Every finding on record at North Carolina In-Home Partner-V, LLC

An onsite recertification survey was conducted 07/14/2026-07/16/2026. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted 07/14/2026-07/16/2026. A deficiency to the Medicare Conditions of Participation was identified.

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 and procedure, clinical record review, observation, and patient interview the agency failed to review all current medications for 4 of 5 home visits conducted (#7,9, 10, and 11). Findings included: Review of policy “Monitoring Medications”, revised 04/01/2026 was received from the agency director on 07/15/2026 at 1624. The policy stated,” …the discipline responsible for the drug regimen will…review all medications including over the counter medications…” 1.Patient #7 was admitted on 06/22/2026 with diagnoses of atrial fibrillation (heart flutter), type 2 diabetes, and copd (chronic obstructive pulmonary disease). The plan of care for 06/22/2026 to 08/20/2026 included the following orders: physical therapy 2 times a week for 2 weeks and 1 time a week for 3 weeks. A home visit was conducted on 07/14/2026 at 1200 with the physical therapist. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: Lasix 20 mg (milligram) fluid pill take 1 tablet daily by mouth daily. Interview with the patient on 07/14/2026 at 1235 revealed, “I’ve been taking this as needed I don’t always swell up”. 2. Patient #9 was admitted on 06/08/2026 with diagnoses of atrial fibrillation (heart flutter), epilepsy (seizures), heart failure and chronic kidney disease. The plan of care for 06/08/2026 to 08/06/2026 included the following orders: skilled nursing 1 time a week for 9 weeks and physical therapy 1 time a week for 1 week then 2 times a week for 4 weeks. A home visit was conducted on 07/15/2026 at 0900 with the physical therapy assistant. The review revealed the following discrepancies: Torsemide 20 mg take 2 takes a day for swelling; folic acid 1 mg every day (vitamin supplement); vitamin D 50 mcg (micrograms) take 1 tablet by mouth daily. Interview with the patient on 07/15/2026 at 0945 revealed, “I’ve been taking this since coming out of the hospital…I’ve been taking this for a while it should be on the list…” 3. Patient #10 was admitted on 04/09/2025 with diagnoses of type 2 diabetes, non-pressure ulcer chronic of the right calf and copd (chronic obstructive pulmonary disease). The plan of care for 06/03/2026 to 08/01/2026 included the following orders: skilled nursing 2 times a week for 1 week, 3 times a week for 8 weeks. A home visit was conducted on 07/15/2026 at 1000 with the registered nurse. The review included the following discrepancy: Plavix 75mg take 1 tablet by mouth daily for thinning the blood. Interview with the patient on 07/15/2026 at 1135 revealed, “I’ve been taking this since April 1, 2025”. 4. Patient #11 was admitted on 06/06/2026 with diagnoses of encounter for surgical aftercare following respiratory surgery; pleural effusion (build up of excess fluid in the pleural space), acute and chronic respiratory failure, and type 2 diabetes. The plan of care for 06/06/2026 to 08/04/2026 included the following orders: skilled nursing 1 time a week for 5 weeks. A home visit was conducted on 07/15/2026 at 1200 with the registered nurse. The review included the following discrepancies: trazadone HCL 100mg take 2 tables by mouth daily for pain and vitamin D3 (vitamin supplement) take 1 tablet by mouth daily. Interview with the patient caregiver on 07/15/2026 at 1505 revealed, “he has been taking this for at least 6 months”.

An onsite recertification and follow up survey was conducted 7/17/23-7/19/23. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification and follow up survey was conducted 7/17/23-7/19/23. Deficiencies to the Medicare Conditions of Participation were identified.

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 and procedure, observation, clinical record review, and staff and patient interview the agency failed to review all current medications for 4 of 5 patients that received a home visit (#13, #14, #7, and #17). Findings included: 3. Patient #7 was admitted on 6/29/23 with a diagnosis of aftercare following a right knee replacement. The Plan of Care (POC) for 6/29/23-8/27/23 included orders for skilled nursing one time per week for one week, two times per week for two weeks, and one time per week for one week; and physical therapy one time per week for one week, three times per week for three weeks, and two times weekly for one week. The patient resided in an assisted living facility. A joint visit was conducted with RN #6. The Medication Administration Record was obtained from the facility. The medications included Nicotine 14 mg/24-hour patch (for smoking cessation) was included on the facility medication list. There was no evidence the use of a nicotine patch was assessed prior to the 7/18/23 nursing visit. An interview with RN #6 during the visit confirmed Nicotine was not included in the home health record. 4. Patient #17 was admitted on 5/5/23 with diagnoses of diverticulitis of the large intestine, type 2 diabetes, and chronic pain. The Plan of Care (POC) for 7/4/23-9/1/23 included orders for skilled nursing weekly for nine weeks; and physical therapy twice weekly for three weeks. The POC included orders for iron 65mg (supplement) daily, and slow-release iron 45 mg (supplement) daily. A home visit was conducted on 7/18/23 at approximately 2:00 p.m. with the physical therapy assistant (PTA) #12. A medication review revealed the patient was only taking one iron supplement. An interview with the clinical director during the home visit confirmed iron was on the POC twice. A policy, “Monitoring Medications” (revised 5/1/19), was provided by the agency director on 7/19/23 at 8:30 a.m. The policy stated, “A drug regimen review will be conducted on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode…”. 1.Patient #13 was admitted on 06/18/23 with diagnoses of type 2 diabetes, acute osteomyelitis (bone infection), and sepsis (blood infection). The plan of care for 06/18/23 to 08/16/23 included the following orders: skilled nursing 5 times a week for 1 week, 3 times a week for 7 weeks, and 2 times a week for 1 week. A home visit was conducted on 07/17/23 at 2:56 p.m. with the nurse. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: Dulcolax 100mg (milligram) by mouth as needed for constipation was not on the medication profile. Per interview with the patient “I started taking it a couple of days ago, I took it for 2 to 3 days”. Per interview with the nurse “I put he was taking it in my note last Thursday, but I forgot to update the medication profile”. 2.Patient #14 was admitted on 06/14/23 with diagnoses of unilateral primary osteoarthritis, left knee; deficiency of other specified b group vitamins, type 2 diabetes, long term use of insulin, and long term use of aspirin. The plan of care for 06/14/23 to 08/12/23 included the following orders: physical therapy 1 time a week for 2 weeks, and 2 times a week for 3 weeks. A home visit was conducted on 07/17/23 at 4:12 p.m. with the physical therapist assistant. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: melatonin 5 mg gummies as needed for sleep. Per interview with the patient “I’ve been taking these for a couple of weeks, I took 2 last night, they don’t work very well”.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, observation and staff interview, the Plan of Care did include medical equipment for 2 of 13 current patients (#11 and 19). Findings included: A policy, “Plan of Care” (revised 12/1/21), was provided by the agency director on 7/19/23 at 8:30 a.m. The policy stated, “The POC [plan of care] includes required equipment and supplies…” 1. Patient #11 was admitted on 5/24/23 with diagnoses of type 2 diabetes mellitus, fibromyalgia (a condition that causes pain all over the body), chronic pain, obesity, and hypertension (high blood pressure). The Plan of Care (POC) for 5/24/23-/7/22/23 included orders for skilled nursing visits weekly for nine weeks; and physical therapy visits weekly for five weeks. The POC failed to include any medical equipment or supplies. A PT evaluation was conducted on 5/26/23. The PT evaluation noted equipment: a beside commode, multi-wheeled walker, rolling walker, and a wheelchair. On 7/16/23 at approximately 1:30 p.m., a home visit was conducted with PT #15. The agency director was also present during the home visit. During the visit, a walker, beside commode, and wheelchair was visualized in the patient’s home. An interview with the agency director was conducted on 7/18/23 at 9:09 a.m. The interview confirmed there was no equipment on the POC, but equipment was identified in the initial PT evaluation and was present during the home visit. 2. Patient #19 was admitted on 6/12/23 with diagnoses of multiple rib fractures left side, fracture of sternum (breastbone), wedge compression fracture (a type of fracture where the bone is broken into a wedge shape) third lumbar vertebrae (bones in the back between the rib cage and the pelvis), stable burst fracture (a traumatic spinal injury) of thoracic vertebrae (T11 and T12) (bones in mid-back), fracture of 4th cervical vertebrae (bones in the neck), and right femur (thigh bone) fracture. The initial assessment conducted on 6/12/23 by PT #10 revealed the patient “has cervical collar to be worn at all times along with thoracic brace to be worn when upright…” The patient refused to wear the thoracic brace. The cervical collar nor the thoracic brace was included on the POC. An interview with the patient care manager on 7/19/23 at 8:48 confirmed the equipment was not on the POC.

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 policy, clinical record review, observation and staff interview, the agency failed to notify the physician that blood sugars were not checked for 1 of 4 diabetic patients that took insulin injections (#11); and to notify the physician of unrelieved symptoms of itching in 1 of 5 home visits (#11). Findings included: A policy, “Coordination of Care from Admit Through Discharge” (revised 4/1/23), was provided by the agency director on 7/19/23 at 8:30 a.m. The policy stated, “At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician…When changes occur in the patient’s condition or response to treatment…When there is a need to change the patient’s plan of care…And at least every 60 days to review, revise, update, and/or continue the plan of care…” 1A. Patient #11 was admitted on 5/24/23 with diagnoses of type 2 diabetes mellitus. The Plan of Care (POC) for 5/24/23-/7/22/23 included orders for skilled nursing visits weekly for nine weeks; and physical therapy visits weekly for five weeks. The POC also included that the agency report blood sugars less than 75 or greater than 350. On 5/24/23, the initial nursing assessment stated that the patient did not check blood sugar. The nursing visit on 6/1/23 also stated that the patient did not check blood sugar. There was no evidence the physician was notified the patient did not check blood sugar. An interview with the agency director confirmed there was no evidence that the physician was made aware the patient did not check blood sugar. 1B. On 7/11/23, RN #7 conducted a home visit. The visit note stated, “Reports itching [sic] continue to use various lotion and hydroxyzine to manage.” There was no evidence the physician was notified of the itching. A home visit was conducted on 7/16/23 at approximately 1:30 p.m. with PT #15. The patient complained of severe itching during the visit. A review of medications revealed the patient had begun taking Benadryl 25 mg 1-2 times per day, had tried Calamine lotion for approximately without relief, used Cerave itch relief 1% topical cream daily as needed, diaper rash 40% topical ointment daily as needed for itching, and hydroxyzine 25 mg 4 times daily as needed for itching. RN #7 was not available for interview. An interview with the agency director on 7/19/23 at 9:27 a.m. revealed there was no evidence the physician was notified of the continued itching.

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, clinical record review, and staff interviews the agency failed to follow the plan of care as ordered by the physician for wound care for 1 of 6 patients with a wound (#5). Findings include: A policy, "Physician Orders" revised 04/01/23 was provided by the agency administrator on 07/19/23 at 8:30 a.m. The policy stated, " ...services are provided according to the most recent orders…” 1. Patient #5 was admitted on 07/26/22 with a diagnosis of UTI (urinary tract infection), site not specified. The plan of care (POC) for 07/26/22-09/23/22 included orders for skilled nursing 1 time a week for 9 weeks. Wound care order for skilled nursing were: Skilled nurse to perform/instruct/reinforce patient/caregiver procedure of wound care to skin tear/trauma to left shin, left upper arm, right hand and right 4th finger: cleanse with soap water daily and prn cover with bandaid until healed. Review of the clinical record revealed wound care was not documented as being done as ordered for the weeks of: 7/26/22, 8/2/22, and 8/9/22. Interview with the patient care manager on 07/19/23 at 9:20 a.m. revealed, “they didn’t document the wound care correctly on the wound care tool”.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on policy review, client record review, and staff interview the agency failed to measure PICC (peripherally inserted central line) for 1 of 1 records reviewed with a PICC line (#6). Findings included: Review of a policy “Dressing change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters”, revised 2016 was received from the agency administrator on 07/19/23 at 8:30 a.m. The policy stated,” …obtain upper arm circumference…measure external length of catheter from the insertion site to the catheter hub…” 1. Patient #6 was admitted on 05/28/23 with diagnoses of sepsis due to group b streptococcus (bacteria), acute kidney failure, and type 2 diabetes. The plan of care for 05/28/23 to 07/26/23 had orders for skilled nursing 1 time a week for 9 weeks. Review of the skilled nursing notes revealed PICC line measurements were not obtained on the admission visit on 05/28/23. Interview on 7/19/23 at 9:12 a.m. with director and patient care manager revealed, “she didn’t do site care on the admission visit, she did labs, she should have measured it”.

An onsite recertification survey was conducted 04/12/21-04/13/21. No deficiencies to the Emergency Prepardness Program were identified. ABH

An onsite recertification survey was conducted 04/12/21-04/13/21. A deficiency to the Medicare Conditions of Participation was identified. ABH

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, clinical record review, and staff interviews the agency failed to follow the plan of care as ordered by the physician for home health aide services for 1 of 3 patients with a home health aide (#9), vital signs for 1 of 1 patients with emphysema (#3). Findings include: A policy, "Plan of Care" revised 01/01/21 was provided by the executive director on 04/13/21 at 4:13 p.m. The policy stated, " ...the plan of care also includes documentation of the following: types, frequency and duration of services to be provided ...patient specific interventions and education; measurable outcomes and goals" 1. Patient #9 was admitted on 03/12/21 with diagnoses of enterocolitis due to clostridium difficile (inflammation in the digestive tract), essential hypertension, spinal stenosis, and other chronic pain . The plan of care (POC) for 03/12/21-05/10/21 included orders for home health aide 1 time a week for 1 week, and 2 times a week for 2 weeks. Review of the clinical record revealed home health aide visits were conducted on the following dates: 03/17/21, 03/23/21, 03/27/21, and 03/31/21. A second visit for the week of 03/30/21 was not in the record. An interview with executive director on 04/13/21 at 3:44 p.m. revealed "it should have been a missed visit, but it wasn't, it's still showing green in the system, it was a computer glitch". 2. Patient #3 was admitted on 02/23/21 with diagnoses of emphysema, essential hypertension, atrial fibrillation, epilepsy, and history of falling. The plan of care for 02/23/21-04/23/21 included orders for skilled nursing 2 times a week for 2 weeks, then 1 time a week for 7 weeks. Skilled nursing orders were to perform pulse oximetry every visit on room air to monitor patient's respiratory status. Review of the clinical record revealed the skilled nurse recorded a temperature of 98 degrees Fahrenheit on the visit of 03/24/21. No other vital signs are documented in the record. An interview with Employee #3 on 4/13/21 at 3:15 p.m. revealed " I checked his blood pressure, respiration, pulse and temperature, I must have forgot to document the others".