Every finding on record at Ur Medicine Home Care, Certified Services, Inc

The following Statement of Deficiencies represents the results of an onsite complaint investigation survey of UR Medicine Home Care, initiated on 03/02/2026 and completed on 03/05/2026. The survey consisted of a review of three (3) clinical records, pertinent policies and procedures and the complaint log. Interviews were conducted throughout the survey with the Senior Director of Certified Home Health (CHHA) Operations and various professional staff. Findings were reviewed at the exit conference on 03/05/2026. The complaint 2737064 was substantiated. The following deficiencies are being cited: G-0544, G-0574, G-0576, G-0580, G-0588, G-0590, G-0610, and G-0984.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record review and staff interview for one (1) of three (3) patients (Patient #1), requiring updates to the comprehensive assessment based on a major change in the patient's health status, the agency failed to ensure the assessments were of sufficient scope to identify current patient needs. Failure to ensure comprehensive assessments contain complete and accurate information has the potential for unmet patient needs. Patient #1 – This 42-year-old with the diagnoses of non-pressure chronic ulcer of right heel and midfoot with unspecified severity, multiple sclerosis, and chronic kidney disease was admitted to the agency on 02/21/2026. Review of the SN (Skilled Nurse) OASIS (Outcome and Information Set) Start of Care dated 02/21/2026 revealed the patient has a urostomy. Review of the SN Home Visit dated 02/24/2026 lacks an assessment of the urostomy. During interview on 03/03/2026 at 09:30 AM, the Senior Director of Certified Home Health Agency (CHHA) stated there is no assessment of the urostomy. In the event a clinician is unable to assess there should be communication with the authorized practitioner and a plan for follow-up. Neither of these requirements were documented.

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 review of clinical records and staff interviews for two (2) of three (3) patients (Patient #s: 1 and 2) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. Patient #1 – This 42-year-old with the diagnoses of non-pressure chronic ulcer of right heel and midfoot with unspecified severity, multiple sclerosis, and chronic kidney disease was admitted to the agency on 02/21/2026. A.) Review of the SN (Skilled Nurse) OASIS (Outcome and Assessment Information Set) Start of Care dated 02/21/2026 revealed the patient receives services at a wound clinic. Review of the Home Health Plan of Care dated 02/21/2026 to 04/21/2026 lacks information regarding the patient receiving services from a wound clinic. During interview on 03/03/2026 at 09:20 AM, the Registered Nurse (RN) was unavailable, but the RN, Clinical Team Manager for Weekend Team stated that it is not information that is typically on the plan of care but will be added. B.) Review of the SN OASIS Start of Care dated 02/21/2026 revealed the patient has a urostomy. Review of the Home Health Plan of Care dated 02/21/2026 to 04/21/2026 lacks orders for a urostomy. During interview on 03/03/2026 at 09:20 AM, the RN was unavailable, but the RN, Clinical Team Manager for Weekend Team stated there is no order for the patient’s urostomy. Patient #2 – This 90-year-old patient with the diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, duodenal ulcer, and benign prostatic hyperplasia with lower urinary tract symptoms was admitted to the agency on 09/10/2025. A.) Review of the Home Health Plan of Care dated 09/10/2025 to 11/08/2025 revealed the following order: Intervention: GU Disease Management - Instruct patient and caregiver in care of latex catheter. - Urinary Catheter Change: managed by urology - Instruct patient and caregiver on home management of urinary catheter including cleaning urinary meatus, sign and symptoms of infection, changing from night bag to leg bag, and securing catheter. - Visit Notes: foley for s/p (status post) surgical urinary retention patient and caregiver instructed on daily care and pt c/g provides teach back. Procedures Performed: catheter care Performed by clinician Placement date: 9/10/25 Insertion site: urethral Catheter type: Foley Catheter material: latex Catheter duration: indwelling Size (Fr) (French): 18 Collection bag: standard Catheter Condition draining per gravity Condition of Skin at Insertion Site: clean, intact Irrigation (blank) The order lacks a frequency for when the foley catheter is due to be changed, how many cc (cubic centimeters) should be instilled in the balloon, and frequency of bag changes. During interview on 03/03/2026 at 10:01 AM, the RN stated a complete order was not obtained until 11/25/2025 (22 (twenty-two) days after admission) but could not recall why there was a delay.

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 clinical record review, agency policy and procedure, and staff interview, one (1) of three (3) patient records (Patient #2) lacks evidence an order was obtained to update the Plan of Care (POC) to reflect the patient's status. Failure to obtain an order to update the POC has the potential for agency staff to act on inaccurate and incomplete information, and places patient health and welfare at risk. Review of the agency policy entitled “Wound Assessment, 557” dated 08/2025 revealed: “C. Any wound noted as "in decline", or as not healing as expected, by the (agency) nurse may be evaluated by the WOCN (Wound, Ostomy, and Continence Nursing) or designee. D. Co-visits and/or consultation with the WOCN may occur anytime it is determined to be in the best interest of the patient. E. The WOCN may work with the ordering provider and the (agency) clinician to determine the best wound product for the specific case.” Patient #2 – This 90-year-old patient with the diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, duodenal ulcer, and benign prostatic hyperplasia with lower urinary tract symptoms was admitted to the agency on 09/10/2025. Review of the SN (Skilled Nursing) Home Visit dated 10/13/2025 revealed the Registered Nurse (RN) documented “caregiver reports some slight confusion yesterday and low output dark urine at this time SN will request urinalysis from urology at this time to be collected at next visit when order is received.” Review of the clinical record lacks an order for the urinalysis or any follow-up regarding obtaining a urine culture from the patient. During interview on 03/03/2026 at 10:15 AM, the RN stated there is no order for the urinalysis in the record, and they don’t recall doing any follow-up. B.) Review of the Case Communication Note dated 09/29/2025 revealed the WOCN conducted a consultation and added the following instructions to the current orders: “Topical wound care recommendations: Recommend cleansing all wounds with Vashe. Recommend continuing foam dressings to bilateral heels. Recommend ABI (Ankle-Brachial Index)/TBI (Toe-Brachial Index) of bilateral lower extremities. If ABI/TBI are WNL (within normal limits) recommend surgical consult for debridement of bilateral heels with NPWT placement. Recommend continuing Triad to buttocks. Teach CG to perform daily when SNs are not available. Reconsult WOCN if wounds open up prior to the above.” Review of the clinical record lacks an updated order to include the WOCN’s recommendations. During interview on 03/04/2026 at 03:20 PM, the Senior Director of Certified Home Health Agency (CHHA) confirmed there is no updated order. C.) Review of the Case Communication dated 11/25/2025 revealed the Occupational Therapist (OT) documented “(patient’s son) is hoping that there is a wound care specialist that can be consulted as needed as he was information that (agency) wound specialist is out on medical leave currently. Ensured that current SN will be consulting with MD (medical doctor) and other specialists as needed to provide excellent care to his father.” Review of the clinical record from 11/25/2025 (date of request) to 12/02/2025 (transfer to hospital) lacks an order for a wound consultation. During interview on 03/03/2025 at 10:50 AM, the Senior Director of CHHA stated the RN educators cover when the wound consultant is not available. However, there is no consult submitted.

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 review of clinical records, agency policy and procedure, and interviews with agency staff, for two (2) of three (3) patients (Patient #’s: 1 and 2), the agency failed to ensure drugs and treatments are administered in accordance with physician orders. Failure to administer drugs and treatments without a physician's order has the potential to result in poor quality of care. Patient #2 – This 90-year-old patient with the diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, duodenal ulcer, and benign prostatic hyperplasia with lower urinary tract symptoms was admitted to the agency on 09/10/2025. Review of the Home Health Plan of Care dated 09/10/2025 to 11/08/2025 revealed the following order: Problem: Pressure Injuries (bilateral heels, left buttocks) Goal: Wound will heal or maintain without complications or signs/symptoms of infection. Description: Wound will heal or maintain without complications or signs of infection in 6 (six) weeks. - Patient and Caregiver will demonstrate wound care procedure, report complications, verbalize pressure relief interventions and verbalize diet to promote wound healing in 6 weeks. Intervention: Wound Protocol- triad (zinc-oxide hyrophilic cream) Description: Gently cleanse wound with NS (normal saline) or wound cleanser. -Apply a dime thick layer of triad to wound bed. OK to apply a '"glazed"" layer onto peri wound skin. -Cover with foam dressing. -When soiled, clean off only soiled barrier cream and apply another layer. -Skilled Nurse and caregiver to perform ordered wound care 2 (two) times weekly. -Skilled clinician to complete weekly wound measurements and photograph wound to monitor healing/wound progress. -Skilled clinician to assess and describe wound bed, periwound skin, odor and drainage, and pain associated with wound/wound care. -Skilled clinician to assess and instruct patient/caregiver for signs and symptoms of wound infection/deterioration. -Instruct patient and caregiver in how to perform wound care. A.) Review of the clinical record revealed the SN (Skilled Nurse) conducted one visit for the week of 09/10/2025 to 09/13/2025 on 09/10/2025. Review of the SN OASIS (Outcome and Information Set) Start of Care dated 09/10/2025 lacks a measurement of the left buttocks wound. During interview on 03/03/2026 at 10:07 AM, the Registered Nurse (RN) stated the patient was unable to stand long enough to obtain a full assessment to include measurements. They did not move the patient to the bed or couch where he could roll over so that the wound could be fully assessed. B.) Review of the clinical record from 10/19/2025 to 10/25/2025 revealed the SN conducted visits on 10/20/2025 and 10/23/2025. Review of the SN Home Visits dated 10/20/2025 and 10/23/2025 lack measurements for the left hip. C.) Review of the clinical record from 10/26/2025 to 11/01/2025 revealed the SN conducted visits on 10/27/2025 and 10/30/2025. Review of the SN Home Visits dated 10/27/2025 and 10/30/2025 lack measurements for the left buttocks and bilateral hips. D.) Review of the clinical record from 11/02/2025 to 11/08/2025 revealed the SN conducted visits on 11/03/2025 and 11/06/2025. Review of the SN Home Visits dated 11/03/2025 and 11/06/2025 lack measurements for the left hip. E.) Review of the clinical record from 11/09/2025 to 11/15/2025 revealed the SN conducted visits on 11/11/2025 and 11/14/2025. Review of the SN Home Visits dated 11/11/2025 and 11/14/2025 lack measurements for the left hip. During interview on 03/03/2025, the RN stated they were unable to assess the wounds because the patient could not stand long enough to do a full assessment and obtain measurements as ordered. When asked why the patient wasn’t moved to bed or a couch so that a proper assessment could be completed, the RN stated the patient has mobility issues and it is hard to transfer him. The RN confirmed the patient does use a walker. Patient #1 – This 42-year-old with the diagnoses of non-pressure chronic ulcer of right heel and midfoot with unspecified severity, multiple sclerosis, and chronic kidney disease was admitted to the agency on 02/21/2026. Review of the agency’s undated policy entitled “Pain Assessment and Management” revealed: 21.Provide patient comfort. a. the patient with repositioning to a comfortable position, maintaining proper body alignment. b. Smooth wrinkles in the bed linens. c. Loosen constrictive bandages or devices (e.g., band of antiembolism stockings). 22.Assist the patient to splint any painful areas (e.g., pillow, folded blanket) as needed. 23.Provide nonpharmacologic or complementary interventions in addition to administering analgesics, as appropriate. These interventions include using aromatherapy, distraction, massage, meditation, and music of the patient's choice. Documentation: Education Patient's progress toward goals Unexpected outcomes and related interventions Assessment of pain, treatment if necessary, and reassessment Pain assessment tool used Pain assessment before and after intervention Review of the Home Health Plan of Care dated 02/21/2026 to 03/02/2026 revealed the following: Problem: Pain/Comfort Deficit Skilled Clinicians Starting: 2/21/2026 -Assess pain (with standardized pain assessment tool) -Notify MD (medical doctor) of any changes to the patient's pain experience or pain that is not acceptable to patient. -Instruct patient in pharmacologic and nonpharmacologic pain management techniques Distraction Technique and Relaxation Breathing Assess effectiveness of pain management for patient each visit Assess patient for signs and symptoms of acute pain each visit Assess and classify patient's pain/physical discomfort using numeric scale. Perform ongoing assessment to determine if the pain management plan meets the patient's stated goal. 0-10 (zero to ten) numeric scale, report pain >8/10 (greater than eight out of ten) At every visit; maintain Review of the SN (Skilled Nurse) OASIS (Outcome and Information Set) Start of Care dated 02/21/2026 revealed the patient reported a pain level of 7/10 (seven out of ten) and the following assessment: Effects of Pain: Pain Effect on Sleep - Ask patient: "Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?" - Frequently Pain Interference with Therapy Activities - Ask patient: "Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?" - Frequently Pain Interference with Day-to-Day Activities - Ask patient: "Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain?" - Frequently The assessment lacks interventions to alleviate the pain in accordance with orders and agency policy. During interview on 03/03/2026 at 09:27 AM, the RN was unavailable, but the RN, Clinical Team Manager for Weekend Team stated there is no documentation that interventions were recommended or implemented.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Review of clinical records and interviews with staff for one (1) of three (3) patients (Patient #2) the agency failed to ensure the Plan of Care (POC) is reviewed and revised to reflect the patient's status. Failure to ensure the POC is updated and revised has the potential to result in negative patient outcomes. Patient #2 – This 90-year-old patient with the diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, duodenal ulcer, and benign prostatic hyperplasia with lower urinary tract symptoms was admitted to the agency on 09/10/2025. A.) Review of the Home Health Plan of Care dated 11/09/2025 to 01/07/2026 revealed the following order: Intervention: GU Disease Management - Instruct patient and caregiver in care of latex catheter. - Urinary Catheter Change: managed by urology - Instruct patient and caregiver on home management of urinary catheter including cleaning urinary meatus, sign and symptoms of infection, changing from night bag to leg bag, and securing catheter. - Visit Notes: foley for s/p (status post) surgical urinary retention patient and caregiver instructed on daily care and pt c/g provides teach back. Procedures Performed: catheter care Performed by clinician Placement date: 9/10/25 Insertion site: urethral Catheter type: Foley Catheter material: latex Catheter duration: indwelling Size (Fr) (French): 18 Collection bag: standard Catheter Condition draining per gravity Condition of Skin at Insertion Site: clean, intact Irrigation (blank) The order lacks a frequency for when the foley catheter is due to be changed, how many cc (cubic centimeters) should be instilled in the balloon, and frequency of bag changes. During interview on 03/03/2026 at 10:41 AM, the RN stated a complete order was not obtained until 11/25/2025 (22 (twenty-two) days after admission) but could not recall why there was a delay.

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 review of clinical records and interviews with staff for one (1) of three (3) patients (Patient #2), the agency failed to ensure the Authorized Practitioner is notified of changes in the patient's condition or needs that suggest the Plan of Care (POC) may need to be altered. Failure to promptly notify the Authorized Practitioner to changes in the patient's condition or needs that may suggest that outcomes are not being achieved and/or the POC should be altered has the potential to result in unmet patient needs and negative patient outcomes. Patient #2 – This 90-year-old patient with the diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, duodenal ulcer, and benign prostatic hyperplasia with lower urinary tract symptoms was admitted to the agency on 09/10/2025. A.) Review of the SN (Skilled Nurse) Home Visit dated 10/20/2025 revealed the Registered Nurse (RN) documented “patient reports that he feels like he moved too quickly this morning and is dizzy with some blurred vision. Patient noted to have low bp (blood pressure today (98/60)) foley draining well urine noted to be cloudy today.” Review of the communication with the Nurse Practitioner (NP) revealed the RN sent the following electronic message: “patient seen today urine cloudy at this time patient denies any pain. Blood pressure low 98/60 no medication. Reports good hydration. Can you place UA (urinalysis) orders to rule out urinary tract infection (UTI).” Review of the NP’s electronic response revealed the NP stated, “would not recommend urine culture in the setting of cloudy urine without other symptoms.” Review of the clinical record lacks evidence the RN follow-up with the NP to communicate the rest of the patient’s symptoms. Review of the OT (Occupational Therapy) Home Visit dated 10/22/2025 revealed the OT documented “(patient) did go to the ED (emergency department) yesterday after OT left and was positive for UTI.” During interview on 03/03/2026 at 10:20 AM, the RN stated they don’t recall following up with the NP regarding the patient’s symptoms (dizziness and blurred vision). There is no documentation of follow-up. B.) Review of the SN Home Visit dated 11/14/2025 revealed the following wound measurement: Left Buttocks 0.3 cm (centimeters) x 0.2 cm x (depth left blank). Review of the SN Home Visit dated 11/16/2025 revealed the following wound measurement: Left Buttocks 4 cm x 2.5 cm x (depth left blank). Review of the clinical record lacks documented evidence the SN reported the change in size of the wound to the authorized practitioner. During interview on 03/03/2025 at 09:43 AM, the RN was unavailable, but the RN, Clinical Team Manager for Weekend Team stated there is no documentation the change was reported to the Authorized Practitioner.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interviews, for three (3) of three (3) patients (Patient #'s: 1, 2, and 3), the agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the plan of care (POC). Failure to provide appropriate education has the potential to result in the patient receiving inadequate care and could result in patient harm. Patient #1 – This 42-year-old with the diagnoses of non-pressure chronic ulcer of right heel and midfoot with unspecified severity, multiple sclerosis, and chronic kidney disease was admitted to the agency on 02/21/2026. Review of the Home Health Plan of Care dated 02/21/2026 to 04/21/2026 revealed the following order: Skin integrity deficit related to: Wound Type: unstageable Location/site: right heal Skilled Clinicians Starting: 2/21/2026 Other Dressing: wet to dry - Skilled Nurse, skilled clinician, patient and caregiver to perform ordered wound care at time of visit. - Skilled clinician to complete weekly wound measurements and photograph wound to monitor healing/wound progress. - Skilled clinician to assess and describe wound bed, periwound skin, odor and drainage, and pain associated with wound/wound care. - Skilled clinician to assess and instruct patient/caregiver for signs and symptoms of wound infection/deterioration. -Instruct caregiver in how to perform wound care. Dressing: - Cleanse wound with normal saline dampened gauze or wound cleanser. - May apply skin barrier to periwound as needed for protection from excess moisture or strong adhesives. - Apply dry dressing or damp to dry dressing. - Cover with dry cover dressing. Review of the SN (Skilled Nurse) OASIS (Outcome and Information Set) Start of Care dated 02/21/2026 lacks documented evidence of demonstration or teach back of wound care by the patient and/or caregiver to ensure appropriate education has been provided. During interview on 03/03/2026 at 09:20 AM, the Registered Nurse (RN) was unavailable, but the RN, Clinical Team Manager for Weekend Team stated there is no documentation stating education was provided and teach back was complete. Patient #2 – This 90-year-old patient with the diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, duodenal ulcer, and benign prostatic hyperplasia with lower urinary tract symptoms was admitted to the agency on 09/10/2025. Review of the Home Health Plan of Care dated 09/10/2025 to 11/08/2025 revealed the following order: Problem: Pressure Injuries (bilateral heels, left buttocks) Goal: Wound will heal or maintain without complications or signs/symptoms of infection Description: Wound will heal or maintain without complications or signs of infection in 6 (six) weeks. Patient and caregiver will demonstrate wound care procedure, report complications, verbalize pressure relief interventions and verbalize diet to promote wound healing in 6 weeks. Intervention: Wound Protocol- triad (zinc-oxide hyrophilic cream) Description: Gently cleanse wound with NS (normal saline) or wound cleanser. -Apply a dime thick layer of triad to wound bed. OK to apply a '"glazed"" layer onto peri wound skin. -Cover with foam dressing. -When soiled, clean off only soiled barrier cream and apply another layer. -Skilled Nurse and Caregiver to perform ordered wound care 2 (two) times weekly. -Skilled clinician to complete weekly wound measurements and photograph wound to monitor healing/wound progress. -Skilled clinician to assess and describe wound bed, periwound skin, odor and drainage, and pain associated with wound/wound care. -Skilled clinician to assess and instruct patient/caregiver for signs and symptoms of wound infection/deterioration. -Instruct patient and caregiver in how to perform wound care. Review of the SN OASIS Start of Care dated 09/10/2025 lacks documented evidence of demonstration or teach back of wound care by the patient and/or caregiver to ensure appropriate education has been provided. During interview on 03/03/2026 at 10:04, the RN stated the patient demonstrated foley care, which is documented, but they did not provide teach back of wound care. Patient #3 – This 78-year-old patient with the diagnoses of encounter for change or removal of nonsurgical wound dressing, inflammatory disorders of the scrotum, and type II mellitus with hyperglycemia was admitted to the agency on 02/07/2026. Review of the Home Health Plan of Care dated 02/07/2026 to 04/07/2026 revealed the following order: Problem: Wound - Other Skin integrity deficit related to: Wound Type: scrotal abscess/surgical Location/site: groin Goal: Wound will heal or maintain without complications or signs/symptoms of infection Intervention: Wound Protocol- Wet to Dry Dressing -Cleanse wound with normal saline dampened gauze or wound cleanser. -Use skin barrier wipes to periwound as needed for protection from excess moisture or strong adhesives. - Damp packing strip to wound bed and tunneling area at 6 (six) o'clock and dry abd (abdominal) pad was placed over top. -Cover with dry dress/mesh underwear. -If stuck to the wound bed, moisten gauze with normal saline prior to removal. -Skilled Nurse, Skilled Clinician, patient and caregiver to perform ordered wound care daily. -Skilled clinician to complete weekly wound measurements and photograph wound to monitor healing/wound progress. -Skilled clinician to assess and describe wound bed, periwound skin, odor and drainage, and pain associated with wound/wound care. -Skilled clinician to assess and instruct patient/caregiver for signs and symptoms of wound infection/deterioration. -Instruct patient and caregiver in how to perform wound care. Review of the SN OASIS Start of Care dated 02/07/2026 lacks documented evidence of demonstration or teach back of wound care by the patient and/or caregiver to ensure appropriate education has been provided. During interview on 03/03/2026 at 09:38 AM, the RN was unavailable, but the Senior Director of Certified Home Health Agency (CHHA) stated there is no documented evidence stating teach back was done.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of clinical records, agency policy and procedure, the CDC (Centers for Disease Control) website, and staff interview, for two (2) of three (3) patients (Patient #’s: 1 and 2), the agency failed to follow agency policies and procedures, current clinical practice guidelines and accepted professional standards when providing services. Failure to follow agency policies and procedures and ensure compliance with accepted professional standards has the potential to result in unmet patient needs and inadequate care. Review of the agency policy entitled “Wound Assessment, 557” dated 08/2025 revealed: As per provider orders as they relate to wound care, a complete wound assessment for all wounds including surgical wounds, must be documented weekly at minimum. A complete wound assessment includes: A. A photograph including a wound marker refer to the (agency) Wound Photography Procedure #2501. 1. Wound location may be noted on the marker if multiple wounds are documented; B. Wound dimensions (length, width, depth). Dimensions must be documented in appropriate fields in the medical record; C. Wound attributes (wound bed, drainage, peri-wound, pain). Review of the undated agency policy entitled “Urinary Catheter: Indwelling Care” revealed: “An indwelling catheter (also referred to as a Foley catheter) is inserted via the urethra using a sterile preassembled closed drainage system to let urine drain from the bladder. Closed drainage systems and preassembled drainage systems may help reduce the incidence of CAUTls (Catheter-Associated Urinary Tract Infections).” Review of the CDC website “Summary of Recommendations Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009)” revealed: III.A. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. III.E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Patient #2 – This 90-year-old patient with the diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, duodenal ulcer, and benign prostatic hyperplasia with lower urinary tract symptoms was admitted to the agency on 09/10/2025. A.) Review of the SN (Skilled Nurse) OASIS (Outcome and Information Set) Start of Care dated 09/10/2025 revealed the following wound measurements: Left Heel: Length – 6.2 cm (centimeters) Width – 5 cm Left Hip: Length- 13 cm Width – 0.3 cm Review of the wound assessments lack a measurement of the wounds' depths. B.) Review of the SN Home Visits dated 09/29/2025, 10/02/2025, 10/06/2025, 10/10/2025, 10/13/2025, 10/16/2025, 10/20/2025, 10/23/2025, 10/27/2025, 10/30/2025, 11/03/2025, 11/06/2025, 11/11/2025, 11/14/2025, and 11/16/2025 reveal length and width wound measurements for bilateral heels and left buttocks but lack measurements of the wounds’ depths. During interview on 03/03/2025 at 09:45 AM, the Registered Nurse (RN) agreed that the depth of each of the wounds was not documented. C.) Review of the SN Home Visit dated 11/14/2025 revealed the RN documented “foley cath (catheter) changed per MD (medical doctor) orders with sterile technique 18 fr (French) regular balloon filled with 10 mL (milliliters) normal saline and urine return present at this time. Unable to change foley bag as it was forgotten prior to visit today. Foley bag to be changed at next visit.” Review of the Case Communication dated 11/15/2025 revealed the RN documented the following phone call: “patient had his foley catheter exchanged yesterday. Since then, the patient has been feeling pressure, burning, pain, and the urge to urinate. Still having some output from foley, however, not as much as normal. Due to the symptoms, writer advised for patient to go to an urgent care or ED (emergency department) for evaluation.” Review of the Incident Report dated 11/16/2025 revealed “catheter changed 11/14; however, tubing and bag reportedly not changed. At visit on 11/16. Dark - brown/grey, cloudy, discoloration was noted in catheter bag. Writer went to office to retrieve new tubing/bag. on call MD provided order for UA (urinalysis)/Cultures and sent in broad spectrum abx (antibiotics) for pt to start. Writer instructed pt to go to ED if no UOP (urine output) in 6 hours son called writer around 05:00 PM to report no UOP, went to hospital; when at hospital balloon was deflated and Review of the Complex SN Home Visit dated 11/16/2025 conducted by a different RN (not the RN who changed the foley on 11/14/2025) revealed “Writer spoke to (doctor) to obtain order for UA. UOP cloudy, malodorous. Patient felt relief after moving urine overnight. Low UOP, encouraged hydration. Cather bag changed Friday, tubing/bag not changed. Unsure of last change, mold growth found in bag.” Review of the SN Home Visit dated 11/18/2025 revealed the RN documented “patient states they had the foley changed at the ED this past weekend, urine is clear, yellow in bag, no issues today.” During interview on 03/03/2025 at 10:43 AM, the RN that completed the catheter change stated they don’t recall when the last order for supplies was. The RN was unable to explain how they set up for the foley change without realizing there was not a new bag available. A new bag should have been used. The RN stated they do not remember if they went back to change the bag once a new one was obtained, or when a new one was obtained. During interview on 03/03/2025 at 09:40 AM, the RN who conducted the visit on 11/16/2025 was unavailable, but the RN, Clinical Team Manager for Weekend Team stated the RN did not document changing the foley or the bag during this visit. Patient #1 – This 42-year-old with the diagnoses of non-pressure chronic ulcer of right heel and midfoot with unspecified severity, multiple sclerosis, and chronic kidney disease was admitted to the agency on 02/21/2026. Review of the SN OASIS Start of Care dated 02/21/2026 revealed the following wound measurements: Posterior, right ankle: Length - 4.5 cm Width – 4.5 cm Review of the wound assessment lacks a measurement of the wound’s depth. During interview on 03/03/2026 at 09:30 AM, the RN was unavailable, but the RN, Clinical Team Manager for Weekend Team stated the depth was not documented.

The following statement of deficiencies represents the results of an onsite complaint investigation survey (114722) of UR Medicine Home Care, initiated on 05/08/2025 and completed on 05/09/2025. The survey consisted of a review of three (3) clinical records, pertinent policies and procedures and the complaint log. The certified home health agency (CHHA) census is 901 patients.­­­­ Interviews were conducted throughout the survey with the Senior Director of CHHA Operations and various professional staff. ­­Findings were reviewed at the exit conference on 05/09/2025. The complaint 114722 was substantiated. The following deficiencies are being cited: G- 0520, G- 0528, G- 0538, G- 0544, G- 0574, G- 0592, G- 0602, and G- 0606.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with staff, for three (3) of three (3) patients, (Patient #’s: 1, 2, and 3), the agency failed to ensure that a comprehensive assessment consistent with the patient's needs was performed within five (5) calendar days after the Start of Care (SOC). Failure to ensure a comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. Patient #1- This 51-year-old patient with diagnoses that include aftercare following kidney transplant, essential hypertension and immunodeficiency was admitted to the home health agency on 04/08/2025. Review of the Home Health Plan of Care from 04/08/2025 to 06/06/2025 revealed the following Physical Therapy (PT) orders: - one (1) visit every five (5) days for five (5) days from 04/08/2025 to 04/12/2025 (discontinued as of 04/12/2025); - one (1) visit every five (5) days for five (5) days from 04/14/2025 to 04/18/2025 (discontinued as of 04/18/2025); and - one (1) visit every five (5) days for five (5) days from 04/19/2025 to 04/23/2025 (discontinued as of 04/22/2025). Review of the Physical Therapy Initial Evaluation dated 04/22/2025 revealed the PT evaluation was completed on 04/22/2025, fourteen (14) days after the start of care. Review of the clinical record lacks documentation the patient was offered and/or refused a PT evaluation prior to 04/22/2025. During interview on 05/09/2025 at 01:36 PM, the Senior Director of Certified Home Health Agency (CHHA) Operations stated the agency delayed the PT evaluation until 04/22/2025 due to insufficient staffing to complete an earlier evaluation, but the plan of care was updated to reflect delaying the evaluation. Patient #2 – This 77-year-old patient with diagnoses that include cervicalgia, unspecified kyphosis and dermatitis was admitted to the home health agency on 03/23/2025. Review of the Home Health Plan of Care from 03/23/2025 to 05/21/2025 revealed the following Occupational Therapy (OT) orders: - one (1) visit every five (5) days for five (5) days from 03/23/2025 to 03/27/2025 (discontinued as of 03/27/2025); - one (1) visit every seven (7) days for seven (7) days from 03/28/2025 to 04/03/2025 (discontinued as of 04/03/2025); and - one (1) visit every seven (7) days for seven (7) days from 04/04/2025 to 04/10/2025. Review of the clinical record lacks documentation the patient received and/or refused an OT evaluation. During interview of 05/09/2025 at 1:59 AM, the Senior Director of CHHA Operations stated the agency never provided OT services to the patient due to insufficient staffing, but the plan of care was updated to reflect delaying the evaluation until the patient was hospitalized 04/18/2025 and died on 04/20/2025. Patient #3 – This 57-year-old patient with diagnoses that include type 2 diabetes mellitus with foot ulcer, cellulitis of left lower limb, and pseudomonas was admitted to the home health agency on 04/18/2025. Review of the Ambulatory Referral To Home Health Services dated 04/15/2025 revealed the following services were requested to be provided to the patient: Physical Therapy (PT), Skilled Nursing (SN), and Occupational Therapy (OT). Review of the Case Communication Note dated 04/21/2025 revealed the Registered Nurse (RN) documented receiving a call back from the physician’s office and received approval for the agency to provide SN, PT and OT Services. Review of the clinical record lacks documentation the patient was assessed for, offered and/or declined an OT evaluation. During interview on 09/09/2025 at 01:35 PM, the Senior Director of CHHA Operations stated there is no documentation that the patient was offered and declined an OT evaluation.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on review of patient care records, and interview with agency staff for one (1) of three (3) patient records (Patient #2), the agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs. Failure to ensure the initial comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. Patient #2 – This 77-year-old patient with diagnoses that include cervicalgia, unspecified kyphosis and dermatitis was admitted to the home health agency on 03/23/2025. Review of the Ambulatory Referral To Home Health Services dated 03/19/2025 revealed the patient has venous stasis of both lower extremities and is to continue to apply compression stockings daily. Review of the Skilled Nurse (SN) Outcome and Assessment Information Set (OASIS) Start of Care Visit dated 03/23/2025 revealed the Registered Nurse (RN) documented the patient has bilateral, non-pitting lower extremity edema noted. The documentation lacks an assessment of the compression stockings to include if in home, condition of stockings, if patient able to apply and duration of use. During interview on 05/09/2025 at 11:20 AM, the RN stated there were compression stockings in the patient’s home but failed to be assessed at the identified visit.

Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient's primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for one (1) of three (3) patients (Patient #2), the agency failed to ensure the primary caregiver was assessed on their ability to provide care. Failure to assess the primary caregiver’s ability to provide care has the potential for unmet patient needs that could result in negative outcomes. Patient #2 – This 77-year-old patient with diagnoses that include cervicalgia, unspecified kyphosis and dermatitis was admitted to the home health agency on 03/23/2025. Review of the Home Health Plan of Care from 03/23/2025 to 05/21/2025 revealed the following daily wound treatment to the patient’s dermatitis plaques on the back: - gently cleanse area with mild soap and water or wound cleanser; - may cleanse with mineral oil or petroleum jelly to avoid skin stripping; - apply a layer of barrier cream; - when soiled, clean off soiled layer of barrier cream and apply new layer on top. - skilled caregiver to perform ordered wound care daily, and Skilled Nurse (SN) as needed. Review of the SN Outcome and Assessment Information Set (OASIS) Start of Care Visit dated 03/23/2025 revealed the Registered Nurse (RN) documented the patient has significant dermatitis on the back, pain to back is rated a ten (10) on a one (1) to ten (10) pain scale with ten (10) worst level of pain, patient is frustrated, anxious, unable to sit for more than a few minutes and is unable to sleep due to the dermatitis on the back. Additionally, the RN documented the patient lives alone, has family who live in Florida, and has a neighbor who assists as needed. The documentation lacks identification of a caregiver able and willing to perform the identified treatment to the patient’s back. During interview on 05/09/2025 at 11:40 AM, the RN stated there was no caregiver present, willing and able to perform the back care during the identified assessment and developed the plan of care with a daily treatment to be completed by a caregiver incorrectly.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record review and staff interview for one (1) of three (3) patients (Patient #1) the agency failed to ensure the comprehensive assessment is updated and revised to reflect changes in the patient's health status. Failure to ensure comprehensive assessments are updated and revised, has the potential for negative patient outcomes. Patient #1- This 51-year-old patient with diagnoses that include aftercare following kidney transplant, essential hypertension and immunodeficiency was admitted to the home health agency on 04/08/2025. Review of the Home Health Plan of Care from 04/08/2025 to 06/06/2025 revealed the following orders: - Jackson-Pratt (JP) drain to be emptied at least twice daily, log amount and consistency of output; - Skilled Nurse (SN), patient and caregiver to perform JP drain dressing changes every three (3) to five (5) days, or if dressing is soiled; and - Prevena wound vac is to stay in place for seven (7) days to right lower quadrant incision or until follow-up with physician next week. Physician will discontinue the wound vac and cover area with dry cover dressing. Review of the SN Missed Visit Note dated 04/10/2025 revealed the patient cancelled the visit for 04/10/2025 due to having a physician clinic appointment. Review of the SN Home Visit dated 04/15/2025 revealed the Licensed Practical Nurse (LPN) documented the right anterior pelvis wound bed as slough, peri-wound dry, drainage small amount of serosanguinous and covered with a dry dressing. Additionally, the LPN documented the patient declines need for dressing change, dressing clean, dry and intact, so reapplied. The assessment lacks documentation regarding the JP drain and Prevena wound vac status that had been present at previous SN visit on 04/08/2025. During interview on 05/092025 at 02:55 PM, the LPN stated the Prevena wound vac and JP drain had been discontinued at the clinic visit on 04/10/2025 and the patient had new staples in place over the surgical incision, but failed to document this.

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 review of clinical records and staff interview for two (2) of three (3) patients (Patient #'s 2 and 3), the agency failed to ensure a comprehensive plan of care (POC), was developed to meet the individualized needs of the patients. Failure to ensure the POC is comprehensive to meet the patient's needs has the potential for staff to provide inappropriate care. Patient #2 – This 77-year-old patient with diagnoses that include cervicalgia, unspecified kyphosis and dermatitis was admitted to the home health agency on 03/23/2025. Review of the Ambulatory Referral To Home Health Services dated 03/19/2025 revealed the patient has venous stasis of both lower extremities and is to continue to apply compression stockings daily. Review of the Skilled Nurse (SN) Outcome and Assessment Information Set (OASIS) Start of Care Visit dated 03/23/2025 revealed the Registered Nurse (RN) documented the patient has bilateral non-pitting lower extremity edema noted. The documentation lacks an assessment of the use of the compression stockings. Review of the Home Health Plan of Care from 03/23/2025 to 05/21/2025 lacks documentation of orders for the application of compression stockings to include: when to apply, when to remove, and who is responsible for the task. During interview on 05/09/2025 at 11:37 AM, the RN stated there were compression stockings in the patient’s home but failed to be assessed and ordered on the plan of care. Patient #3 – This 57-year-old patient with diagnoses that include type 2 diabetes mellitus with foot ulcer, cellulitis of left lower limb, and pseudomonas was admitted to the home health agency on 04/18/2025. Review of the Home Health Plan of Care from 04/18/2025 to 06/16/2025 revealed an order for insulin regular human, concentration (Humulin R U-500 kwikpen) 500 unit per milliliter (ml), inject 40 units into the skin every morning, inject 40 units into the skin with lunch, then inject 30 units into the skin with dinner. Max daily dose is 100 units. The POC is inconsistent. The order for 110 units of insulin in twenty-four (24) hours exceeds the maximum daily dose of 100 units ordered. During interview on 05/09/2025 at 02:11 PM, the Senior Director of Certified Home Health Agency Operations stated the Registered Nurse that developed the plan of care is not available for interview and acknowledged the identified order is incorrect.

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 review of clinical records and staff interview for one (1) of three (3) patients (Patient #2), the agency failed to ensure the plan of care (POC) was reviewed and revised to reflect the patient’s current status. Failure to ensure the POC is updated to reflect the patient’s status has the potential to result in negative patient outcomes. Patient #2 – This 77-year-old patient with diagnoses that include cervicalgia, unspecified kyphosis and dermatitis was admitted to the home health agency on 03/23/2025. A.) Review of the Skilled Nurse (SN) Home Visit dated 04/08/2025 revealed the Licensed Practical Nurse (LPN) documented the patient had a bottle of a “current antibiotic ordered by dermatology” noted in the home during the visit. Review of the clinical record lacks documentation the plan of care was updated to reflect the new antibiotic order the patient was started on and the duration of the medication. During interview on 05/09/2025 at 12:48 PM, the LPN stated the new antibiotic was visualized in the home during the identified visit but failed to be added to the plan of care. B.) Review of the Home Health Plan of Care from 03/23/2025 to 05/21/2025 revealed orders for Physical Therapy (PT) two (2) visits every week for six (6) weeks from 03/30/2025 to 05/10/2025. Review of Case Communication Note dated 04/08/2025 revealed the Director of Clinical Operations was speaking to the patient’s brother over the telephone and documented the brother expressed concerns regarding the SN and PT visit frequencies. The brother stated PT was ordered to see the patient four (4) times weekly. “Writer informed (brother) (agency) does not provide therapy at that frequency and will do three (3) times weekly for two (2) weeks.” Review of the clinical record lacks documentation the plan of care was updated to increase PT to three (3) times weekly for two (2) weeks as identified in the 04/08/2025 note. During interview on 05/09/2025 at 01:23 PM, the Director of Clinical Operations stated an email was sent to the PT regarding the increased visit frequency but failed to order the increased PT frequency and should have done so.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on review of clinical records, and interview with agency staff, for one (1) of three (3) patients (Patient #2), the agency failed to ensure the clinician communicated with all physicians involved in the patient's care. Failure to communicated with all physicians involved in the plan of care has the potential for unmet patient needs and patient harm. Patient #2 – This 77-year-old patient with diagnoses that include cervicalgia, unspecified kyphosis and dermatitis was admitted to the home health agency on 03/23/2025. A.) Review of the Skilled Nurse (SN) Home Visit dated 03/28/2025 revealed the Registered Nurse (RN) documented the following: - patient with bilateral lower extremity edema and complains regarding the inability to apply compression stockings; - patient with dermatitis to the back and is anxious about not being able to apply topical creams to the back; - patient reports inability to shower for several days or perform household tasks, and SN assured patient that Home Health Aide referral pending to assist when aide available. Review of the clinical record lacks documentation the RN communicated with the physician regarding the patient’s concerns. During interview on 05/09/2025 at 12:16 PM, the RN Case Manager stated the physician was not contacted regarding the identified patient concerns at that time. B.) Review of the SN Home Visit dated 04/03/2025 revealed the Licensed Practical Nurse (LPN) documented the patient recently was seen by dermatology and the patient raised concerns regarding SN and Home Health Aide visit frequencies being provided and how the current schedule received from the agency will not fully support his needs as recommended by the dermatologist. Additionally, the LPN documented the information was relayed to the Clinical Team Manager. Review of the clinical record lacks documentation of communication with the dermatology office regarding the identified patient concerns and updates regarding the recent referenced appointment. During interview on 05/09/2025 at 12:20 PM, the RN Case Manager stated the agency failed to follow-up with dermatology regarding the patient’s recent appointment and identified concerns.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on review of clinical records and interview with agency staff, for two (2) of three (3) patients (Patient #’s 1 and 2), the agency failed to effectively coordinate services to support the objectives of the plan of care. Failure to ensure adequate coordination and communication occurs, has the potential to result in poor quality of care. Patient #1- This 51-year-old patient with diagnoses that include aftercare following kidney transplant, essential hypertension and immunodeficiency was admitted to the home health agency on 04/08/2025. Review of the Home Health Plan of Care from 04/08/2025 to 06/06/2025 revealed Skilled Nurse (SN) orders for two (2) visits every week for four (4) weeks from 04/08/2025 to 05/03/2025 (discontinued as if 04/22/2025). Review of the SN Missed Visit Note dated 04/10/2025 revealed the Licensed Practical Nurse (LPN) documented “Patient cancelled visit today, states at (hospital) clinic today and thought that when at clinic there would not have a visiting nurse. Would like to be seen tomorrow.” Review of the clinical record lacks documentation of interdisciplinary coordination/communication regarding the clinic appointment and patient visit request for 04/11/2025. During interview on 05/09/2025 at 02:25 PM, the Senior Director of Certified Home Health Agency (CHHA) Operations stated there is no documentation of follow-up with the patient for a visit on 04/11/2025 as the patient requested. Patient #2 – This 77-year-old patient with diagnoses that include cervicalgia, unspecified kyphosis and dermatitis was admitted to the home health agency on 03/23/2025. Review of the SN Home Visit dated 03/25/2025 revealed the LPN documented the following: - Patient complains of being greatly bothered by dermatitis to back often opening up and ruining clothing. - Patient requests SN to call patient’s brother who resides out of state who wants dermatitis on back cultured. - Brother on phone requesting agency use hydrocolloid dressing on patient’s back and wanting to know if LPN will wait in the patient’s home for provider to write a script for a culture to back, then obtain the culture, and take culture to lab for processing. LPN advised brother that was not possible and that the Case Manager RN and Wound Nurse had been made aware of the request and would be following up with them. Review of the clinical record lacks documentation of interdisciplinary communication regarding the patient/brother’s request for obtaining wound cultures/wound consult for treatment recommendations from the identified visit. Review of the Case Communication Note dated 04/12/2025 revealed the Wound, Ostomy, Continence Nurse (WOCN) documented making a consult regarding back lesions (17 days after patient’s brother requested this) “currently managed by dermatology, seen last by dermatology on 04/04/2025 with treatment recommendations. Plan for dermatology to continue to manage. During interview on 05/09/2025 at 12:45 PM, the LPN stated the identified concerns were shared with the RN via a Zoom meeting but failed to document this. During interview on 05/09/2025 at 03:11 PM, the WOCN stated a referral was made on 04/11/2025 and on 04/12/2025 conducted a consult for back lesions. The WOCN stated dermatitis is not a wound and would not make any treatment recommendations.

The following statement of deficiencies represents the results of an onsite complaint investigation survey 38820-H1 of UR Medicine Home Care, Certified Services, INC. initiated on 04/05/2022 and completed on 04/07/2022. The survey consisted of a review of three (3) clinical records and pertinent policies and procedures. Interviews were conducted throughout the survey with the Senior Director of Certified Home Health Agency (CHHA) Services and various professional staff. The CHHA census was 1,089 patients.­­­­ Findings were reviewed at the exit conference on 04/07/2022. The complaint 62619 was substantiated. The complaint 59343 was not substantiated. The following deficiencies are being cited: G- 526, G- 536, G- 544, ;G- 574, G- 576, G- 578, G- 586, G- 590, G- 608, G- 610, G- 716 and G- 984.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on review of clinical records, agency policy and procedure, and interview with agency staff for two (2) of three (3) patients (Patient #'s: 2 and 3), the agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. Failure to ensure comprehensive assessments accurately reflect the patient status and needs has the potential for unmet patient needs and the potential for negative patient outcomes. Patient #2 - This 68-year-old patient with diagnoses that include malignant neoplasm of the colon, encounter for adjustment and management of vascular device, and type II diabetes mellitus was admitted to the home care agency on 08/08/2021. Review of the SN OASIS Admission Note dated 08/08/2021 revealed the patient has an ileostomy for bowel elimination but lacks an assessment of the ileostomy site and output. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 04/06/2022 at 03:20 PM, the Senior Director of Certified Home Health Agency (CHHA) Services stated there is no assessment of the ileostomy at the start of care. Review of agency policy entitled “Patient Assessment” reviewed 07/2020 revealed "2. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: a) The patient's current health, psychosocial, functional and cognitive status." Patient #3 – This 91-year-old patient with diagnoses that include stage 2 pressure ulcer of right buttock, type 2 diabetes mellitus and hypertensive heart disease with heart failure was admitted to the home care agency on 03/20/2022. Review of the SN (Skilled Nurse) OASIS (outcome and assessment information set) Admission Visit Note dated 03/20/2022 revealed the Registered Nurse (RN) documented the patient has two (2) unhealed stage 2 pressure ulcers, one to the right buttock and another small pressure ulcer above it. The visit note includes a wound assessment and performance of wound care to one pressure ulcer on the right buttock. The visit note lacks a wound assessment and performance of wound care to the second pressure ulcer. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient’s status and needs. During interview on 04/06/2022 at 02:25 PM, the RN confirmed the patient had two (2) stage 2 pressure ulcers on admission. She stated she measured and performed wound care to both wounds but only documented on the larger wound on the right buttock.

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 review of clinical records and interview with agency staff for one (1) of three (3) clinical records (Patient #1), the clinical record lacks a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns. Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for the patient harm. Patient #1 – This 79-year-old patient with diagnoses that include stage 2 pressure ulcer of sacrum, dementia and urinary tract infection was admitted to the home care agency on 02/22/2022. Review of the facility discharge summary dated 02/21/2022 revealed the patient was discharged on Diclofenac 1% gel (Voltaren) 4 g (grams) topically 2 (two) times daily to joints. Review of the Home Health Certification and Plan of Care for certification period 02/22/2022 to 04/22/2022 revealed an order for Voltaren Arthritis Pain 1% gel apply 4 grams by topical route 4 (four) times per day to joints. Review of the SN (Skilled Nurse) OASIS (outcome and assessment information set) Admission Visit Note dated 02/22/2022 revealed the Registered Nurse (RN) documented no issues were found during the drug regimen review. Review of the clinical record lacks documented evidence of notification to the physician and clarification of the discrepancy of the frequency to apply Voltaren. The RN failed to identify and reconcile the medication discrepancy identified in the referral for services and the POC. During interview on 04/06/2022 at 12:05 PM, the RN stated she did not document the clarification obtained for the med discrepancy.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record review and staff interview for one (1) of three (3) patients (Patient #1), the agency failed to ensure the comprehensive assessment is updated and revised to reflect changes in the patient's health status. Failure to ensure comprehensive assessments are updated and revised, has the potential for negative patient outcomes. Patient #1 – This 79-year-old patient with diagnoses that include stage 2 pressure ulcer of sacrum, dementia and urinary tract infection was admitted to the home care agency on 02/22/2022. A.) Review of the SN (Skilled Nurse) OASIS (outcome and assessment information set) Admission Visit Note dated 02/22/2022 revealed the patient has a stage 2 pressure ulcer on the coccyx requiring barrier cream applied to the ulcer twice daily and as needed with peri-care. Review of the Case Communication Note dated 03/10/2022 revealed the Physical Therapist (PT) documented the Registered Nurse (RN) contacted him on 03/09/2022 requesting the PT look into getting an air mattress for the patient because the patient’s pressure ulcer was not healing and the gel pad the spouse had reported was in the home for patient use was not working. Review of the SN Routine without Supervisory Visit Note dated 03/09/2022 revealed the RN documented the following: - “Wound care performed, wound healing with current treatment, PT working on air mattress; - Concerns requiring MD notification: No.” The visit note lacks assessments of the patient’s wound and gel pad overlay in the home. The SN failed to ensure the updated comprehensive assessment reflects changes in the patient’s health status. During interview on 04/06/2022 at 03:00 PM, the Therapy Quality Coordinator stated the PT was unavailable for interview and the RN no longer works at the agency. The Therapy Quality Coordinator stated the 03/09/2022 RN visit documentation failed to reflect the concerns identified in the 03/10/2022 Case Communication Note. B.) Review of the Case Communication Note dated 03/18/2022 by the Physical Therapy Assistant (PTA) revealed the following documentation: - BP (blood pressure) 149/112, rechecked BP with different cuff 101/51. - Patient presenting with dark urine, loss of appetite, lethargy and confusion. - Aide concerned symptoms present as UTI (urinary tract infection). - MD called to report high BP and possible UTI, MD office recommends patient go to ED (emergency department). - Aide does not think family will agree to take patient to ED. - Case Communication sent. Review of the clinical record revealed the next SN Visit occurred on 03/23/2022 (five days after case communication was sent notifying all active disciplines of patient status changes). Review of the SN Routine without Supervisory Visit dated 03/23/2022 revealed the RN documented performing wound care with the patient’s private pay aide. The visit note lacks an assessment of the patient’s genitourinary status. The SN failed to ensure the updated comprehensive assessment reflects changes reported in the patient’s health status. During interview on 04/06/2022 at 12:28 PM, the PTA stated the family refused to take the patient to the ED on 03/18/2022 when symptomatic and all active disciplines were notified of the change of status in the Case Communication Note. During interview on 04/06/2022 at 12:35 PM, the Clinical Manager stated the RN in question no longer works for the agency. She stated the RN should not have delayed five (5) days to assess the patient after there was a report regarding status changes.

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 review of clinical records and staff interviews for one (1) of three (3) patients (Patient #2) the agency failed to develop individualized plans of care (POC) that are complete and accurate and address the total needs of the patients. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. Patient #2 - This 68-year-old patient with diagnoses that include malignant neoplasm of the colon, encounter for adjustment and management of vascular device, and type II diabetes mellitus was admitted to the home care agency on 08/08/2021. A.) Review of the SN (Skilled Nurse) OASIS (Outcome and Assessment Information Set) Admission Note dated 08/08/2021 revealed the patient has an ileostomy for bowel elimination. Review of the Home Health Certification and Plan of Care for certification period 08/08/2021 to 10/06/2021 lacks documented evidence of an order for the ileostomy to include supplies, who is responsible for care, and when it was placed. The agency failed to develop individualized POC that are complete and accurate and address the total needs of the patients. During interview on 04/06/2022 at 03:19 PM, the Senior Director of Certified Home Health Agency (CHHA) Services stated there are no orders for the ileostomy, but it should have been included on the POC. B.) Review of the Home Health Certification and Plan of Care for certification period 08/08/2021 to 10/06/2021 revealed orders to flush and clean/dress the patient’s mediport but lacks documented evidence to specify when it was placed. The agency failed to develop individualized POC that are complete and accurate and address the total needs of the patients. During interview on 04/06/2022 at 03:24 PM, the Senior Director of Senior Director of CHHA Services stated the insertion date is not something the clinicians usually document unless it is a new mediport. C.) Review of the Home Health Certification and Plan of Care for certification period 08/08/2021 to 10/06/2021 revealed the patient has the diagnosis of type II diabetes mellitus, is ordered for diabetic supplies, and takes insulin glargine 25 units by subcutaneous route every evening. Review of the Home Health Certification and Plan of Care for certification period 08/08/2021 to 10/06/2021 lacks an order specifying the frequency for testing, who is responsible, and parameters specifying when to notify the physician. The agency failed to develop individualized POC that are complete and accurate and address the total needs of the patients. During interview on 04/06/2022 at 03:10 PM, the Senior Director of Senior Director of CHHA Services stated there are no orders to address the patient’s diabetic testing.

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 clinical record review and staff interview, one (1) of three (3) patient records (Patient #2) lack evidence an order was obtained to update the Plan of Care (POC) to reflect the patient's current status. Failure to obtain an order to update the POC has the potential for agency staff to act on inaccurate and incomplete information, and places patient health and welfare at risk. Patient #2 - This 68-year-old patient with diagnoses that include malignant neoplasm of the colon, encounter for adjustment and management of vascular device, and type II diabetes mellitus was admitted to the home care agency on 08/08/2021. Review of the Home Health Certification and Plan of Care for certification period 08/08/2021 to 10/06/2021 revealed the following order: “Insulin Glargine 300 unit/mL (milliliter) take 25 (twenty-five) units subcutaneous route every evening.” Review of the Medication Reconciliation Patient Discharge Summary (discharge from the hospital) dated 09/09/2021 revealed the patient’s insulin order was changed to “Insulin Glargine (Toujeo Solostar) 300 unit/mL injection 20 (twenty) units subcutaneously once daily.” The clinical record lacks evidence an order was obtained to update the POC to reflect the patient's status. During interview on 04/06/2022 at 03:30 PM, the Registered Nurse (RN) Quality Coordinator stated there is no supplemental order for the medication change.

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 review of clinical records and interviews with agency staff for one (1) of three (3) patients (Patient #3), the agency failed to provide services in accordance with physician orders and the Plan of Care (POC). Failure to ensure patient care is provided in accordance with physician orders and the POC has the potential for patients to receive poor care and for health care needs to go unmet. Patient #3 – This 91-year-old patient with diagnoses that include stage 2 pressure ulcer of right buttock, type 2 diabetes mellitus and hypertensive heart disease with heart failure was admitted to the home care agency on 03/20/2022. Review of the Home Health Certification and Plan of Care for certification period 03/20/2022 to 05/18/2022 revealed the following orders: - Metformin 500 mg (milligram), take 1 (one) tablet by oral route 2 (two) times per day; - Skilled Nursing observation and assessment of endocrine status; - BG (blood glucose) frequency daily at minimum, checked by cg (caregiver); and - VN (Visiting Nurse) to do BG PRN (as needed) for patient assessment and/or signs or symptoms of hypo/hyperglycemia. Review of the SN (Skilled Nurse) Routine without Supervisory Visit Note dated 03/28/2022 revealed the Registered Nurse (RN) documented the patient did not test her BG today and she instructed on checking blood glucoses. The visit note lacks documented evidence of recorded reported BG’s and/or obtaining a BG during the visit. Review of the SN Non OASIS (outcome and assessment information set) Discharge Visit dated 03/31/2022 lacks a diabetic assessment, recording of daily reported BG’s and/or obtaining a BG during the visit. The agency failed to provide services in accordance with physician orders. During interview on 04/06/2022 at 02:13 PM, the RN stated she did not record reported BG’s or obtain a BG during her two visits. She stated she did not notify the physician that the patient was not checking her BG daily as ordered.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Review of clinical records and interviews with staff for two (2) of three (3) patients (Patient #'s: 1 and 2), the agency failed to ensure the Plan of Care (POC) is reviewed and revised to reflect the patient's status. Failure to ensure the POC is updated and revised has the potential to result in negative patient outcomes. Patient #2 - This 68-year-old patient with diagnoses that include malignant neoplasm of the colon, encounter for adjustment and management of vascular device, and type II diabetes mellitus was admitted to the home care agency on 08/08/2021. A.) Review of the SN Recert (Recertification) Visit Note dated 10/06/2021 revealed the SN documented “colostomy producing soft to liquid stool, appliance intact.” Review of the Home Health Certification and Plan of Care for certification period 10/07/2021 to 12/05/2021 lacks documented evidence of an order for the ostomy to include supplies, who is responsible for care, and when it was placed. The agency failed to ensure the POC is reviewed and revised to reflect the patient's status. During interview on 04/06/2022 at 01:43 PM, the RN stated the patient actually has an ileostomy, and there are no orders for it on the POC. B.) Review of the Home Health Certification and Plan of Care for certification period 10/07/2021 to 12/05/2021 revealed orders to flush and clean/dress the patient’s mediport but lacks documented evidence to specify when it was placed. The agency failed to ensure the POC is reviewed and revised to reflect the patient's status. During interview on 04/06/2022 at 01:48 PM, the RN stated she is not sure of the insertion date and it was not included on the POC. C.) Review of the Home Health Certification and Plan of Care for certification period 10/07/2021 to 12/05/2021 revealed the patient has the diagnosis of type II diabetes mellitus, is ordered for diabetic supplies, and takes insulin glargine 25 units by subcutaneous route every evening. Review of the SN Recert Visit Note dated 10/06/2021 revealed the SN documented the patient is not checking his blood glucoses. Review of the Home Health Certification and Plan of Care for certification period 10/07/2021 to 12/05/2021 lacks documented evidence specifying the patient does not check his blood glucoses or who is managing his diabetes. The agency failed to ensure the POC is reviewed and revised to reflect the patient's status. During interview on 04/06/2022 at 01:48 PM, the RN stated there are no orders to address the patient’s blood glucose testing frequency or refusal to do so. Patient #1 – This 79-year-old patient with diagnoses that include stage 2 pressure ulcer of sacrum, dementia and urinary tract infection was admitted to the home care agency on 02/22/2022. Review of the SN (Skilled Nurse) OASIS (outcome and assessment information set) Admission Visit Note dated 02/22/2022 revealed the following wound assessment for the stage 2 posterior coccyx pressure ulcer: Length 1.30 cm (centimeter), Width 0.40 cm, Depth 0.00 cm, Wound bed: Clean non-granulating 100%, Wound drainage: None. Review of the Home Health Certification and Plan of Care for certification period 02/22/2022 to 04/22/2022 revealed the following wound care order to the stage 2 coccyx pressure ulcer: perform three times a day, cleanse area with mild soap and water, apply thick layer of barrier cream, when soiled, clean off only soiled barrier cream and apply another layer. Review of the SN Routine without Supervisory Visit Note dated 03/31/2022 revealed the following wound assessment for the stage 2 coccyx pressure ulcer: Length 2.50 cm, Width 2.50 cm, Depth 0.10 cm, Wound bed: Slough greater than 25%, Granulation less than 25%, Wound drainage: minimal. Review of the Case Communication Note and Order dated 03/31/2022 revealed the Registered Nurse (RN) documented speaking to the physician's office to inform of the worsening wound status and change in wound care to medihoney (gel that decreases bacterial growth within the wound) and cover dressing three (3) times weekly. The order does not specify the current wound care is to be performed until the new wound care supplies are delivered. Review of the SN Routine without Supervisory Visit Note dated 04/04/2022 revealed the new wound care supplies were not in the home and the daughter reported she purchased foam dressings and applied calamine lotion (used to treat mild itchiness) to the wound bed when she applied the dressing. Review of the clinical record from 03/31/2022 to 04/05/2022 (date of survey) revealed the patient has not had the new wound care supplies delivered to the home. The agency failed to ensure the POC is review and revised to reflect the patient’s status. During interview on 04/06/2022 at 12:40 PM, the RN Case Manager stated she failed to specify on the new wound care order for the patient to continue on the current wound care until the new wound supplies were delivered to the patient’s home.

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 review of clinical records and interviews with staff for three (3) of three (3) patients (Patient #'s: 1, 2, and 3), the agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest the Plan of Care (POC) may need to be altered. Failure to promptly notify the physician to changes in the patient's condition or needs that may suggest that outcomes are not being achieved and/or the POC should be altered has the potential to result in unmet patient needs and negative patient outcomes. Patient #2 - This 68-year-old patient with diagnoses that include malignant neoplasm of the colon, encounter for adjustment and management of vascular device, and type II diabetes mellitus was admitted to the home care agency on 08/08/2021. Review of the SN Recert (Recertification) Visit Note dated 10/06/2021 revealed the SN documented the following “non-compliant with Vitamin C, D3, Insulin. Refuses flu vaccine. Has not been testing BG (blood glucose), has not been taking insulin d/t (due to) not eating.” Review of the clinical record lacks documented evidence the physician was notified of the patient’s noncompliance or poor intake. The agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest the POC may need to be altered. During interview on 04/06/2022 at 01:28 PM, the RN stated the physician was not notified because she thought the physician was notified during the previous episode. Patient #1 – This 79-year-old patient with diagnoses that include stage 2 pressure ulcer of sacrum, dementia and urinary tract infection was admitted to the home care agency on 02/22/2022. Review of the Case Communication Note and Order dated 03/31/2022 revealed the Registered Nurse (RN) documented speaking to the physician’s office to inform of the patient’s worsening wound status and recommend a change in wound care to medihoney (wound product used to reduce bacterial growth) and cover dressing three (3) times weekly. Review of the SN (Skilled Nurse) Routine without Supervisory Visit Note dated 04/04/2022 revealed the RN documented the following: - New wound care supplies have not been delivered; - Patient’s daughter purchased dry foam dressings and applied calamine lotion (used to treat mild itchiness) to wound bed when she applied the dressing; - Maceration (causes skin to be broken down from excessive moisture) noted around wound when SN performed wound care on 04/04/2022. Review of the clinical record lacks documented evidence the physician was notified of the patient receiving a wound treatment that was not ordered and the change of the wound appearance. The agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest the POC may need to be altered. During interview on 04/06/2022 at 12:45 PM, the RN Case Manager stated the physician was not notified of the family applying a wound product that was not ordered and the wound appearing macerated at the following visit. The RN Case Manager stated she would follow-up with the supply vendor again regarding the delayed supply delivery. Patient #3 – This 91-year-old patient with diagnoses that include stage 2 pressure ulcer of right buttock, type 2 diabetes mellitus and hypertensive heart disease with heart failure was admitted to the home care agency on 03/20/2022. Review of the Home Health Certification and Plan of Care for certification period 03/20/2022 to 05/18/2022 revealed Skilled Nursing orders for endocrine assessments and BG (blood glucose) checks daily performed by cg (caregiver). VN (Visiting Nurse) to perform BG PRN (as needed) for patient assessment and/or signs or symptoms of hypo/hyperglycemia. Review of the PT (Physical Therapy) Non OASIS (outcome and assessment information set) Admission Visit dated 03/22/2022 revealed the PT documented the patient’s BG readings of 412, 228, 291 and 93. Additionally, the PT documented the BG is not taken regularly. Review of the SN (Skilled Nurse) Routine without Supervisory Visit dated 03/28/2022 revealed the RN documented the patient’s BG test was not obtained that day. Review of the clinical record lacks documented evidence the physician was notified of the patient’s BG not being checked daily. The agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest the POC may need to be altered. During interview on 04/06/2022 at 02:11 PM, the RN stated the physician was not notified the patient’s BG’s were not being checked daily.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with agency staff for two (2) of three (3) patients (Patient #’s 1 and 3), the agency failed to coordinate care delivery and ensure patient needs are addressed. Specifically, the clinicians failed to ensure medical equipment and supplies were obtained and placed in the home. Failure to coordinate care delivery has the potential for negative patient outcomes. Patient #1 – This 79-year-old patient with diagnoses that include stage 2 pressure ulcer of sacrum, dementia and urinary tract infection was admitted to the home care agency on 02/22/2022. Review of the PT (Physical Therapy) Non OASIS (outcome and assessment information set) Admission Visit dated 02/22/2022 revealed the patient has a hospital bed, wheelchair and hoyer lift in the home. The patient requires the hoyer lift for all transfers. A.) Review of the PT Routine Without Supervisory Visit dated 02/24/2022 revealed the PT documented instructing the patient’s caregiver (PCG) in pressure relief measures and discussed the need for “waffle cushion for wheelchair which nurse is going to order.” Review of the clinical record lacks documented evidence of the Skilled Nurse (SN) ordering a wheelchair cushion. Review of the PT Evaluation Visit dated 03/10/2022 revealed the PT documented “looking into either cushion for current WC (wheelchair) or possibly getting new transport chair if patient qualifies with better cushion to help with pressure relief.” Review of the Case Communication Note dated 03/14/2022 revealed the PT documented contacting the supply vendor regarding getting a new manual wheelchair or at least a new chair cushion due to the pressure ulcer. Additionally, the PT documented contacting the physician and requesting a prescription be faxed to the supply vendor in an attempt to obtain the identified equipment. Review of the clinical record from 03/15/2022 to 04/05/2022 lacks documented evidence of any further follow-up or delivery of the identified equipment. The agency failed to coordinate care delivery and ensure patient needs are addressed. During interview on 04/06/2022 at 03:05 PM, the Clinical Manager stated the PT and SN were unavailable for interview. During interview on 04/06/2022 at 01:05 PM, the Registered Nurse (RN) Case Manager stated she started working with the patient on 03/31/2022 and noted a wheelchair cushion was in the home at that time. B.) Review of the PT Routine Without Supervisory Visit Note dated 02/24/2022 revealed the PT documented “the patient’s spouse reports they have a gel cushion for the bed ordered a while ago and it is stored in the garage. Aide states they will put it on the bed later today when they get her (the patient) out of bed.” Review of the clinical record lacks documented evidence the Skilled Nurse (SN), PT and PT Assistant (PTA) assessed if the identified gel cushion was placed on the patient’s hospital bed and if it was functional and appropriate for providing adequate pressure relief. Review of the Case Communication Note dated 03/10/2022 revealed the PT documented the following “Nurse called PT asking if he could look into getting air mattress for patient since pressure ulcer not healing well and pad the spouse stated they had in garage is not working.” Review of the SN Routine without Supervisory Visit Note dated 03/14/2022 revealed the SN documented that the PT was “working on air mattress.” Review of the clinical record lacks documented evidence of follow-up after 03/14/2022 on ordering and obtaining an air mattress for the patient’s hospital bed. The agency failed to coordinate care delivery and ensure patient needs are addressed. During interview on 04/06/2022 at 12:30 PM, the PTA stated the patient had a gel mattress on her hospital bed but she never assessed if it was functional and believed the PT was looking into all the patient’s equipment needs. During interview on 04/06/2022 at 03:05 PM, the Clinical Manager stated the PT was unavailable to be interviewed and the SN no longer works for the agency. The Clinical Manager stated it is the agency expectation that all clinicians involved would assess equipment needs and assess if equipment in the home was functional. The Clinical Manager acknowledged the clinical record lacks follow-up regarding obtaining a new pressure relief mattress. During interview on 04/06/2022 at 01:03 PM, the RN Case Manager stated she started working with the patient on 03/31/2022 and was under the impression the insurance would not cover a new pressure relieving mattress because the patient had a gel mattress previously ordered. She stated she did not document this in the record. She additionally stated she did not assess the current gel mattress to see if it was appropriate and functional for providing adequate pressure relief. Patient #3 – This 91-year-old patient with diagnoses that include stage 2 pressure ulcer of right buttock, type 2 diabetes mellitus and hypertensive heart disease with heart failure was admitted to the home care agency on 03/20/2022. Review of the SN OASIS Admission Visit Note dated 03/20/2022 revealed the SN documented the patient has a glucometer in the home but the test strips to use with the glucometer expired in 2018. The SN contacted the physician and requested the physician order new test strips. Review of the PT Non OASIS Admission Visit Note dated 03/22/2022 revealed the PT recorded blood glucoses (BG’s) for the last four days of: 412, 228, 291, 93 and noted BG’s are not taken regularly. The visit note lacks documentation to confirm if new test strips are in the home and being used or if the expired test strips were used to obtain the BG readings. Review of the LPN (Licensed Practical Nurse) Routine Visit Note dated 03/24/2022 revealed the LPN documented the patient has no BG test strips. Review of the clinical record from 03/25/2022 to 04/05/2022 (date of survey) lacks documented evidence to ensure if the new test strips for the glucometer were obtained and are being used. The agency failed to coordinate care delivery and ensure patient needs are addressed. During interview on 04/06/2022 at 02:20 PM, the PT stated she did not check if new test strips for the patient’s glucometer were in the patient’s home and being used during the visit. During interview on 04/06/2022 at 02:13 PM, the RN stated she never checked to see if new test strips were obtained and being used to test BG’s.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview for three (3) of three (3) patients (Patient #'s: 1, 2, and 3), the agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the plan of care (POC). Failure to provide appropriate education has the potential to result in the patient receiving inadequate care and could result in patient harm. Patient #2 - This 68-year-old patient with diagnoses that include malignant neoplasm of the colon, encounter for adjustment and management of vascular device, and type II diabetes mellitus was admitted to the home care agency on 08/08/2021. Review of the Home Health Certification and Plan of Care for certification period 08/08/2021 to 10/06/2021 revealed the patient has the diagnosis of type II diabetes mellitus, is ordered for diabetic supplies, and takes insulin glargine 25 units by subcutaneous route every evening. Review of the SN OASIS Admission Note dated 08/08/2021 lacks documented evidence the SN observed a demonstration of the patient/caregiver obtaining a blood glucose and/or administrating insulin. Review of the clinical record lacks documented evidence the patient received appropriate education regarding obtaining a blood glucose and administering insulin. The agency failed to ensure the patient/caregiver was able to successfully re-demonstrate the ability to independently obtain a blood glucose or administer a subcutaneous diabetic medication. During interview on 04/06/2022 at 03:10 PM, the Senior Director of Certified Home Health Agency (CHHA) Services stated there is no documentation to show the SN observed the patient or caregiver testing his blood glucose or administering insulin. Patient #1 – This 79-year-old patient with diagnoses that include stage 2 pressure ulcer of sacrum, dementia and urinary tract infection was admitted to the home care agency on 02/22/2022. Review of the Case Communication Note and Order dated 03/31/2022 revealed the Registered Nurse (RN) documented speaking to the physician office to inform of the worsening wound status and change in wound care to medihoney (gel that decreases bacterial growth within the wound) and cover dressing three (3) times weekly. Review of the SN (Skilled Nurse) Routine without Supervisory Visit Note dated 04/04/2022 revealed the RN documented the following: - New wound care supplies have not been delivered; and - Patient’s daughter purchased dry foam dressings and applied calamine lotion (used to treat mild itchiness) to wound bed when she applied the dressing. Review of the clinical record lacks documented evidence the patient’s caregiver received education regarding the wound care to perform until new dressing supplies are delivered to the home. During interview on 04/06/2022 at 12:55 PM, the RN Case Manager stated the patient was to remain on the previous wound care until the new dressing supplies were delivered to the home but she failed to document this. Patient #3 – This 91-year-old patient with diagnoses that include stage 2 pressure ulcer of right buttock, type 2 diabetes mellitus and hypertensive heart disease with heart failure was admitted to the home care agency on 03/20/2022. Review of the Home Health Certification and Plan of Care for certification period 03/20/2022 to 05/18/2022 revealed orders for SN wound care assessment and treatment effectiveness. Wound care to right gluteus maximus stage 2 pressure ulcer 2 (two) times weekly: cleanse wound with normal saline dampened gauze or wound cleanser. Apply skin barrier to periwound as needed for protection, apply hydrocolloid to wound bed, cover with foam dressing. Cg (caregiver) to perform wound care after instruction and demonstrating proper procedure independently. Review of the SN Non OASIS (outcome and assessment information set) Discharge Visit Note dated 03/31/2022 revealed the RN documented “Wounds healing well, Granddaughter able to do dressing changes. No further SN needed at this time.” Review of the clinical record lacks documented evidence the patient’s caregiver received appropriate education, including demonstration of the patient’s wound care. The agency failed to ensure the caregiver was able to successfully re-demonstrate the ability to perform the patient’s wound care. During interview on 04/06/2022 at 02:10 PM, the RN stated she verbally instructed the caregiver in the wound care but did not have her re-demonstrate the dressing change.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with staff, for one (1) of three (3) patients (Patient #2), the agency failed to prepare and document complete and accurate clinical notes. Failure to document complete and accurate clinical and progress notes has the potential for unmet patient needs. Patient #2 - This 68-year-old patient with diagnoses that include malignant neoplasm of the colon, encounter for adjustment and management of vascular device, and type II diabetes mellitus was admitted to the home care agency on 08/08/2021. Review of the SN (Skilled Nurse) OASIS (Outcome and Assessment Information Set) Admission Note dated 08/08/2021 revealed the patient has an ileostomy for bowel elimination. Review of the SN Recert (Recertification) Visit Note dated 10/06/2021 revealed the SN documented “colostomy producing soft to liquid stool, appliance intact.” During interview on 04/06/2021 at 01:45 PM, the Registered Nurse (RN) stated she mistakenly documented the patient has a colostomy, the patient has an ileostomy. The agency failed to prepare and document complete and accurate clinical notes.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of clinical records, agency policy and procedure, and staff interview, for three (3) of three (3) patients (Patient #'s: 1, 2, and 3), the agency failed to follow agency policies and procedures, current clinical practice guidelines and accepted professional standards when providing services. Failure to follow agency policies and procedures and ensure compliance with accepted professional standards has the potential to result in unmet patient needs and inadequate care. Review of agency policy entitled “Patient Assessment” reviewed 07/2020 revealed “The comprehensive assessment must be updated and revised (including the administration of the OASIS (outcome and assessment information set) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than: b) within 48 (forty-eight) hours of the patient’s return home from a hospital admission of 24 (twenty-four) hours or more for any reason other than diagnostic tests.” Patient #2 - This 68-year-old patient with diagnoses that include malignant neoplasm of the colon, encounter for adjustment and management of vascular device, and type II diabetes mellitus was admitted to the home care agency on 08/08/2021. Review of the Home Health Certification and Plan of Care for certification period 08/08/2021 to 10/06/2021 revealed the patient receives SN services every other week. Review of the clinical record revealed the patient was in the hospital from 09/07/2021 to 09/09/2021. Review of the Case Communication Report signed by the LPN (Licensed Practical Nurse) on 09/09/2021 revealed the LPN documented “telemetry monitoring and imaging of brain with no acute findings. VSS (vital signs stable). Medically stable to be discharged home.” Review of the clinical record revealed the patient did not receive SN services until 09/26/2021, 17 (seventeen) days after he was discharged home from the hospital. Review of the clinical record lacks documented evidence the agency attempted to schedule a visit with the patient before the visit on 09/26/2021. The agency failed to follow agency policies and procedures when providing services. During interview on 04/06/2022 at 03:16 PM, the Senior Director of Certified Home Health Agency (CHHA) Services stated the patient should have been seen after he was discharged home from the hospital. Review of agency procedure entitled “Wound Assessment and Documentation” revealed “2. Wounds are measured and photographed on the first visit of each week (with the week starting on Monday) at a minimum…f. For a planned discharge visit, in order to establish the status of the wound when care is assumed by patient/family/caregiver, any remaining open wounds are photographed.” Patient #1 – This 79-year-old patient with diagnoses that include stage 2 pressure ulcer of sacrum, dementia and urinary tract infection was admitted to the home care agency on 02/22/2022. Review of the Home Health Certification and Plan of Care for certification period 02/22/2022 to 04/22/2022 revealed orders for skilled observation and assessment of wound status and treatment effectiveness. Wound care to stage 2 coccyx pressure ulcer: gently cleanse area with mild soap and water, apply thick layer of barrier cream three times daily. When soiled, clean off only soiled barrier cream, and apply another layer. Review of the SN (Skilled Nurse) OASIS (outcome and assessment information set) Admission Visit Note dated 02/22/2022 revealed the following wound assessment for the stage 2 posterior coccyx pressure ulcer: Length 1.30 cm (centimeter), Width 0.40 cm, Depth 0.00 cm, Wound bed: Clean non-granulating 100%, Wound drainage: None, Peri-wound: Intact. Review of the clinical record revealed the patient received weekly SN visits on the following days: 03/09/2022, 03/14/2022, 03/23/2022 and 03/31/2022. Review of the SN Routine without Supervisory Visit Notes lack documented evidence of wound assessments to include wound measurements on the following dates: 03/09/2022, 03/14/2022 and 03/23/2022. The agency failed to perform weekly wound measurements as specified in the agency policy and procedure. During interview on 04/06/2022 at 03:05 PM, the Clinical Manager stated the RN that performed the visits on 03/09/2022 and 03/14/2022 is unavailable to interview as she no longer works for the agency. The Clinical Manager acknowledged the identified SN visits lack wound measurements and stated the wound should have been measured during those visits. During interview on 04/06/2022 at 01:03 PM, the RN stated that during the 03/23/2022 SN visit she forgot to measure the patient’s wound. Patient #3 – This 91-year-old patient with diagnoses that include stage 2 pressure ulcer of right buttock, type 2 diabetes mellitus and hypertensive heart disease with heart failure was admitted to the home care agency on 03/20/2022. Review of the Home Health Certification and Plan of Care for certification period 03/20/2022 to 05/18/2022 revealed orders for skilled observation and assessment of wound status and treatment effectiveness. Wound care to stage 2 right gluteus maximus pressure ulcer: cleanse wound with normal saline dampened gauze or wound cleanser, apply skin barrier to periwound as needed for protection from excess moisture or strong adhesives. Apply hydrocolloid to wound bed, cover with foam dressing two times weekly. Review of the SN OASIS Admission Visit Note dated 03/20/2022 revealed the following wound assessment for the stage 2 right gluteus maximus pressure ulcer: Length 1.20 cm, Width 0.60 cm, Depth 0.20 cm, Wound bed: Clean non-granulating 100%, Wound Drainage: Minimal red serosanguineous, Peri-wound: Intact. Review of the clinical record revealed the patient received subsequent SN visits on 03/24/2022, 03/28/2022 and 03/31/2022. Review of the SN Routine without Supervisory Visit Note dated 03/28/2022 lacks documented evidence of a wound assessment to include wound measurements. (This is the first visit occurring for the week). Review of the SN Non OASIS Discharge Visit Note dated 03/31/2022 lacks documented evidence of a wound assessment to include a photograph and wound measurements. The agency failed to perform wound measurements as specified in the agency policy and procedure. During interview on 04/06/2022 at 02:02 PM, the RN stated the patient was unable to be positioned in a manner to perform complete wound assessments during the identified visits but she did not document this.