Every finding on record at Well Care Home Health,Inc

An unannounced on-site complaint investigation was conducted on 04/06/26. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to include an order for Social Worker (SW) visits in the plan of care for 1 of 1 patient with a referral for SW visits (patient #1). Findings included: A policy, Initial and Comprehensive Assessment Policy (approved 12/2024), received on 4/6/26 at 1:48 PM from the Regional Director of Clinical Operations stated, “The assessment will be patient-specific and comprehensive to include the patient’s need for home health care, rehabilitative care, social services, and discharge planning…” Patient #1 was admitted on 1/10/26 with a diagnosis of orthostatic hypotension (sudden drop in blood pressure with position changes). The plan of care (POC) for 1/10/26-3/10/26 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 5 weeks, 1 every other week for 2 weeks; and physical therapy visits 2 times a week for 2 weeks, 1 time a week for 2 weeks, 2 every other week for 4 weeks; and occupational therapy 1 time a week for 1 week. Review of the clinical record revealed that the physician that referred the patient for home health included an order for social worker (SW) visits. Further review revealed that there was no order for SW visits included in the POC. During an interview conducted on 4/6/26 at 1:38 PM the Regional Director of Clinical Operations stated, “It [the order for SW visits] should have been added [to the POC] by the start of care clinician.”

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to document an incident report for 1 of 1 patient with falls (patient #1). Findings included: A policy, Incident Report Policy (approved 12/2024), received on 4/6/26 at 1:51 PM from the Executive Director of Clinical Operations stated, “Staff will promptly complete an Incident Report for any of the incidents/accidents or concerns. This will include, but is not limited to the following: … All falls (Attended or Unattended) …” Patient #1 was admitted on 1/10/26 with a diagnosis of orthostatic hypotension (sudden drop in blood pressure with position changes). The plan of care (POC) for 1/10/26-3/10/26 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 5 weeks, 1 every other week for 2 weeks; and occupational therapy 1 time a week for 1 week and 1 time a week for 6 weeks. Review of the clinical record revealed that on 1/19/26 the Certified Occupational Therapy Assistant (COTA) #4 documented a caregiver reported fall on 1/17/26 and on 2/26/26 COTA #4 documented, “CG [care giver] reports PNT [patient] fall yesterday…” An interview conducted on 4/6/26 at 11:37 AM with the Manager of Compliance and Quality revealed that the incident reports were not documented for the falls on 1/19/26 or 2/26/26 and should have been.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the medication Ozempic [GLP-1 glucagon-like peptide] was documented as an insulin (patient #3). Findings included: Patient #3 was admitted on 2/23/26 with diagnoses of hemiplegic migraine (severe migraine with temporary paralysis on one side of the body), type 2 diabetes (bodies inability to produce insulin), and long term (current) use injectable non-insulin antidiabetic drugs. The plan of care for 2/23/26-4/23/26 included orders for skilled nurse visits 2 times a week for 1 week, 1 time a week for 2 weeks, 1 every other week for 6 weeks with 3 PRN (as needed) and “Ozempic 0.25 mg or 0.5 mg (injectable non-insulin antidiabetic drug) subcutaneous (sub-Q) pen, inject Sub-Q weekly.” Review of the clinical record revealed that on 2/23/26 registered nurse (RN) #5 documented, “Is the patient taking any of the following categories of high alert medication? … Insulins…” Further review revealed that patient #3 did not have an order for insulin. During an interview conducted on 4/6/26 at 1:02 PM RN #5 stated, “We were listing all the GLP-1 [Glucagon-like-peptide-1, injectable non-insulin medication] medications under insulins...” The interview revealed that RN #5 understood that Ozempic was not insulin. During an interview conducted on 4/6/26 at 1:10PM the Regional Director of Clinical Operations stated, “We are including the GLP-1 medication as insulin… there is a misunderstanding about [documentation of] the high-risk care pathway and high-risk medications.”

An onsite, unannounced complaint investigation was conducted 09/12/23-09/13/23. Deficiencies to the Medicare Conditions of Participation were identified.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, voicemail call log review, interagency email review, caregiver interview, and staff interview, the agency failed to notify the physician that the caregiver was changing the patient’s indwelling catheter for 1 of 1 record reviewed of patients with a caregiver changing the indwelling catheter (Patient #1). Findings included: Policy titled “Coordination of Care” revised 02/2022, revealed, “Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group, will be appropriate to the needs and abilities of the patient, and will be relevant to the care provided…Care coordination will include, but not be limited to…coordinate communication with all physicians…involved in the plan of care…integrate orders from all physicians…involved in the plan of care so that all services and interventions are coordinated.” Patient #1 was admitted to the agency on 04/29/23 with diagnoses including multiple sclerosis and encounter for changing urinary device. Plan of Care from 04/29/23 to 6/27/23 revealed orders for skilled nursing one time per week for nine weeks and included orders for indwelling catheter changes every four weeks and as needed “if blocked or dislodged”. Plan of Care from 06/28/23 to 08/26/23 revealed orders for skilled nursing one time per week for one week and once every two weeks for eight weeks and included orders for indwelling catheter changes every three weeks and as needed “if blocked or dislodged”. In an interview on 09/12/23 at 5:07 PM, Patient #1’s caregiver stated that he has changed the patient’s catheter when he knew it was clogged because he had previously called the agency’s main telephone number “multiple times” without a response, and he did not want the patient to remain uncomfortable indefinitely. Patient #1’s caregiver stated that he would much rather have the agency nurses change the patient’s indwelling catheter and stated that he now knew, “a lot more about the female anatomy [than he] ever wanted to know.” There was no evidence in the clinical record that the physician was notified that Patient #1’s caregiver had been changing the patient’s indwelling catheter. In an interview on 09/13/23 at approximately 8:45 AM, Employee #5, licensed practical nurse, stated, “…he [Patient #1’s caregiver] will call the office and instead of waiting for nurse to come out he will take care of things himself [change Patient #1’s catheter]…” In an interview on 09/12/23 at 3:18 PM, Employee #4, registered nurse, stated, “I had called [the physician’s office] and left a message. I don’t know that it’s documented I’ll be honest with you…I know that I had called the office and talked to them when she had the UTIs [urinary tract infections]”. In an interview on 09/13/23 at 9:09 AM, a nurse representative from the physician’s office stated that she did not have any knowledge of Patient #1’s caregiver changing the patient’s indwelling catheter. The nurse representative also stated that there was no evidence in the clinical record regarding Patient #1’s caregiver changing the patient’s indwelling catheter. The nurse representative also stated that the only information that she could find in the patient’s record regarding the indwelling catheter was from an entry on 06/01/23 where it was documented that Patient #1’s caregiver stated that there had been ‘some issues with changing the patient’s catheter but stated this was now resolved with home health visiting’.

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 policy review, clinical record review, voicemail call log review, interagency email review, caregiver interview, and staff interview, the agency failed to respond to a caregiver’s call to the agency for assistance with the patient’s indwelling catheter for 1 of 3 records reviewed of patients with an indwelling catheter (Patient #1). Findings included: Policy titled “Coordination of Care” revised 02/2022, revealed, “Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group, will be appropriate to the needs and abilities of the patient, and will be relevant to the care provided. The clinicians will be responsible for facilitating communications about changes in the patient’s status among the assigned personnel. Written evidence of care coordination will be recorded during the case conference and repeated in visit reports in the patient’s clinical records where applicable…Care coordination will include but not be limited to…coordinate with all physicians (or other authorized licensed independent practitioner) involved in the plan of care…Organization personnel will communicate changes in a timely manner via telephone, one-to-one meetings, case conferences and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication.” Patient #1 was admitted to the agency on 04/29/23 with diagnoses including multiple sclerosis and encounter for changing urinary device. Plan of Care from 04/29/23 to 6/27/23 revealed orders for skilled nursing one time per week for nine weeks. This Plan of Care also included orders for indwelling catheter changes every four weeks and as needed “if blocked or dislodged”. Review of the agency’s voicemail call log revealed calls from Patient #1’s caregiver on 05/09/23 between 10:32 AM and 10:33 AM and 05/10/23 between 2:13 PM and 2:14 PM with voicemail messages left. There was no evidence of follow-up regarding the call(s) placed on 05/09/23. Review of email documentation dated 05/10/23 revealed evidence of interagency communication between 2:15 PM and 3:06 PM regarding the call(s) received on 05/10/23; however, there was no evidence of follow up with Patient #1’s caregiver on 05/10/23. The next visits conducted for Patient #1 were on 5/11/23 when Employee #3, social worker, conducted a social work evaluation and on 05/12/23 when Employee #5, licensed practical nurse, conducted a skilled nursing visit. In an interview on 09/12/23 at 5:07 PM, Patient #1’s caregiver stated that historically the patient had had a lot of problems with her indwelling urinary catheter being blocked and that the catheter would frequently need to be changed sooner than the four-week timeframe ordered. The caregiver stated that he called the agency’s main telephone number “multiple times” during business hours since the start of care without a response. He stated that he would press the number for the nursing or for an operator without a return call or that a nurse would come to the home, without calling first, “several hours later”. The caregiver said more recently he started texting nurses directly on their cell phones when Patient #1 has problems with the indwelling catheter to ensure that he received a timely response. In an interview on 09/13/23 at approximately 8:50 AM Employee #1, compliance and quality manager, stated that when a patient or caregiver contacts regarding an indwelling catheter problem, the expectation would be for the caller to receive a return call and the patient would receive a visit the same day.

An unannounced, onsite complaint investigation was conducted 05/31/22-06/01/22. The complaint was unsubstantiated, however, standard level deficiencies to the Medicare Conditions of Participation were identified. -MHB

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to change an indwelling catheter according to the ordered frequency for 1 of 3 (Patient #3) patients with indwelling catheters. Findings include: Policy PC-31, titled Monitoring Patient’s Response – Reporting to Physician, origination date 02/2022, was received from the Compliance Manager on 06/01/22 at 2:14 PM. This policy revealed, “…The patient’s physician (or other authorized licensed independent practitioner) will be contacted when any of the following occur…when there is any problem implementing the plan of care…Based on communication with the physician (or other authorized licensed independent practitioner), a verbal order will be obtained for any change in the plan of care and communicated to all appropriate team members to ensure that care is provided according to the revised plan of care…All physician orders shall be integrated into the plan of care…The plan of care will be updated according to the organization’s policies and procedures.” Patient #3 was admitted to the agency on 12/24/19. Diagnoses from the 04/12/22 to 06/10/22 Plan of Care included Stage 4 pressure ulcer (deep wound that has reached the muscle or bone) of right hip and other site, hypertension, Type 2 diabetes, paraplegia, protein calorie malnutrition, and history of urinary tract infections. This Plan of Care revealed orders for skilled nursing services 1 time per week for 1 week, 2 times per week for 6 weeks, 5 times per week for 1 week, and 2 times per week for 1 week and home health aide services 1 time per week for 2 weeks and included an order for “SKILLED NURSE FOR INSERTION OF SUPRACATHETER MAINTENANCE WITH CATHETER 16 FRENCH 5 CC (cubic centimeters) BALLOON, CHANGE Q (every) 30 DAYS AND PRN (as needed) DISLODGMENT OR STOPPAGE, AND OBTAIN URINE SPECIMEN AS INDICATED.” Clinical record review revealed no evidence of a catheter change for Patient #3 between 04/12/22 and 05/16/22. In an interview on 06/01/22 at approximately 2:00 PM, Employee #1, the Compliance Manager, stated that he was unable to locate documentation related to any catheter change since 04/01/22 and stated, “I’m not seeing where one was done since then…I’m not seeing where it is scheduled out…”