Interim Healthcare - Home Health

“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 Home Health Agency (HHA) failed to provide services as ordered per physician according to the Plan of Care (POC) for three of 18 sampled patients (Patient 1, Patient 6 and Patient 10), when: 1. Patient 1 had multiple missed visits that did not reflect the reason for the missed visits; 2. Patient 6 did not receive physical therapy services (PT, a form of rehabilitation) in accordance with the physician’s order and the plan of care (POC); and 3. Patient 10 did not receive Home Health Aide services per physician ‘s order and POC. These failures resulted in multiple missed Skilled Nursing and Home Health Aide visits with the potential for Patient 1 and Patient 10’s HH needs to be unmet causing adverse health outcomes and had the potential to cause Patient 6’s physical condition to decline further and affect patient’s quality of life. 3. During a review of Patient 10’s POC for certification period 4/1/26 to 5/30/26, the POC indicated Patient 10 had a SOC date of 4/1/26 with diagnoses that included Spinal Stenosis of cervical region (space around the spinal cord in the neck becomes too narrow), myelopathy (injury to the spinal cord caused by severe compression), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). The POC further indicated an order for Home Health Aide (HA) visits twice a week for four weeks and indicated, “[HA] to assist with showers, light housework…” During a review of Patient 10’s document titled “CARE AUTHORIZATION REQUEST,” dated 4/10/26, the document indicated, “…Discipline: HHA – Home Health Aide…Request Start Date: 4/11/2026…Authorization Date 04/10/26…” During a review of Patient 10’s “Master Calendar,” dated 4/1/26 to 5/30/26, the calendar indicated Patient 10 did not have HA visits done from 4/10/26 to 5/3/26. The calendar further indicated Patient 10 had the first HA visit on 5/4/26. During a concurrent interview and record review on 6/4/26 at 12:03 p.m. with the CS, the CS confirmed Patient 10 had an HA order for two visits for four weeks and stated “…I don’t have any idea why [HA] was not scheduled.” The CS also confirmed HA visits for Patient 10 started on 5/4. The CS stated the authorization for HA service was approved on 4/11/26 and confirmed that there was no documented evidence on why HA visits were not started. The CS stated the expectation was for staff to follow physician order and stated there should be documentation if not followed. During a review of the agency’s P&P titled “PLAN OF CARE,” dated 2023, the P&P indicated, “…Services are furnished in accordance with accepted standards of practice and orders in the plan of care…II. The individualized POC specifies the care and services necessary to meet the patient’s specific needs as well as measurable outcomes anticipated by the agency’s implementation and coordination of the plan of care. 2. A review of Patient 6’s medical record indicated that agency admitted patient on 4/24/26 with multiple diagnoses which included infection of left leg, osteoarthritis (a condition when cushioning tissue covering end of bones wears down and bones start rubbing against each other, causing pain, stiffness, and reduced movement) and spondylosis (inflammation) of lower back. A review of Patient 6’s physician referral for home health agency dated 4/24/26 contained a physician’s request for physical therapy services for gait training (a type of physical training that helps how to walk safely) and to “establish Home Exercise Program.” A review of Patient 6’s Plan of Care (POC) for the certification period from 4/24/26 through 6/22/26 indicated that the patient had severe mobility limitations, experienced significant difficulty with transfers and sit-to-stand activities and required a walker for ambulation. The POC contained a physician order for physical therapy to evaluate and assess the patient’s overall physical and mobility the week of 4/24/26. The POC indicated that the comprehensive assessment indicated that Patient 6 required skilled nursing (SN) and therapy care to address the patient’s needs and falls prevention. A review of Patient 6’s clinical record contained physical therapy missed visit note dated 4/25/26 indicated that patient’s family stated “they want to hold off on therapy’” due to Patient 6’s having lots of pain. The nurse documented that Patient 6’s family was informed that agency will follow up with offering therapy at a later date. A review of nursing visit note dated 5/6/26 indicated, “Patient reports falling all the time…Fall risk remains high due to poor balance and ambulation difficulties…[Patient 6] uses walker for ambulation. Physical therapy has been requested but agency has not yet responded.” A review of nursing visit note dated 5/11/26 indicated, “Patient reports not walking much…Fall risk remains high due to poor balance and ambulation difficulties… Physical therapy has been requested but agency has not yet responded.” A review of Patient 6’s clinical record had no documented evidence that the patient had been evaluated for Home Exercise program. A further review of Patient 6’s clinical records did not contain any communication notes or other documents regarding physical therapy evaluation and/or assessment. During a joint home visit on 6/3/26 at 11:45 a.m., with Licensed Nurse (LN1), 6’s family stated, “We were supposed to have PT evaluation but for some reason it’s not done. I talked to nurses a few times and was told they were going to arrange for PT, but we never heard back.” LN 1 reviewed Patient 6’s visit calendar and stated there were no PT visit scheduled for Patient 6. During an interview on 6/3/26 at 12:15 p.m., Patient 6’s family members (FM) stated,” No PT eval and dad really needs to have therapy.” Patient 6’s FM stated they did not recall that physical therapy was offered to Patient 6 when he started services in April. FM explained, “We keep asking [for PT] because dad is very unstable when he walks, and the nurses keep saying they will get the referral but never heard back.” The FM stated that the agency did not provide Home Exercise program. The FM added, “We would like to have some written guidance for us for correct exercises and safe transfers with dad. Nobody talked to us about it and nurses do not do any exercises with him.” A review of the agency’s policy and procedure (P&P) titled, “PHYSICIAN ORDER MANAGEMENT,” dated 2025, indicated, “The agency will follow defined procedures when receiving physician/practitioners orders…To ensure… Orders are properly managed for the provision and coordination of treatment services… Orders shall be initiated based on…Start of Care (SOC)…All physician orders must be documented in the clinical record, integrated into plan of care, and communicated to all relevant staff…Clinicians must implement orders.” During an interview and record review on 6/3/26 at 4:10 p.m., the Director of Patient Care Services (DPCS) validated that Patient 6 had a physician order to start physical therapy the week of 4/24/26. The DPCS was not able to find any records that Patient 6 was evaluated by PT. Upon reviewing physical therapy missed visit note dated 4/25/26, the DPCS stated, “Patient might not be ready for therapy]at that time… If patient or family refused PT services at the time it was ordered…the PT services should be offered at later time. I don’t know why there was no follow up.” The DPCS validated that physician order for PT services was not followed. During a continued interview and review of clinical records for Patient 6 on 6/3/26 at 4:10 p.m., discussed with the DPCS that patient’s family verbalized they talked to nurses regrading PT services on multiple occasions. The DPCS stated, “I do not see any communication notes addressing PT services.” A review of the agency’s P&P titled, “Scope of Services: Physical Therapy,” dated 2022, indicated, “All physical therapy services will be provided by qualified physical therapists and physical therapy assistants as appropriate) in accordance with state practice acts, regulations, agency policies and job description.” The policy explained that PT services will include assessment and reassessment of the patient’s needs and implementation of gait training and therapeutic exercises to ensure the safety of the patient. The P&P explained further,” A maintenance program will ensure the safety of the patient and the effectiveness of the program to prevent or slow further deterioration of the patient’s injury or illness.” 1.A review of Patient 1’s “Home Health Certification and Plan of Care [POC],” for certification period 3/13/26 to 5/11/26, indicated Patient 1 had a Start of Care (SOC) date with the agency on 3/13/26 for multiple diagnoses including dementia (loss of memory, language, problem solving, and thinking abilities that interfere with daily life), schizoaffective disorder (mental health condition characterized by delusions and hallucinations), catatonic disorder (when a person is not responding or moving at all), and pressure ulcer of sacral region (skin injury due to prolonged pressure near the lower back and spine). A review of Patient 1’s POC indicated order “...Frequencies...SN [Skilled Nursing]: 1w1 [1 time a week for 1 week], 2w3 [2 times a week for 3 weeks], 1w5 [1 time a week for 5 weeks] ... Home Health-Aide...HHA [Home Health-Aide]: 1w4 1 time a week for 4 weeks] ...” A review of Patient 1’s Visit Calendar for SN visits, for 3/13/26 to 5/11/26, reflected missed visits on 3/21/26, 3/27/26, 4/1/26, 4/12/26, 4/15/26, 4/23/26, and 5/5/26. A review of Patient 1’s “Missed Visit Forms (...Skilled Nursing Visit),” dated 3/21/26, 3/27/26, and 4/23/26 indicated “... Reason: Other (Specify) Comments: patient is aware and agreeable to next available visit...” A review of Patient 1’s “”Missed Visit Form (...Skilled Nursing Visit),” dated 4/12/26, indicated “...Reason: Other (Specify) Comments: SN unable to accommodate patient...” A review of Patient 1’s “Aide Care Plan,” for 3/13/26 to 5/11/26, indicated that Vital Signs, Household Care (linen changes, light housekeeping, make bed) and Personal Care (dressing assist, nail care, shampoo, skin care, and shower) was to be done every visit. A review of Patient 1’s Visit Calendar for HHA visits, for 3/13/26 to 4/29/26, reflected missed visits on 4/2/26, 4/10/26, 4/17/26, and 4/29/26. A review of Patient 1’s “Missed Visit Forms (HHA Visit),” dated 4/2/26, 4/10/26, 4/17/26 indicated “...Reason: Other (Specify) Comments: patient is aware and agreeable to next available visit...” A review of Patient 1’s “Missed Visit Form (HHA Visit),” dated 4/29/26 “...Traveled to Patient: Yes ...Reason: Family-Caregiver Able to Assist Patient Comment; [Caregiver] said she already gave shower today...” During a concurrent interview and record review on 6/4/26 at 10:34 a.m. with the Clinical Supervisor (CS), reviewed Patient 1’s SN Missed Visit notes for 3/21/26, 3/27/26, 4/12/26, and 4/23/26. The CS stated the “Missed Visit Form” is used to document the reason for the missed visit and the notification of the patient and the physician. The CS stated that the “Missed Visit Form” for 3/21/26, 3/27/26, and 4/23/26 did not give reason for missed visit. The CS stated the “Missed Visit Form” for 4/12/26 indicated that staff was not available. The CS stated, “Don’t understand why was not able to go out. Why not able to accommodate. We have on call staff. Can’t imagine why another nurse wasn’t assigned.” The CS stated her expectation is that the reason for the missed visit will be documented in the “Missed Visit Form.” Further reviewed with the CS Patient 1’s “Missed Visit Forms (HHA Visit)” for 4/2/26, 4/10/26, 4/17/26, and 4/29/26. The CS stated Patient 1’s “Aide Care Plan” was completed 3/13/26 and included recommended tasks to be done and frequency of visits. The CS stated Patient 1 was authorized for six visits. The CS stated the “Missed Visit Forms” did not explain why the visits were missed. The CS stated that it may have been that the patient or caregiver was not available but there was no documentation for reason of missed visit. The CS stated the visits were not provided per the POC. A review of the HHA’s Policy and Procedure (P&P) titled “Plan of Care,” dated 2023, indicated “...Each patient receiving home health services from the agency receives an individualized, written plan of care...Services are furnished in accordance with accepted standards of practice and orders in the plan of care...The POC must include the following...The frequency and duration of visits to be made...Any changes to the patient’s condition or needs that suggest outcomes are not being achieved and/or plan of care should be altered are promptly communicated to the relevant physician(s)...Changes to the POC and visit schedule will be communicated to the patient and/or representative...Services are furnished in accordance with the POC and under the direction of a allowed physician/practitioner...” A review of the HHA’s P&P titled “Notification Regarding Missed Service or Treatment,” dated 2026, indicated “...A missed visit or treatment is an alteration in the plan of care, and therefore, requires notification to the ordering physician...patient and/or patient representative...A missed visit or treatment is an alteration to physician...plan of care and should only be missed for valid reasons...Scheduling Issues...Administrative Errors...A missed visit or treatment which cannot be rescheduled within the ordered duration shall be documented and communicated to the physician...Documentation of missed visits or treatment are as follows...Notation in patient’s clinical record or within a communication note with the reason for missed visit or treatment and method of communication...””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the home health agency failed to ensure standards of practice to prevent infections were followed for one of 18 patients (Patient 9) when Home Health Aide 1 (HHA 1) did not wear gloves while shaving Patient 9. This failure had the potential to result in transmission of infection and diseases among patients and staff, and decreased the agency’s potential to prevent exposure to blood, body fluids and/or infectious materials. During a review of Patient 9’s Plan of Care (POC) for certification period 5/25/26 to 7/23/26, the POC indicated Patient 9 had a start of care (SOC) date of 5/25/26 with diagnoses that included Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (occurs when blood supply to part of the brain is blocked or reduced) affecting right dominant side, and presence of right artificial hip joint. The POC further indicated that Patient 9 had orders for Home Health Aide (HHA) visits three times a week for four weeks. During a home visit observation on 6/3/26 at 12:05 p.m. in Patient 9’s home, HHA 1 was observed providing personal hygiene to Patient 9. After the shower, HHA 1 was observed asking Patient 9 about shaving facial hair and Patient 9 told HHA 1 that he usually shaves twice a week and would like to have a shave. HHA 1 was observed turning on the electric shaver and started shaving Patient 1’s facial hair without gloves. After shaving, HHA 1 opened the head of the shaver and rinsed the shaver blades on running water without gloves. During a follow-up interview on 6/3/26 at 12:41 p.m. with HHA 1, when asked about the expectation on wearing gloves while shaving a patient, HHA 1 stated she did not need to wear gloves during Patient 9’s shaving because Patient 9 already had a bath and was already clean. HHA 1 further stated if the shaving was done before the bath, she would wear gloves. During an interview on 6/3/26 at 4:53 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated the expectation was for staff to wear gloves during shaving due to the potential of nicks that could lead to exposure to blood-borne pathogens (infectious microorganisms that can cause disease). During a review of the agency’s policy and procedure (P&P) titled “INFECTION PREVENTION & CONTROL IN THE HOME SETTING,” dated 1/29/26, the P&P indicated, “…Standard precautions shall be used by all health care workers in a home setting regardless of suspected or confirmed infection status at the time health care is delivered and shall consist of:…D. Appropriate use of personal protective equipment (PPE)…E. Minimizing potential exposure…I. PPE shall be used for protection and as a barrier against infectious materials and any potential infectious disease exposure…” During a review of the agency’s P&P titled “GLOVES,” dated 6/26/25, the P&P indicated, “…I. Gloves are to be changed between patients and worn in the following circumstances:…B. With any procedure where there is the possibility of contact with any potential infectious materials (blood, body secretions…)…E. When a health care worker performs personal hygiene care for a patient…””

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to have evidence in the patient’s medical record the patient was initially consulted and consented to planned services and care for 10 of 18 sampled patients (Patient 1, Patient 2, Patient 8, Patient 10, Patient 11, Patient 12, Patient 13, Patient 15, Patient 16 and Patient 18). These failures had the potential for Patient 1, Patient 2, Patient 8, Patient 10, Patient 11, Patient 12, Patient 13, Patient 15, Patient 16 and Patient 18 to not be informed of all aspects of the care and services to be delivered, and to receive services they did not consent to. A review of Patient 8’s “Home Health Certification and Plan of Care (POC),” for certification period 3/20/26 to 5/18/26, indicated Patient 8 had SOC date with the HHA on 3/20/26 for diagnoses including ESRD (End Stage Renal Disease-kidneys are unable to filter the blood), diabetes (too much sugar in the blood), and chronic pain. Further review of Patient 8’s POC indicated orders “...Frequencies Physical Therapy...Skilled PT [Physical Therapy] x 1wk1 [1 time a week for 1 week] 2wk2 [2 times a week for 2 weeks] 1wk1 [1 time a week for 1 week] effective 03/20/2026...” During a record review on 6/2/26 of Patient 8’s “Episode Manager” Patient 8’s consent had not been entered into his medical record. During an interview on 6/4/26, at 10:42 a.m., with Clinical Supervisor (CS), CS stated the nurse completes the consent at the initial Start of Care visit, takes a photo of the signed consent, and then it is scanned and uploaded into the medical record. The CS stated consents were uploaded to the miscellaneous section of the medical record on 6/3/26. A review of the HHA’s Policy and Procedure (P&P) titled “Admission Criteria and Patient Acceptance,” dated 2024, indicated “...The patient is not accepted for service until all consent forms are signed...” A review of Patient 16’s Plan of Care (POC) dated 4/28/26, POC indicated, Patient 16’s care started on 4/28/26, and began receiving skilled nursing services. A review of Patient 16’s consent form page in his medical record dated 6/2/26, indicated no consent forms in Patient 16’s medical record. During an interview on 6/4/26, at 10:42 a.m., with Clinical Supervisor (CS), CS stated they upload consent forms in the office, after the nurse does the initial assessment with the patient. CS stated, we uploaded the consent forms for Patient 16 last night, they are supposed to be uploaded into the medical record on admission. During a review of Patient 10’s Plan of Care (POC) for certification date of 4/1/26 to 5/30/26, the POC indicated Patient 10 had a Start of Care (SOC) date of 4/1/26 with diagnosis that included spinal stenosis (narrowing of spaces within the spine). During a concurrent interview and record review on 6/4/26 at 12:07 p.m. with the Clinical Supervisor (CS), the CS reviewed Patient 10’s clinical record and confirmed there was no informed consent for Patient 10 in the clinical records. The CS stated, “…looks like we have a blank form, I would assume it’s in his folder at the house, but not in the electronic chart.” The CS further stated the expectation was for the informed consent to be sent and uploaded in the clinical record. The CS also stated every patient should have a copy of the informed consent at home and in the medical record and stated, “[Patients] sign [consent] before we touch them.” The CS stated that if something happens to a patient without consent, it could be a liability to the agency and could be construed as assault. The CS confirmed that it has been more than two months and Patient 10’s consent was still not uploaded in the clinical record. During a review of Patient 18’s POC for certification date 8/22/26 to 10/20/26, the POC indicated Patient 18 had a SOC date of 8/22/26 with diagnoses that included Type 2 diabetes mellitus (high blood sugar) with diabetic amyotrophy (a neurological disorder that causes severe pain and weakness in the lower body). During a concurrent 6/4/26 at 1:37 p.m. with the CS, the CS reviewed Patient 18’s clinical record and confirmed Patient had a SOC date of 8/22/25. The CS also confirmed that it has been almost a year and Patient 18’s informed consent was still not uploaded in the clinical records. A review of the Patient 13’s POC for the certification period from 5/18/26 through 7/16/26, indicated the patient had SOC date on 5/18/26. Patient 13’s POC indicated the patient was admitted with multiple diagnoses, including aftercare for back surgery. A further review of Patient 13’s POC contained physician orders for skilled nursing (SN) services for wound and medication management, physical therapy (PT) evaluation and treatment for safety and mobility therapeutic exercises, occupational therapy (OT) evaluation and treatment for instruction in safety, and home health aide services for personal assistance. A review of Patient 13’s clinical record revealed visit notes and documentation that SN, PT, OT, and HHA services were provided to the patient since 5/18/26. Patient 13’s clinical record did not contain documented evidence that informed consent for treatment was obtained from the patient prior to initiation of services and treatments. There was no documented evidence in Patient 13’s clinical record indicating the purpose of the treatments had been discussed with the patient. During a concurrent interview and record review on 6/4/26 at 11:30 a.m., the Clinical Supervisor (CS) stated that the nurses obtain informed consent for treatment from patient or family members during initial assessment, then the copy is provided to the patient, and the signed consent is uploaded into patient’s electronic chart. The CS reviewed Patient 13’s clinical record and acknowledged that the patient’s record did not contain signed consent form. A review of Patient 2’s Plan of Care (POC) for the certification period from 6/17/25 through 8/15/25 indicated Patient 2 had a start of care (SOC) on 6/17/25 with diagnoses including fracture (broken or cracked bone) of the upper end of the left tibia (shin bone -located in the front of the lower leg). Patient 2’s POC indicated orders for skilled nursing (SN) and physical therapy (PT) services. Further review of Patient 2’s clinical record indicated a recertification period from 8/16/25 through 10/14/25 and Patient 2 was discharged from the agency on 8/29/25. A review of Patient 11’s POC for the certification period from 4/8/26 through 6/6/26 indicated Patient 11 had a SOC on 4/8/26 with diagnoses including pneumonia (an infection/inflammation in the lungs). Patient 11’s POC indicated orders for SN and PT services. A review of Patient 12’s POC for the certification period from 4/6/26 through 6/4/26 indicated Patient 12 had a SOC on 4/6/26 with diagnoses including aftercare following neck surgery. Patient 12’s POC indicated orders for SN and PT services. A review of Patient 15’s POC for the certification period from 4/9/26 through 6/7/26 indicated Patient 15 had a SOC on 4/9/26 with diagnoses including candidal cystitis (fungal infection of the bladder) and urethritis (swelling and irritation of the tube [or urethra] that carries urine from the bladder out of the body). Patient 15’s POC indicated an order for SN services. During a concurrent interview and record review on 6/4/26 starting at 2:37 p.m. with the Clinical Supervisor (CS), the Admission Consent Forms for Patient 2, Patient 11, Patient 12, and Patient 15 were reviewed. The CS stated the Admission Consent form should be signed by the patient on the first visit. The CS confirmed the following information in the clinical records: -Patient 2’s consent was uploaded or entered in the clinical records on 6/2/26; -Patient 11’s consent form was uploaded in the clinical records today (6/4/26); -Patient 12’s consent form was not uploaded or entered in the clinical records; and, -Patient 15’s consent form had no date, and the consent was uploaded yesterday (6/3/26). The CS further stated her expectation was for the clinician to have the patient sign the Admission Consent form prior to any care being rendered and for the agency to provide a copy of the signed consent form to the patient or Responsible Party.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to conduct an initial assessment for three of 18 sampled patients (Patient 8, Patient 17, and Patient 13) within 48 hours of the referral. This failure resulted in a delay in the Start of Care (SOC) for HH services for Patient 8, Patient 17, and Patient 13 with potential for immediate care needs to be unmet. A review of Patient 13’s POC for the certification period from 5/18/26 through 7/16/26, indicated the patient had SOC date on 5/18/26. Patient 13’s POC indicated the patient was admitted with multiple diagnoses, including spinal stenosis (narrowing of the spaces inside the spine causing pain, weakness and numbness in the legs), following spine surgeries on 4/20/26 and 4/22/26. The POC contained a physician order for skilled nursing (SN) for post-surgical care, including wound care to patient’s midback, lower abdomen, and right flank (side) incisions. A review of Patient 13’s referral documents dated 5/11/26 and 5/12/26 contained physician orders for HHA services. Additional referral included in Patient 13’s clinical record was dated 5/14/26 and indicated “URGENT”. A review of Patient 13’s clinical record contained a communication note dated 5/13/26 indicated that patient had been discharged from the hospital on 5/12/26. Per communication note, Patient 13 was “taking care of her own wound care.” A review of communication note dated 5/14/26 indicated that start of care was planned for 5/15/26. According to the note, Patient 13 declined to have visit on 5/15/26. Patient 13’s clinical records did not contain other documents or communication notes explaining the delay of initial assessment and start of care (SOC) until 5/18/26. During a concurrent interview and record review on 6/4/26 at 11:30 a.m., the Clinical Supervisor (CS) validated that the initial referral documents for Patient 13 were received on 5/11 and 5/12/26. The CS explained that the referral was incomplete, and the agency requested to have all orders and face-to-face (a document from physician certifying why the patient required home health services). The CS stated that Patient 13 declined conduct initial assessment on 5/15/26. The CS was not able to provide documented evidence why Patient 13’s initial assessed until 5/18/26 three days later. The CS stated the agency should have scheduled the SOC visit the next day on 5/16/26 or 5/17/26, but it was not done. The CS stated there was no communication note explaining the delay with SOC and there was no documentation if the physician was notified of the delay. A review of the agency’s policy and procedure (P&P) titled, ASSESSMENT AND REASSESSMENT,” dated 2026, indicated, “Each patient receives a patient-specific comprehensive assessment…An initial assessment visit is completed by a registered nurse to determine the immediate care and support needs of the patient.” The P&P indicated that initial assessment is conducted within 48 hours of referral, within 48 hours of the patient’s return home, or the start of care date ordered by physician. A review of Patient 8’s referral indicated it was received by the HHA on 3/15/26. A review of Patient 8’s “Patient Communication,” note, dated 3/17/26, indicated “...The patient is home and ready to schedule...Dialysis: TTS [Tuesday Thursday Saturday] PT [Patient] SOC: 3/20/26...” A review of Patient 8’s “OASIS-E2 Start of Care [Outcome and Assessment Information Set-standardized assessment tool used to gather information about the patient to provide a patient specific Plan of Care -POC],” visit date 3/20/26, indicated “...The comprehensive assessment finds that there is a need to provide skilled Therapy care to safely address the patient/caregivers knowledge deficits in weakness, balance, and safety awareness...” A review of Patient 8’s “Home Health Certification and Plan of Care (POC),” for certification period 3/20/26 to 5/18/26, indicated Patient 8 had SOC date with the HHA on 3/20/26 for diagnoses including ESRD (End Stage Renal Disease-kidneys are unable to filter the blood), diabetes (too much sugar in the blood), and chronic pain. Further review of Patient 8’s POC indicated orders “...Frequencies Physical Therapy...Skilled PT [Physical Therapy] x 1wk1 [1 time a week for 1 week] 2wk2 [2 times a week for 2 weeks] 1wk1 [1 time a week for 1 week] effective 03/20/2026...” A review of Patient 17’s referral indicated it was received by the HHA on 5/1/26. A review of Patient 17’s “Physician Order,” dated 5/5/26, indicated ...Orders: Delay in SOC Referral received: 5/1/2026 for 5/02/2026 Patient contacted: 5/1/2026...MD [medical Doctor] Contacted: 5/1/2026 SOC Scheduled: 05/05/2026...” A review of Patient 17’s “OASIS-E2 Start of Care [Outcome and Assessment Information Set-standardized assessment tool used to gather information about the patient to provide a patient specific Plan of Care],” visit date 5/5/26, indicated “... The comprehensive assessment finds that there is a skilled need to provide SN [skilled nursing] care...The patient...needs intermittent skilled nursing care, physical therapy, occupational therapy...” A review of Patient 17’s “Home Health Certification and Plan of Care (POC)”, for certification period 5/5/26 to 7/3/26, indicated Patient 17 had a SOC date with the HHA on 5/5/26 for diagnoses including epilepsy (a brain disorder causing seizures), wound right lower leg, and dependence on wheelchair. Further review of Patient 17’s POC indicated orders “...Frequencies Skilled Nursing...2w9 [2 times a week for 9 weeks] ...effective 05/05/2026...” During a concurrent interview and record review on 6/4/26 at 11:18 a.m. with the Clinical Supervisor (CS), the CS acknowledged that Resident 17 had a referral dated 5/1/26 but did not have initial assessment completed until 5/5/26. Reviewed Resident 17’s “Physician Order,” dated 5/5/26, with the CS, who acknowledged that there was no documentation to indicate why the SOC was delayed or if it was the patient’s choice to have SOC delayed until 5/5/26. The CS stated the SOC assessment should be completed within 48 hours of receipt of the referral unless patient requests another date. During a concurrent interview and record review on 6/4/26 at 11:23 a.m. with the Clinical Supervisor (CS), the CS acknowledged that Patient 8’s referral date was 3/15/26 but the initial assessment was not completed until 3/20/26. Reviewed Patient 8’s “Patient Communication,” note dated 3/17/26, that indicated Patient 8 was ready for visit to be scheduled. The CS stated the initial assessment may have been delayed due to Patient 8’s dialysis schedule, but it was not documented that Patient 8 requested a delay in SOC. A review of the HHA’s Policy and Procedure (P&P) titled “Admission Criteria and Patient Acceptance,” dated 2024, indicated “...Patients are accepted for treatment on the reasonable expectation that the agency can meet the patient’s anticipated medical, nursing, rehabilitative, and social needs in the patient’s place of residence in an appropriate and safe manner...The agency shall screen potential patients and make decisions on the acceptance of patients for care on an individual basis and have reasonable expectation that the home health agency can meet the referred patient’s needs...Considerations relevant to patient acceptance include... Adequate staffing levels...If the agency does not have sufficient resources to provide the necessary care, the patient will not be admitted to the agency...” A review of the HHA’s P&P titled “Referrals,” dated 2023, indicated “...The registered nurse or qualified therapist shall perform the initial visit and comprehensive assessment and determine if the patient meets eligibility...” A review of the HHA’s P&P titled “Assessment and Reassessment,” dated 2026, indicated “... An initial assessment visit is completed by a registered nurse to determine the immediate care and support needs of the patient and to determine eligibility for the Medicare home health benefit, including homebound status. Ther initial assessment is conducted...Within 48 hours of referral...Each patient receives a patient-specific comprehensive assessment completed in a timely manner...but no later than 5 calendar days after the start of care...” A review of the HHA’s P&P titled “Plan of Care,” dated 2023, indicated “...Each patient receiving home health services from the agency receives an individualized, written plan of care... Purpose: To ensure care and services meet the patient-specific needs identified in the comprehensive assessment...””

“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 Home Health Agency (HHA) failed to ensure a comprehensive medication review was conducted for two of 18 sampled patients (Patient 7 and Patient 11) when: 1. Patient 7’s current medication record did not match the home medication; and, 2. Patient 11’s current medication record did not match the home medication, and the insulin sliding scale order was not clarified with the physician. These failures resulted in the HHA having inaccurate medical records for Patient 7 and Patient 11’s active medications and had the potential for Patient 7 and Patient 11 to have adverse effects from taking medications incorrectly or contrary to physician orders. 2. A review of Patient 11’s Plan of Care (POC) for certification period from 4/8/26 through 6/6/26 indicated Patient 11’s start of care (SOC) was on 4/8/26 and the following medications were on the list: -oxygen 2 liters per nasal cannula as needed for shortness of breath; -insulin Lispro (rapid acting, used to control high blood sugar) injection 100 unit/ml[milliliters] (unit of measurement) sliding scale (adjust insulin dose based on current blood sugar level) four times a day; -Bumex (water pill, used to reduce swelling and fluid buildup) 0.5 mg (milligrams, unit of measurement) 1 tab [tablet] daily; -Colace (stool softener) 100 mg 1 cap [capsule] twice a day as needed for constipation; -Humalog (rapid acting insulin) injection 100 unit/ml 3 units three times a day; -Flomax (to improve urine flow and reduce urine frequency) 0.4 mg 1 cap daily; -Entresto (for congestive heart failure) 24-26 mg 1 tab twice a day; -Spironolactone (helps the body shed excess fluid and spares the potassium) 25 mg 1 tab daily; -Jardiance (lowers blood sugar and protects the heart and kidneys) 10 mg 1 tab daily; -Lantus (long-acting insulin to manage blood sugar) 100 unit/ml 30 ml sq (subcutaneous) daily; -Lexapro (used to treat depression) 10 mg 1 tab daily; -Aspirin (used to prevent stroke) 81 mg 1 tab daily; -Atorvastatin calcium (used to lower bad cholesterol) 40 mg 1 tab daily; -Finasteride (to treat enlarged prostate) 5 mg 1 tab daily; -Carvedilol (to treat high blood pressure) 25 mg 1 tab twice a day; -Plavix (prevent blood clots)75 mg 1 tab twice a day; and -B12 (supports brain health and energy levels) 1000 mcg/15ml microgram/milliliters, unit of measurement). During a concurrent observation and interview on 6/3/26 starting at 11:10 a.m. with Licensed Nurse 2 (LN 2) and Patient 11, the LN 2 started taking out Patient 11’s medication bottles from the plastic bin. Patient 11 had Entresto 49-51 mg instead of the 24-26 mg. There were over-the-counter supplements such as omega fish oil (lower fat levels in the blood), probiotic (promote digestive health), cod liver oil (support bone strength), cinnamon (help to manage blood sugar and lower cholesterol), cranberry capsule ((prevent bladder infection), iron (prevent anemia), and focus factor (boost memory). The supplements were not included in Patient 11’s medication list. Patient 11 stated his physician changed his Lantus order from 30 units to 45 units. Patient 11 further stated he no longer takes the Spironolactone and the probiotic. Patient 11 was further asked by LN 2 how he determines how much humalog insulin he needs and Patient 11 responded for every 50 increments in his blood sugar, one unit of insulin will be added. Patient 11 further added his daughter helps him with managing his medications. During a concurrent interview and record review on 6/4/26 at 11:10 a.m. with the Administrator (ADM), Patient 11’s medication list was reviewed. The ADM stated the Registered Nurse (RN) who did the medication profile on the SOC should have clarified the insulin lispro sliding scale order from the physician. The ADM further stated her expectation was for the RN to list all prescription and nonprescription (supplements) medications to ensure there was no medication interactions. The ADM added if a medication was not currently ordered for the patient, the medication bottle should be separated from the active medications to prevent medication error. A review of the HHA’s policy and procedure dated 2025 and titled, “DRUG REGIMEN REVIEW” indicated, “All patients will have a drug regimen review...performed each time a comprehensive assessment is completed, and as needed to accommodate changes in the patient’s medication regimen...must be performed by a qualified professional...RN...Upon admission to service...all patients will have a thorough review of all current prescribed and over-the-counter medications the patient is currently taking...administered by any route...oral...injection...The assessing clinician will question the patient about old prescriptions that are in the home...All medications that the patient is currently taking will be listed on the patient’s plan of care...Questions regarding medication orders or prescribed medications will be handled...communicate questions/concerns with the ordering physician...” A review of Patient 7’s “Current Medications” dated 5/28/26 indicated, Patient 7’s current medications were the following: Furosemide (diuretic: used to remove excess fluid from body Oral 20 MG 1 Tab, take daily, Tamsulosin (prescription medication primarily used to treat symptoms of an enlarged prostate) 0.4 1 cap daily, Rivaroxaban (used to treat and prevent harmful blood clots) 20 mg 1 tab take daily, Lactobacillus Rhamnoses (probiotic) take 1 capsule daily, Albuterol Sulfate Inhalation (prescription bronchodilator used as a fast-acting “rescue” medication to treat or prevent breathing difficulties like wheezing and shortness of breath), inhale 2 puffs as needed for asthma, Acetaminophen 650 mg/20.3mL (pain medication), take 1 mL every 6 hours while awake, Sennosides oral (stimulant laxative) 8.6 mg 1 tab take two times a day, Polyethylene Glycol (MiraLAX laxative used to relieve occasional constipation) 3350 oral 17 gm 1 packet daily as needed for constipation, oxycodone (opioid pain medication) oral 5 mg 1 tab take every 6 hours as needed for pain, oxygen at 2 L per trach. During an observation on 6/3/25, at 10:34 a.m., in Patient 7’s home, Patient 7’s spouse placed all of Patient 7’s current medications on the counter. The medications observed were Ipratropium Bromide Inhalation Solution 0.02% (a liquid medication used in a nebulizer device: It is used to open up the airways and treat airflow blockages), Docusate Sodium (stool softener used to relieve occasional constipation)100 mg, Tamsulosin oral capsule 0.04 MG take 1 pill two times daily, Furosemide) 20 mg 1 tab daily, lactobacillus Rhamnoses take 1 tab daily, albuterol inhaler 108. During an interview on 6/3/25, at 10:55 a.m., with Patient 7’s spouse, Spouse stated that Patient 7 was not taking Oxycodone, Tylenol 650mg, MiraLAX, sennosides, or Rivaroxaban. Spouse further stated Patient 7 was not taking these medications for many weeks. During an interview on 6/3/26, at 10:59 a.m., with Licensed Nurse (LN) 1, LN 1 stated he checked Patient 7’s active medication list and he did not see the nebulizer medication (Ipratropium Bromide Inhalation Solution) or Docusate in Patient 7’s medication list. LN 1 further stated the list still shows Patient 7 is taking Rivaroxaban, Oxycodone, and Tylenol 650 even though those medications have been discontinued per Patient 7’s spouse for some time. During an interview on 6/4/25, at 11:04 a.m., with Clinical Supervisor (CS), CS stated the policy of the HHA for medications is the nurses are supposed to assess for medication changes during each visit and they are supposed to ensure the patients are being compliant with medications as ordered, if there are no changes they don’t need to update the medications. CS stated, the medication list should match what the patient is taking at home. CS stated, for Patient 7 the medication list should have been updated on the 5/28/26 assessment. CS stated, if the nurses do not update the medication list there could be an issue of medication errors. A review of the HHA’s Policy & Procedure (P&P) titled, “Physician Order Management” dated 2025, indicated, “Responsibilities: A. Clinical Staff: obtain, document, and implement physician orders accurately”.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to complete a comprehensive assessment (Oasis Recertification: a mandatory follow-up comprehensive assessment completed every 60 days for a patient remaining on home health service) within the last five days of every 60 days of the start of care date for one of 18 sample patients (Patient 7). This failure had the potential for Patient 7 to receive services outside of his certification period, and to receive services not personalized to his current health status. A review of Patient 7’s “Home Health Certification and Plan of Care” dated 2/2/26, indicated Patient 7’s start of care date was 2/2/26, with the certification period listed as 2/2/26-4/2/26. A review of Patient 7’s “Home Health Certification and Plan of Care” dated 4/4/26, indicated, Patients 7’s Oasis Recertification was not completed until 4/4/26 (2 days after the first certification period ended on 4/2/26). During an interview on 6/4/26, at 11:04 a.m., with Clinical Supervisor (CS), CS stated, “Recertification assessments are supposed to be done five days prior to the end of the episode”. CS further stated, she can see in the medical record, Patient 7’s Recertification was completed late. CS stated, “We are practicing outside the episode” if the HHA does not recertify timely. A review of the HHA’s Policy and Procedure (P&P), titled, “Assessment and Reassessment” dated 2026 indicated, “Purpose: To ensure the reassement process in ongoing and is triggered at key timepoints during the home health care stay. . .C For recertification of home health care services. 1. A comprehensive assessment visit will be performed between the days of 56 and 60 of each episode utilizing the OASIS Recertification”.”

“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 home health agency failed to ensure the individualized plan of care (POC) developed in consultation with the agency staff included all pertinent diagnoses for one of 18 sampled patients (Patient 14). A review of Patient 14’s clinical record contained HHA referral documents from the patient’s physician dated 5/29/26. The referral contained physician orders for skilled nursing (SN) services and Patient 14’s history and physical, including all diagnoses. A review of Patient 14’s POC dated 5/30/26 through 7/28/26 indicated she was admitted to the agency on 5/30/26. The POC included Patient 14’s physician’s orders, patient’s assessment, medication list, disciplines ordered and frequencies of visits. The POC did not reflect Patient 14’s diagnoses listed in referral documents. During a concurrent interview and record review on 6/4/26 at 11:30 a.m., with Clinical Supervisor (CS) stated that POC should include primary diagnosis and all other diagnoses as one of the requirements. The CS validated that Patient 14’s POC did not have diagnoses listed. The CS reviewed Oasis (Outcome and Assessment Information Set, a standardized patient assessment) dated 5/30/26 and was not able to find Patient 14’s diagnoses listed. A review of the agency’s policy and procedure (P&P) titled, “Care Planning, Coordination of Services and Quality of Care,” dated 2025, indicated, “To assure agency functions in accordance with federal regulations which states that a physician, nurse practitioner…may order home health services, establish and periodically review the plan of care…Each patient shall receive an individualized written plan of care…Plan of care will contain: A. Pertinent diagnoses including, but not limited to, the chief reason the patient is receiving home care.””

“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 interview and record review, the home health agency (HHA) failed to ensure the plan of care (POC) developed for two of 18 sampled patients (Patient 4 and Patient 9), included a physician order for home health aide (HHA) services for Patient 4, and a physician order for physical therapy for Patient 9. These failures resulted in Patient 4 not receiving assistance with activities of daily living (activities done every day such as personal hygiene, bathing, dressing, and toileting) and had the potential to result in Patient 9 experiencing decline in function and independence. During a review of Patient 9’s POC for certification period 5/25/26 to 7/23/26, the POC indicated Patient 9 had a start of care (SOC) of 5/25/26 with diagnoses that included Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (occurs when blood supply to part of the brain is blocked or reduced) affecting right dominant side, and presence of right artificial hip joint. The POC further indicated that Patient 9 had orders for Skilled Nursing (SN) visits three times a week for 9 weeks and for Home Health Aide (HHA) visits three times a week for four weeks. The POC also indicated Patient 9 did not have orders for physical therapy. During a review of Patient 9’s “HOME HEALTH REFERRAL ORDERS,” dated 5/22/26, the orders indicated, “Primary Qualifying Service: Skilled Nursing…Secondary Services Requested: Physical Therapy…Physical Therapy Orders…Assess Mobility Devices…Gait Training…Transfer Training…Establish Home Exercise Program…” During a concurrent interview and record review on 6/3/26 at 4:53 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS confirmed Patient 9’s referral orders, dated 5/22/26, indicated orders for SN and PT services. The ADM/DPCS also confirmed SN and HHA services were ordered during the SOC but not the PT services. The ADM/DPCS confirmed Patient 9 is not currently receiving PT services. The ADM/DPCS stated patients sometimes decline services, and the expectation was for the clinician to document the refusal if a patient declined a service. The ADM/DPCS was not able to provide documented evidence that Patient 9 refused or declined PT services. During a review of the agency’s policy and procedure (P&P) titled “CARE PLANNING, COORDINATION OF SERVICES AND QUALITY OF CARE,” dated 2025, the P&P indicated, “…Patients are accepted for treatment on the reasonable expectation that the agency can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence…” During a review of the agency’s P&P titled “ SCOPE OF SERVICES: PHYSICAL THERAPY,” dated 2022, the P&P indicated, “ The physical therapist will provide skilled professional services in the patient’s place of residence as specified by a physician or allowed practitioner and in accordance with the state and federal regulations and the standards of practice…” During a review of the agency’s P&P titled “PHYSICIAN ORDER MANAGEMENT,” dated 2025, the P&P indicated, “…I. General Requirements…A. An Individual admitted to the agency has an order from a physician/allowed practitioner…IV. Documentation and Communication…A. All physician orders must be documented in the clinical record, integrated into the plan of care, and communicated to all relevant staff…” A review of Patient 4’s clinical record contained HHA referral orders from the patient’s physician signed and dated 4/16/26. The referral contained physician orders for skilled nursing (SN) services for wound care and medication management and home health aide services for personal care and household chores. A review of Patient 4’s clinical record indicated the agency admitted the patient on 4/17/26 with primary diagnosis of skin cancer, aftercare following surgery for skin tumor removal (wound treatment), diabetes (chronic condition where person’s blood glucose is too high), and high blood pressure. A review of Oasis (Outcome and Assessment Information Set, a standardized patient assessment) dated 4/17/26 indicated that Patient 4 was alert and oriented. According to Oasis, Patient 4 had multiple chronic conditions and functional limitations, required to use assistive devices such as walker, required assistance with dressing, grooming, bathing, toileting, and transferring. The POC indicated that Patient 4 lived alone and had intermittent assistance from friends and nephew. A review of Patient 4’s plan of care (POC), for the certification period from 4/17/26 through to 6/15/26 contained physician orders to receive skilled nursing (SN) services one time per week for one week, two times per week for 4 weeks, and one time a week for last 4 weeks. The POC did not contain order for HHA services as indicated in referral documents. A review of Patient 4’s clinical record did not contain any documented evidence that HHA services were offered to the patient as requested by her physician. During a concurrent interview and record review on 6/3/26 at 3:45 p.m., with Director of Patient Care Services (DPCS), the DPCS acknowledged that per SN visit notes, Patient 4 required assistance with personal care. The DPCS was unable to find documented evidence that HHA services were offered to Patient 4 and the patient refused the services. The DPCS acknowledged that the physician order for HHA services was not reflected in Patient 4’s POC and the physician order was not followed. The DPCS stated if the patient refused HHA services, the expectation would be that the patient’s refusal was communicated to the physician, but it was not done. A review of agency’s policy and procedure (P&P) titled, “Care Planning, Coordination of Services and Quality of Care,” dated 2025, indicated, “Patients are accepted for treatment on the reasonable expectation that the agency can meet the patient’s medical, nursing, rehabilitative, and social needs.” The P&P indicated that all services provided to the patients must be furnished in accordance with physician orders and accepted standards of practice. The P&P further indicated that the agency will integrate orders from all physicians involved in the plan of care to assure coordination of all services and interventions provided to the patient.”

“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 Home Health Agency (HHA) failed to ensure effective communication and coordination of care between the HHA staff and the physician for two of 18 sampled patients (Patient 1 and Patient 4), when: 1. Patient 1’s physician was not notified of a skilled nursing missed visit, and 2. Patient 4’s concerns with obtaining food, housing and transportation issues were not addressed, and the patient was not referred to a Medical Social Worker (MSW) and community resources. These failures had the potential to result in Patient 1’s physician not being aware of Patient 1’s changing condition or care needs, resulted in Patient 4’s unmet social needs, and prevented the patient from benefiting from community resources. 2.A review of Patient 4’s clinical record indicated the agency admitted the patient on 4/17/26 with primary diagnosis of skin cancer, aftercare following surgery for skin tumor removal (wound treatment), and diabetes (chronic condition where person’s blood glucose is too high). A review of Patient 4’s plan of care (POC), for the certification period from 4/17/26 through to 6/15/26, indicated that Patient 4 had multiple chronic conditions and functional limitations, required to use assistive devices such as walker, and special transportation. The POC indicated that Patient 4 lived alone and only had intermittent support from friends and nephew. A further review of Patient 4’s POC from 4/17/26 through to 6/15/26, contained a physician order to receive skilled nursing (SN) services one time per week for one week, two times per week for 4 weeks and one time a week for last 4 weeks. A review of SN visit notes dated 4/20 and 4/23/26 indicated that Patient 4 had fixed income and expressed her concerns regarding affordable housing, rent increases, and affording healthy food. The SN indicated that Patient 4 reported ongoing “significant financial constraints affecting ability to maintain adequate nutrition and diabetic diet management, states she can only afford health meals approximately four days a month, typically running out of food during the last week of each month…Patient lacks personal transportation and relies on community resources including food bank services.” The SN documented, “Continued monitoring of psychosocial support needs and follow up regarding social work resource coordination recommended.” A review of SN visit note dated 4/27/26 indicated that Patient 4 had “poor home environment, poor coping skills, depressed mood” and reported “ongoing significant financial constraints affecting ability to purchase adequate food and supplies. Patient [4] states she is out of everything and needs to shop.” A further review of SN note indicated Patient 4 continued “to experience significant sleep disturbances… difficulties falling asleep…Demonstrates ongoing emotional …challenges and mood concerns…Follow up regarding…coping strategies recommended.” A review of SN visit notes dated 4/30, 5/5, 5/13/26 indicated that Patient 4 continued to demonstrate and/or express anxiety, continued reporting significant financial constraints, and expressing frustration regarding transportation issues and housing costs. A review of SN visit notes dated 5/19/26 and 6/2/26 indicated Patient 4 verbalized that she experienced anxiety and difficulties with obtaining in -home aide services and ongoing housing concerns. SN documented, “These ongoing financial and resource-related stressors continue to impact patient’s psychosocial wellbeing.” A review of Patient 4’s clinical record did not contain any documented evidence that the patient’s psychosocial concerns were communicated to Patient 4’s physician. A further review of the clinical record failed to reveal an order for MSW evaluation or referral to address the patient’s social and emotional needs. During an interview and record review on 6/3/26 at 3:45 p.m., with the Director of Patient Care Services (DPCS), the DPCS validated that nursing staff was aware that Patient 4 experienced anxiety and verbalized concerns regarding obtaining meals, transportation, and housing on multiple occasions. The DPCS stated that social worker should have been involved to help Patient 4 with her emotional and social concerns and to possibly refer to community resources. The DPCS was not able to show evidence that Patient 4’s needs were communicated to other team members, including MSW to assist the patient with obtaining available community resources and provide psychosocial counseling. The DPCS stated, “I don’t see physician was contacted and order for social services requested.” A review of the agency’s policy and procedure (P&P) titled, “Communication,” dated 2021, indicated, “Communication regarding patient care is documented and filed in the patient’s clinical record. The documentation shows effective interchange, reporting and coordination of care regarding the patient…Each communication received or made by agency personnel related to problems or requests made by a patient…will be documented within the patient’s medical record.” A review of the P&P titled, “Care Planning, Coordination of Services and Quality of Care,” dated 2025, indicated, “The agency shall: A. Assure communication with all physician/allowed practitioners involved in the plan of care…D. Coordinate care delivery to meet the patient’s needs.” 1.A review of Patient 1’s “Home Health Certification and Plan of Care [POC],” for certification period 3/13/26 to 5/11/26, indicated Patient 1 had a Start of Care (SOC) date with the agency on 3/13/26 for multiple diagnoses including dementia (loss of memory, language, problem solving, and thinking abilities that interfere with daily life), schizoaffective disorder (mental health condition characterized by delusions and hallucinations), catatonic disorder (when a person is not responding or moving at all), and pressure ulcer of sacral region (skin injury due to prolonged pressure near the lower back and spine). A review of Patient 1’s POC indicated order “...Frequencies...SN [Skilled Nursing]: 1w1 [1 time a week for 1 week], 2w3 [2 times a week for 3 weeks], 1w5 [1 time a week for 5 weeks] ...” A review of Patient 1’s “”Missed Visit Form (...Skilled Nursing Visit),” dated 4/12/26, indicated “...Reason: Other (Specify) Comments: SN unable to accommodate patient...MD Notified: No...” During an interview on 6/23/26 at 11:12 a.m. with Licensed Nurse (LN) 1, LN 1 stated if a visit is missed, he would complete the “Missed Visit Form.” LN 1 stated he would notify the scheduler, notify the physician by phone, and document the physician was notified in the “Missed Visit Form.” During a concurrent interview and record review on 6/4/26 at 10:34 a.m. with the Clinical Supervisor (CS), reviewed Patient 1’s SN Missed Visit note 4/12/26. The CS stated the “Missed Visit Form” is used to document the reason for the missed visit and the notification of the patient and the physician. The CS stated the “Missed Visit Form” for 4/12/26 indicated that staff was not available. The CS acknowledged that the “Missed Visit Form” for 4/12/26 did not indicate the physician was notified of the missed visit. The CS stated the physician should have been notified of the missed visit. A review of the HHA’s Policy and Procedure (P&P) titled “Notification Regarding Missed Service or Treatment,” dated 2026, indicated “...A missed visit or treatment is an alteration in the plan of care, and therefore, requires notification to the ordering physician...patient and/or representative...The organization must notify the relevant physician...to any changes in ordered frequency of ordered services or treatment including reason...A missed visit or treatment which cannot be rescheduled within the ordered duration of visits shall be documented and communicated to the physician...Documentation of missed visits or treatments are as follows... Physician.. notification...fax/email with details of date and time...Telephone notification with details of date, time, and person notified...mailed copy of the documentation with date of mailing...””

“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 interview and record review, the home health agency (HHA) failed to provide services ordered by physician and as indicated in the plan of care (POC) for 5 of 18 sampled patients (Patient 2, Patient 3, Patient 5, Patient 11, and Patient 15). These failures resulted in the HHA’s inability to ensure needed services were provided and had the potential to affect patients’ quality of care. During a review of Patient 5’s Plan of Care (POC) for certification period 1/2/26 to 3/2/26, the POC indicated Patient 5 had a Start of Care (SOC) date of 1/2/26 with diagnoses that included hypertensive heart disease (damage to the heart from unmanaged high blood pressure) and history of falling. The POC further indicated an order for physical therapy (PT) evaluation effective 1/4/26, and one visit for a week (1w1), two visits for three weeks (2w3) and one visit for one week effective 1/7/26. During a review of Patient 5’s “Missed Visit Form,” dated 2/14/26, the form indicated, “…Missed Visit Form (PT Re-evaluation w/ [with] Supervisory Visit)…Traveled to Patient: No…Reason: Other (Specify)…Comments: patient is aware and agreeable to next available visit…” During a review of Patient 5’s “Missed Visit Form,” dated 2/21/26, the form indicated, “…Missed Visit Form (PTA Visit)…Traveled to Patient: No…Reason: Other (Specify)…Comments: patient is aware and agreeable to next available visit…” During a concurrent interview and record review on 6/4/26 at 12:03 p.m. with the Clinical Supervisor (CS), the CS confirmed Patient 5 had an order for 1w1 2w3 1w1 effective 1/7/26. The CS further confirmed Patient 5 missed her PT reevaluation on 2/14/26 and PTA visit on 2/21/26. The CS also confirmed that Patient 5’s missed visit notes for 2/14/26 and 2/21/26 both indicated “patient is aware and agreeable to next available visit.” The CS stated, “…that’s not a reason…” and stated the expectation was to document a reason for the missed visit and to reschedule the visit as soon as possible. The CS further stated if visits were missed without a reason, agency staff were not following plan of care, and the patient could have a change of condition. During a review of the agency’s policy and procedures (P&P) titled “NOTIFICATION REGARDING MISSED SERVICE OR TREATMENT,” dated 2026, the P&P indicated, “…I. A missed visit or treatment is an alteration to the physician/allowed practitioner plan of care and should only be missed for valid reasons…VI. Documentation of missed visits or treatments are as follows:…B. Patient and/or patient representative- 1. Notation in patient’s clinical record or within a communication note with reason for missed visit or treatment and method of communication…” A review of Patient 3’s clinical record indicated the agency admitted the patient on 7/29/25 with a primary diagnosis of aftercare following cerebral infarction (stroke) affecting Patient 3’s left side. Patient 3 clinical record indicated that she had been recertified every 60 days after the initial episode. A review of Patient 3’s POC most recent POC the period 11/26/25 through 1/24/26 indicated that Patient 3 had a decline in mental, emotional, or behavioral status in the past 3 months. The POC indicated skilled nurse (SN) was to visit Patient 3 once a week for nine weeks to perform evaluation, assessment of patient’s vital signs and all body system. A review of Patient 3’s clinical record contained SN missed visit notes dated 12/2/25 and 12/27/25. Both notes indicated, “Cancellation of Care…Visit missed and rescheduled due to low staffing. Patient is aware and agreeable with next available visit.” Patient 3’s clinical record indicated that missed visits were not rescheduled for the same week. A review of Patient 3’s POC for the period 9/27/25 through 11/25/25 indicated skilled nurse (SN) was to visit Patient 3 once a week for 9 weeks to perform evaluation, assessment of patient’s vital signs and all body system. A review of Patient 3’s clinical record indicated SN missed visit note dated 10/24/25. The note indicated, “Cancellation of Care…Visit missed and rescheduled due to low staffing. Patient is aware and agreeable with next available visit.” The SN visit was not rescheduled for the same week and SN visit scheduled for the next week on 10/31/25 was not completed as scheduled indicating that Patient 3 was not seen by SN for two weeks. The missed visit note dated 10/31/25 indicated that Patient 3’s scheduled visit was cancelled due to low staffing. A review of Patient 3’s clinical record indicated that the recertification SN visit to scheduled for 11/25/25 was not completed as scheduled “due to low staffing.” A review of the agency’s policy and procedure (P&P) titled, “Notification Regarding Missed Service or Treatment,” dated 2026 indicated, “A missed visit or treatment is an alteration to the physician/ allowed practitioner plan of care and should only be missed for valid reasons.” The P&P contained a list of valid patient-related reasons and did not indicate “low staffing” as one of the valid reasons. During a concurrent interview and record review on 6/2/26 at 2:50 pm., Patient 3’s missed visits were discussed with Director of Patient Care Services (DPCS). The DPCS validated that Patient 3’s multiple missed visits were due to low staffing. The DPCS explained the process, “If we do not have enough staff for visits, we triage, notify physician, and reschedule, preferably the same week… Once we identify we can’t staff properly, we notify patient/family…if it was okay to reschedule visit.” The DPCs did not provide any explanation regarding the potential impact of missed visits on patient’s care. A review of the agency’s P&P titled, “PLAN OF CARE,” dated 2023, indicated, “Services are furnished in accordance with the POC and under the supervision and direction of allowed practitioner.” A review of Patient 2’s POC for the certification period from 6/17/25 through 8/15/25 indicated Patient 2 had a start of care (SOC) on 6/17/25 with diagnoses including fracture (broken or cracked bone) of the upper end of left tibia (shin bone- located in the front of the lower leg. Patient 2’s POC further indicated orders for skilled nursing (SN), 2 visits per week x 5 weeks, and 1 visit per week x 2 weeks. A review of Patient 2’s calendar of visits and communication notes indicated Patient 2 had a SN missed visit on 8/1/25. Patient 2’s communication note indicated, “Visit missed and rescheduled due to low staffing. [Patient 2] aware and agreeable with next available visit.” During a concurrent interview and record review on 6/4/26 at 10:29 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 2’s POC, visit calendar, and communication notes were reviewed. The ADM/DPCS stated there was no SN to see Patient 2 on 8/1/25. The ADM/DPCS further stated this was a true missed visit since there was no visit scheduled for that work week. A review of Patient 11’s POC for the certification period from 4/8/26 to 6/6/26 indicated Patient 11 had a SOC on 4/8/26 with diagnoses including pneumonia (an infection/inflammation in the lungs). Patient 2’s POC further indicated an order for Physical Therapy (PT), 1 visit per week for 1 week from 4/8/26 through 4/11/26. A review of Patient 11’s calendar of visits indicated a PT evaluation on 4/22/26, 11 days later. There was no PT visit conducted between 4/8/26 to 4/11/26. During a concurrent interview and record review on 6/4/26 at 10:56 a.m. with the ADM/DPCS, Patient 11’s POC and calendar of visits were reviewed. The ADM/DPCS stated she did not know why PT was not able to see Patient 11 between 4/8 to 4/11/26. The ADM/DPCS further stated this was a scheduling error and it was a true missed visit. A review of Patient 15’s POC for the certification period from 4/9/26 through 6/7/26 indicated Patient 15 had a SOC on 4/9/26 with diagnoses including candidal cystitis (fungal infection of the bladder) and urethritis (swelling and irritation of the tube [or urethra] that carries urine from the bladder out of the body). Patient 15’s POC further indicated orders for skilled nursing (SN), 1 visit per week for 9 weeks. A review of Patient 15’s calendar of visits and communication notes indicated Patient 15 had a SN missed visit on 4/18/26. Patient 2’s communication note indicated, “Other” for the reason of the missed visit. During a concurrent interview and record review on 6/4/26 at 11:26 a.m. with the ADM/DPCS, Patient 15’s calendar of visits and communication notes were reviewed. The ADM/DPCS stated the original SN schedule was on 4/10/26 and the schedule was moved multiple times on 4/14/26, 4/16/26, 4/17/26 and on 4/18/26. The ADM/DPCS further stated the SN visit was missed on 4/18/26 and there was no communication made by clinician (Licensed Nurse) why the schedule was moved and there was no SN service done that week. A review of the HHA’s policy and procedure (P & P) dated 2023 and titled, “PLAN OF CARE” indicated, “Each patient receiving home health services from the agency receives...written plan of care...Services are furnished in accordance with accepted standards of practice and orders in the plan of care.” A review of the HHA’s P & P dated 2026 and titled, “NOTIFICATION REGARDING MISSED SERVICE OR TREATMENT” indicated, “A missed visit or treatment is an alteration to the physician...plan of care...””

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure a completed discharge summary was sent to the patient’s primary care provider who will be responsible for care after discharge from the HHA within five business days of the patient’s discharge, for two of 18 sampled patients (Patient 1 and Patient 2). This failure had the potential for Patient 1 and Patient 2’s Primary Care Provider to be unaware of the discharge and not be informed of Patient 1 and Patient 2’s response and/or progress with HHA services received. A review of Patient 2’s clinical records indicated Patient 2 had a start of care (SOC) on 6/17/25 for the certification period from 6/17/25 through 8/15/25 with diagnoses including fracture (broken or cracked bone) of the upper end of left tibia (shin bone- located in the front of the lower leg). Further review of Patient 2’s clinical records indicated Patient 2 had a second episode of certification (recertification) period from 8/16/25 through 10/14/25 and Patient 2 was discharged from the agency on 8/29/25. A review of Patient 2’s Discharge summary dated 8/29/25 indicated Patient 2 was discharged from home health services and all services were notified and discontinued. There was no documented evidence the physician was notified of Patient 2’s discharge from home health services. During an interview on 6/2/26 at 2:45 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), she stated the Registered Nurse will do the discharge summary, and the physician will be notified by facsimile (fax). During a follow up interview on 6/4/26 at 11:37 a.m. with the ADM/DPCS, she stated Patient 2’s discharge was unplanned. The HHA was informed Patient 2 requested to move to another HHA. The ADM/DPCS further stated there was no documented evidence the physician was informed of Patient 2’s discharge from the agency. A review of the HHA’s policy and procedure dated 2025 and titled, “TRANSFER, DISCHARGE AND DISCHARGE PLANNING” indicated, “The agency will maintain and implement an effective transfer and discharge planning process...will ensure safe, coordinated transitions of care...The patient’s primary care provider or other health care professional who will be responsible for providing care and services after discharge will be notified of plans for patient discharge...A completed discharge summary will be sent to these individuals within 5 days of the patient’s discharge.” A review of Patient 1’s Discharge Oasis dated 5/16/26, indicated Patient 1 was discharged on this date from HHA services, which began on 3/13/26. Oasis indicated, the section for care coordination, “Discharge Summary sent to the primary care practitioner” was NOT selected. During an interview on 6/4/26, at 10:42 a.m., with Clinical Supervisor (CS), CS stated, after reviewing the medical record, she could not find documentation, Patient 1’s discharge summary was sent to Patient 1’s primary care provider within five days of discharge. CS stated, the administrator just sent the summary at 12:46 a.m. today. CS stated, Patient 1 was discharged from the HHA on 5/16/26. A review of the HHA policy and procedure (P&P) titled, “Care Planning, Coordination Services and Quality of Care” dated 2025, the P&P indicated, “Coordination of care. The agency shall: A. Assure communication with all physician/allowed practitioners involved in the plan of care”. A review of the HHA p&P titled, “Transfer, Discharge and Discharge Planning”, dated 2025 indicated, “Purpose: To ensure safe. effective, and patient-cetnered transfer and discharge from home health services, consistent with regulatory requirements and best practices. . .XIII, A discharge summary will be completed for all patients, including those initially transferred and later discharged. It will be sent to the primary care practitioner within 5 business days of discharge”.”

“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 Home Health Agency (HHA) failed to ensure the Plan of Care (POC) was followed for two of five sampled patients (Patient 2 and Patient 5) when Patient 2 and Patient 5’s POCs were not followed and the MD (Medical Doctor) was not notified of Patient 2 and Patient 5’s missed visits. This failure had the potential for Patient 2 and Patient 5’s care to be adversely affected and MD to be unaware of changes in Patient 2 and Patient 5’s care needs. A review of Patient 2’s POC for 2/24/26 to 4/24/26, indicated Start of Care (SOC) date with the HHA on 2/24/26 for diagnoses including bacteremia (bacterial infection of the blood), hypertension (high blood pressure), and pancytopenia (lower than normal number of red and white blood cells and platelets in the blood). The POC indicated “...Orders and Treatments...SN [Skilled Nursing] to change midline [a long thin catheter tube for peripheral venous access inserted into a vein in the upper arm] dressing every week using sterile technique...Skilled Nursing: 2/24/2026 (Tuesday)- 4/24/2026 (Friday) 1 visit per week for 9 weeks...” A review of Patient 2’s “Master Calendar” indicated Patient 2 had LVN visit on 3/2/26 and RN visits on 2/24/26 and 3/4/26. A review of Patient 2’s “LPN/LVN-Skilled Nursing Visit,” dated 3/2/26, indicated “...right upper arm pick [PICC-peripherally inserted central catheter, long thin tube inserted through a vein in the arm passed through to the larger veins of the heart] line dressing dry intact...” A review of Patient 2’s “RN- Skilled Nursing Visit,” dated 3/4/26, indicated “...The clinician performed a PICC line dressing change using sterile technique. The previous dressing had been in place longer than the recommended weekly schedule due to a previous clinician’s missed visit, which delayed the dressing change by two days...” A review of Patient 5’s POC for 10/8/25 to 12/6/25 indicated SOC date with the HHA on 10/8/25 for diagnoses including neurosyphilis (bacterial infection of the brain or spinal cord), management of VAD (ventricular assist device that helps pump blood to the body from the heart), and malignant neoplasm of right breast (cancerous tumor of the right breast). The POC indicated “...Orders and Treatments SN: 1w9 [1 time a week for 9 weeks], 2 X PRN [2 as needed visits] PICC Line complications... SN to perform Sterile dressing changes are done weekly and as needed...” A review of Patient 5’s “Master Calendar” for 10/8/25 to 12/6/25, did not reflect a SN visit was done for week of 11/9/25 to 11/15/25. A review of Patient 5’s “Transfer Summary” dated11/19/25, indicated “...Transfer Date: 11/19/25...Reason for Transfer...Hospitalized...” A review of Patient 5’s “Patient Communication,” dated 11/20/26, indicated “...Patient admitted at [name of hospital] ...11/19/25...” During an interview on 4/14/26 at 10:10 a.m. with the Clinical Supervisor (CS), the CS stated PICC line care and midline care is performed by RNs only. PICC line and midline care, including dressing changes, is done once a week. The CS stated PICC lines and midlines are treated the same regarding dressing changes and care done by RN only. During a concurrent interview and record review on 4/14/26 at 12:34 p.m. with the CS, reviewed Patient 2’s “Skilled Nursing Visit Notes” for 3/2/26 and 3/4/26. The CS stated Patient 2 was seen by Licensed Vocational Nurse (LVN) on 3/2/26 and did not have PICC line dressing changed until 3/4/26 by Registered Nurse (RN). The CS stated the PICC line dressing change was done on 2/24/26 and should have been changed on 3/3/26. The CS acknowledged the PICC line dressing was changed on 3/4/26 by the RN. The CS acknowledged that there was no indication in the clinical record of why the RN visit was missed on 3/3/26. The CS stated there was no missed visit note and no indication the MD was notified of the missed visit and delay in PICC line dressing change for Patient 2. The CS stated the expectation is that the PICC line dressing would be changed every 7 days per the POC. The CS stated there was a risk of PICC line associated infection and clotting problems if it was not changed every 7 days. During a review of Patient 5’s POC with the CS, the CS acknowledged Patient 5’s POC indicated weekly nursing visits. The CS acknowledged that there were no nursing visit notes for the week of 11/9/25 to 11/15/25 and no missed visit note. The CS stated there was no documentation to indicate why the visit was missed or if the MD had been notified. The CS stated the expectation is that the patient was to be seen weekly as ordered per the POC. During a concurrent telephone interview and record review on 4/14/26 at 1:09 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), reviewed Patient 2’s skilled visit notes for 3/2/26 and 3/4/26. The ADM/DPCS acknowledged that the skilled nursing note on 3/4/26 indicated a missed visit for PICC line dressing change. The ADM/DPCS acknowledged there was no missed visit note that indicated why the visit was not done on 3/3/26. The ADM/DPCS stated, “Don’t know why was seen by LVN on 3/2/26. There should have been an RN visit the next day on 3/3/26.” The ADM/DPCS stated only RNs are allowed to do PICC line care. The ADM/DPCS stated Patient 2’s PICC line dressing should have been changed within the 7 days and was not done per the orders. During a review of Patient 5’s POC and skilled visit notes with the ADM/DPCS, the ADM/DPCS stated Patient 5 was to have weekly nursing visits and that there was no nursing visit note for the week of 11/9/25 to 11/15/25. The ADM/DPCS stated there should have been a missed visit note for that week. The ADM/DPCS stated there was a visit scheduled for 11/12/25 but was removed from the schedule. The ADM/DPCS stated, “Not sure why that visit was removed. No indication that visit was done.” A review of the HHA’s Policy and Procedure (P&P) titled “Plan of Care,” dated 10/23, indicated “... Each patient receiving home health services from the agency receives an individualized, written plan of care, including any revisions or additions.... Services are furnished in accordance with accepted standards of practice and orders in the plan of care...The individualized POC specifies the care and services necessary to meet the patient’s specific needs as well as measurable outcomes anticipated by the agency’s implementation and coordination of the plan of care...The POC must include the following...All medications and treatments...Any changes to the patient’s condition or needs that suggest outcomes are not being achieved and/or the plan of care should be altered are promptly communicated to the relevant physician(s) or allowed practitioner(s)...Changes to the POC and visit schedule will be communicated to the patient and/or representative...Any changes related to the plans for the patient discharge are also communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioners issuing orders for the plan of care...Services are furnished in accordance with the POC and under the supervision and direction of a allowed physician/practitioner...” A review of the HHA’s P&P titled “Notification Regarding Missed Service or Treatment,” dated 1/26, indicated “...A missed visit or treatment is an alteration in the plan of care, and therefore, requires notification to the ordering physician/allowed practitioner, patient and/or patient representative (if any)...A missed visit or treatment is an alteration to the physician/allowed practitioner plan of care and should only be missed for valid reasons...The organization must notify the relevant physician/allowed practitioner(s) to any changes in ordered frequency of ordered services or treatment including reason...A missed visit or treatment which cannot be rescheduled within the ordered duration of visits shall be documented and communicated to the physician/practitioner...Documentation of missed visits or treatment are as follows:...Physician/allowed practitioner notification-1. Fax/email with details of date and time (ensuring compliance with HIPAA); 2. Telephone notification with details of date, time, and person notified; or 3. Mailed copy of the documentation with date of mailing...””

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure rehabilitation therapy service was provided timely for one of three sampled patients (Patient 1) when Patient 1’s initial assessment was not conducted within 48 hours of referral. This failure increased the potential for Patient 1 to not receive consistent care and delay recovery or progress. A review of Patient 1’s Plan of Care (POC) indicated a start of care (SOC) on 12/30/25 for certification period from 12/30/25 through 2/27/26. Patient 1’s primary diagnosis indicated displaced trimalleolar ankle fracture of right lower leg (all three bony protrusion of the ankle joint are broken and pushed out of place). Further review of Patient 1’s clinical record indicated physical therapy (PT) conducted the initial assessment on 12/30/25. A review of Patient 1’s home health agency (HHA) referral indicated Patient 1 was referred to the HHA on 12/22/25 for PT evaluation within 2 days. A review of Patient 1’s referral information indicated Resident 1 was approved for home health PT with a start date of 12/23/25. During a telephone interview on 3/12/26 starting at 3:17 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated the agency requested an authorization (a requirement by health plans that providers obtain approval before a service is covered) for Patient 1 to receive PT/OT (Occupational Therapy) services. The ADM/DPCS further stated the agency received the authorization on 12/29/25 and PT conducted the initial assessment on 12/30/25. During a follow up telephone interview on 3/13/26 at 1:33 p.m. with the Adm/DPCS, the ADM/DPCS stated the authorization indicated the approval start date of 12/23/25 for Patient 1. The ADM/DPCS further stated the agency had no documented evidence to show the agency received the authorization on 12/29/25. A review of the agency’s policy and procedure dated 12/20/24 and titled, “Initial Comprehensive Assessment” indicated, “...An initial assessment of an individual is conducted...within 48 HOURS of referral for home care/services...The initial assessment determines the individual’s immediate need for care/services...and the type of care/service to be provided...designee assigns...qualified employee to complete an initial comprehensive assessment of the individual referred for home care/services...A designated employee contacts the patient/client to schedule a visit to conduct the initial comprehensive assessment within 48 hours of referral or the patient’s return home...When physician...orders are solely for one or more therapy discipline(s),...the appropriately qualified rehabilitation clinician...PT,OT...may conduct the initial comprehensive assessment.””

“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 interview and record review, the Home Health Agency (HHA) failed to ensure physician was notified of wound changes for one of three sampled patients (Patient 1), when Patient 1 had increase in size and open areas of venous stasis ulcers (wound on leg caused by abnormal or damaged veins) of right lower leg. This failure resulted in Patient 1’s wound care orders not being revised to enable wound healing. A review of Patient 1’s “Home Heath Certification and Plan of Care (POC),” for certification period 5/21/25 to 7/19/25, indicated Patient 1 had a Start of Care (SOC) with the HHA on 3/22/25 for diagnosis of venous insufficiency (damage to the leg veins and blood does not flow back to the heart) with chronic venous stasis ulcers on the right and left leg. The POC indicated Patient 1 was to receive skilled nursing (SN) visits for wound care two times a week for nine weeks. A review of Patient 1’s POC, for certification period 7/20/25 to 9/17/25, indicated Patient 1 was to have skilled nursing visits for wound care two times a week for nine weeks. A review of Patient 1’s communication note, dated 6/27/25, indicated “...The patient has had a change in condition that I want to inform the patient’s care team about. The patient is now exhibiting mild erythema [redness] and swelling around the right lower extremity venous stasis ulcer, with increased wound size since the last dressing change. Although the area is not warm to touch and there is not purulent [milky fluid due to infection] drainage, these changes indicate progression and place the patient at higher risk for infection, requiring increased skilled nursing visits to closely monitor and manage the wound...” A review of Patient 1’s “RN-Skilled Nursing Visit,” dated 6/27/25, indicated “...Skilled Intervention...Visit today focused on wound assessment and care for RLE (right lower extremity) venous stasis ulcer. Caregiver reported wound is worsening...On assessment, wound noted to have increased in size, mild erythema and swelling present at wound margins...Coordination Plan...Progress to Goals: Wound worsening; increased nursing visits ordered to prevent decline...Conferenced with: MD [Medical Doctor] ... Left VM [voicemail] Request for increased SN frequency due to worsening wound condition ... Physician Contacted Re: Left VM to increase SN to 3x/week ...” A review of Patient 1’s “RN-Skilled Nursing Visit.” dated 7/4/25, indicated “...Skilled Intervention...Patient caregiver stated that wound is not healing properly and draining...” The note did not indicate physician follow up for wound care was obtained. A review of Patient 1’s “RN-Skilled Nursing Visit,” dated 7/5/25, indicated “...Coordination Plan Progress to Goals: Wound care orders need to be updated...Plan for next visit: Wound care orders medication recommendations...” This note did not indicate physician follow up for wound care was obtained. A review of Patient 1’s “RN-Skilled Nursing Visit,” dated 7/9/25, indicated “...Coordination Plan...Plan for Next Visit: wound care med [medication] reconciliation...” This note did not indicate physician follow up for wound care was obtained. During a telephone interview on 7/30/25 at 4:24 p.m. with Patient 1’s Family Member (FM), Patient 1’s FM stated the HHA was providing nursing services for wound care. Patient 1’s FM stated the number of wounds had increased since Patient 1 started with the HHA. Patient 1’s FM stated that the wound care was only being done by the HHA and nurses were not bandaging the wounds properly. During an interview on 7/31/125 at 11:15 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated typically wound care visits are done two to three times a week or as needed if wound dressing comes off. During an interview on 7/31/25 at 12:06 p.m. with the Scheduler (SR), the SR stated the owner of the board and care home where Patient 1 resided called and requested visit on 7/23/25 because the wound dressing needed to be changed. The SR stated nurse completed wound care visit on 7/23/25. During an interview on 7/31/25 at 12:10 p.m. with the Administrator (ADM), the ADM stated Patient 1 was receiving nursing services for wound care two times a week. During an interview on 7/31/25 at 2:34 p.m. with the Clinical Educator (CE), the CE stated that she spoke with Patient 1’s FM in May about concern with wound care orders and that it did not seem to be helping. The CE stated the nurse went out the next day on 5/24/25 and the FM was pleased with care and did not hear anything else from Patient 1’s FM. During a concurrent interview and record review on 7/31/25 at 4:18 p.m. with the DPCS, reviewed Patient 1’s communication note 6/27/25, reflecting change of condition indicating worsening of wound. The DPCS stated it was the nurse’s responsibility to notify the physician of the change in condition. The DPCS acknowledged that there was no response back from the physician regarding 6/27/25 communications to the physician. The nurses continued to carry out same wound care orders. The DPCS stated someone should have called the physician to follow up on the communications. The DPCS acknowledged that there was no documentation in the nurse’s notes that follow up with the physician had occurred. The DPCS stated the visit notes on 7/4/25 and 7/5/25 indicated the nurse was to follow up for treatment orders but that did not occur. During a concurrent interview and record review on 7/31/25 at 4:43 p.m. with the ADM, reviewed Patient 1’s wound pictures and communication note 6/27/25. The ADM acknowledged that the wounds appeared to be worsening. The ADM acknowledged that the physician had not responded to the communication. The ADM stated her expectation is that the nurse would have followed up with the physician regarding the change in the wounds. The ADM stated there was no documentation that the nurse followed up with the physician and requested new orders after the communication on 6/27/25. A review of the HHA Policy and Procedure (P&P) tiled “Coordination of Care/Services,” dated 4/2/21, indicated “... [HHA] maintains regular communication with the patient/client and with others providing patient /client care/ servicers...The designated employee contacts the physician or allowed practitioner...when any of the following events occurs...The patient’s /client’s condition changes...The patient’s/ client’s response to care/ treatments or medications is not as expected...The designated Clinical Manager...Monitors and timely implementation of physician allowed practitioner...orders...””

“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 interview and record review, the Home Health Agency (HHA) failed to confirm with the Family Member (FM) of one of three sampled patients (Patient 1) a request for discharge from home health services when the HHA was directed by the staff of Patient 1’s board and care to discharge from the HHA. This failure had the potential for disruption of needed HH care services including wound care for Patient 1. A review of Patient 1’s “Home Health Certification and Plan of Care (POC),” for certification period 7/20/25 to 9/17/25, indicated Patient 1 had a Start of Care (SOC) with the HHA on 3/22/25 with diagnoses including chronic venous insufficiency (damage to the leg veins and blood does not flow back to the heart, chronic venous stasis ulcers (wound on leg caused by abnormal or damaged veins), and dementia (loss of memory and thinking abilities). The POC indicated Patient 1 had memory issues, forgetfulness, was disoriented to time, place and situation due to dementia and cerebral atherosclerosis (plaque in the brain’s arteries builds up and restricts blood flow). A review of Patient 1’s “Homecare Admission Consent Form,” dated 3/22/25, indicated it was not signed by Patient 1 but by MPOA (Medical Power of Attorney). A review of Patient 1’s communication note, dated 7/23/25, indicated “...Patient’s facility owner, [name of owner] called stating that patient is due for a nursing visit as wound needs a dressing change. He stated that the patient’s [FM]s wish to change HH agency. [Name of RN] has agreed to accept this patient as an add on today and discharge patient from our services per patient’s request...” During a telephone interview on 7/30/25 at 4:24 p.m. with Patient 1’s FM, Patient 1’s FM stated the HHA discharged patient from services on 7/23/25 based on the staff of Patient 1’s board and care request to discharge from services. Patient 1’s FM stated the board and care contacted the HHA on 7/23/25 to request a nursing visit for wound care and to discharge the patient from the HHA. Patient 1’s FM stated the HHA discharged Patient 1 based on direction from the board and care on 7/23/25. Patient 1’s FM stated she contacted the HHA today, 7/30/25, to notify the HHA she had located a new HHA and was notified that Patient 1 had been discharged from the HHA on 7/23/25. Patient 1’s FM stated Patient 1 has dementia and she is DPOA (Durable Power of Attorney-grants authority to act on another’s behalf) for Patient 1. During an interview on 7/31/25 at 11:45 a.m. with the Administrator (ADM), the ADM stated the HHA clinician received a text on 7/23/25 that indicated the board and care and the family were in the process of changing HHA and needed a visit and paperwork to discharge Patient 1 from services with the HHA. During an interview on 7/31/25 at 12:06 p.m. with the Scheduler (SR), the SR stated the board and care owner called last week and stated Patient 1’s wound dressing needed to be changed and requested discharge visit per family request. The SR stated the nurse did a wound care visit and completed the discharge on 7/23/25. During an interview on 7/31/25 at 12:10 p.m. with the ADM, the ADM stated the HHA was directed to discharge Patient 1 from services and believed the family was aware. The ADM stated the HHA believed they had no reason to call the family to confirm discharge plan as they were told to move forward with the discharge. During a subsequent interview on 7/31/25 at 4:43 p.m. with the ADM, when asked how did you know Patient 1’s FM was aware of discharge from HHA, the ADM stated that she assumed Patient 1’s FM was aware and had no reason to question it. The ADM stated a group text with Patient 1’s FM included, was sent to the nurse who forwarded it to the ADM that indicated wanting to discharge Patient 1 from HH services with this agency. Reviewed Patient 1’s Admission Consent with the ADM, the ADM acknowledged that it appeared to be signed by MPOA (Medical Power of Attorney). The ADM stated “Should have called the family directly to verify discharge from agency. I assumed family was in agreement when nurse was asked to discharge.” A review of the HHA Policy and Procedure (P&P) titled “Discharge from Home Care,” dated 4/2/21, indicated “... A decision to discharge a patient/client from care/service is made in collaboration with the patient/client/family and if applicable, the ordering physician or allowed practitioner...For patients who are transferred to another HHA...the DHCS or designee assists patients and their caregivers in selecting a post-acute care provider...The DHCS and Administrator/Manager are responsible for patient/client discharge decisions....The patient/client/family...actively participates in planning for discharge...The patient’s/client’s physician or allowed practitioner...and the patient/client/family is involved in arranging for any continuing care /service for the patient/client as appropriate...” A review of the HHA P&P titled “Coordination of Care/Services,” dated 4/2/21, indicated “...[HHA] employees coordinate patient/client care/service from admission to discharge to ensure that patients/clients receive care/services necessary to meeting specified goals or outcomes... [HHA] coordinates care delivery to meet patient’s needs, and involves the patient representative...and caregiver(s)...in the coordination of care activities...Purpose...To facilitate coordination and continuity of care/service for patients/clients from time of referral through discharge...””