Medi Home Health Agency

Clinicians failed to document OASIS [Outcome and Assessment Information Set - mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] question N0415 [high risk drug classes] correctly for 5 of 13 [#1, 3, 6, 9…

Staff interviews the Registered Nurse failed to obtain wound measurements for 1 of 2 patients with a wound [2]. The findings included: The policy, Wound Care Standards [last revised 7/2025], was provided by the agency administrator on 2/25/26 at 8:30 am.

Staff interviews the agency failed to complete the occupational therapy [OT] evaluation within 5 days for 2 of 8 patients [#6 and 7] with OT orders . The findings included: The policy, Comprehensive Assessment [last revised 9/2025], was provided by the agency administrator on 2/25/26 at 8:30 am.

The Plan of Care failed to included the correct/current medications for 5 of 5 patients who received home visits [#9, 10, 11, 12 and 13]. The findings included: The policy, Medication Management [last reviewed 12/2024], was provided by the agency administrator on 2/25/26 at 8:30 am.

Staff interviews the Registered Nurse failed to follow the physician's order related to the amount of heparin used for flushing a PICC line [a thin, flexible tube inserted into a large arm vein and threaded toward the heart to deliver long-term treatments like antibiotics, chemotherapy, or…

Staff interviews the agency failed to have Resumption of Care [ROC-comprehensive assessment completed after an in-patient stay] orders for 2 of 2 patients with ROC assessments [#9 and 15]. The findings included: The policy, Physician Telephone/Verbal Orders HH2018, [last revised 6/21], was provided…

Direct observation and staff interview the agency staff failed to use proper hand hygiene for 1 of 6 home visits (#17).

The agency failed to include all medications on the plan of care for 4 of 6 home visits (#17,11,14,16), and failed to have complete wound care orders for 1 of 1 wound care records reviewed (#7).

Staff interviews the agency failed to obtain an order for wound care for 3 of 9 patients with a wound [#3, 7 and 18]. The findings included: The policy, Physician Telephone/Verbal Orders HH2018, [last revised 6/21], was provided by the agency administrator on 2/14/23 at 2:14 pm.

Staff interviews the agency failed to notify the physician of a new wound for 2 of 9 patients with a wound [#3 and 18]. The findings included: The policy, Care Planning and Coordination HH2014 [last revised date 12/21], was provided by the agency administrator on 2/14/23 at 2:14 pm.

Staff interview the agency failed to coordinate with the physician for blood pressures outside of parameters for 1 of 5 discharged records reviewed (#2), failed to follow up with the physician related to the patient being seen at the wound clinic for 1 of 1 wound records reviewed (#3), and failed…

The RN [registered nurse] failed to communicate with ST [speech therapy] information related to possible swallowing difficulties for 1 of 1 patients [#9]. The findings included: Patient # 9 had a Start of Care date of 1/13/23 and admitting diagnoses of infection/inflammatory reaction due to…

The RN [registered nurse] documented the presence of a wound with no wound present for 1 of 18 patients [#15] ; and failed to document a wound assessment for 1 of 9 patients with a wound [#18]. The findings included: 1. Patient # 15 had a Start of Care date of 1/18/23 with admitting diagnoses of…

Staff interviews the agency failed to document accurate indwelling urinary catheter sizes for 1 of 1[#9] patients with an indwelling urinary catheter; and failed to complete documentation for a routine visit for 1 of 18 patients [#18]. The findings included: The policy, Assessments HH2005 [last…

The Registered Nurse failed to assess a wound for 1 of 1 patient during the resumption of care visit [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 8/28/21 and diagnoses of Cellulitis of right lower limb, cellulitis of left lower limb, osteomyelitis, and alcoholic…

Staff interviews the Plan of Care failed to include the frequency in which a treatment was to be performed for 1 of 3 charts [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 8/28/21 and diagnoses of Cellulitis of right lower limb, cellulitis of left lower limb…

The agency failed to obtain orders for wound care for 1 of 3 charts [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 8/28/21 and diagnoses of cellulitis of right lower limb, cellulitis of left lower limb, osteomyelitis, and alcoholic cirrhosis of liver with ascites.

Staff interviews the RN/LPN failed to report changes related to a wound to the physician for 1 of 3 charts [# 1]. The findings included: The policy, Coordination of Services [12/20], was provided by the agency director on 12/14/21. The policy stated, "...______ [name of agency] Home Health Agency…

Hospital record review and staff interview the agency failed to provide care in accordance with the condition of skilled professional services for 2 of 3 patients [#2 and 3]. The following tags are cross-referred: G704, G710, G716, and G718. Findings include: G:704: Based on policy review, clinical…

Hospital record review and staff interviews nursing failed to assess/treat an ulcer on the right toe for 1 of 1 patient [#3]; and failed to obtain weekly wound measurements for 2 of 3 patients [#2 and 3]. The findings included: The policy, Wound Care Standards [revised date of 7/20], was provided…

The agency failed to update the comprehensive assessment within 48 hours after the patient was discharged from the hospital for 1 of 3 charts [#3]. The findings included: Patient 3 had a Start of Care [SOC] date of 5/1/20 and diagnoses of Non-pressure Chronic Ulcer Other Part Left Lower Leg w…

The staff the plan of care failed to include all medications the patient was using for 1 of 3 charts reviewed [#1]. The findings included: The policy, Medication Management [revised date 7/2020], was provided by the agency administrator on 9/15/20 at approximately 10:30 am.

Agency policy review and staff interviews nursing failed to notify the physician of a pulse rate being outside given parameters for 1 of 3 [#2]; and failed to make SN (skilled nursing) visits as ordered on the Plan of Care for 2 of 3 [#2 and 3]; and failed to follow the Plan of Care for wound care…

The RN failed to clearly document interventions taken related to a malfunctioning wound vac for 1 of 1 patient [#2]. The findings included: Patient # 2 had a Start of Care [SOC]date of 5/1/20 and diagnoses of Disruption of External Operation Wound and Intraductal Carcinoma in situ of Left Breast.

Staff interviews nursing failed to communicate to the physician the patient's refusal to have wound vac reapplied in 1 of 3 charts [#2]; and changes in the patient's wound condition in 1 of 3 charts [#3]; and the discharge of a patient before end of episode for 2 of 2 charts [#2 and 3]. The…