Mission Home Health of Irvine, LLC

“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 interview and record review, the agency failed to ensure the SN visits were conducted as ordered for two of five sampled patients (Patients 1 and 4). This failure had a potential risk to provide necessary care and services to the patients. Findings: Review of the agency’s P&P titled Missed Visit revised 12/25 and approved 6/26/26, showed if a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician (or allowed practitioner) ordered frequency is maintained and would not be considered a missed visit. 1. Review of Patient 1’s closed clinical record was initiated on 8/26/26. The clinical record showed SOC was 12/30/25. The patient was certified for home health services during the certification periods from 12/30/25 to 2/27/26. The patient was transferred to the hospital on 1/21/26. Review of the Physician’s Order dated 1/2/26, showed SN visits one time a week for two weeks, two times a week for three weeks and one time a week for four weeks, effective 12/30/25. Review of the Client Coordination Note Report dated 1/11/26, showed the following: -Date of Missed Visit: 1/9/26 (Friday) -Discipline (Visit Type): SN11 -Reason: No answer phone -Next Visit Date: blank -Case Manager Notified: Yes -MD Notified via fax of Missed Visit. * However, there was no documented evidence of an attempt to reschedule the visit for the next day, 1/10/26, a Saturday (Week of 1/4/26 to 1/10/26). On 9/3/26 at 1529 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if there was documented evidence of attempt to reschedule for the next day, the DPCS acknowledged there was none. 2. Review of Patient 4’s clinical record was initiated on 8/26/26. The clinical record showed SOC was 7/9/26. The patient was certified for home health services during the certification period from 7/9/26 to 9/6/26. Review of the Home Health Certification and Plan of Care dated 7/9/26, showed SN visits one time a week for nine weeks. Review of the Client Coordination Note Report dated 8/13/26, showed the following: -Date of Missed Visit: 8/13/26 (Thursday) -Discipline (Visit Type): RN -Reason: Clinician Sick -Next Visit Date: Next Week -Case Manager Notified: Yes -MD Notified via fax of missed visit. * However, there was no documented evidence of an attempted reschedule during the same week (Week of 8/9/26 to 8/15/26), to ensure the patient received SN visit as ordered. On 9/3/26 at 1410 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“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 interview and record review, the agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient’s immediate needs, but no later than five calendar days after the SOC date for three of five sampled patients (Patients 1, 4, and 5). This failure created the risk of not identifying and addressing the care needs timely for these patients. Findings: 1. Review of Patient 5’s clinical record was initiated on 8/26/26. The clinical record showed the SOC was 5/16/26. The patient was certified for home health services during the certification periods from 5/16/26 to 7/14/26 and 7/15/26 to 9/12/26. Review of the Ambulatory Referral to Home Health Order from the hospital dated 5/14/26, showed services requested were wound/ostomy and urinary catheter care. Review of the RN OASIS Admission dated 5/16/26, showed the patient had indwelling/suprapubic catheter and nephrostomy. * However, there was no documented evidence of the initial comprehensive assessment of both indwelling/suprapubic catheter and nephrostomy, including the site/location, size of catheters, date when it was changed, patency of tubing, and presence of signs and symptoms of infection. On 9/3/26 at 1441 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if there was detailed initial comprehensive assessment of the indwelling catheter and nephrostomy in the OASIS documentation. The DPCS acknowledged there was none in the RN OASIS documentation. 2. Review of Patient 1’s closed clinical record was initiated on 8/26/26. The clinical record showed SOC was 12/30/25. The patient was certified for home health services during the certification periods from 12/30/25 to 2/27/26. The patient was transferred to hospital on 1/21/26. Review of the PT OASIS Admission dated 12/30/26, showed the following: -Grade 2 pressure sore with slight pinkish skin, no signs of infection. -The patient’s right lateral heel showed bruising in circular pattern with possible DTI. -The patient had small abrasion on the right anterior lateral midfoot. -Sacral wound was dressed with Optifoam sacral pad (wound dressing) using clean technique. Review of the PT Oasis Admission dated 12/30/26, showed the completed initial comprehensive assessment for Stage 2 mid posterior sacral pressure injury with onset date of 12/28/26. * However, there was no documented evidence the initial comprehensive assessment was conducted on the possible DTI in circular pattern of the right lateral heel and small abrasion on the right anterior lateral midfoot. There was no documented evidence the size and description were included in the assessment. Review of the SN Visit Note Report dated 1/2/26, showed the patient with DTI on the left lateral foot and Stage 2 pressure injury on the sacrum. * However there was no documented evidence of the initial comprehensive assessment including the size and description conducted for the DTI of the left lateral foot . On 9/3/26 at 1526 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 3. Review of Patient 4’s clinical record was initiated on 8/26/26. The clinical record showed SOC was 7/9/26. The patient was certified for home health services during the certification periods from 7/9/26 to 9/6/26. Review of the Ambulatory Referral to Home Health faxed dated 7/6/26, showed a diagnosis of healing Stage 1 pressure injury and wound care needed on the buttock wound. Review of the RN OASIS Admission dated 7/9/26, showed the patient had rash. * However, there was no documented evidence of the detailed initial comprehensive assessment of the rash showing appearance, body location, characteristics, distribution and extent. On 9/3/26 at 1405 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.”

“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 observation, interview, and record review, the agency failed to ensure the medication profiles were reviewed and updated to reflect the current medications for two of five sampled patients (Patients 3 and 4). This failure had the potential for the patients not to receive the appropriate care and necessary services and negatively affect the patients’ well-being. Findings: 1. Review of Patient 4’s clinical record was initiated on 8/26/26. The clinical record showed SOC was 7/9/26. The patient was certified for home health services during the certification period from 7/9/26 to 9/6/26. Review of the Physician’s order dated 7/29/26, showed SN to apply wound care to Stage 2 right medial buttock pressure injury. Documentation showed to cleanse with normal saline solution/soap and water, pat dry, apply calcium alginate (wound dressing) to wound bed, cover with a dry sterile dressing, and change two times a week or as needed if soiled. Review of the current Client Medication Report dated 9/2/26, showed all the current and discontinued prescribed medications. *However, the Client Medication Report dated 9/2/26, did not include the prescribed calcium alginate dated 7/29/26. On 9/3/26 at 1407 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 3’s clinical record was initiated on 8/26/26. The clinical record showed SOC was 8/20/26. The patient was certified for home health services during the certification period from 8/20/26 to 10/18/26. A joint home visit with RN 2 was conducted on 8/27/26 at 1409 hours, in Patient 3’s residence. The family member was by the patient’s bedside during the home visit observation. The family member was asked to show the medications she was giving to the patient. The family member included to show a bottle of docusate sodium (laxative) and an antifungal cream. The family member was further asked how long she was using the medications for the patient. The family member stated she had been administering both medications for more than 2 weeks. Review of the Home Health and Certification plan of Care dated 8/20/26, for the certification period from 8/20/26 to 10/18/26, showed to include the prescribed medications as aspirin 81 mg one oral tablet daily as antiplatelet medication and metoprolol succinate ER 50 mg one oral tablet daily for hypertension. * However, there was no documented evidence to show the antifungal cream and docusate sodium were updated in the Medication Profile. On 8/27/26 at 1440 hours, a home visit observation, interview, and concurrent document review was conducted with RN 2. RN 2 was asked if the Client Medication Report should have been updated. RN 2 acknowledged it should have been updated.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the update comprehensive assessment at discharge was completed for one of two discharge sampled patients (Patient 2). This failure created the risk of not updating the patient’s status for the patient. Findings: Review of Patient 2’s closed clinical record was initiated on 8/26/26. The clinical record showed the SOC was 11/4/26. The patient was certified for home health services during the certification period from 11/4/25 to 1/2/26. The patient was discharged on 12/26/25. Review of the Visit Note Report dated 12/26/26, showed the visit type was the PT discharge. The PT Visit Note showed the following: -The supervisor and physician were the disciplines communicated involved in this case, -The PT Visit Note Report was the “DC” Summary and the trustee was agreeable to discontinue from home health services. -Under Therapy Goals, for transfers (sit to stand), the Status: modified independent; Target Date: 12/27/25; Goal Met: yes; and Comments: (blank documentation). * However, further review of the clinical record showed no documented evidence of the update comprehensive assessment at discharge. On 8/31/26 at at 1009 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“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 interview and record review, the agency failed to ensure the POC included specific interventions related to the patient’s indwelling/suprapubic catheter and nephrostomy for one of five sampled patients (Patient 5). This failure created the risk of not addressing the care needs for this patient. Findings: Review of Patient 5’s clinical record was initiated on 8/26/26. The clinical record showed SOC was 5/16/26. The patient was certified for home health services during the certification periods from 5/16/26 to 7/14/26 and 7/15/26 to 9/12/26. Review of the Ambulatory Referral to Home Health dated 5/14/26, showed the requested services were wound/ostomy care and urinary catheter care. The RN OASIS Admission dated 5/16/26, showed the patient had an indwelling/suprapubic catheter and a nephrostomy. The Home Health Certification and Plan of Care for the certification period from 6/16/26 to 7/14/26, showed SN visits 1W1 (one time a week for one week), 3W1, 2W1, 3W6, 1W1, and 2 PRN visits for ostomy dysfunction, emergent wound care, and change in condition. * However, there was no documented evidence an individualized plan of care was developed addressing the patient’s indwelling/suprapubic catheter and nephrostomy. On 9/3/26 at 1446 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“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 interview and record review, the agency failed to ensure the treatment was provided only as ordered by the physician for two of five sampled patients (Patients 1 and 5). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 1’s closed clinical record was initiated on 8/26/26. The clinical record showed SOC was 12/30/25. The patient was certified for home health services during the certification period from 12/30/25 to 2/27/26. The patient was transferred to the hospital on 1/21/26. Review of the Home Health Certification and Plan of Care dated 12/30/25, for certification period from 12/30/25 to 2/27/26, showed the following: -SN to observe and assess integumentary status to identify changes and intervene and minimize complications -SN to perform wound care to Stage 2 sacrum pressure injury: cleanse with wound cleanser, apply barrier cream cover with Mepilex (wound dressing), using aseptic technique daily and as necessary with peri-care. Patient/caregiver may perform wound care on days no SN visit. -SN to perform wound care to DTI on lateral ankle: cleanse with wound cleanser, position foot floating above bed using pillows or booties, using clean aseptic technique daily. Patient/caregiver may perform wound care on the no SN visit days. a. Review of the PT OASIS Admission dated 12/30/25, showed the right lateral heel bruising in circular pattern with possible DTI, small abrasion on right anterior lateral midfoot, and the sacral wound was dressed with Optifoam sacral pad (wound dressing) using clean technique. * However, review of the clinical record failed to show documented evidence of a physician’s order for treatment of the sacral wound to be dressed with Optifoam sacral pad. On 9/3/26 at 1532 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. b. Review of the SN Visit Note Report dated 1/2/26, showed the RN evaluation for wound care, DTI present on the left lateral foot, and Stage 2 sacrum pressure injury. * However, there was no documented evidence of wound assessments and wound measurements. Review of the SN Visit Note Report dated 1/13/26, showed the patient had Stage 2 mid posterior sacral region pressure injury. Documentation showed the wound measurements were not performed. Documentation showed the measurements were not obtained because it was not yet due. Under the Nursing Narrative, it showed the patient had multiple bed sores and the wound care was performed as ordered. * There was no documented evidence of the wound assessment for the DTI on the lateral ankle. Review of the SN Visit Note Report dated 1/16/26, showed wound care was the patient’s skilled nursing need. * However, there was no documented evidence of the wound assessments for the Stage 2 sacral pressure injury and DTI on lateral ankle. On 9/3/26 at 1538 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 5’s clinical record was initiated on 8/26/26. The clinical record showed SOC was 5/16/26. The patient was certified for home health services during the certification periods from 5/16/26 to 7/14/26 and 7/15/26 to 9/12/26. Review of the Home Health Certification and Plan of Care dated 5/16/26, for the certification period from 5/16/26 to 7/14/26, showed the following: -SN to observe and assess integumentary status to identify changes and intervene to minimize complications. Review of the SN Visit Note Reports dated 5/19, 5/20, and 5/22/26, showed the patient had Stage 4 iliac crest pressure injury, unstageable right heel wound, and Stage 2 left heel pressure injury. * However, there was no documented evidence the wound measurements for the Stage 4 iliac crest pressure injury, unstageable right heel wound, and Stage 2 left heel pressure injury were taken for Week 2 (5/17/27 to 5/23/26). Review of the SN Visit Reports dated 5/26 and 5/29/26, showed the patient had Stage 4 left lower buttock pressure injury, Stage 4 iliac crest pressure pressure injury, unstageable right heel wound, and Stage 2 left heel pressure injury. * However, there was no documented evidence of the wound measurements on all wounds for Week 3 (5/24/26 to 5/30/26) Review of the SN Visit Note Reports dated 6/1, 6/3, and 6/5/26, showed the patient had Stage 4 left lower buttock pressure injury, Stage 4 iliac crest pressure injury, unstageable right heel wound, and Stage 2 left heel pressure injury. * However, there was no documented evidence of the wound measurements for the unstageable right heel wound and Stage 2 left heel pressure injury for Week 4 (5/31/26 to 6/6/26) Review of the SN Visit Note Reports dated 6/8, 6/10, and 6/12/26, showed the patient had Stage 4 left lower buttock pressure injury , Stage 4 iliac crest pressure injury, unstageable right heel wound, and Stage 2 left heel pressure pressure injury * However, there was no documented evidence of the wound measurements for the Stage 4 iliac crest pressure ulcer, unstageable right heel wound, and Stage 2 left heel pressure injury of left heel during Week 5 (6/7/26 to 6/13/26). Review of the SN Visit Note Reports dated 6/16, 6/17, and 6/19/26, showed the patient had Stage 4 left lower buttock pressure injury, Stage 4 iliac crest pressure injury, unstageable right heel wound, and Stage 2 left heel pressure injury. * However, there was no documented evidence of the wound measurements for the Stage 4 iliac crest pressure injury, unstageable right heel wound, and Stage 2 left heel pressure injury during Week 6 (6/14/26 to 6/20/26). Review of the SN Visit Note Reports dated 6/22, 6/24, and 6/26/26, showed the patient had Stage 4 left lower buttock pressure injury, Stage 4 iliac crest, pressure injury, unstageable right heel wound, and Stage 2 left heel pressure injury. * However, there was no documented evidence of the wound measurements for Stage 4 pressure injury of of iliac crest, unstageable right heel wound, and Stage 2 left heel pressure injury during Week 7 (6/21/26 to 6/27/26). Review of the SN Visit Note Reports dated 6/29, 7/1 and 7/3/26, showed the patient had Stage 4 left lower buttock pressure injury, Stage 4 iliac crest pressure injury, unstageable right heel wound, and Stage 2 left heel pressure injury. * However, there was no documented evidence of the wound measurements on the Stage 4 iliac crest pressure injury, unstageable right heel wound, and Stage 2 left heel pressure injury during Week 8 (6/28/26 to 7/6/26). Review of the SN Visit Note Reports dated 7/6 and 7/8/26, showed the patient had Stage 4 left lower buttock pressure injury, Stage 4 iliac crest pressure injury, unstageable right heel wound, and Stage 2 left heel pressure injury. * However, there was no documented evidence of the wound measurements for the Stage 4 iliac crest pressure injury, unstageable right heel wound, and Stage 2 pressure injury of the left heel during Week 9 (7/5/26 to 7/11/26). On 9/3/26 at 1446 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the verbal orders were authenticated and dated by the physician for one of five sampled patients (Patient 1) . This failure created the risk for not providing the necessary care and services to this patient. Findings: According to Title 22, California Code of Regulations 74697 Plan of Treatment; Plan of Care; Plan for Personal Care Services (a) A written plan of treatment (or plan of care for home health agencies participating in the Medicare and/or Medi-Cal program) shall be established for each patient whose care requires medical orders. A plan of treatment or plan of care for patients requiring medical orders shall be: (1) Approved and signed within 30 working days by the attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice. According to Title 22, California Code of Regulations 74701 Orders for Medication and Treatment (a) No medication or treatment shall be given except on signed order of a person lawfully authorized to give such order. Such order may be given by telephone and shall be signed by the patient’s attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice within 30 working days. (b) All initial orders and subsequent changes in orders for the administration of drugs shall be signed by the physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice and incorporated in the patient’s record maintained by the agency. (c) All other changes in orders shall be signed by the physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice. All telephone orders shall be received only by a licensed nurse or any other person lawfully authorized to receive such orders as appropriate to their specialty areas. Orders shall be recorded immediately in the patient’s health record and shall be countersigned by the attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice. Review of Patient 1’s closed clinical record was initiated on 8/26/26. The clinical record showed SOC was 12/30/25. The patient was certified for home health services during the certification periods from 12/30/25 to 2/27/26. The patient was transferred to the hospital on 1/21/26. a. Review of the Clinical Coordination Note Report dated 12/22/25, showed the following: -Confirmed following physician: MD 1. -Date of the patient’s last appointment or follow-up appointment: last date of service: 12/9/25 -Called to confirm information: chart confirmed -Confirmed fax number for order: chart confirmed -Confirmed with the office staff, the provider will be back 1/2/26. Review of the Client Coordination Note Report dated 1/1/26, showed the primary physician who was overseeing the patient’s care was MD 1. Documentation showed the verbal approval for plan of care was on 12/31/25 at 1000 hours, with the Office Staff of MD 1 . However, review of the Home Health Certification and Plan of Care for certification period from 12/30/25 to 2/27/26, showed the documentation was authenticated and dated by MD 2, instead of MD 1. b. Review of the Physician’s Order dated 1/2/26, showed the certification orders from 12/30/25 to 2/27/26. Review of the Physician’s Order dated 12/30/25, showed SN visits one time a week for two weeks, two times a week for three weeks, and one time a week for four weeks, effective 12/30/25, Review of the Physician’s Order dated 12/31/25, showed adding RN services to address catheter and wounds. * However, the physician’s orders were note authenticated and dated by the physician. Further review of the clinical record showed a faxed physician’s order dated 1/14/26, from MD 1, which included urinalysis with culture and sensitivity. The physician’s order was signed by MD 1. On 8/31/26 at 1017 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated MD 1 refused to sign the physician’s orders for the HHA. When asked for documentation MD 1’s refusal to sign the physician’s order, the DPCS was unable to provide. The DPCS stated the physician would not follow the patient, the doctor refused, the agency made all attempts, and the agency would not get paid. The DPCS was further asked of any documentation that could show the physician refused to follow the patient in the clinical record. The DPCS acknowledged there was none in the clinical record. The DPCS was shown a copy that MD 1 signed a physician’s order for the patient dated 1/14/26, wherein the physician’s order included urinalysis with culture and sensitivity. The DPCS stated he did not know why MD 1 was not signing the rest of orders. The DPCS was informed and acknowledged the authentication was past 30 days.”

“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 interview and record review, the agency failed to ensure the coordination of care with the physician for two of five sampled patients (Patients 1 and 4). This failure created the risk of not providing the necessary care and services to these patients. Findings: Review of the P&P titled Monitoring Patient’s Response/Reporting to Physician revised 12/2025 showed the following: -The patient’s physician or allowed practitioner will be contacted on the same day when any of the following occur: A. Significant changes in the patient’s condition. - All conferences or attempts to communicate with physician (or allowed practitioner) will be documented in the clinical record. A. Documentation of the physician (or allowed practitioner) notification will include: 1. Date and time contacted 2. Patient name 3. Name of Physician (or allowed practitioner) notified or his/her representative 4. Reason for notification 5. Physician’s (or allowed practitioner) response 6. Action taken or orders obtained 7. Professional signature and title - Based on the communication with physician (or allowed 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. - The organization shall communicate with all physicians (or allowed practitioner) involved in the plan of care to avoid duplication or contradictory physician (or allowed practitioner) orders and to assure that all patient needs are being met. All physician (or allowed practitioner) orders shall be integrated into the plan of care. The plan of care is reviewed and signed by the physician (or allowed practitioner) responsible for the plan of care. 1. Review of Patient 1’s closed clinical record was initiated on 8/26/26. The clinical record showed SOC was 12/30/25. The patient was certified for home health services during the certification period from 12/30/25 to 2/27/26. The patient was transferred to the hospital on 1/21/26. Review of the Home Health Certification and Plan of Care dated 12/30/25, for certification period from 12/30/25 to 2/27/26, showed SN to observe and assess integumentary status to identify changes and intervene to minimize complications, and skilled nurse to report significant changes in status to the physician for early intervention. Review of the Client Coordination Note dated 12/22/25, showed the following information: -Note Type: Confirmed Physician Verification -Confirmed following physician: MD 1 -Date of patient’s last appointment: 12/9/26 -“#” called to confirm information: chart confirmed, -Confirmed fax number for orders: chart confirmed -Name of office staff confirmed with: (a name was documented). Provider will be back 1/2/26. Review of the PT OASIS Admission Visit Note Report dated 12/30/25, showed the patient had Stage 2 mid posterior sacral region pressure injury. Documentation showed there was no necrotic tissue. Review of the SN Visit Note Report under Wound Assessment dated 1/13/26, showed Stage 2 pressure injury on the mid posterior sacral region, with formed black necrotic tissue. * However, there was no documented evidence the change of condition was reported to the patient’s physician. There was no documented evidence that included the name of the physician informed/his or her representative, date and time contacted, reason for notification, physician’s response, and action taken or orders obtained. Review of the SN Visit Note Report dated 1/16/26, showed urine in diaper, dark brown in color. Documentation showed per the family member, it had a foul scent. Documentation showed the nurse called the “PCP OFFICE REPORT URINE FINDINGS.” * However, there was no documented evidence the change of condition was reported with the patient’s physician. There was no documented evidence of the name of the physician informed/his or her representative, date and time contacted, reason for notification, physician’s response, and action taken or orders obtained. On 9/3/26 at 0838 hours, an interview was conducted with LVN 1. LVN 1 was asked the process on change in condition of the patient. LVN 1 stated all should be documented in the patient’s chart or clinical record, SN Visit Note, and Coordination Note. On 9/3/26 at 1230 hours, an interview and concurrent clinical record review was conducted with the LVN Clinical Coordinator. The LVN Clinical Coordinator was asked if there was documentation in the clinical record showing the physician was informed regarding the patient’s wound change in condition from no presence of necrotic tissue as per the PT Visit Note dated 12/30/25, to formed black necrotic tissue located at mid posterior sacral region as per the SN Visit Note Report dated 1/13/26; and the foul odor dark brown urine showed in the Coordination Note dated 1/16/26. LVN Clinical Coordinator verified here was none. On 9/3/26 at 1535 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed of the above findings . The DPCS stated the physician would not follow the patient, the doctor refused, the agency made all attempt, and the agency would not get paid. The DPCS was further asked of any documentation he could show the physician refused to follow the patient in the clinical record. The DPCS acknowledged there was none in the clinical record. 2. Review of Patient 4’s clinical record was initiated on 8/26/26. The clinical record showed SOC was 7/9/26. The patient was certified for home health services during the certification period from 7/9/26 to 9/6/26. Review of the Home Health Certification and Plan of Care dated 7/9/26, for the certification period from 7/9/26 to 9/6/26, showed SN to observe and assess integumentary status to identify changes and intervene to minimize complications and to report significant changes in status to the physician for early intervention. Review of the SN Visit Note Report, under Wound Assessment dated 7/22/26, showed the patient developed Stage 2 pressure injury on the right lower buttock, with scant serous exudate. Review of the Physician’s Order dated 7/22/26, showed SN to apply nystatin (antifungal) 100,000 USP cream twice daily to the bilateral buttocks and low back due to fungal rash, and the patient caregiver able to complete on the days SN does not visit. * However, there was no documented evidence the change of condition was reported to the patient’s physician. There was no documented evidence of the name of the physician informed/his or her representative, date and time contacted, reason for notification, physician’s response, and action taken or orders obtained On 9/3/26 at 1413 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged finding.”

“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 interview and record review, the agency failed to ensure the SOC visit was coordinated timely for one of five sampled patients (Patient 1). This failure created the risk of not providing the necessary care and services to the patient. Findings: Review of Patient 1’s closed clinical record was initiated on 8/26/26. The clinical record showed SOC was 12/30/25. The patient was certified for home health services during the certification period from 12/30/25 to 2/27/26. The patient was transferred to the hospital on 1/21/26. Review of the hospital discharge summary encounter dated 12/12/25, showed the hospital date of admission was 12/12/25, and the date of discharge was 12/19/25. Review of the hospital’s ambulatory referral to home health dated 12/15/25, showed the initial evaluation should occur within 48 hours of hospital discharge. Review of the Clinical Coordination Note Report dated 12/16/25, showed the following: -Note Type: Follow up on pending admission -Note: Open episode with another home health agency. Review of the Clinical Coordination Note Report dated 12/16/25, showed the following: -Note Type: Follow up on pending admission -Note: Agency was chosen, discharge tomorrow. Review of the Clinical Coordination Note Report dated 12/18/25, showed the following: Note Type: Follow up on pending admission Note: Patient’s phone just rings, unable to leave voicemail message, sent messages to screen patient, left voicemail for family member, will continue to follow. Review of the Clinical Coordination Note Report dated 12/19/25 showed the following: -Note Type: Screen completed call -Note: Scheduling requests were open, requested Monday for SOC. Review of the Clinical Coordination Note Report dated 12/22/25, showed the following: Note Type: Scheduler notification, Note: Attempted to contact the patient to schedule, no answer, unable to leave voicemail message. Review of Client Coordination Note Report dated 12/23/25, showed the following: Note Type: Scheduling, Note: SOC Details included the SOC Date 12/24/25; SOC clinician: PT 1; and scheduling requests was blank. * However, there was no documented evidence the HHA followed up/communicated on the SOC for 12/24/25, as per the Client Coordination Note Report dated 12/23/25. Review of the Clinical Coordination Note Report dated 12/29/25, showed the following: Note Type: Home Health delay in SOC Note: The patient requested date anytime after holidays, please switch to 12/29/25, which is beyond the 48 hour regulation from receiving complete referral. Date provider notification was “12/26/25.” Review of the Client Coordination Note Report dated 12/30/25 showed the following: Note Type: Clinical, Note: Contacted by the patient’s family member complaining that no one has been out for 12 days since the patient arrived home, he now has open bleeding wound on his back and needs to be seen. She was requesting for a nurse to come out and see the patient, to call the family member if needed advise or verify any information. Review of the Clinical Coordination Note Report dated 12/31/25, showed the following: Note Type: Home Health Delay in SOC Note: Patient’s requested date was “12/30” which was beyond the 48 hour regulation from receiving complete referral. Date of provider notification was “12/28.” * However, there was no documented evidence in the clinical record to show coordination on attempted SOC for the patient from 12/24, 12/25, 12/26, and 12/27/25. On 8/31/26 at 1145 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed of the delayed SOC of the patient. The DPCS stated the reasons of delay were as mentioned above in the Clinical Coordination Notes. The DPCS was further asked if there was any documentation in the clinical record to show coordination for attempted SOC visit between 12/24 to 12/27/25. The DPCS acknowledged all documents were already given as shown above.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the instructions or teachings on wound care were provided to patient/caregiver for one of five sampled patients (Patient 1). This failure posed a potential for the caregiver not knowing how to care for this patient. Findings: 1. Review of Patient 1’s closed clinical record was initiated on 8/26/26. The clinical record showed SOC was 12/30/25. The patient was certified for home health services during the certification period from 12/30/25 to 2/27/26. The patient was transferred to the hospital on 1/21/26. Review of the SN Visit Note Report dated 1/16/26, showed the skilled nursing need for this visit was wound care. Documentation showed the specific interventions provided were vitals and wound care. Documentation showed the patient was nonverbal on the section for the patient/caregiver response to specific interventions provided. * However there was no documented evidence the authorized representative or caregiver was provided with wound care education. On 9/10/26 at 1536 hours, an interview and clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 5’s clinical record was initiated on 8/26/26. The clinical record showed SOC was 5/16/26. The patient was certified for home health services during the certification periods from 5/16/26 to 7/14/26 and 7/15/26 to 9/12/26. Review of the SN Visit Note Report dated 5/19/26, showed the assessment and wound care were provided on Stage 4 pressure injury on the left lower buttock. Documentation showed the patient refused for wound care on Stage 4 pressure injury on the right iliac crest, unstageable right heel, and Stage 2 pressure injury of the left heel * However, there was no documented evidence the patient and/or authorized representative was provided with health teachings as to the risks and benefits for the refusals of wound care on Stage 4 pressure injury on the right iliac crest, unstageable right heel, and the Stage 2 pressure injury of on the left heel. On 9/3/26 at 1443 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the skilled professionals prepared accurate clinical notes for two of five sampled patients (Patients 4 and 5). This failure created the increased risk of substandard healthcare outcomes to these patients. Findings: 1. Review of Patient 5’s clinical record was initiated on 8/26/26. The clinical record showed SOC was 5/16/26. The patient was certified for home health services during the certification periods from 5/16/26 to 7/14/26 and 7/15/26 to 9/12/26. Review of the Ambulatory Referral to Home Health dated 5/14/26, showed the services requested were wound/ostomy care and urinary catheter care. Review of the SN Visit Note Report dated 5/16/26, showed the patient had an indwelling/suprapubic catheter and nephrostomy. * However, the SN Visit Note Reports dated 5/20, 5/22, 5/26, 5/29, 6/1, 6/3, 6/5, 6/8, 6/10, 6/12, 6/16, 6/17, 6/19, 6/22, 6/24, 6/26,6/29, 7/1, 7/3, 7/6, and 7/8/26, showed WNL (within normal limits). Review of the RN Recertification Visit Note Report dated 7/10/26, showed the patient had indwelling/suprapubic catheter. Review of the SN Visit Note Report dated 7/13/26, showed under the section of Genitourinary Assessment, the patient had indwelling/suprapubic catheter and the section of Nursing Narrative showed the right nephrostomy flushed with saline per the patient’s request. * However, the SN Visit Note Reports dated 7/15, 7/17, 7/20, 7/22, 7/24, 7/27, 7/29, 7/31/, 8/3, 8/5, 8/7, 8/10, 8/12, 8/14, 8/17, 8/21, and 8/28/26, showed WNL (within normal limits) and there was no documented evidence of the updated assessment on the indwelling/suprapubic catheter and the nephrostomy. On 9/3/26 at 1446 hours an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 2. Review of Patient 4’s clinical record was initiated on 8/26/26. The clinical record showed the SOC was 7/9/26. The patient was certified for home health services during the certification period from 7/9/26 to 9/6/26. Review of the SN Visit Note Report, under section of Integumentary Assessment dated 7/14/26, showed no problems identified. * However, the section for Nursing Narrative showed the patient had some skin irritation on the buttocks. Documentation showed the physician ordered nystatin powder (antifungal) and the caregiver was applying daily. On 9/3/26 at 1414 hours an inteview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the inconsistency of the documentation.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on interview and record review, the agency’s Administrator failed to be responsible for the agency’s day-to-day operations related to the implementation of organizational P&P for one of five sampled patients (Patient 1). This failure created the risk of not providing quality of care and services to the patient receiving services from the HHA. Findings: The agency’s P&P titled Administrative Qualifications and Responsibilities revised 12/2025 showed the Administrator shall be appointed by and report to the Governing Body and shall be responsible for the day-to-day operations of the HHA. The Administrator shall ensure compliance with applicable federal and state laws, regulations, accreditation standards, organizational policies, and Conditions of Participation. Review of the agency’s P&P titled Transfer Summary revised 12/25 and approved 7/23/26, showed to include the following: All patients transferred from the organization will have a transfer summary completed in the clinical record. Within 48 hours of transfer, the transferring clinician will complete a transfer summary that includes, as appropriate: A. The reason for transfer B. The physical and psychosocial status at the time of transfer, including specific medical, psychosocial, or other problems requiring interventions or follow-up C. All necessary medical information pertaining to the patient’s current course of illness and treatment D. Continuing symptom management needs E. Medication Profile F. A summary of the care provided and the progress toward achieving goals G. Any instructions and/or referrals provided to the patient H. The existence of any Advance Directives known to the organization I. Date of face-to-face encounter, if during initial certification J. Post-discharge goals of care and treatment preferences K. The date of transfer, which is the date of the last visit made 1. Review of Patient 1’s closed clinical record was initiated on 8/26/26. The clinical record showed the SOC was 12/30/25. The patient was certified for home health services during the certification period from 12/30/25 to 2/27/26. The patient was transferred to the hospital on 1/21/26. Review of the Coordination Notes dated 2/3/26, showed the following: -The patient had been hospitalized for more than 24 hours. -The reason for hospitalization was debridement of pressure injury. -The patient was transferred Hospital A. -The admission date was 1/30/26. -The section for the HHA notified of the inpatient admission was blank. -The date when the HHA was notified of hospitalization was blank. Review of the hospital ER record showed the patient was admitted in the ER dated 1/21/26. On 8/31/26 at 1124 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and asked about the Transfer Summary documentation. The DPCS acknowledged there was none in the clinical record.”