressure. The COTA instructed the patient to continue to monitor. The patient was "too dizzy" to check the blood pressure while standing. There was no documentation the COTA notified the nurse of the patient's blood pressure or dizziness. Review of the RN aide supervisory visit dated 01/28/2023 showed the home health aide followed the POC. There was no documentation the RN addressed the aide visit on 01/23/2023 with the COTA. During an interview on 03/22/2023 beginning at 1:50 PM, the clinical manager stated that he/she expected the nurse to look back at the aide visits and address any concerns with the home health aide.