Every finding on record at On Call Care Services Inc

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 04/01/2026. 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 04/01/2026. The provider had eight current patients.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure the plan of care (POC) included all interventions and orders to address patient needs, safety measures, and all physicians that were providing orders, in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect the provision of care for all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 03/10/2026 with a primary diagnosis of change or removal of surgical dressing, cutaneous abscess of groin (pus-filled lump under the skin caused by bacterial infections, necrotizing fasciitis (rapidly progressing, life-threatening bacterial infection) and type two diabetes mellitus (a chronic disease that affects how the body uses sugar for energy). The patient lived at an assisted living facility. Review of the POC, dated 03/10/2026-05/08/2026, showed, in part: -The patient was prescribed lovenox (a blood thinner); -The patient was prescribed novolog insulin (injectable medication used to lower blood sugar) 13 units subcutaneous (under the skin) three times a day with meals; -The patient was prescribed novolog insulin sliding scale 0-199: 0 units, 200-250: 2 units, 251-299: 4 units, 300-349: 6 units, 350-399: 8 units, 400-449: 10 units, 450 and greater: 12 units SQ for elevated blood sugar; and -The skilled nurse (SN) to provide negative pressure wound therapy (a vacuum dressing system to promote healing in acute or chronic wounds by applying subatmospheric pressure) to right periwound area using aseptic technique. SN to clean/irrigate the wound with Vashe (saline-based wound cleanser), dry the wound with gauze, prepare the skin around the wound with skin prep, fill the wound cavity with black foam, cover and secure area with drape and apply tubing. Apply negative pressure device at 125 (millimeters of mercury) mm Hg continuously. SN may use wet-to-dry dressing as an alternative as needed or until the machine is available. Instruct patient/caregiver on application of wet-to-dry dressing as needed for device malfunction. Review of the patient’s physician order, dated 03/17/2026, showed to cleanse the wound with wound cleanser, apply Vashe soaked gauze packing in wound bed, cover and secure with abdominal dressing or 4x4 gauze and tape, using aseptic technique. Dressing to be changed daily. Observation on 03/31/2026 at 09:30 AM, showed registered nurse (RN) A provided wound care to the patient’s right groin area as per the 03/17/2026 order. The patient no longer had the negative pressure wound therapy. The POC failed to show a safety measures for bleeding precautions, diabetes symptom management, and the updated wound care orders. During an interview on 03/31/2026 at 11:35 AM, the predesignated administrator backup stated that he/she would expect bleeding precautions, diabetes symptom management and updated wound orders to included on the POC. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 10/2017, showed in part: - The plan of care is a written plan that specifies the care and services necessary to meet the patient-specific needs identified in the comprehensive assessment, and the measurable outcomes that the agency anticipates would occur as a result of implementing and coordinating the plan of care; - The plan of care is required to include all medications and treatments; - The planning care is required to include in the individualized plan of care all appropriate interventions that are necessary to address and mitigate identified risk factors that contribute to the agencies establishment of a particular risk level for a patient to be re-hospitalized or revisit the emergency room; - Agency professional staff will revise the plan of care, as necessary, to reflect current information from the patients updated comprehensive assessment, and to record the patient's progress towards meeting the patient specific measurable outcomes and goals selected by the agency and patient, as specified in the plan of care; and - The plan of care is updated/revised as new orders are received and when a significant change in condition occurs. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted for home health services on 03/17/2026 with a primary diagnosis of non-pressure chronic ulcer to the left ankle and the patient resided at home. Review of the hospital discharge records showed: - The patient was discharged home on intravenous (IV) antibiotics (ABT) via a tunneled central catheter line for treatment of osteomyelitis (infection in the bone); - Ceftazidime (ABT) 1 gram (g) in 50 milliliters (ml), 2 g IV every Monday, Wednesday, and Friday; - Vancomycin (ABT) 500mg IV every Monday, Wednesday, and Friday; - Weekly labs: complete blood count (CBC) with differential, complete metabolic panel (CMP), and c-reactive protein (CRP). Fax results to infectious disease (named provider and fax number); - Central line care per protocol; - Hydralazine 25 mg tablet, one (1) tablet every eight hours for high blood pressure (hold prior to hemodialysis on Monday, Wednesday and Friday, and hold for systolic blood pressure below 110); - Oxygen 3 liters (L) nightly as needed; - Diet: hemodialysis (renal diet) and a 1200 ml fluid restriction; and - The patient was to follow up with (named) wound care clinic, (named) vascular clinic, and (named) infectious disease clinic. Review of the POC showed: - Ceftazidime 2 g IV every Monday, Wednesday, and Friday through central venous catheter (the POC failed to include interventions or orders regarding who was responsible for administering the IV antibiotic); - Vancomycin 500 mg IV via central venous catheter every Monday, Wednesday, and Friday during dialysis (the POC failed to include interventions or orders regarding who was responsible for administering the antibiotic and who was responsible for obtaining the weekly labs); - The POC failed to include weekly labs orders, the name of the infectious disease clinic, contact information, and fax number for the lab results to be sent to); - The POC failed to include interventions or orders for central line care; - Hydralazine 25 mg tablet, three times a day by mouth. If blood pressure is not over 89/40, hold this medication along with the other blood pressure medications except for Coreg (the hospital discharge orders showed the patient was to hold the medication on Monday, Wednesday and Friday, and to hold for systolic blood pressure below 110); - Oxygen 2-4 L via nasal cannula as needed (the hospital discharge orders showed 3L of oxygen); - Diet: 2000 ml fluid restriction (the hospital discharge showed 1200 ml); and - The POC failed to show the patient was to follow up with (named) wound care clinic, (named) vascular clinic, and (named) infectious disease clinic. The POC failed to include all relevant physicians that were providing orders for the POC. During an interview on 04/01/2026, at 11:10 AM, the predesignated administrator backup stated that all of the patient’s interventions, orders, and physicians should be listed on the POC.

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, record review, and interview, the home health provider failed to provide a completed discharge summary to the health care provider care within five (5) days of discharge in one of two discharge records reviewed (Record/Patient #6). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, "Discharge/Reduction in Services," dated 10/2017, showed in part: - All discharge paperwork will be due in the office within 72 hours of the discharge date; and - A completed discharge summary will be sent to the primary medical doctor (MD) within five (5) business days of discharge. RECORD/PATIENT #6: Review of the clinical record showed that the patient was admitted for home health services on 12/09/2025 with a primary diagnosis of an unspecified open wound to the right lower leg and resided at home. Review of the discharge summary showed: - The discharge date was 01/30/2026; and - The discharge summary was not completed until 02/07/2026 (eight days after the patient was discharged). During an interview on 04/01/2026, at 11:10 AM, the predesignated administrator backup stated that he/she would expect the discharge summary to be completed and sent to the primary care provider within 5 days.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure the accuracy of documentation in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 03/10/2026 with a primary diagnosis of change or removal of surgical dressing, cutaneous abscess of groin (pus-filled lump under the skin caused by bacterial infections), necrotizing fasciitis (rapidly progressing, life-threatening bacterial infection) and type two diabetes mellitus (a chronic disease that affects how the body uses sugar for energy). The patient lived at an assisted living facility. Review of the clinician visit notes showed: -On 03/14/2026, the registered nurse (RN) documented the patient was alert and the skin had been washed. When the wound vac was discontinued, the skilled nurse (SN) was informed that the patient had schizoaffective disorder. After being educated on the removal of wound vac, wound is to be packed with Vashe dressing, the patient began to giggle indicating that he/she was responding to internal stimuli. He/she was encouraged to maintain the areas dry and intact, and he/she replied that he/she had no open areas on his/her buttocks and does not want them dressed right now. The surgeon was notified that the patient is unable to keep the wound vac on. New orders to pack the wound with Vashe soaked gauze, place ABD pad (absorbant dressing) and tape in place using tape using clean technique. Dressing was performed in the treatment room; -On 03/15/2026, (RN) documented the patient was alert and the skin had been washed. When the wound vac was discontinued, the skilled nurse (SN) was informed that the patient had schizoaffective disorder. After being educated on the removal of wound vac, wound is to be packed with Vashe dressing, the patient began to giggle indicating that he/she was responding to internal stimuli. He/she was encouraged to maintain the areas dry and intact, and he/she replied that he/she had no open areas on his/her buttocks and does not want them dressed right now. The surgeon was notified that the patient is unable to keep the wound vac on. New orders to pack the wound with Vashe soaked gauze, place ABD pad (absorbant dressing) and tape in place using tape using clean technique. Dressing was performed in the treatment room (same entry as 03/14/2026); -On 03/16/2026, (RN) documented the patient was alert and the skin had been washed. When the wound vac was discontinued, the skilled nurse (SN) was informed that the patient had schizoaffective disorder. After being educated on the removal of wound vac, wound is to be packed with Vashe dressing, the patient began to giggle indicating that he/she was responding to internal stimuli. He/she was encouraged to maintain the areas dry and intact, and he/she replied that he/she had no open areas on his/her buttocks and does not want them dressed right now. The surgeon was notified that the patient is unable to keep the wound vac on. New orders to pack the wound with Vashe soaked gauze, place ABD pad (absorbant dressing) and tape in place using tape using clean technique. Dressing was performed in the treatment room (same entry as 03/15/2026); -On 03/18/2026, the RN documented the patient’s skin had been cleaned and the patient was conscious. The SN was notified that the patient had schizoaffective disorder after the wound vacuum was stopped. The patient started reacting to him/herself after being instructed on how to remove wound packing using Vashe dressing, suggesting that he/she was reacting to internal sensations. He/she responded that he/she had no exposed regions on his/her buttocks when asked to keep the areas dry and intact. They are being seen every day for minimum drainage. Take note that he/she removes his/her dressing because his/her mind won’t let him/her wear it all day; and -On 03/19/2026, the RN documented the patient’s skin had been cleaned and the patient was conscious. The SN was notified that the patient had schizoaffective disorder after the wound vacuum was stopped. The patient started reacting to him/herself after being instructed on how to remove wound packing using Vashe dressing, suggesting that he/she was reacting to internal sensations. He/she responded that he/she had no exposed regions on his/her buttocks when asked to keep the areas dry and intact. They are being seen every day for minimum drainage. Take note that he/she removes his/her dressing because his/her mind won’t let him/her wear it all day (same entry as 03/18/2026). During an interview on 03/31/2026 at 11:35 AM, the predesignated administrator backup stated that he/she would not expect staff to carry forward previous visit notes. Findings included: Review of the provider’s policy titled, “Clinical Records,” dated 10/2017, showed in part: - The clinical record documentation provides patients information specific to care and services provided (not provided), current patient status, and progress towards goals and outcomes of care; - Documentation standards include: * All entries that are legible, clear, complete, concise, appropriately authenticated must include a signature and title, or a secured computer entry by a unique identifier or a primary author who has reviewed and approved the entry * Dates/times, types of intervention, assessments and coordination of care - Clinical records are accurate and adhere to current clinical record documentation standards of practice; and - All entries into the clinical record for services rendered will be written within 24 hours (by the pervert person providing the service) and shall be incorporated into the patient's clinical record within seven days of the delivery of service. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted for home health services on 03/17/2026 with a primary diagnosis of non-pressure chronic ulcer to the left ankle and the patient resided at home. Review of the hospital discharge records showed that the patient was admitted to the hospital on 03/01/2026 and discharge home on 03/14/2026 with orders for home health services. Review of the skilled nursing (SN) start of care visit on 03/17/2026, showed: - Ethnicity: patient unable to respond; - Race: patient unable to respond; - Sensory status: impaired hearing (no documentation of speech impairment); - Neurological status: oriented to person, place, and time; - The documentation was unclear why the patient was unable to respond but was alert and oriented to person, place, and time; and - Inpatient discharge within the past 14 days: patient was not discharged from an inpatient facility (the patient was discharged from the hospital three days prior). During an interview on 04/01/2026, at 11:10 AM, the predesignated administrator backup stated that he/she would expect the documentation to be complete and accurately reflect the patient’s status.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 03/29/2023. 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 certification for the home health provider was completed on 03/29/2023. The agency had 71 current patients.

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 home health provider failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, in but not limited to, two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #5: Review of the referral records, dated, 11/01/2022 at 11:27 AM, showed, in part: - Disciplines: Physical therapy (PT) and Occupational therapy (OT; and - Skilled interventions: ADL’s/IADL’s, ambulation/mobility, and home safety. Review of the POC, failed to show the: - PT established treatment plan; and - OT established treatment plan. Findings included: Review of the provider’s policy, titled, “Assessments,” dated, 03/01/18, showed, in part: - The initial assessment will be performed by a RN (Registered Nurse) for patients receiving nursing only services or nursing and therapy (unless therapy only), within 48 hours of the patient’s referral, discharge from a facility to home or specific date specified by the MD (medical doctor); and - It will be completed timely, no later than 5 (five) calendar days after SOC (start of care). RECORD/PATIENT #1: Review of the referral information, showed, in part: - Referral for home health services was sent to the home health provider on 02/03/2023; - Requested start date/time: 02/03/2023 at 8:53 AM; - Disciplines: Physical therapy (PT), Occupational therapy (OT), and Skilled nurse (SN); and - Skilled interventions: ADL’s/IADL’s (Activities of daily living-basic self-care tasks/instrumental activities of daily living-things you do every day to take care of yourself and your home), ambulation/mobility (ambulation-the ability to walk/mobility-to move from place to place), home safety, disease process/management, and medication management. Review of the clinical record showed, in part: - SOC (start of care) was dated 02/07/2023; - OASIS (Outcome and Assessment Information Set- is a standardized data set that measures quality and outcomes) question M0102 (Physician ordered start of care date), was answered with N/A- No specific SOC/ROC (resumption of care) date ordered by the physician; - SOC orders, dated, 02/07/2023 at 10:00 PM, showed, admit to home health on 02/07/2023; - OASIS question M0104 (Date of Referral), was answered with 02/05/2023; - SOC orders, dated, 02/07/2023 at 10:00 PM, showed, admit to home health on 02/07/2023; and - The clinical record failed to show documentation of the reason the SOC was late and no documentation of verbal order being received for late SOC within 48 (forty-eight) hours of the referral and/or the patient returning home. During an interview on 03/28/2023, at 11:00 AM, the pre-designated administrator stated that: - The reason for the late SOC was not documented in the clinical record; - The referral was received on 02/03/2023; and - There is no documentation that shows if the late SOC order was received prior to 02/07/2023.

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 ensure an accurate medication review and/or update of the patient medications was completed in, but not limited to, two of five full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to adversely affect the agency’s ability to ensure safe and effective use of medications for all patients served by the agency. Findings included: Review of the agency’s policy titled “Medication Management” (Policy Number C: 41), dated effective 10/2017 showed: - Home medications shall be administered only with appropriate, current, MD (medical doctor) ordered prescription medications; - Patients shall be evaluated at SOC (start of care), and thereafter for safe handling and memory of their medication regime; - Medication in the home (prescription presently being taken) shall be compared against the ordered medications for discrepancies. Any drug or dosage discrepancy is to be reported to the MD immediately for resolution. All over the counter pills the patient is taking will be recorded on the medication profile; - The agency will have complete and up-to-date medication profiles for each patient; - The medication profile will be a part of the patient's clinical record, with a copy in the patient's home file; - The medication profile shall be completed at SOC/ROC (resumption of care), and follow up assessments for accuracy and updated whenever there is a change in the patient's medications (additions, changing dose, deletions); - Prescription, and all over-the-counter drugs shall be included. Nursing staff shall document drug, dose, route, frequency and duration plan; -Medication lists are updated for each change to reflect current medications, new and/or discontinued medications; - Assess medications at every visit; - Ensure medication profile is correct; and - Address medications with the patient at every visit to identify changes, compliance, questions, or problems to report to the physician. RECORD/PATIENT #2: Review of the current agency medication profile showed, in part: - Tylenol 500 mg (milligram) oral tablet, 1,000mg three times a day by mouth (for pain); - Collagenase santyl 250 U/GM (units per gram) ointment 1 (one) tube wound care topical (prescription ointment used to remove dead tissue from wounds); - Polyethylene glycol 3350 oral powder for reconstitution 300 ml (milliliter) daily (used to treat constipation); - Saccharomyces boulardii LYO (a specific form of yeast used to aid in preventing diarrhea) 250 mg oral capsule three times a day; - Magnesium oxide 400 mg oral tablet daily (mineral supplement); - Magnesium hydroxide/aluminum hydroxide/simethicone (used to treat heartburn, indigestion and upset stomach) 400mg-400mg-40mg/5 ml oral suspension 300ml daily at hs (bedtime); - Meloxicam (nonsteroidal anti-inflammatory medication used to treat relieve pain and reduce inflammation) daily every six hours by mouth; and - Piperacillin-tazobactam (antibiotic to treat infection) 3 G-0.375 G/50 ml intravenous solution daily intravenous (IV). Observation on 03/27/2023 at 12:48 PM, during the patient’s home visit RN A failed to do a medication review/reconciliation. This surveyor requested to observe the medication bottles to compare to the agency’s provided list. The patient refused to allow the surveyor to look at the bottles stating “I know what I am taking and I can just tell you.” Per interview conducted during observation the patient stated that: - He/she takes the Tylenol only as needed; - The collagenase santyl was discontinued a couple weeks ago at the wound clinic; - He/she is not taking the polyethylene glycol; - He/she is not taking the saccharomyces boulardii LYO and that it was probably something he/she was on in the rehab place; - He/she takes 500mg daily of Magnesium oxide; - He/she just takes the Magnesium hydroxide/aluminum hydroxide/simethicone when needed; - Very seldom does he/she take the meloxicam; and - The Piperacillin-tazobactam was completed a long time ago. Per interview conducted during observation, RN A stated that: - The patient gets offended when questioned about their medications; and - You have to tread lightly with the patient. During an interview on 03/29/2023 at 10:32 AM the pre-designated administrator stated that: - What the patient is taking should match the agency’s current medication profile; and - We have no excuses. RECORD/PATIENT #3: Review of the current agency medication profile showed, in part: - Fish oil 1,000mg one capsule twice daily; - Haldol 2mg/ml 1 (one) ml nightly; - Melatonin 6mg nightly; - TAO (triple antibiotic ointment) two times a day; and - It failed to contain Cogentin. Observation on 03/28/2023 at 10:56 AM, during the patient’s home visit RN A failed to do a medication review/reconciliation. This surveyor requested to observe the medication bottles to compare to the agency’s provided current medication profile. Per interview conducted during observation, the DSP (direct support profession) stated that the patient: - Is no longer taking fish oil and hasn’t all month; - Takes Haldol 1 mg tablet every night; - Takes melatonin 5mg nightly; and - Takes Cogentin 1 mg twice daily. Per interview conducted during observation RN B stated that he/she: - Was unaware the patient was taking Cogentin; - Was unaware the patient was taking Haldol in tablet form; and - The triple antibiotic was changed to gentamycin about a week after start of care. During an interview on 03/29/2023 at 10:30 AM the pre-designated administrator stated that he/she would expect the patient to be taking what is on the current medication profile list.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. 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 patient care orders, including verbal orders, were recorded in the plan of care (POC), in two of five full records reviewed (Records/Patients #1 and #5). This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #5: Review of the referral records, dated, 11/01/2022 at 11:27 AM, showed, in part: - Disciplines: Physical therapy (PT) and Occupational therapy (OT; and - Skilled interventions: ADL’s/IADL’s, ambulation/mobility, and home safety. Review of the POC, failed to show the: - PT established treatment plan; and - OT established treatment plan. Findings included: Review of the provider’s policy, titled, “Plan of Care (POC),” dated, 03/01/18, showed, in part: - POC is a written plan that specifies the care and services necessary to meet the patient-specific needs identified in the comprehensive assessment, and the measurable outcomes that the home health provider anticipates would occur as a result of implementing and coordinating the plan of care; - Staff will revise the plan of care, as necessary, to reflect current information from the patient’s updated comprehensive assessment, and to record the patient’s progress towards meeting the patient-specific measurable outcomes and goals, as specified in the plan of care; - The POC includes, in part: * Frequency and duration of visits to be made; and * Patient specific interventions and education; and - All patient care orders, including verbal orders, must be recorded in the plan of care. RECORD/PATIENT #1: Review of the referral records, dated, 02/03/2023 at 8:53 AM, showed, in part: - Disciplines: Physical therapy (PT), Occupational therapy (OT), and Skilled nurse (SN); and - Skilled interventions: ADL’s/IADL’s (Activities of daily living-basic self-care tasks/instrumental activities of daily living-things you do every day to take care of yourself and your home), ambulation/mobility (ambulation-the ability to walk/mobility-to move from place to place), home safety, disease process/management, and medication management. Review of the POC, failed to show: - PT visit frequency and established treatment plan; and - OT visit frequency and established treatment plan. During an interview on 03/29/2023 at 11:00 AM, the pre-designated administrator stated that: - The POC should have all of the disciplines and their visit frequencies; and - PT and OT treatment plans should be on the POC with patient-specific interventions.

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 review, record review, and interview, the home health provider failed to promptly alert the physician to changes in the patient's condition, in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the provider’s policy, titled, “Plan of Care (POC),” dated, 03/01/18, showed, in part: - Promptly alert the physician who is responsible for the provider’s home health POC to any changes in the patient’s condition or needs that would suggest that measurable outcomes are not being achieved and/or that the provider should alter the plan; and - Verbal communication with all physicians providing orders to the home health provider, is performed routinely as changes in the patient’s condition occur or goal achievement is reached. RECORD/PATIENT #1: Review of the clinical records showed, in part: - The POC, showed, notify physician of vital signs out of range: Heart rate (Pulse) greater than 110 or less than 50, temperature greater than 100.4 or less than 96, respirations greater than 24 or less than 12, systolic blood pressure greater than 160 or less than 95, diastolic blood pressure greater than 90 or less than 50, oxygen saturation less than 92, and pain rated greater than 8; - Skilled nurse SOC (start of care) visit, dated 02/07/2023, showed, pulse rate of 113; - SN (skilled nurse) visit note, dated, 02/21/2023, showed, pulse rate of 115; - PTA (physical therapy assistant) visit note, dated, 03/15/2023, showed, pulse rate of 111; and - The clinical record failed to show documentation that the physician was notified of the patient’s pulse rate being greater than 110. During an interview on 03/28/2023 at 11:00 AM, the pre-designated administrator stated that: - There was no documentation of the physician being notified of the heart rate being above 110; and - The physician should have been notified each visit that the patient’s heart rate was above the parameters.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review and interview, the agency failed to ensure the plan of care was revised/updated to address patient's needs in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to adversely affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Plan of Care (POC)” (Policy Number C:48) showed, in part: - Each patient will receive 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 physician; - A plan of care is a written plan that specifies the care and services necessary to meet the patient-specific needs identified in the comprehensive assessment, and the measurable outcomes that “named agency” anticipates would occur as a result of implementing and coordinating the plan of care; - The plan of care is developed by the RN (registered nurse) acting as the PCM (patient care manager), from the comprehensive OASIS (Outcome & Assessment Information Set- a standardized assessment form) assessment; - A revised plan of care must reflect current information from the patient's updated comprehensive assessment and contain info from the patient's progress toward measurable outcomes and goals identified by “named agency” and the home health patient in the plan of care; and - The plan of care is updated/revised at least every 60 days beginning with the SOC date, as new orders are received, and at follow up for recertification periods. RECORD/PATIENT #2: Review of the plan of care dated 01/20/2023 to 03/20/2023 showed Piperacillin-tazobactam (antibiotic) 3G-0.375G/50ml solution daily intravenous with a pharmacy fill amount of 10 doses. Review of the plan of care dated 03/21/2023 to 05/19/2023 showed Piperacillin-tazobactam 3G-0.375G/50ml solution daily intravenous with a pharmacy fill amount of 10 doses. Per interview conducted on 03/27/2023 at 12:48 PM, during the home visit observation the patient stated that the IV antibiotic had completed a long time ago. Per interview conducted on 03/27/2023 at 12:48 PM, during the home visit observation RN A stated that the IV was only for ten days at the start of care. During an interview on 03/29/2023 at 10:32 AM the pre-designated administrator stated that: - The IV medication shouldn’t be on the recertification POC dated 03/21/2023 to 05/19/2023; and - He/she was not sure why it was on there.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation and interview, the agency failed to ensure each patient received updated/current written instructions related to the patient’s medication schedule in, but not limited to, one of three home visit observations (Record/Patient #2). This deficient practice has the potential to adversely accurate administration of medications of all patients admitted to the home care agency. Findings included: Review of the agency’s policy titled “Medication Management” (Policy Number C: 41), dated effective 10/2017 showed: - Home medications shall be administered only with appropriate, current, MD (medical doctor) ordered prescription medications; - The agency will have complete and up-to-date medication profiles for each patient; - The medication profile will be a part of the patient's clinical record, with a copy in the patient's home file; - The medication profile shall be completed at SOC/ROC (resumption of care), and follow up assessments for accuracy and updated whenever there is a change in the patient's medications (additions, changing dose, deletions); -Medication lists are updated for each change to reflect current medications, new and/or discontinued medications; - Assess medications at every visit; - Ensure medication profile is correct; and - Address medications with the patient at every visit to identify changes, compliance, questions, or problems to report to the physician. RECORD/PATIENT #2: Review of the clinical record showed the patient’s most recent recertification was dated 03/21/2023 to 05/19/2023. The patient was receiving skilled nursing services two times weekly to provide wound care to cutaneous abscess (a buildup of pus in the skin) of the buttocks. Observation on 03/27/2023 at 12:48 PM, during the patient’s home visit, the home folder/book was reviewed and failed to contain a current medication list. Per interview conducted during observation, RN A stated that: - He/she messed up. - He/she did not leave a medication list; and - There is a list but it’s from “named agency” (another home care provider). During an interview on 03/29/2023 at 10:30 AM the pre-designated administrator stated that he/she would expect a current/updated medication list left in the patient’s home file.

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, observation, and interview, the agency failed to ensure staff followed acceptable standards of practice for infection control in two (Records/Patients #2 and #3) of three home visit observations. This deficient practice has the potential to adversely affect the safety from infection of all the patients served by the agency. Findings included: According, in part, to McGoldrick, M. (2015), Infection Prevention and Control Program. Saint Simons Island, GA: Home Health Systems, Inc., the following guiding principles should be considered to reduce the risk of product contamination and subsequent patient infection when utilizing irrigation and skin cleansing solution: - Use the smallest (e.g., 50ml (milliliter)) container of solution whenever possible on a one-time use basis; - When using a container of solution that will be used on multiple, separate occasions, write the “discard by” date on the container; and - Store the solution up to 28 (twenty eight) days in a safe place that minimizes the possibility of tampering. Refrigerate the irrigating/skin cleansing solution after opening the container for its initial use to reduce bacterial growth, and warm to room temperature 30 (thirty) minutes prior to use. Review of the agency’s policy titled “Bag Technique: Nursing” (Policy Number C: 8), dated effective 10/2017 showed, in part: - The visit bag is maintained in accordance with infection control policy to prevent potential spread of infection between staff and patients; - In the home, identify a clean and safe area for the visit bag; - Never set the visit bag on the floor or a couch; and - Spread impervious (not allowing entrance or passage) barrier on the surface before setting the bag down. RECORD/PATIENT #2: Observation on 03/27/2023 at 12:48 PM, during the patient’s home visit, RN A was observed placing his/her nursing bag directly on the patient’s dresser. An impervious barrier failed to be placed on the surface before setting the bag down. Per interview conducted during observation, RN A stated that: - A lot of times he/she utilizes a barrier underneath the nursing bag; and - With this patient he/she just uses the dresser. During an interview on 03/29/2023 at 10:32 AM the pre-designated administrator stated that the nurse should follow the agency’s policy by placing a barrier under the bag. RECORD/PATIENT #3: Observation on 03/28/2023 at 10:56 AM, during the patient’s home visit, RN B was observed breeching acceptable standards of practice when he/she was observed: - Placing the nursing bag on the floor and failed to place an impervious barrier on the surface before setting the bag down; and - Utilizing a previously opened/partially filled, undated, 250ml (milliliter) bottle of normal saline to cleanse the patient’s wounds as well as to soak the Hydrofera Blue classic dressing (an antibacterial foam dressing) prior to application to the wounds. Per interview conducted during the observation, RN B stated that he/she: - Does not put a barrier down under the bag; - Thought the barrier was just for supplies; and - Was unaware of a time limitation on an opened multi use bottle of normal saline. During an interview on 03/29/2023 at 10:30 AM the pre-designated administrator stated that he/she: - Would expect the nurse to follow the nursing bag technique policy; and - Would expect the normal saline bottle to be dated after opening and used within the appropriate time frame.

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, record review, and interview, the home health provider failed to ensure a completed discharge summary was 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, in two of two discharge records reviewed (Records/Patients #5 and #6). This deficient practice has the potential to affect all discharged or transferred patients served by the agency. RECORD/PATIENT #5: Review of the clinical record showed a discharge OASIS (Outcome and Assessment Information Set- is a standardized data set that measures quality and outcomes) was completed on 01/03/2023; and - A discharge summary was not completed until 01/15/2023. During an interview on 03/29/2023 at 10:21 AM, the pre-designated administrator stated that he/she would expect the discharge summary completed and sent to the primary MD within five business days of discharge. Findings included: Review of the provider’s policy, titled, “Discharge/Reduction in Services,” dated, 03/01/18, showed: - The home health provider will verbally and in writing, notify the patient of the decision to terminate/reduce services at least 5 (five) days prior to the change in service is to occur; and - A completed discharge summary will be sent to the primary MD (medical doctor) within 5 business days of discharge. Review of the provider’s policy, titled, “Transfers,” dated, 10/2017, showed: - A transfer summary will be completed and sent within 2 (two) business days of a planned transfer if the care will be immediately continued in the health care facility; and - A transfer summary will be completed and sent within 2 business days of becoming aware if the unplanned transfer if the patient is still receiving care in the health care facility at the time when the home health provider becomes aware of the transfer. RECORD/PATIENT #6: Review of the clinical record, showed: - A discharge OASIS (Outcome and Assessment Information Set- is a standardized data set that measures quality and outcomes) was completed on 03/08/2023, with a narrative note that showed, SN (skilled nurse) was notified that the patient’s PICC (peripherally inserted central catheter- a thin, flexible tube that is inserted into a vein and guided into a large vein above the right side of the heart called the superior vena cava) line was removed and no longer needing SN; and - A discharge summary was not completed until 03/19/2023. During an interview on 03/28/2023 at 11:00 AM, the administrator stated that, the discharge summary was completed and sent to the physician late.