Every finding on record at L. Woerner, Inc.

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 clinical record review the agency failed to ensure in one out of six records (Patient # 2) the comprehensive assessment included a complete picture of the patient's status to assist the agency in developing the patient's plan of care (POC). Failure to ensure comprehensive assessments include a complete picture of the patient's status to assist the agency in developing the patient's plan of care has the potential to result in unmet patient needs and negative patient outcomes. Findings: Patient # 2 (start of care 01/22/2021) has diagnoses of Duchenne or Becker Muscular Dystrophy and Atrioventricular Block. The physician's POC for certification period 06/30/2025 through 08/28/2025 is lacking documentation of the patient's psychosocial status. The findings were confirmed on 07/29/2024 at 3 PM with the Clinical Nursing Officer, Clinical Operations Manager and two Directors of Patient Services; no additional evidence was provided.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review the agency failed to ensure home health aides provide services in accordance with the established aide plan of care (POC), are permitted to be performed under state law and consistent with home health aide training in two of two records reviewed of patients receiving paraprofessional aide services (Patient # 1 and 3). Failure to ensure home health aides provide services in accordance with the aide POC, are permitted to be performed under state law and consistent with home health aide training may result in poor quality of care and possible negative outcomes. Patient # 1 (start of care 06/30/2025) has diagnosis of Pneumonia and Acute Respiratory Failure with Hypoxia. The record contains an aide POC for the episode period 06/30/2025 through 08/28/2025 that instructs the aide to provide a bath/shower "assist as needed" and a frequency of every visit. An assessment of as needed is outside the paraprofessional's scope of practice. Patient # 3 (start of are 04/28/2021) has diagnoses of Multiple Sclerosis and Paraplegia. The Aide Care Plan Report for episode period 06/06/2025 through 08/04/2025 states the aide is to: Hair Shampoo Monday, Wednesday, Thursday and Friday. The Visit Note Reports for 06/06/2025, 06/09/2025, 06/13/2025, 06/16/2025, 06/18/2025, 06/19/2025, 06/25/2025, 06/26/2025, 07/02/2025, 07/03/2025 and 07/24/2025 lack documented evidence this task was offered, refused or completed. The findings were confirmed on 07/29/2024 at 3 PM with the Clinical Nursing Officer, Clinical Operations Manager and two Directors of Patient Services; no additional evidence was provided.

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 clinical record review and staff interview evidence is lacking in two of six records (Patient # 2 and 6) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes. Findings: Patient # 2 (start of care 05/04/2022) has diagnoses of Pneumonia due to Pseudomonas and Emphysema. The POC for certification period 05/04/2022 through 07/02/2022 contains an order for: "Skilled Nurse to provide skilled teaching related to the signs and symptoms of Heart Failure Exacerbation and associated self monitoring techniques. Check weight every day. Call Medical Doctor (MD) for weight gain greater than 2 pounds/day or change in weight greater than 5 pounds a week". The record contains a registered nurse (RN) visit note (dated 05/09/2022) that states the patients weight is 182.2 and a RN visit note (dated 05/16/2022) that states the patients weight is 176.2. The record lacks documented evidence the physician was notified of the weight change of over 5 pounds in one week. Patient # 6 (start of care 05/17/2022) has diagnoses of Chronic Venous Hypertension with Ulcer and Inflammation of Right Lower Extremity and Non-Pressure Chronic Ulcer other Part of Left Lower Leg Limited to Breakdown of Skin. The record contains an order for Occupational Therapy (OT) 1 time for 1 week and then 2 times (a week) for 8 weeks dated 05/18/2022. The record contains a notification note to the physician of 1 missed OT visit on 5/25/2022. The record lacks documentation of a second OT visit or notification to the physician of another missed visit made the week of 05/22/2022. The findings were confirmed on 06/02/2022 at 10:15 AM with the Director of Patient Services; no further evidence was provided.

The following statement of deficiencies represents the results of a standard re-certification survey of HCR Home Care, Certified Home Health Agency conducted on 11/15/2021 through 11/18/2021. The survey consisted of a review of seventeen clinical records including five discharge records, seven observational home visits, eight personnel records for professional and paraprofessional personnel. The survey included review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past twelve months, the agency's Admission Packet, Emergency Preparedness Plan, and the Complaint Log. The patient census at the time of the survey was five hundred thirty-one. Pre-survey activities consisted of review on 10/28/2021 of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Certification and Survey Provider Enhanced Reports (CASPER) for the period 08/2020 through 07/2021, the agency's compliance with report submissions for the 2019 statistical report and participation in the June 11 through June 13, 2019 Emergency Preparedness drill. A focused COVID 19 survey was conducted in conjunction with the recertification survey. The Director of Nursing Services, Executive Director and staff were interviewed. Findings were reviewed at the exit conference on 11/18/2021. The following deficiencies are identified as a result of the survey: Federal: G 0512 Standard: Initial Assessment Visit; G 0572 Plan of Care; G 0574 Plan of Care Must Include the Following; G 1010 Contents of Clinical Record. State: J 0404 Policies and Procedures of Service Delivery; J 1108 Governing Authority; J 1268 Governing Authority; J 1276 Governing Authority; J 1416 Personnel; J 1420 Personnel; J 1424 Personnel; J 1440 Personnel; J 1444 Personnel; J 1452 Personnel; J 1512 Records and Reports.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, evidence is lacking in three of seventeen records (Patient # 2, 15 and 16) the initial assessment visit was conducted within 48 hours of receiving the referral for services, within 48 hours of the patient's return home or on the physician ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. Findings: Patient # 2 (start of care 11/02/2021) has diagnoses of Unspecified Displacement Fracture of Surgical Neck of Right Humerus, Subsequent encounter for Fracture with Delayed Healing and Essential Primary Hypertension. The record contains documentation of a visit to physician's office visit (dated 10/27/2021) and a community referral (undated), with no specific physician ordered start of care date. Agency's first documented patient contact was upon initial assessment (dated 11/02/2021). Patient # 15 (start of care 10/11/2021) has a diagnoses of Venous Insufficiency (Chronic) (Peripheral) and Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene. The record contains a community referral dated 09/30/2021, with no specific physician ordered start of care date. The Skilled Nurse (SN) conducted the initial assessment on 10/11/2021, twelve days after the agency received the referral. Patient # 16 (start of care 05/25/2021) has a diagnoses of Hypertensive Heart Disease with Heart Failure and Heart Failure, Unspecified. The record contains a community referral dated 05/18/2021, with no specific physician ordered start of care date. The Skilled Nurse (SN) conducted the initial assessment on 05/25/2021, seven days after the agency received the referral. The findings were confirmed on 11/16/2021 at 11:00 AM and 11/17/2021 at 3:15 PM and 3:20 PM with the Director of Nursing Services and Executive Director, no additional evidence was provided.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure services are provided in accordance with the physician's Plan of Care (POC) in two of seventeen patient records (Patient # 3 and 11). Failure to follow the POC has the potential for patients to receive care that is inconsistent with the physician's orders resulting in unmet patient needs and possible negative patient outcomes. Findings: Patient # 3 (start of care 10/28/2021) has diagnoses of Hypertensive Heart and Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney Disease. The POC for the certification period 10/28/2021 through 12/26/2021 contains an order for: Skilled Nurse to provide skilled teaching to check weight everyday. Call MD (Doctor of Medicine) for weight gain greater than 2 pounds a day or change in weight greater than 5 pounds a week. The record lacks documentation weights were obtained or documentation of a review of patients weight log during the skilled nursing visits completed on 11/04 and 11/10/2021. Patient # 11 (start of care 09/03/2021 and discharged 10/28/2021) has diagnoses of Hypertensive Heart Disease with Heart Failure and Acute on Chronic Systolic (Congestive) Heart Failure. The POC for the certification period 09/03/2021 through 11/01/2021 contains an order to check weight daily and to call the MD (physician) for weight change greater than 2lb/24 hrs. (2 pounds in 24 hours) or 5 lbs./week (5 pound in one week). The record contains a vital signs report that states: - On 09/18 the patient weighed 162.2 lbs. and 165.7 lbs. on 09/19, for a weight gain of 3.5 pounds. The record lacks documentation physician was notified of a weight gain greater than 2 lbs. in 24 hours. - On 09/21 the patient weighed 158.2 lbs. and 162.0 lbs. on 09/22, for a weight gain of 3.8 pounds. The record lacks documentation physician was notified of a weight gain greater than 2 lbs. in 24 hours. - On 10/13 the patient weighed 150.9 lbs. and 154.7 lbs. on 10/14, for a weight gain of 3.8 pounds. The record lacks documentation physician was notified of a weight gain greater than 2 lbs. in 24 hours. - On 10/16 the patient weighed 152.7 lbs. and 155.4 lbs. on 10/17, for a weight gain of 2.7 pounds. The record lacks documentation physician was notified of a weight gain greater than 2 lbs. in 24 hours. The findings were confirmed on 11/16/2021 at 2:15 PM and 2:20 PM and 11/17/2021 at 9:25 AM with the Director of Nursing Services and Executive Director; no additional evidence was provided.

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 clinical record review and staff interview the agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in fourteen of seventeen patient records reviewed (Patient # 2, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Findings: Patient # 2 (start of care 11/02/2021) has diagnoses of Unspecified Displacement Fracture of Surgical Neck of Right Humerus, Subsequent encounter for Fracture with Delayed Healing and Essential Primary Hypertension. The POC for the certification period 09/17/2021 through 11/15/2021 contains an order for: Physical Therapy to monitor blood pressure, pulse rate, respiration, oxygen saturation, temperature and weight PRN (As Needed); Notify physician for measures that fall outside of physician-ordered parameters at rest. The order is incomplete as there are no weight parameters stated. Patient # 3 (start of care 10/28/2021) has diagnoses of Hypertensive Heart and Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney Disease. The POC for certification period 10/28/2021 through 12/26/2021 contains orders for: - Levothyroxine 100 mcg (microgram) tablet, tablet, daily, oral. The order is in complete as it lacks instruction to take medication 30 minutes to 1 hour before meal. - O2 (Oxygen), 2-3 liters, O2-Continuos. The order is incomplete as it lacks the route the O2 is to be administered (Nasal Cannula, Face Mask). Additionally, the Registered Nurse (RN) initial assessment (dated 10/28/2021) documents patient utilizes Durable Medical Equipment (DME), specifically an Elevated Toilet Seat, Tub Chair, Reacher and Grab Bars. The POC is incomplete as it does not list these DME. Patient # 4 (start of care 11/02/2021) has a diagnoses of Alzheimer's Disease, Unspecified and Dementia in Other Diseases Classified Elsewhere Without Behavioral Disturbance. The POC for certification period 11/02/2021 through 12/31/2021 contains and order for: - Levothyroxine 100 mcg tablet, tablet, daily, oral. The order is in complete as it lacks instruction to take medication 30 minutes to 1 hour before meal. Patient # 7 (start of care 11/02/2021) has a diagnoses of Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Acute Respiratory Failure with Hypoxia. The POC for certification period 11/02/2021 through 12/31/2021 contains orders for: - O2 (Oxygen), 4 liters, O2-Continuous. The order is incomplete as it lacks the route the O2 is to be administered (Nasal Cannula, Face Mask). - Prednisone 10 mg (milligram) Tablet, 4 tablets, daily, oral. The order is incomplete as it does not provide an end date for medication. - Prednisone 10 mg Tablet, 2 tablets, daily, oral. The order is incomplete as it does not provide an end date for medication. - Prednisone 10 mg Tablet, 1 tablets, daily, oral. The order is incomplete as it does not provide an end date for medication. Additionally, the RN initial assessment (dated 11/02/2021) documents patient utilizes DME, specifically a Tub Chair and Bi-Pap (Bilevel Positive Airway Pressure) . The POC is incomplete as it does not list these DME. Patient # 8 (start of care 09/17/2021 and discharged 11/08/2021) has a diagnoses of Acute Pain Due to Trauma and Pain in Left Knee. The POC for the certification period 11/02/2021 through 12/31/2021 contains an order for: - Physical Therapy to monitor blood pressure, pulse rate, respiration, oxygen saturation, temperature and weight PRN (As Needed); Notify physician for measures that fall outside of physician-ordered parameters at rest. The order is incomplete as there are no weight parameters stated. Additionally, the Physical Therapist (PT) initial assessment (dated 09/17/2021) documents the patient utilizes DME, specifically a Raised Toilet Seat and Wheelchair Cushion. The POC is incomplete as it does not list these DME. Patient # 9 (start of care 10/16/2021 and discharged 11/02/2021) has a diagnoses of Drug Rash with Eosinophilia and Systemic Symptoms Syndrome and Adverse Effect of Cephalosporin. The POC for certification period 10/16/2021 through 12/14/2021 contains orders for: - Critic-Aid Clear 71.5% Topical Ointment, Topical, Daily. For Saturated/Soiled Skin. Maximum Daily Dose 1 time Application. The order is in complete as it does not specify the location to apply the ointment. - DICLO Gel 1% Topical Kit, Topical, 3 Times a Day/PRN (As Needed). For Pain. Maximum Daily Dose 3 Applications. The order is in complete as it does not specify the location to apply the ointment. - Miconazole Nitrate 2% Topical Cream, Topical, 2 Times Daily. The order is in complete as it does not specify the location to apply the ointment. Patient # 10 (start of care 10/24/2021 and discharged 10/28/2021) has a diagnoses of Mechanical Complication of Bile Duct Prosthesis and Malignant Neoplasm of Pancreas, Unspecified. The POC for certification period 10/16/2021 through 12/14/2021 contains an order for: - Diclofenac Gel 1% Topical Kit, Topical, 2 cm (centimeter) 4 Times a Day PRN. Pain, Maximum Daily Dose 3 Applications. The order is in complete as it does not specify the location to apply the ointment. Additionally, the POC contains an order for Enoxaparin 80 mg/0.8 ml (milliliter) Subcutaneous Syringe 68 mg, Daily. The POC is incomplete as it does not contain bleeding precautions. Patient # 11 (start of care 09/03/2021 and discharged 10/28/2021) has a diagnoses of Hypertensive Heart Disease with Heart Failure and Acute On Chronic Systolic (Congestive) Heart Failure. The POC for certification period 09/03/2021 through 11/01/2021 contains an RN initial assessment (dated 09/03/2021) that documents the patient utilizes DME, specifically a Lift Recliner. The POC is incomplete as it does not list this DME. Patient # 12 (star of care 10/12/2021 and discharged 11/01/2021) has a diagnoses of Abscess of Lung and Unspecified Atrial Fibrillation. The POC for certification period 10/14/2021 through 12/12/2021 contains orders for: - Fentanyl 100 mcg/HR (Hour)Transdermal Patch, 1 patch, Transdermal 72 hours, On the Skin, As Directed/PRN. Change Every 72 Hours. The order is incomplete as it fails to instruct to rotate patch sites. - Fentanyl 25 mcg/HR (Hour)Transdermal Patch, 1 patch, Transdermal 72 hours, On the Skin, As Directed/PRN. Change Every 72 Hours. The order is incomplete as it fails to instruct to rotate patch sites. Patient # 13 (start of care 10/18/2021) has a diagnoses of Laceration without Foreign Body, Right Lower Leg, Subsequent Encounter and Fracture Unspecified Part of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing. The POC for certification period 10/18/2021 through 12/16/2021 contains orders for: - Oxygen, 2 liters, O2-Continuous. The order is incomplete as it lacks the route the O2 is to be administered (Nasal Cannula, Face Mask). - Prednisone 1 mg (milligram) Tablet, 3 tablets, daily, oral. The order is incomplete as it does not provide an end date for medication. - Prednisone 5 mg (milligram) Tablet, 1 tablet, 3 times daily, oral. The order is incomplete as it does not provide an end date for medication. - Prednisone 5 mg (milligram) Tablet, 0.5 tablet, 3 times daily, oral. The order is incomplete as it does not provide an end date for medication. Additionally, the RN initial assessment (dated 11/03/2021) documents patient utilizes Durable Medical Equipment (DME), specifically a bedside Commode, Elevated Toilet Seat, Bi-Pap (Bilevel Positive Airway Pressure) and Reacher. The POC is incomplete as it does not list these DME. Patient # 14 (start of care 10/04/2021) has a diagnoses of Other Intervertebral Disc Degeneration, Lumbar Region and Radiculopathy, Lumbar Region. The POC for certification period 11/03/2021 through 01/01/2022 contains and order for: - Nitroglycerin 0.4 mg Sublingual Tablet, 1 tablet As Directed/PRN, Sublingual. Every 5 Minutes X (times) 3 As Needed for Chest Pain. Maximum Daily Dose 3. The order is incomplete as it fails to provide instructions for the next step if chest pain is not relieved after third dose. Additionally, the RN initial assessment (dated 11/03/2021) documents patient utilizes Durable Medical Equipment (DME), specifically a Reacher and Nebulizer. The POC is incomplete as it does not list these DME. Patient # 15 (start of care 10/11/2021) has a diagnoses of Venous Insufficiency (Chronic)(Peripheral) and Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene. The POC for certification period 10/11/2021 through 12/09/2021 contains an order for: - Oxygen, 3 liters, O2-Continuous. The order is incomplete as it lacks the route the O2 is to be administered (Nasal Cannula, Face Mask). Additionally, the RN initial assessment (dated 10/11/2021) documents patient utilizes Durable Medical Equipment DME, specifically a Standard Walker, Tub Chair and Nebulizer. The POC is incomplete as it does not list these DME. Patient # 16 (start of care 05/25/2021) has a diagnoses of Hypertensive Heart Disease with Heart Failure and Heart Failure, Unspecified. The POC for certification period 09/22/2021 through 11/20/2021 contains an order for: - Levothyroxine 150 mcg Tablet, 1 Tablet, Daily, Oral. The order is incomplete as it is lacking instruction to take medication 30 minutes to 1 hour before meal. Patient # 17 (start of care 11/06/2021) has a diagnoses of Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side and Unspecified Fracture Lower End of Right Humerus, Subsequent for Fracture with Routine Healing. The POC for certification period 11/06/2021 through 01/04/2021 contains an RN initial assessment (dated 11/06/2021) documents patient utilizes DME, specifically a Lift Recliner. The POC is incomplete as it does not list this DME. The findings were confirmed on 11/16/2021 at 11:00 AM, 2:15 PM and 2:20 PM and 11/17/2021 at 9:25 AM, 3:20 PM with the Director of Nursing Services and Executive Director; no additional evidence was provided.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure in four of seventeen records (Patient # 2,10, 11 and 16) professional staff maintain an accurate, current and clearly documented record related to the provision of the patient's care. Failure to maintain an accurate, current and clearly documented record has the potential for staff to make clinical decisions based on inaccurate and/or missing information with the potential to result in negative patient outcomes. Findings: Patient # 2 (start of care 11/02/2021) has diagnoses of Unspecified Displacement Fracture of Surgical Neck of Right Humerus, Subsequent encounter for Fracture with Delayed Healing and Essential Primary Hypertension. The physician Plan of Care (POC) for certification period 11/02/2021 through 12/31/2021 contains on order for Durable Medical Equipment (DME) of a Wheelchair. The clinical record lacks documentation that patient utilizes a wheelchair. Patient # 10 (start of care 10/24/2021 and discharged 10/28/2021) has a diagnoses of Mechanical Complication of Bile Duct Prosthesis and Malignant Neoplasm of Pancreas, Unspecified. The record contains a discharge summary dated 10/28/2021. The "Discharge Information" states: Discharged/Transferred to a Short-Term General Hospital for Inpatient Care/Reason: Patient Expired /Condition: Patient Expired. Below that entry states "Date/Time of Death" which is blank. The Discharge Summary requires clarification as to whether the patient was transferred to another facility or expired. Patient # 11 (start of care 09/03/2021 and discharged 10/28/2021) has a diagnoses of Hypertensive Heart Disease with Heart Failure and Acute On Chronic Systolic (Congestive) Heart Failure. The POC for certification period 09/03/2021 through 11/01/2021 contains an order for DME of a Walker. The clinical record lacks documentation that patient utilizes a Walker. Patient # 16 (start of care 05/25/2021) has a diagnoses of Hypertensive Heart Disease with Heart Failure and Heart Failure, Unspecified. The POC for certification period 07/24/2021 through 09/21/2021contains an order for DME of Shower/Tub Equipment and a Walker. The clinical record lacks documentation that patient utilizes Shower/Tub Equipment and a Walker. The findings were confirmed on 11/17/2021 at 9:25 AM, 3:20 PM with the Director of Nursing Services and Executive Director; no additional evidence was provided.