Every finding on record at Pruitthealth Home Health,Inc

A recertification survey was conducted 4/27/26-4/29/26. No deficiencies for Emergency Preparedness were identified.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to provide notice of the patient’s rights and responsibilities in a language understandable for 1 of 1 patient with Spanish as the preferred language (# 11). Findings included: A policy, Meaningful Access for Patients with Limited English Proficiency (revised 10/26/2016), received on 04/28/26 at approximately 4:00 PM from the agency director stated, “It is the policy of [agency name] and it’s affiliated providers… to provide meaning access to each individual with Limited English Proficiency (LEP)… [agency name] contracts with [agency name], a qualified interpreter and translator service…” The agency Patient Admission Book (not dated) received on 04/27/26 at 10:15 AM from the administrator stated, “Patient’s Bill of Rights… Right to Be Informed and Involved in Your Care. You have the right to be informed of your rights before care begins, in a language you understand…” Patient #11 was admitted on 03/23/26 with a diagnosis of Congestive Heart Failure (heart can not pump blood effectively]. The plan of care for 3/23/26-5/21/26 included orders for Skilled Nursing to Assess and Evaluate 3/20/26 through 3/24/26 and 1 time a week for 9 weeks. A review of the clinical record revealed that on 3/23/26 registered nurse (RN) #10 documented, “What is your preferred language? Spanish. Do you need or want an interpreter to communicate with a doctor or health care staff? 1. Yes” Further review revealed that there was no documentation that RN #10 utilized an interpreter for the admission or provided the patient with the patient rights and responsibilities in Spanish. A review of the agency’s patient admission book revealed that it was written only in English. During an interview conducted on 4/29/26 at 9:20 AM RN#10 stated, “No [did not use a translator] … Yes [provided the patient rights in Spanish] … I gave them the patient handbook, the other agencies that I have worked for included Spanish in the handbook…” During an interview conducted on 4/28/26 at 4:27 PM the agency administrator stated that the agency’s does not have the patient right available in Spanish. During an interview conducted on 4/29/26 at 9:24 AM the administrator stated, “Everyone has access to the language line; she (RN#10) should have used it.”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy, observation, clinical record review, and staff interviews, the agency failed to include all medications in the plan of care for 1 of 2 patients with a urinary tract infection (#3); and 1 of 2 patients with a home visit conducted (#17). Findings included: A policy, Medication Management for Home Health (revised 7/21/21) received on 4/29/26 at 11:18 AM from the administrator stated, “The home health agency will maintain accurate documentation of all medications that the patient is taking.” 1. Patient #3 was admitted on 9/18/25 with a diagnosis of encounter for orthopedic aftercare following a surgical amputation. The plan of care for 9/18/25-11/16/25 included orders for physical therapy (PT) 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 5 weeks. Review of the clinical record reveal that on 11/13/25 PT #9 completed a discharge from PT not from the agency and documented, “Patient reports that he is doing fine other than a urinary infection which he is being treated with antibiotics.” Further review revealed that the antibiotic was not included on the medication list. During an interview conducted on 4/29/26 at 10:39 AM PT #9 stated, “Normally I would add the med but may not have because it was a discharge…” 2. Patient #17 was admitted on 4/20/26 with a diagnosis of, Athscl native arteries of left leg w ulceration oth prt foot (plaque build up in left leg arteries with a wound). The plan of care for 4/20/26-6/18/26 included orders for skilled nurse visits 1 time a week for 3 weeks. During a home visit conducted on 4/28/26 at 11:30 AM with registered nurse #5 the patient’s spouse stated that patient #17 was prescribed oxycodone (narcotic pain medication) 5mg as needed. Review of the clinical record revealed that oxycodone was not included on the medication list. Further review revealed that RN #5 did not update the medication list after the visit. RN #5 was not available for an interview. An interview conducted on 4/29/26 at 11:34 AM with the agency administrator revealed that the medications should have been included in the plan of care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the occupation therapist failed to contact the physician for an order prior to documenting an order for a delayed assessment for 1 of 3 patients with a delayed occupation therapy assessment (#9). Findings included: A policy, Plans of Care for Home Health Patients (revised 11/06/2018), received on 4/28/26 at 8:00 AM from the administrator stated, “If a physician refers a patient under a plan of care that can not be completed until after an evaluation visits, the physician is consulted to approve additions or modification to the original plan.” Patient #9 was admitted on 3/29/26 with a diagnosis of acute kidney failure. The plan of care for 3/29/26-5/27/26 included orders for occupational therapy (OT) assess and evaluate the week of 3/30/26-4/04/26. Review of the clinical record revealed that on 4/03/26 OT# 13 documented, “OT eval scheduled for week of 4/5.” An interview conducted on 4/29/26 at 9:37 AM with OT #13 revealed that order for the delay in the evaluation was documented in the plan of care without contacting a physician. An interview conducted on 4/29/26 at approximately 9:40 AM with the administrator revealed that the physician should be contacted to obtain a verbal order prior to documenting an order and changing the plan of care.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Condition level Determination The cumulative effect of this systemic problem resulted in the agency’s ability to ensure that the physicians are promptly notified of the need for changes to the plan of care and the inability to complete care as ordered. Cross Refer to 484.75(b)(7), Tag G0718; Cross Refer to 484.75(b)(3) Tag G0710; Cross Refer to 484.75(c)(1), Tag G0726.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on agency policy, observation, clinical record review and staff interviews, the registered nurses failed to obtain PICC (peripherally inserted central catheter) line measurements for 1 of 3 patients with a PICC line (#12); and failed to obtain Labs for 1 of 3 patients with lab orders (#13); and failed to measure wounds for 1 of 8 patients with wound (#17). Findings included: A policy, Coordination and Management of Home Health Services (revised 9/22/22), received on 4/28/26 at 4:00 PM from the administrator stated, “Services are provided in accordance with the attending physician’s orders and the written plan of care…” A policy, Skilled Nursing Services for Home Health (revised 11/21/22), received on 4/28/26 at 4:00 PM from the administrator stated, “The home health agency will provide nursing services to the extent necessary to meet the needs of the patient as ordered by the physician.” 1. Patient #12 was admitted on 1/24/26 with a diagnosis of postsurgical malabsorption (inability of intestines to absorb nutrients). The plan of care for 3/25/26-5/23/26 included orders for skilled nurse visits 1 time a week for 9 weeks with 2 PRN (as needed) and, “Skilled nurse to change PICC [peripherally inserted central catheter] line dressing weekly and as needed… PICC line should be measured from insertion site to hub weekly…” Review of the clinical record revealed that for the SN visits on 3/27/26, 4/03/26, 4/15/26, and 4/24/26 registered nurse (RN) #8 failed to document the PICC line measurement. During an interview conducted on 4/29/26 at 9:14 AM RN #8 stated, “That, [PICC line measurements] I did not do… I looked at it and it didn’t change.” An interview conducted on 4/29/26 at 1:30 PM with the administrator revealed that the PICC line should be measured as ordered. 2. Patient #13 was admitted on 3/28/26 with a diagnosis of acute and subacute infective endocarditis (infection of the inner heart valves). The plan of care for 3/28/26-5/26/26 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 1 time a week for 9 weeks and, “Labs to be obtained weekly beginning with 3/30/26 Using a septic [sic] technique, skilled nurse to obtain Weekly CBC with diff [compete blood count] and CMP [comprehensive metabolic panel] while on IV cefazolin [antibiotic] …” and “cefazolin 2 g Intravenous powder for injection; Inject 2 gm(s) intravenously…” Review of the clinical record revealed that for the SN visit on 4/27/26 there was no documentation that RN #8 completed the labs. An interview conducted on 4/29/26 at 8:55 AM revealed that RN #8 did not complete the lab order. An interview conducted on 4/29/26 at 9:00 AM with the administrator revealed that the expectation is for labs to be drawn if ordered. 3. Patient #17 was admitted on 4/20/26 with a diagnosis of, Athscl native arteries of left leg w ulceration oth prt foot (plaque buildup in left leg arteries with a wound). The plan of care for 4/20/26-6/18/26 included orders for skilled nurse visits 1 time a week for 3 weeks and “Venous ulcer/Left Scattered Foot Great Toe Cleanse wound with vase [sic] soak 5-10 minuted [sic]. Pat dry Apply iodoflex [wound dressing] to wound bed, cover with gauze, secure with tape on Tuesday and Friday.” During a home visit conducted on 4/28/26 at 11:30 AM with registered nurse (RN) #5 failed to obtain measurements of the left foot great toe wound and failed to assess and measure a new wound on the right shin. An interview conducted on 4/28/26 at approximately 12:00 PM revealed that RN #5 was not aware of the agency’s policy on wound measurements. An interview conducted on 4/29/26 at approximately 1:00 with the administrator revealed that the expectation is for wound to be measured weekly.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on agency policy, observation, clinical record review, patient/caregiver interviews, staff interviews, the clinicians failed to provide services as ordered in the plan of care for 6 of 16 active patients (#’s 8, 9, 11, 14, 18, &20). Findings included: A policy, Coordination and Management of Home Health Services (revised 9/22/22), received on 4/28/26 at 4:00 PM from the administrator stated, “Services are provided in accordance with the attending physician’s orders and the written plan of care…” Findings included: 1. Patient #8 was admitted on 1/19/26 with a diagnosis of pressure ulcer of the sacral region, stage 3 (full-thickness wound at the base of the spine). The plan of care for 1/19/26-5/18/26 included orders for skilled nurse (SN) visits 1 time a week for 1 week and 2 times a week for 7 weeks. Review of the clinical record revealed there was no evidence that the patient refused the visits or was unavailable for the SN visits that were not conducted on 3/31/26, 4/07/26, 4/14/26. 4/17/26, 4/21/26, and 4/24/26. 2. Patient #9 was admitted on 3/29/26 with a diagnosis of acute kidney failure. The plan of care for 3/29/26-5/27/26 included orders for skilled nurse (SN) visits 1 time a week for 6 weeks; and occupational therapy (OT) assess and evaluate 3/30/26-4/04/26. Review of the clinical record revealed no nursing visit was made the week of 4/17/26 nor was the OT evaluation conducted. Further review of the clinical record revealed there was no evidence that the patient refused the visits or was unavailable 3. Patient #11 was admitted on 3/23/26 with a diagnosis of acute on chronic diastolic (congestive) heart failure (heart with ineffective pumping of blood). The plan of care for 3/23/26-5/21/26 included orders for skilled nurse (SN) visits 1 time a week 9 weeks. Review of the clinical record revealed there was no evidence that the patient refused the visits or was unavailable for the SN visits of 4/03/26, 4/07/26 that were not conducted. 4. Patient #14 was admitted on 3/19/26 with a diagnosis of malignant neoplasm of the parietal lobe (brain cancer). The plan of care for 3/19/26-5/17/26 included orders for skilled nurse (SN) visits 1 time a week for 4 weeks; and speech therapy (ST) visits 1 time a week for 7 weeks. Review of the clinical record revealed there no nursing visits made the week of 4/1/26 nor 4/15/26; no ST visit was conducted the week of 4/13/26. Further review of the revealed that there was no evidence that the patient refused the visits or was unavailable 5. Patient #18 was admitted on 3/17/26 with a diagnosis of peritoneal abscess (collection of pus in the abdomen). The plan of care for 3/17/26-5/15/26 included orders for skilled nurse (SN) visits 1 time a week for 8 weeks, home health aide (HHA) visits 1 time a week for 9 weeks, and occupational therapy (OT) 0 times a week for 1 week and 1 time a week for 3 weeks. Review of the clinical record revealed there was no SN visit was made the week of 4/25/26; no HHA visits were conducted for the weeks of 3/27/26, 4/03/26, 4/10/26 or 4/17/26; and no OT visits were conducted the week of 3/31/26. Review of the clinical record revealed there was no evidence that the patient refused the visits or was unavailable. During a home visit was conducted on 04/28/26 at 12:00 PM an interview with the patient revealed that patient #18 did not know why a nurse didn’t come the week before and stated that she liked the HHA visit and didn’t know why it stopped. 6. Patient #20 was admitted on 3/09/26 with a diagnosis of acute and subacute infective endocarditis (infection of the inner heart valves). The plan of care for 3/09/26-5/07/26 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 2 times a week for 1 week, and 1 time a week for 7 weeks. Review of the clinical record revealed there was no documentation any completed SN visits after 3/17/26. During an interview conducted on 4/28/26 at 3:09 PM the patient stated, “I haven’t had [agency name] in more that 35 days. I was in the hospital.” During an interview conducted on 4/29/26 at 10:20 AM RN #11 stated, “They were missed because we couldn’t contact them or doctors’ appointments. I need to go back and make sure that they submitted…” An interview conducted on 4/29/26 at 11:29 AM with HHA #12 revealed that they did not know who the patient was and stated, “I’m guessing that I was calling and didn’t get an answer…” During an interview conducted on 4/29/26 at 10:27 AM LPN #6 stated, “If I miss a patient I try to put why…” During an interview conducted on 4/29/26 at 10:02 AM OT #15 stated, “I had this assigned to another OT because it’s out of my area.” RN #5 was not available for an interview. An interview conducted on 4/29/26 at 11:20 AM with the administrator revealed that the expectation is for of all missed visit documentation to include the reason why it was not conducted.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency policy, observation, clinical record review, and staff interviews, the agency failed to provide accurate documentation for 6 of 20 patients with record reviews. (#2, 3, 13, 18, &19). Findings included: A policy, Home Health Clinical Record (Revised 11/12/18), received on 4/28/26 at 8:00 AM from the administrator stated, “Information contained in the clinical record is to be complete, promptly and accurately documented…” 1. Patient #2 was admitted on 12/3/25 with a diagnosis of Unspecified fracture of left patella (kneecap). The plan of care for 12/3/25-1/31/26 included orders for skilled nurse visits 1 time a week for 8 weeks and “Assess blood sugar monitoring and results.” Review of the clinical record revealed that there was no diagnosis or medication that would indicate that there was a need to monitor blood sugars. During an interview conducted on 4/29/26 at 10:23 AM RN #11 stated, “She said she was diabetic, so I know she checked her blood sugar. Or if not, I need to go in and change that.” 2. Patient #3 was admitted on 9/18/25 with diagnoses of encounter for orthopedic aftercare following a surgical amputation and type 2 diabetes mellitus. The plan of care for 9/18/25-11/16/25 included orders for physical therapy (PT) 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 5 weeks and “Trulicity Pen 3mg/0.5mL [injectable diabetes medication] subcutaneous solution; Inject 3 milliliter(s) subcutaneously.” Review of the clinical record revealed the following: On 9/30/25 PT #9 documented, “Diabetes… Diet controlled Oral-Hypoglycemics… Patient reports pain over the medial aspect of the left eye, especially with knee flexion…” On 10/21/25 PT #9 documented, “… however has not been able to progress to no weight-bearing status on the left lung…” During an interview conducted on 4/29/26 at 10:39 AM with PT #9 stated, “Eye should be leg and lung should be lower leg.” On 10/30/25 PT #9 documented, “Diabetes… Diet controlled Oral-Hypoglycemics… they will transfer sit to stand weight-bearing on the left leg somebody to walker…” On 11/6/25 PT #9 documented, “Diabetes… Diet controlled.” On 11/13/25 PT #9 documented, “Diabetes… Oral-Hypoglycemics.” During an interview conducted on 4/29/26 at 10:39 AM with PT #9 stated, “Generally, I look at the medication list [before documenting diabetes management]. I try to proofread my notes” 4. Patient #13 was admitted on 3/28/26 with a diagnosis of acute and subacute infective endocarditis (infection of the inner heart valves). The plan of care for 3/28/26-5/26/26 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 1 time a week for 9 weeks and physical therapy (PT) visits 2 times a week for 3 weeks. Review of the clinical record revealed that on 4/17/26 PT #17 documented “Patient in seated physician upon arrival” and on 4/27/26 RN #8 documented, “Interventions Performed this Visit Infusion therapy/Venous catheter care.” Further review revealed that there was no order for venous catheter care. During an interview conducted on 4/29/26 at 9:16 AM PT #17 stated, “He was seated on a couch.” During an interview conducted on 4/29/28 at 8:55 AM RN #8 stated, “That was a mistake, I would not be doing venous catheter care.” 5. Patient #18 was admitted on 3/17/26 with a diagnosis of peritoneal abscess (collection of pus in abdominal cavity). The plan of care for 3/17/26-5/15/26 included orders for home health aide (HHA) visits 1 time a week for 9 weeks. Review of the clinical record revealed that HHA #12 documented that a tub bath, a shower chair shower, a partial bath, a complete shower was completed and documented, “She got washed off.” During an interview conducted on 4/29/26 at 10:56 AM HHA #12 stated, “I probably gave her shower… if the shower is in a bathtub then it’s all off them.” 6. Patient #19 was admitted on 3/21/26 with a diagnosis of hypertensive heart and chronic kidney disease. The plan of care for 3/21/26-5/19/26 included orders for skilled nurse visits 2 times a week for 2 weeks and 1 time a week for 7 weeks. Review of the clinical record revealed that on 3/30/26 registered nurse (RN) #5 documented that the PICC line (Peripherally Inserted Central Line, long term intravenous access) dressing was intact. Further review revealed that the patient did not have a PICC line. A home visit was conducted on 4/28/26 at 1:15 PM. During a home visit conducted on 4/28/26 at 1:15 PM it was confirmed that the patient did not have a PICC line. RN #5 was not available for an interview. An interview on 4/29/26 at approximately 1:30 PM with the administrator revealed that the expectation is for the documentation to be accurate.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, observation, and staff interviews, the registered nurses, physical therapist, occupational therapist, and home health aides failed to notify the physicians of missed visits for 13 of 16 active patient records reviewed (#’s 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 18, 19, 20); and failed to notify the physician of a new wound for 1 of 8 patients with wounds (#17); and failed to notify the physician of a low blood pressure (#6); and failed to notify the physician of a newly identified patient which needed a medical social work (MSW) consult for 1 of 6 patient requiring a MSW (#9). Findings included: A policy, Coordination and Management of Home Health Service (revised 9/22/22), received on 4/28/26 at 4:00 PM from the administrator stated, “Services are provided in accordance with the attending physician’s orders… The Clinician will communicate with the team members and the physician regarding the patient’s status and response to the plan of treatment as often as indicated … Coordination of care efforts/outcomes will be documented in the patient’s medical record…” A policy, Skilled Nursing Services for Home Health (revised 11/21/22), received on 4/28/26 at 4:00 PM from the administrator stated, “Nursing visits are individually based on the need, but not necessarily limited, to: … Inform the physician of the patient’s condition…” A policy, Assessments and Reassessments-Home Health (revised 6/19/24), received on 4/28/26 at 4:00 PM from the administrator stated, “The physician will be notified of all findings to obtain appropriate orders.” 1. Patient #6 was admitted on 1/23/26 with a diagnosis of unspecified open wound. The plan of care for 1/23/26-3/23/26 included orders for skilled nurse (SN) visits 3 times a week for 9 weeks and, “Report parameters to MD/NPP outside: Systolic blood pressure > [greater than] 140 90 <60.” Review of the clinical record revealed no nursing visits were made on 1/30/26, 2/2/26, or 3/5/26. Further review of the clinical record revealed there was no documentation of the physician being notified of the missed nursing visits. Further review revealed that on 2/6/26 LPN #18 documented a blood pressure of 98/56. There was no documentation of the physician being notified. 2. Patient #7 was admitted on 3/15/26 with a diagnosis of hypersomnia (severe sleepiness). The plan of care for 3/15/26-5/13/26 included orders for skilled nurse (SN) visits 1 time a week for 8 weeks and occupational therapy (OT) visits 1 time a week for 1 week, 0 times a week for 3 weeks, and 1 time a week for 1 week. Review of the clinical record revealed there was no documentation of the physician being notified that on 4/1/26 and 4/14/26 the SN visits were not conducted and on 3/18/26, 4/10/26 the OT visits were not conducted. 3. Patient #8 was admitted on 1/19/26 with a diagnosis of pressure ulcer of the sacral region, stage 3 (full-thickness wound at the base of the spine). The plan of care for 1/19/26-5/18/26 included orders for skilled nurse (SN) visits 1 time a week for 1 week and 2 times a week for 7 weeks. Review of the clinical record revealed no nursing visits were made on 3/31/26, 4/07/26, 4/14/26, 4/17/26, 4/21/26, or 4/24/26. There was no documentation of the physician being notified of the missed SN visits. 4. Patient #9 was admitted on 3/29/26 with a diagnosis of acute kidney failure. The plan of care for 3/29/26-5/27/26 included orders for skilled nurse (SN) visits 1 time a week for 6 weeks and occupational therapy (OT) assess and evaluate the week of 3/30/26-4/04/26. Review of the clinical record revealed no nursing visit was made the week of 4/17/26 nor was the OT evaluation conducted. The clinical record revealed no evidence of the physician being notified of the missed nursing visit or the missed OT evaluation. 5. Patient #10 was admitted on 2/24/26 with a diagnosis of cellulitis of left upper limb (serious bacterial infection). The plan of care for 2/24/26-4/24/26 included orders for skilled nurse (SN) visits 1 time a week for 6 weeks. Review of the clinical record revealed there was no nursing visits were made for the weeks 3/11/26 or 3/18/26. Further review of documentation revealed no evidence of the physician being notified of the missed nursing visits. 6. Patient #11 was admitted on 3/23/26 with a diagnosis of acute on chronic diastolic (congestive) heart failure (heart with ineffective pumping of blood). The plan of care for 3/23/26-5/21/26 included orders for skilled nurse (SN) visits 1 time a week 9 weeks. Review of the clinical record revealed no nursing visits were conducted for the weeks of 3/25/26, 4/03/26, 4/07/26. Further review of the clinical record revealed no documentation of the physician being notified of the missed nursing visits 7. Patient #13 was admitted on 3/28/26 with a diagnosis of acute and subacute infective endocarditis (infection of the inner heart valves). The plan of care for 3/28/26-5/26/26 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 1 time a week for 9 weeks, physical therapy (PT) visits 2 times a week for 3 weeks, and occupational therapy (OT) 1 time a week for 7 weeks. Review of the clinical record no nursing visits were conducted; no PT visits were made on 4/22/26 or 4/27/26; no OT visit was conducted on 4/2/26. Further review revealed there was no documentation of the physician being notified of the missed visits. 8. Patient #14 was admitted on 3/19/26 with a diagnosis of malignant neoplasm of the parietal lobe (brain cancer). The plan of care for 3/19/26-5/17/26 included orders for skilled nurse (SN) visits 1 time a week for 4 weeks and speech therapy (ST) visits 1 time a week for 7 weeks. Review of the clinical record revealed there no nursing visits made the week of 4/1/26 nor 4/15/26; no ST visit was conducted the week of 4/13/26. Further review revealed no documentation of the physician being notified of the missed visits. 9. Patient #15 was admitted on 2/28/26 with a diagnosis of occlusion and stenosis of bilateral carotid arteries (narrowing and blockage of the large artery of the neck). The plan of care for 2/28/26-4/28/26 included orders for occupation therapy (OT) 1 time a week for 9 weeks. Review of the clinical record revealed no OT visit was made for the week of 3/05/26 or 3/11/26. Further review revealed no evidence that the physician was notified of the missed OT visits. 10. Patient #16 was admitted on 1/30/26 with a diagnosis of Non-ST elevation myocardial infarction (heart attack). The plan of care for 1/30/26-3/30/26 included orders for physical therapy (PT) 2 times a week for 2 weeks and 1 time a week for 7 weeks. Review of the clinical record revealed there was no PT visit was made the week of 4/23/26. Further review revealed that on 4/06/26 OT #13 documented, “Community resource needs identified Other: MSW to assist.” Further review revealed that was no documentation of the physician being notified that the patient needed MSW visits or of the missed PT visit. 11. Patient #17 was admitted on 4/20/26 with a diagnosis of, Athscl native arteries of left leg w ulceration oth prt foot (plaque buildup in left leg arteries with a wound). The plan of care for 4/20/26-6/18/26 included orders for skilled nurse visits 1 time a week for 3 weeks. During a home visit conducted on 4/28/26 at 11:30 AM with registered nurse #5 the spouse reported a new wound to the right shin, which was covered by a bandage. When the spouse began to remove the dressing for the RN to assess RN #5 stated, “Don’t worry about it” and failed to notify the physician of the new wound. 12. Patient #18 was admitted on 3/17/26 with a diagnosis of peritoneal abscess (collection of pus in the abdomen). The plan of care for 3/17/26-5/15/26 included orders for skilled nurse (SN) visits 1 time a week for 8 weeks, home health aide (HHA) visits 1 time a week for 9 weeks, and occupational therapy (OT) 0 times a week for 1 week and 1 time a week for 3 weeks. Review of the clinical record revealed there was no SN visit was made the week of 4/25/26; no HHA visits were conducted for the weeks of 3/27/26, 4/03/26, 4/10/26 or 4/17/26; and no OT visits were conducted the week of 3/31/26. Further review of the clinical record revealed no evidence the physician was notified of the missed visits. 13. Patient #19 was admitted on 3/21/26 with a diagnosis of hypertensive heart and chronic kidney disease. The plan of care for 3/21/26-5/19/26 included orders for skilled nurse (SN) visits 2 times a week for 2 weeks and 1 time a week for 7 weeks and physical therapy (PT) 0 times a week for 1 week and 2 times a week for 7 weeks. Review of the clinical record revealed no SN visits were made on 4/17/26 and 4/20/26; no PT visits were conducted on 3/24/26, 4/7/26, 4/11/26 4/17/26, and 4/25/26; and no OT visit was conducted on 3/24/26. Further review of the clinical record revealed no evidence the physician was notified of the missed visits. 14. Patient #20 was admitted on 3/09/26 with a diagnosis of acute and subacute infective endocarditis (infection of the inner heart valves). The plan of care for 3/09/26-5/07/26 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 2 times a week for 1 week, and 1 time a week for 7 weeks. Review of the clinical record revealed there was no SN visit conducted on 3/20/26. Further review of the clinical record revealed no evidence the physician was notified of the missed visit. The following interviews were conducted regarding missed visits: RN #5 was not available for an interview. During an interview on 4/29/26 at 9:50 AM RN #14 stated, “Normally, I would notify the physician… and document it.” During an interview conducted on 4/29/26 at 10:27 AM LPN #6 stated, “If I miss a patient I try to document why and notify the doctor.” An interview conducted on 4/29/26 at 10:56 AM with HHA #12 revealed that they were not aware of the need to document notification of missed visits. An interview conducted on 4/29/26 at 10:20 AM with RN #11 revealed that they are aware that the physician needs to be notified of missed visits. An interview conducted on 4/29/26 at 9:37 AM with OT #13 revealed that they thought the MSW was already ordered. An interview conducted on 4/29/26 at 11:20 AM with the administrator revealed that the expectation is for the clinicians to notify the physician by telephone of all missed visits, changes of conditions, and any need to change the plan of care.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, the registered nurse documented Licensed Practical Nurse (LPN) supervisory visits for patients that did not receive care from an LPN for 3 of 16 active patients (#13, 17, 19). Findings included: A policy, Plans of Care for Home Health Patients (revised 11/06/2018), received on 4/28/26 at 8:00 AM from the administrator stated, “Nursing services will be provided under the direction of a Registered Nurse (RN)… The RN will monitor and evaluate LPN/LVN performance…” Patient #13 was admitted on 3/28/26 with a diagnosis of acute and subacute infective endocarditis (infection of the inner heart valves). The plan of care for 3/28/26-5/26/26 included orders for skilled nurse (SN) visits 0 times a week for 1 week, 1 time a week. Review of the clinical record revealed that on 04/01/26 and 04/15/26 RN #5 documented LPN supervisory visits. Further review revealed that the patient had not received any LPN visits. Patient #17 was admitted on 4/20/26 with a diagnosis of, Athscl native arteries of left leg w ulceration oth prt foot (plaque buildup in left leg arteries with a wound). The plan of care for 4/20/26-6/18/26 included orders for skilled nurse visits 1 time a week for 3 weeks. Review of the clinical record revealed that on 4/28/26 RN #5 documented an LPN supervisory visit. Further review revealed that the patient had not received any LPN visits. Patient #19 was admitted on 3/21/26 with a diagnosis of hypertensive heart and chronic kidney disease. The plan of care for 3/21/26-5/19/26 included orders for skilled nurse (SN) visits 2 times a week for 2 weeks and 1 time a week for 7 weeks. Review of the clinical record revealed that on 3/30/26 RN #5 documented an LPN supervisory visit. Further review revealed that the patient had not received any LPN visits. RN #5 was not available for an interview. During an interview conducted on 4/29/26 at 1:21 PM the administrator stated, “She [RN #5] should not document a supervisory visit for an LPN if they [LPN] haven’t seen the patient.”

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 agency policy, clinical record review, and staff interviews the agency failed to notify the physician of a patient’s weight change for 1 of 1 patient with orders for weight monitoring (#2) and of a patient’s noncompliance of medication orders 1 of 6 active patients. (#6) Findings included: A policy, CHF [congestive heart failure]: Obtaining Weights and measurements (Updated 06/28/23) was received on 10/31/2023 from the agency director at approximately 11:00 A.M. The policy stated, “All clinicians are to report a weight increase of 2-3 lbs. [pounds] overnight and/or 5 lbs. in 7 days.” A policy, Plans of Care for Home Health Patients (Revised 11/06/18) was received on 10/31/2023 from the agency director at approximately 11:00 A.M. The policy stated, “The HHA [Home Health Agency] must promptly alert the physician…to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or the plan of care should be altered.” 1. Patient #2 was admitted on 08/15/2023 with diagnoses of reaction due to indwelling urethral catheter (urinary catheter), chronic diastolic congestive heart failure (CHF), and chronic kidney disease. The plan of care (POC) for 10/14/2023-12/12/2023 included orders for physical therapy (PT) visits 2 times a week for 2 weeks and 1 time a week for 6 weeks, and licensed professional to report… weight > [greater than] 182 [pounds]. The PT visit of 10/20/23 PTA #2 stated, “Weight (lbs) 180.” The PT visit of 10/23/23, PTA #2 stated, “Weight (lbs) 187.2. Called Office [physician], after hours and not taking messages. Will followcup [sic] tomorrow morning.” There was no evidence in the clinical record of physician notification. An interview was conducted with PTA #2 on 10/30/2023 at approximately 2:00 P.M. PTA #2 stated, “Generally, is that I would call in the morning and do that, after I did that, I talked to patient about calling the doctor’s office, I explained why the doctor’s office wanted to know. I forgot to do that [call the physician] the next morning.” An interview was conducted with the agency director on 10/30/2023 at 2:05 P.M. The agency director stated, “The expectation is to get some medical professional on the phone. With no symptoms we would want to speak to a doctor within 24 hours. The PTA should notify the clinical manager to reduce hospitalization and document follow up.” 2. Patient #6 was admitted on 10/05/2023 with diagnoses of displacement intertrochantic fracture of left femur (type of hip fracture) and acute respiratory failure with hypoxia (deficiency of oxygen to the tissues of the body). The plan of care (POC) for 10/05/2023-12/03/2023 included orders for occupational therapy (OT) visits 1 time a week for 1 week, 2 times a week for 2 weeks and, 1 time a week for 6 weeks and OT to review and reconcile medications every visit. The OT visit of 10/13/2023 OT #5 stated, “Reports although she [spouse] is not giving the patient his furosemide [diuretic to treat fluid retention] he is still up multiple times per night” There was no evidence in the clinical record of the physician being notified. OT #5 did not notify the doctor that the patient was not taking furosemide as ordered. OT #5 was unavailable for an interview. An interview was conducted with the agency director on 10/31/2023 at 12:30 P.M. The agency director stated, ““The doctor should have been notified.”

An onsite recertification survey was conducted May 1, 2023 - May 3, 2023. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted May 1, 2023 - May 3, 2023. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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 interviews the agency failed to notify the physician of refusals of treatment for 1 of 1 patient with frequent refusals of treatment. (Patient # 15) Findings included: Patient #15 was admitted on 11/24/2022 with a diagnoses of Chronic Venous ulcer and inflammation of the right lower extremity, chronic venous hypertension with ulcer and inflammation of the left lower leg, and lymphedema. The Plan of Care (POC) for 03/24/2023-05/22/2023 included orders for skilled nurse visits 1 time a week for 1 week and 3 times a week for 8 weeks. Skilled nurse orders were to perform/teach wound care to bilateral lower extremity wounds. Review of the skilled nursing notes revealed measurements were not obtained for the weeks of 03/26/23, 04/09/23, 04/16/23, and 04/24/23. There was no evidence of notification to the physician for the weeks of 04/16/23 and 04/24/23.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visits, and staff interviews, the agency failed to include all medications in the plan of care for 3 of 4 patients with home visits. (Patient #13, 11, 14) Findings included: 2. Patient #11 was admitted on 12/02/22 with diagnoses of pressure ulcer to sacral region, stage 4; type 2 diabetes, essential hypertension and vitamin d deficiency. The plan of care for 04/01/23 to 05/30/23 had orders for skilled nursing 3 times a week for 8 weeks, and 1 time a week for 1 week. A home visit with the registered nurse was observed on 05/03/23 at 10:00 a.m. The medication review during the home visit revealed the following discrepancy: brilinta (blood thinner) 90mg 1 tablet by mouth twice a day. Interview with the patient confirmed she had been taking this medication since November 2022. 3. Patient #14 was admitted was admitted on 03/23/23 with diagnoses of dehydration, sprain of left ankle, bilateral osteoarthritis, essential hypertension and constipation. The plan of care for 03/23/23 to 05/21/23 had orders for physical therapy 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 6 week. Occupational therapy 1 time a week for 1 week, 2 times a week for 3 weeks, and 1 time a week for 5 weeks. A home visit with the occupational therapist assistant was observed on 05/02/23 at 12:00 p.m. The medication review during the home visit revealed the following discrepancies: carvedilol (blood pressure) 25 mg (milligrams) by mouth 2 times a day and spironolactone (fluid pill) 50 mg 1 tablet daily by mouth. Interview with patient confirmed she had been taking these medications since 4/4/23. A policy, Medication Management for Home Health (revised 07/21/21) was received from the agency Administrator on 05/02/23 at approximately 3:00 P.M. The policy stated, “Upon the patient’s admission, all medications, including prescribed, OTC (over the counter) and herbal, will be included in the medication profile.” 1. Patient #13 was admitted on 02/14/23 with a diagnosis of unspecified fall, subsequent encounter, congestive heart failure, and urinary tract infection. The Plan of Care (POC) included orders for physical therapy 2 times a week for 2 weeks and 1 time a week for 6 weeks and occupational therapy (OT) 1 time a week for 8 weeks. On 05/02/2023 a home visit was conducted with OT #3 at approximately 11:15 A.M. The comprehensive medication review found that Patient #13 had been taking melatonin 1 time a day (used for a sleep aid), Vitamin C 1,000mg 1 time a day (used as a supplement), Fish oil 1,200mg 1 time a day (used for a supplement) and multivitamin 1 time a day. There was no evidence of these medications in the POC. Patient #13 stated, “I’ve taken those for a long time.” An interview was conducted with OT #3 on 05/02/23 at approximately 12:00 P.m. OT #3 stated, “If I had done the start of care, I would have added them (to the POC). An interview was conducted with the Agency Director on 05/02/23 at approximately 12:45 P.M. The Agency Director stated, “All medications should be included in the medication profile.”

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on agency policy, record review, and staff interviews the agency failed to obtain an order for a PT/INR (Prothrombin Time and International Ratio, a blood test that measures how long it takes blood to clot) for 1 of 1 patient receiving PT/INR testing. Findings included: A policy, Physician Orders for Home Health Patient (revised 09/20/2019), was received on 05/03/23 at approximately 3:00 P.M. from the agency administrator. The policy stated, “It is the policy of [name of agency], in accordance with program regulations that all medications and treatments are administered only upon clear, complete, and signed order of a person lawfully authorized to prescribe.” Patient #18 was admitted on 01/20/23 with diagnoses of cellulitis (bacterial skin infection), congestive heart failure and encounter for therapeutic drug level monitoring. The Plan of Care (POC) for 03/21/23-05/19/23 included orders for skilled nurse visits 2 times a week for 3 weeks and 2 times a week for 6 weeks and for a skilled nurse to obtain PT/INR every 2 weeks. The clinical record included evidence of LPN #3 performing the PT/INR 1 time a week for 3 weeks during visits on 03/30/23, 04/07/23, and 04/13/23. There was no evidence of an order in the POC. An interview was conducted on 05/02/23 at approximately 1:50 with LPN #3 P.M . LPN #3 stated, “I call the doctor (with the PT/INR results) and leave a voice mail, then the doctor contacts the spouse with the order. I wait to document (the visit) until I hear from his wife. I do not enter a new order to be signed in Home Care Home Base (the clinical record)”. An interview was conducted on 05/02/23 at approximately 2:00 P.M. with the agency administrator. The agency administrator stated that the nurse should verify any new orders with the doctor and enter them into the clinical record to be signed by the doctor.

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 observation, policy review, and staff interviews, the Occupational Therapist (OT) failed to perform hand hygiene prior to entering the clinical bag after handling the patient’s medication bottles and touching the household items for 1 of 4 patient observations. (Patient #13) Findings included: A Policy, Bag Technique Policy for Home Health and Hospice (revised 07/21/2021) was received on 05/02/2023 at approximately 3:00 P.M. from the agency Administrator. The policy stated, “If additional equipment or supplies are needed from the bag during the visit, the handwashing procedure must be repeated.” Patient #13 was admitted on 02/14/23 with a diagnosis of unspecified fall, subsequent encounter, congestive heart failure, and urinary tract infection. The Plan of Care (POC) included orders for physical therapy 2 times a week for 2 weeks and 1 time a week for 6 weeks and occupational therapy 1 time a week for 8 weeks. On 05/02/2023 a home visit was conducted with OT #3 at approximately 11:15 A.M. The OT donned gloves retrieved the patient’s medications from the bathroom, and reviewed medications. The Ot then entered the clinical bag with gloved hands and removed items. An interview was conducted on 05/03/2023 at approximately 9:50 A.M. with OT #3. OT #3 stated that she normally removes gloves and performed hand hygiene prior to removing things from the bag. An interview was conducted with the Agency Administrator on 05/03/23 at approximately 10:00 A.M. The Agency Director stated, “She should have removed gloves and performed hand hygiene before removing items from her bag.”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency policy, record review, and staff interviews the agency fail to obtain wound measurements for 2 of 9 (#1, 15) patient with wounds and failed to obtain Peripherally Inserted Central Catheter (PICC, intravenous access that can be used for a prolonged time for the administration of medications.) line measurements for 1 of 1 patient with a PICC line. (# 8) Findings Included: Patient #15 was admitted on 11/24/2022 with a diagnoses of Chronic Venous ulcer and inflammation of the right lower extremity, chronic venous hypertension with ulcer and inflammation of the left lower leg, and lymphedema. The Plan of Care (POC) for 03/24/2023-05/22/2023 included orders for skilled nurse visits 1 time a week for 1 week and 3 times a week for 8 weeks. Skilled nurse orders were to perform/teach wound care to bilateral lower extremity wounds. Review of the skilled nursing revealed measurements were not obtained for the weeks of 03/26/23, 04/09/23, 04/16/23, and 04/24/23. An interview was conducted with LPN #2 on 05/03/2023 at approximately 9:45 A.M. LPN #2 stated that she normally measured wounds weekly but patient #15 refused and, “The reason should have been refused instead of not due.” Interview with the agency director on 5/2/23 at 4:33 p.m. confirmed wounds are to be measured weekly. Findings included: Review of a policy “Wound Care: Assessment”, approved 2016 was received from the agency administrator on 05/02/23 at 3:00 p.m. The policy stated,” …document wound measurements in centimeters in the following order length, width and depth…” Review of a policy “Care for PICC Lines”, approved 2022 was received from the agency administrator on 05/02/23 at 3:00 p.m. The policy stated,” …using sterile technique, measure the external length of catheter from the hub to skin entry using the sterile tape measure, this measurements should be the same as documented on the provider orders…” Patient #1 was admitted on 04/07/22 with diagnoses of GI (gastrointestinal) hemorrhage, other shock, other forms of scoliosis (curvature of the spine), and venous insufficiency. The plan of care for 06/06/22 to 08/04/22 had orders for skilled nursing 3 times a week for 8 weeks, then 1 time a week for 1 week. Review of the skilled nursing notes revealed wound measurements were not obtained for the week of 06/06/22. Interview with registered nurse #6 on 05/02/23 at 4:21p.m. “the skin on her legs sloughed off, the wounds all connect the way it looked, and it was difficult to get any measurement”. Interview with the agency director on 5/2/23 at 4:33 p.m. confirmed wounds are to be measured weekly. Patient #8 was admitted on 03/10/23 with diagnoses of discitis (infection of the intervertebral disc space), essential hypertension, and spinal stenosis (narrowing of the spinal canal). The plan of care for 03/10/23 to 05/08/23 had orders for skilled nursing 1 time a week for 10 weeks. Skilled nursing orders were to observe and assess of the IV (intravenous) access site, response to medication and skilled teaching regarding infusion procedure, of the infusion and site care. Review of skilled nursing notes revealed PICC line measurements were not obtained for the weeks of 03/10/23, 03/15/23, 03/27/23, 04/04/23, and 04/10/23. “Interview with the agency director on 05/02/23 at 4:25 p.m. revealed, “I know that you are correct, she didn’t measure the picc line”.

An unannounced on-site recertification survey was conducted 4/5/21-4/6/21. No deficiencies to the Emergency Preparedness Plan was identified.

An unannounced onsite recertification survey was conducted 4/5/21-4/6/21. Standard level deficiencies to the Medicare CoP were identified.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to follow orders on the Plan of Care [POC] related to changing a PICC [peripherally inserted central catheter] line dressing for 1 of 2 patients with a PICC [#1]; follow wound care orders for 1 of 4 patients with wounds [#4, ]; to change an indwelling catheter every 4 weeks for 1 of 2 patients with an indwelling catheter [#11]; follow the POC related to home health aide services for 1 of 3 patients with aide services orders [# 12]; follow the POC related to weekly weights for 1 of 2 patients [#12]. The findings included: The policy, Plans of Care for Home Health Patients [reviewed date of 12/6/20] was provided by RN # 3 on 4/6/21 at approximately 9 am. The policy stated, " ...The plan of care serves to document the specific physician's order for each individual patient ...". 1. Patient # 1 had a Start of Care [SOC] date of 2/25/21 and admitting diagnoses of Infection/Inflammation due to Internal Fixation of Left Humerus and Encounter for Adjustment and Management of VAD [vascular access device]. A review of the Plan of Care [POC] for the certification period 2/25/21 to 4/05/21 revealed orders for SN [skilled nursing] 1 time a week for 8 weeks; 2 times a week for 1 week and 3 PRN [as needed] and " ...perform PICC [peripherally inserted central catheter] dressing changes weekly and PRN. A review of the clinical record revealed on 3/1/21 LPN # 7 made the weekly visit. LPN # 7 documented the following information, " ...Patient declined to have PICC line dressing changed. Reported it was just changed on Friday ..." LPN # 7 was not available for interview. An interview was conducted with RN # 3 on 4/6/21 at approximately 1 pm. During the interview RN # 3 confirmed the PICC line dressing was not changed in accordance with the POC. 2. Patient # 4 had a Start of Care [SOC] date of 2/5/21 and admitting diagnoses of Pneumonia due to Pseudomonas and Encounter for Adjustment and Management of VAD [Vascular Access Device]. A review of the Plan of Care [POC] for the certification period 2/5/21-4/5/21 revealed orders for SN [skilled nursing] 1 time a week for 8 weeks; 2 times a week for 1 week; 1 time a week for 1 week and 3 PRN [as needed] and skilled nurse to perform/teach pressure ulcer care to Stage 1 coccyx as follows: assess for degradation and cleanse with wound cleanser and apply barrier cream. Care to be performed daily. A review of the clinical record revealed the following information: a routine visit was made on 2/9/21 by LPN # 7. LPN # 7 documented, " ...wound care not provided. Caregiver completed care." LPN # 7 was not available for interview. An interview was conducted with RN # 3 on 4/6/21 at approximately 1 pm. During the interview RN # 3 confirmed the wound care was not completed in accordance with the POC. 3. Patient # 11 had a Start of Care [SOC] date of 1/6/21 and an admitting diagnosis of Prurigo [skin condition of itchy papules or small nodular eruptions]. A review of the Plan of Care [POC] for the certification period 1/6/21 to 3/6/21 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks and 3 PRN [as needed] and "skilled nurse for insertion of foley catheter maintenance with catheter 18 FR, 30 cc balloon, change every 4 weeks and PRN dislodgement or stoppage [sic]." A review of the clinical record revealed SN visits were made on 1/9/21, 1/15/21, 1/20/21, 1/27/21, 2/3/21, 2/11/20, 2/18/21, 2/24/21 and 3/3/21. The indwelling catheter was not changed until 3/3/21. An interview was conducted with RN # 3 on 4/6/21 at approximately 1 pm. During the interview RN # 3 confirmed the indwelling catheter was not changed every 4 weeks in accordance with the POC. 4A. Patient # 12 had a Start of Care [SOC] date of 11/12/20 and admitting diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer, Chronic Venous Hypertension with ulcer of Bilateral Lower Extremities, Non Pressure Chronic Ulcer of other part of Right Lower Leg with Fat Layer Exposed, Non Pressure Chronic Ulcer of other part of Left Lower Leg with Fat Layer Exposed, Non Pressure Chronic Ulcer of other part of Right Foot with Fat Layer Exposed and Non Pressure Chronic Ulcer of other part of Left Foot with Fat Layer Exposed. A review of the Plan of Care [POC] for the certification period 11/12/20 to 1/10/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 8 weeks and 3 PRN [as needed] and HHA [home health aide] effective the week of 11/15/20 2 times a week for 1 week; 2 times every 2 weeks for 2 weeks and 1 time a week for 4 weeks for assistance with personal care, hygiene and activities of daily living. A review of the clinical record revealed no aide visits were made. An interview was conducted with RN # 3 on 4/26/21 at approximately 1 pm. During the interview RN # 3 confirmed she had written the order for the home health aide. "The order was obtained for the home health aide, but the visits were not plotted out so the home health aide would know there was an order for the patient to get aide services." RN # 3 confirmed Patient # 12 did not receive aide services in accordance with the POC. 4B. Patient # 12 had a Start of Care [SOC] date of 11/12/20 and admitting diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer, Chronic Venous Hypertension with ulcer of Bilateral Lower Extremities, Non Pressure Chronic Ulcer of other part of Right Lower Leg with Fat Layer Exposed, Non Pressure Chronic Ulcer of other part of Left Lower Leg with Fat Layer Exposed, Non Pressure Chronic Ulcer of other part of Right Foot with Fat Layer Exposed and Non Pressure Chronic Ulcer of other part of Left Foot with Fat Layer Exposed. A review of the Plan of Care [POC] for the certification period 11/12/20 to 1/10/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 8 weeks and 3 PRN [as needed] and "Skilled nurse to obtain weight and/or teach patient/caregiver to obtain weight Q weekly [sic] and notify RN/MC of weight gain or loss of 5 pounds within 7 days." A review of the clinical record revealed a weight of 270 pounds was documented on 11/12/20 by RN # 6. Patient # 12 received 2 SN visits the week of 11/20/20. Further review of the clinical record revealed no weight was obtained the week of 11/20/20. RN # 3 was interviewed on 4/6/21 at approximately 1 pm. RN # 3 confirmed there was no weights documented the week of 11/20/20 in accordance with the POC.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to obtain orders for the application of a dressing for 1 of 1 patient with a new wound [# 8]. The findings included: Patient # 8 had a Start of Care [SOC] date of 3/10/21 and admitting diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer and Non Pressure Chronic Ulcer of Right Heel and Midfoot with Fat Layer Exposed. A review of the Plan of Care [POC] for the certification period 3/10/21 to 5/8/21 revealed orders for SN [skilled nursing] 2 times a week for 9 weeks and 3 PRN [as needed]. A review of the clinical record revealed LPN # 4 made a routine visit to on 3/19/21. During the visit LPN # 4 documented the following information, " SN arrived for visits ...He has a new [old] [sic] wound that has reopened on his left foot ...SN attempted to contact patient's internal med [sic] MD to report new wound, but the office is closed early and the on call provider will only address emergent/urgent needs." Further review of the clinical record revealed LPN # 4 documented the following treatment, " ...cleaned wound using wound cleanser and patted dry. Applied calcium alginate to wound bed and covered with gauze ...Wound care provided per the order ..." A phone interview was conducted with LPN # 4 on 4/6/21 at approximately 10 am. During the interview LPN # 4 stated, " I didn't actually get an order, I just used the same thing we had used in the past and the same thing we was using on another wound."

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: Review of agency policies revealed a policy titled "Plans of Care for Home Health Patients," provided on 4/6/2021 at 11:55 am by the Regional Administrator and last revised on 12/16/2019. The policy stated, "The plan of care serves to document the specific physician orders for each individual patient ...All care provided to the patient is directed toward achieving the patient-specific goals ....Professional staff shall promptly alert the physician to any changes that suggest a need to change the plan of care." Review of the clinical record for Patient #3 revealed a start of care of 2/26/2021 and diagnoses of Type 2 diabetes mellitus with diabetic polyneuropathy (pain or loss of function due to nerve damage) and acute on chronic diastolic heart failure (failure of the left ventricle of the heart). Review revealed the frequency of skilled nursing visits for the 2/26/21-4/26/21 episode of care was once per week for eight weeks. The plan of care included obtaining weights and teaching the patient to obtain weights daily, and reporting a weight gain or loss of two pounds in one day. Review of the clinical record failed to reveal any recorded weights during the episode. Patient #3 was admitted to the hospital on 3/24/2021 for fluid overload. Interview on 4/6/2021 at 1:38 pm with RN #6, the case manager for Patent #3, revealed that no weights were taken or recorded because the patient had weakness in her legs and did not have a scale. RN #6 stated, "At the start of care when she didn't have a scale ...I did not notify anyone. I would try to normally. Does it always happen? No. I was probably just really busy." Interview on 4/6/2021 at 2:27 pm with RN #3, the Regional Administrator, revealed that clinicians are provided with scales to keep in their cars in case the patient does not have one. Review of the clinical record for Patient #9 revealed a start of care of 2/18/21 and diagnoses of essential hypertension (high blood pressure) and type 2 diabetes. Review of the plan of care for the 2/18/21-4/18/21 episode of care revealed skilled nursing visits once per week for one week and twice per week for eight weeks. The orders included reinforcement of diabetic care including blood glucose testing. Review of the clinical record failed to reveal documentation of any blood glucose readings or review of home blood glucose logs during the episode, or any notification of noncompliance to the physician. Review revealed a note on 2/19/21 documented by RN #6 which stated, "Patient required nursing for disease management r/t (related to) DM (diabetes mellitus)." Interview on 4/6/21 at 12:19pm with LPN #1 revealed that the patient did not have a glucometer and refused to check her blood sugar. LPN #1 was unsure whether she had notified anyone about the patient's noncompliance and was not able to find any documentation of notification. Interview with RN #6 on 4/6/21 at 1:38pm revealed that she did not check blood sugars and she wasn't sure whether the patient was a diabetic but that "[the patient] swears up and down she is not a diabetic anymore." RN #6 stated, "I honestly don't recall if I let anyone know. If [documentation] wasn't there, I would say no, I didn't." Interview on 4/6/21 at 2:27 PM with RN #3, the Regional Administrator, revealed that when a patient is noncompliant, the clinician should notify the doctor so that the noncompliance can be noted on the care plan. Review of the clinical record for Patient #13 revealed a start of care of 6/23/20 and a diagnosis of urethral stricture. For the certification period of 6/23/2020-8/23/2020, home health aide visits were ordered once per week for three weeks beginning on 7/5/2020. No home health aide visits were documented the week of 7/5/2020. HHA #8 documented a missed visit on 7/16/2020; review failed to reveal documentation that the case manager or physician were notified. No further home health aide visits or missed visits were documented for the episode. Interview on 4/6/2021 at 2:54 with RN #3, the Regional Administrator, revealed that HHA #8 no longer worked at the agency and was not available for interview. RN #3 confirmed that Patient #13 did not receive any of the home health aide visits ordered in the plan of care.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record view and staff interviews the RN/LPN failed to provide accurate documentation related to PICC [peripherally inserted central catheter]line measurements for 2 of 2 patients with a PICC line [#1 and 4]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 2/25/21 and admitting diagnoses of Infection/Inflammation due to Internal Fixation of Left Humerus and Encounter for Adjustment and Management of VAD [vascular access device]. A review of the Plan of Care [POC] for the certification period 2/25/21 to 4/05/21 revealed orders for SN [skilled nursing] 1 time a week for 8 weeks; 2 times a week for 1 week and 3 PRN [as needed]. A review of the clinical record revealed LPN # 4 made routine visits on 3/16/21, 3/17/21 and 3/18/21. Further review of the clinical record revealed LPN # 4 documented the following information related to the PICC line site: 99 cm for length of exposed catheter and 999 arm circumferences on all 3 visits. A phone interview was conducted with LPN # 4 on 4/6/21 at approximately 11 am. During the interview LPN # 4 stated, "Those are not actual measurements, I put those numbers in the chart as place holders." 2. Patient # 4 had a Start of Care [SOC] date of 2/5/21 and admitting diagnoses of Pneumonia due to Pseudomonas and Encounter for Adjustment and Management of VAD [Vascular Access Device]. A review of the Plan of Care [POC] for the certification period 2/5/21-4/5/21 revealed orders for SN [skilled nursing] 1 time a week for 8 weeks; 2 times a week for 1 week; 1 time a week for 1 week and 3 PRN [as needed]. A review of the clinical record revealed the following information: RN # 6 performed the Start of Care visit on 2/5/21. RN # 6 documented the following information related to the PICC line assessment, " PICC line length 99 cm and arm circumference 99. A phone interview was conducted with RN # 6 on 4/6/21 at approximately 12 pm. During the interview RN # 6 stated, " I didn't actually measure the length or the arm circumference because I didn't change the dressing. The guidance has been given to us from the manager that we have to put something in for a measurement and so I put in 99 for the arm circumference and 99 for the length." An interview was conducted with RN # 3 on 4/6/21 at approximately 1 pm. During the interview RN # 3 stated, "I see where documenting in that way is very misleading. We don't really have a policy related to what the nurses should enter in that section, but we will address this."

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to communicate with the physician when a PICC [peripherally inserted central catheter] line dressing change was not performed for 1 of 2 patients with a PICC line [#1]; failed to notify the physician of a new open area for 1 of 4 patients with wounds [#8]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 2/25/21 and admitting diagnoses of Infection/Inflammation due to Internal Fixation of Left Humerus and Encounter for Adjustment and Management of VAD [vascular access device]. A review of the Plan of Care [POC] for the certification period 2/25/21 to 4/05/21 revealed orders for SN [skilled nursing] 1 time a week for 8 weeks; 2 times a week for 1 week and 3 PRN [as needed] and " ...perform PICC [peripherally inserted central catheter] dressing changes weekly and PRN. A review of the clinical record revealed on 3/1/21 LPN # 7 made the weekly visit. LPN # 7 documented the following information, " ...Patient declined to have PICC line dressing changed. Reported it was just changed on Friday ..." LPN # 7 was not available for interview. An interview was conducted with RN # 3 on 4/6/21 at approximately 1 pm. During the interview RN # 3 confirmed there was no evidence the physician was notified the PICC line dressing was not completed. 2. Patient # 8 had a Start of Care [SOC] date of 3/10/21 and admitting diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer and Non Pressure Chronic Ulcer of Right Heel and Midfoot with Fat Layer Exposed. A review of the Plan of Care [POC] for the certification period 3/10/21 to 5/8/21 revealed orders for SN [skilled nursing] 2 times a week for 9 weeks and 3 PRN [as needed]. A review of the clinical record revealed LPN # 4 made a routine visit to on 3/19/21. During the visit LPN # 4 documented the following information, " SN arrived for visits ...He has a new [old] [sic] wound that has reopened on his left foot ...SN attempted to contact patient's internal med [sic] MD to report new wound, but the office is closed early and the on call provider will only address emergent/urgent needs." Further review of the clinical record revealed LPN # 4 documented the following treatment, " ...cleaned wound using wound cleanser and patted dry. Applied calcium alginate to wound bed and covered with gauze ...Wound care provided per the order ..." An interview was conducted with RN # 3 on 4/6/21 at approximately 1 pm. During the interview, RN # 3 confirmed there was no evidence the physician was notified of the new open area.

An onsite complaint investigation was conducted January 4-6, 2021. The complaint was substantiated. Immediate Jeopardy was identified on 01/05/21 at 1:46 p.m. beginning 11/23/20 and was cited at G710- Providing services that are ordered by the physician as indicated in the plan of care. Then immediate jeopardy was abated on January 6, 2021 but continued at a lower level with condition and standard level non-compliance. The agency was notified of the immediate jeopardy on January 5, 2021 at 1:46 p.m. Patient #1 had multiple wounds on the back, buttock and hip. Patient #1 was admitted on 11/18/20. The agency conducted the admit visit on 11/18/20 and two additional skilled nursing visits on 12/01/20 and 12/03/20 which were not in the record as of 01/04/21. According to the plan of care, the agency was to perform the dressing changes 2 times per week. The agency failed to conduct skilled nursing visits the week of 11/22/20 as ordered by the physician, a total of two visits. Missed visits were done for 12/7/20 and 12/10/20 which were not documented in the record. The patient was discharged on 12/10/20. The agency failed to notify the physician of the changes in the plan of care and failed to have documentation completed in the record in a timely manner. The immediate jeopardy was abated on 01/06/21 at 2:26 p.m. The deficient practice remains at a lower level. The condition of Skilled Professional Services is not met based on policy review, clinical record review, and staff interview. The agency failed to provide care in accordance with the condition of skilled professional services for 1 of 3 patients reviewed (#1).

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: The condition is not met based on policy review, agency document review, clinical record review, and staff interviews. The agency failed to conduct visits according to the Plan of Care and to document 2 of 3 skilled nursing visits conducted for 1 of 1 patients with wounds (#1) Cross refer to : 484.75(b)(3) tag G710 484.75(b)(6) tag G716

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, client record review and staff interview the agency failed to follow the plan of care related to skilled nursing visits for 1 of 1 patients with a wound (#1). Immediate Jeopardy was identified beginning 11/23/20 and was abated on 01/06/21 with an acceptable allegation of compliance. Findings included: Review of a policy "Plans of Care for Home Health Patients", revised 12/01/17 was received from Employee #1 on 01/05/21 at 9:40 a.m. The policy stated," ....the hha (home health agency) must promptly alert the physician who is responsible for the hha plan of care 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 ...". Patient #1 referral was made to the home health agency on 11/10/20. RN (registered nurse) went to admit Patient #1 on 11/11/20 and sent the patient to the ED (emergency department) due to multiple wounds with green drainage. Patient #1 was admitted to the hospital on 11/11/20 and was discharged home on 11/17/20. Patient #1 was admitted to home health agency on 11/18/20 with diagnoses of pressure ulcer of right hip stage 3; pressure ulcer of unspecified part of back, stage 2; pressure ulcer of left buttock stage 2, pleural effusion, not specified; hemiplegia following cerebral infraction affection left side, and chronic pain syndrome . The plan of care for 11/18/20 to 01/16/21 had orders for skilled nursing 1 time a week for 1 week, then 2 times a week for 8 weeks with 3 as needed for skilled nurse to observe and assess integumentary status to identify changes and intervene to minimize complications. Skilled nurse to provide skilled teaching related to altered skin integrity including pathophysiology , nutrition, medication regimen, and bed bound status. Skilled nurse to perform/teach pressure ulcer care to back (#1 &2), right hip/buttock (#3), and left buttock (#4 &5) as follows: wash back with soap and water, pat dry, apply lotion to healthy skin irrigate wound beds with NS (normal saline) apply foam bordered dressing to back and left buttock (#1,2, 4 &5) apply vashe (wound cleanser) soaked gauze to right hip/buttock (#3) cover with dry gauze, secure with tape. Review of the clinical record revealed only 1 skilled nursing visit was documented in the record which was the admission visit on 11/18/20. Nursing visits were not completed for the week of 11/22/20 as ordered. The visits for 12/01/20 and 12/03/20 completed by Employee #4 were not documented in the record. Patient discharged to another agency on 12/11/20 per patient request. Interview on 01/04/21 at 3:12 p.m. with Employee #1 "" ..., so everything on the clinical end was completed on 11/24/20 and at that point it was sent to the scheduler to schedule for the next week and sat in that workflow until 11/30/20 and the visits were missed." Interview on 01/05/21 at 9:57 a.m. with Employee #4 revealed " ...Yes, I saw him twice on 12/1/20 and 12/3/20 ...". Allegation of Compliance Agency failed adherence with the plan of care as ordered by the physician for patient #1, specifically in following the ordered visit frequency, performing the wound treatment ordered, obtaining wound measurements, communicating the progression of the wound measurements to physician, and completing documentation per Pruitt Health @Home policies/processes. Plan of Corrective Action- - Adherence with scheduling visits via HCHB as ordered. HCHB workflow managed daily per process. Administrator and BOM to monitor scheduling throughout the day and ensure it is up to date. Ensure compliance with all scheduling for the next day is completed before BOM and Scheduler leave for the day. Adherence with performing visits per ordered plan of care within HCHB per process.- - Admin reviewed on 1/5 and 1/6 with BOM, TA, and CM to monitor scheduling throughout the day and ensure it is up to date. Ensure compliance with all scheduling for the next day is completed before BOM and Scheduler leave for the day. - Review Daily Census meeting process with the Administrator/Clinical Manager/ Business Office Manager- BOM. To include obtaining HCHB Agency Summary Report to reconcile clinicians with no orders, incomplete visits and the Client No visit report. o This report will identify all visits not completed, allows the agency (Administrator, Clinical Manager, Business Office Manager- BOM) to reconcile incomplete/completed visits. Completed on 1/5 and 1/6 o Administrator/Clinical Manager will follow-up with the clinician to ensure visit documentation is completed timely. No further visits will be scheduled with the clinician until all documents are completed satisfactorily. Met with RN this morning 1/6 and discussed follow up visits and documentation completed timely - Adherence with following wound processes to include, compliance with wound treatment orders, performing weekly wound measurements, and communicating with physician with any declines in measurements. - Adherence with the required HCHB wound visit documentation. Specifically, to note, wound treatment performed, utilizing aseptic procedures, wound measurements, and the progression/decline noted to the wound sites. - Adherence with documenting the changes noted within the wound beds, coordination of care with the physician and verbal orders received. - Adherence with policy regarding attempted and/or missed visits. Specifically, coordination with the physician with missed visits regardless of the reason. - Formal disciplinary action will be taken with partner #4 to include reporting to the agency on January 6-a.m. to complete all incomplete documentations. Partner's personnel file will be reviewed for prior disciplinary action and further action taken as appropriate. - Met with nursing staff via Teams on 1/6 at 2pm. Monitoring- - 100% of clinical records with wound treatment orders/visits/measurements will be reviewed from 11/15/20 through 12/15/20 until 100% accuracy is achieved. Performed on 1/6. Responsible Persons- Administrator, Clinical Manager, Business Office Manager (BOM)

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on policy review, client record review and staff interview the agency failed to document skilled nursing visits in the clinical record for 1 of 1 patients with a wound (#1). Review of a policy "Plans of Care for Home Health Patients", revised 12/01/17 was received from Employee #1 on 01/05/21 at 9:40 a.m. The policy stated," ....the hha must promptly alert the physician who is responsible for the hha plan of care 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 ...". Client #1 was admitted on 11/18/20 with diagnoses of pressure ulcer of right hip stage 3; pressure ulcer of unspecified part of back, stage 2; pressure ulcer of left buttock stage 2, pleural effusion, not specified; hemiplegia following cerebral infraction affection left side, and chronic pain syndrome . The plan of care for 11/18/20 to 01/16/21 had orders for skilled nursing 1 time a week for 1 week, then 2 times a week for 8 weeks with 3 as needed for skilled nurse to observe and assess integumentary status to identify changes and intervene to minimize complications. Skilled nurse to provide skilled teaching related to altered skin integrity including pathophysiology , nutrition, medication regimen, and bed bound status. Skilled nurse to perform/teach pressure ulcer care to back (#1 &2), right hip/buttock (#3), and left buttock (#4 &5) as follows: wash back with soap and water, pat dry, apply lotion to healthy skin irrigate wound beds with NS (normal saline) apply foam bordered dressing to back and left buttock (#1,2, 4 &5) apply vashe (wound cleanser) soaked gauze to right hip/buttock (#3) cover with dry gauze, secure with tape. Review of the clinical record revealed no documentation for SN visits on 12/01/20 and 12/3/20 by Employee #4. Missed visits were to be done by Employee #4 on 12/07/20 and 12/10/20. These notes were not in the record. Interview on 01/05/21 at 9:57 a.m. with Employee #4 revealed "Yes, I saw him twice on 12/1/20 and 12/3/20", and missed 12/7/20 and 12/10/20 ,the visits were missed because he had a colonoscopy, and the other was because another agency was seeing him".