Antelope Valley Home Care

“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 observation, interview and record review, the Home Health Agency (HHA – an organization that provides skilled nursing, therapeutic services and aide services directly to patients in their homes) failed to ensure the Skilled Nurse (SN) followed the plan of care (POC) for four of seventeen sampled selected patients (Patient 3, Patient 4, Patient 6, and Patient 16). This deficient practice placed the patients at risk of complications, and hospitalization by not following the plan of care. 1. During a review of Patient 3’s undated medical record titled, “Patient Information Facesheet”, the Patient Information Facesheet indicated a start of care of 12/6/2025, with a diagnosis of nontraumatic subdural hemorrhage (bleeding inside a person’s head that is caused without a significant injury or hit to the head). During a concurrent interview and record review on 2/19/2026 at 12:15 p.m. with the Director of Patient Care Services (DPCS), Patient 3’s Home Health Certification and Plan of Care, dated 2/5/2026 through 4/5/2026, was reviewed. The DPCS stated the Plan of Care indicated that Patient 3 was receiving services for wound care around a nephrostomy tube (a flexible tube inserted through the lower back skin and into the kidney to help drain the urine), Foley catheter (a flexible tube inserted into the bladder to help drain urine) care and medications. DPCS stated Patient 3 was receiving nursing services once a week for ten weeks and on the days the nurses would not visit, the patient was to perform their own wound care around the nephrostomy tube During a concurrent interview and record review on 2/19/2026 at 12:18 p.m. with the DPCS, Patient 3’s Licensed Vocational Nurse (LVN) Direct Skilled Care Visit Note, dated 2/6/2026, and Skilled Nursing (SN) Direct Skilled Care Visit Note, dated 2/13/2026, was reviewed. The LVN and SN Direct Skilled Care Visit Note did not indicate that patient teaching response on nephrostomy wound care was done for the days the nurses did not visit the patient. The DPCS stated that including the daily wound care teaching response from the patient would help clarify the patient understood that daily care was to be performed. 2. During a review of Patient 4’s undated medical record titled, “Patient Information Facesheet”, the Patient Information Facesheet indicated a start of care of 6/25/2025, with a diagnosis of unilateral osteoarthritis of the left hip (a breakdown of the joint and it affects one side of the body). During a concurrent interview and record review on 2/19/2026 at 12:21 p.m. with the DPCS, Patient 4’s Home Health Certification and Plan of Care, dated 6/25/2025 through 8/23/2025, was reviewed. The DPCS stated the Plan of Care indicated that Patient 4 was receiving nursing services once a week for wound care to the left hip and the nursing staff would instruct the patient to perform wound care on the days the nurses did not visit the patient. During a concurrent interview and record review on 2/19/2026 at 12:29 p.m. with the DPCS, Patient 4’s LVN Direct Skilled Care Visit Note, dated 7/8/2025 and 7/17/2025, was reviewed. The LVN Direct Skilled Care Visit Note did not indicate the nurse educated the patient on how to perform wound care on the left hip on the days the nurses did not visit the patient according to the Plan of Care. The DPCS stated there was no documentation wound care teaching was done or that the patient was checked off for wound care which would indicate the teaching was completed. The DPCS stated it was important for the teaching to be done to ensure the patients are able to do their wound care on the days the nurses do not visit so the wound can heal without any complications. 3. During a record review of Patient 6’s undated medical record form titled “Patient Information Facesheet”, the Facesheet indicated a start of care date of 1/30/2026 with an active diagnosis of Type 2 diabetes mellitus (high blood sugar) with other specified complication. During an interview at the home visit on 2/18/2026, at 11:05 a.m., Patient 6’s caregiver (CG 2) stated that the HHA staff had not taught her how to perform daily wound care. During a concurrent observation and interview during the wound treatment at the home visit on 2/18/2026, at 11:30 a.m., Registered Nurse 3 (RN 3) requested CG 2 to provide the Triad Paste (an ointment for the wound). CG 2 stated she did not have the Triad Paste and that she was using a different ointment for the wound. During an interview at the home visit on 2/18/2026, at 11:45 a.m., with Patient 6’s second caregiver (CG 3) CG 3 stated she was not taught on how to perform daily wound care and stated CG 2 would have been the one to teach about daily wound care because CG 2 is always present during the HHA visits. During a concurrent interview and record review on 2/19/2026, at 9:10 a.m., with the DPCS, the DPCS reviewed Patient 6’s POC titled, “Home Health Certification and Plan of Care”, for certification period 1/30/2026 to 3/30/2026. The record indicated the wound care was to be done daily, specifically “Please educate and eval (evaluate) caregiver) training”. The DPCS stated this intervention on the POC meant that the HHA staff had to demonstrate the wound care, teach the family/caregiver how to perform the wound care and evaluate that the wound care was done by the family. The DPCS reviewed the nursing visit notes for the certification period 1/30/2026 through 3/30/2026 and stated the nurses documented that the patient was taught all teaching, but it did not specify that daily wound treatment was taught. The DPCS stated it was important to follow the plan of care so the patient can receive the ordered treatment, and the HHA can follow up to make sure the patient has everything the patient needs. 4. During a record review of Patient 16’s undated medical record form titled “Patient Information Facesheet” the Facesheet indicated a start of care date of 5/10/2025 with an active diagnosis of non-pressure chronic ulcer of other part of right foot with unspecified severity. During a record review of Patient 16’s medical record form titled “Home Health Certification and Plan of Care” dated from 11/06/2025 through 1/4/2026, the record indicated Patient 16 was ordered to have skilled nursing (SN) visits twice a week for eight weeks. During a concurrent interview and record review on 2/20/2026 at 10:15 a.m. with the Director of Patient Care Services (DPCS) of Patient 16’s medical record, the DPCS stated that Patient 16 had four missed visits on November 5, 10, 13, and 17. The DPCS stated that there was documentation on Patient 16’s communication notes dated on 2/18/2026, that notified staff of the missed visits. The DPCS stated that besides the communication note dated 2/18/2026, there were no other entries in Patient 16’s medical record that explained why there were missed visits. During a review of the HHA’s record titled, “Plan of Care”, dated 8/28/2024, the record indicated “Home Care services are provided under a plan of care established by the physician...The plan of care includes the following: Treatments to be taught to patient care or caregiver.””

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, interview, and record review, Home Health Agency (HHA – an organization that provides skilled nursing, therapeutic services and aide services directly to patients in their homes) failed to ensure five of seventeen sampled patients (Patient 1, Patient 2, Patient 5, Patient 6 ), had a written plan of care (POC) at home. This failure resulted in patients not having written reference of what services, frequency, and overall plan of care was. During an interview on 2/19/2026 at 9:57 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated that once the patient’s plan of care is signed and finalized, the agency mails a copy to the patient’s home. The DPCS stated it is important for patients to have a copy of their plan of care so they understand the services they are receiving and the instructions for their care. During a review of Patient 1’s undated medical record titled “Patient Information Facesheet,” the document indicated a start of care date of 1/29/2026 with diagnoses that included urinary tract infection (UTI) and altered mental status. During a concurrent interview and record review on 2/18/2026 at 11:28 a.m. with Registered Nurse 1 (RN 1), the “Patient Coordinated Plan of Care” contained in the patient’s Start of Care (SOC) booklet was reviewed and observed to be blank and not completed. RN 1 stated that nurses do not routinely provide a written plan of care outlining the services and care instructions, and that teaching and instructions are typically provided verbally. RN 1 further stated that the Patient Coordinated Plan of Care should be completed during the start of care visit, but it had not been completed for Patient 1. During a review of Patient 2’s undated medical record titled “Patient Information Facesheet,” the record indicated a start of care date of 12/17/2025 with a diagnosis of non-pressure chronic ulcer of the other part of right foot. During a concurrent interview and record review on 2/18/2026 at 12:55 p.m. with RN 1, the “Patient Coordinated Plan of Care” located in the SOC booklet was reviewed and observed to be blank and not completed. RN 1 stated that Patient 2 had a wound care plan, and completing the Patient Coordinated Plan of Care was considered redundant. During an interview on 2/19/2026 at 9:30 a.m. with the DPCS, the DPCS stated that the plan of care is completed on the day the patient is admitted and that it is important for patients to have written instructions in the home so they understand the care they are receiving. During a review of Patient 5’s undated medical record titled “Patient Information Facesheet,” the record indicated a start of care date of 1/21/2026 with diagnoses including infection and sepsis. During a concurrent observation and interview at a home visit on 2/18/2026 at 1:08 p.m. with Registered Nurse 3 (RN 3), RN 3 reviewed the contents of Patient 5’s agency folder in the home. Observation of the folder did not indicate the presence of a written plan of care. RN 3 confirmed that there was no written plan of care in the patient’s home and stated that the agency uses a calendar document to notify patients when staff will visit, rather than providing a written plan of care. During a review of Patient 6’s undated medical record titled “Patient Information Facesheet,” the record indicated a start of care date of 1/30/2026 with a diagnosis of Type 2 diabetes mellitus with complications. During an interview conducted at the home visit on 2/18/2026 at 12:20 p.m. with RN 3, RN 3 stated that there was no written plan of care present in Patient 6’s home. During a review of the HHA’s policy titled “Plan of Care,” dated 8/28/2024, the policy indicated: “Patients and/or caregivers participate in the care planning process. Patients are provided a copy of expected discipline frequencies on page two (2) of the Patient Consents, a provided copy of the 485/Plan of Care, as well as in the back of the patient handbook on the Coordinated Care pages.””

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to ensure patient care records were complete and properly authenticated for six of seventeen patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 10, Patient 16). This failure resulted in patient medical records being modified or completed by individuals who were not involved in the patients care, which compromised the accuracy and integrity of the clinical record. 1). During a review of Patient 1’s undated medical record titled “Patient Information Facesheet,” the Facesheet indicated a start of care date of 1/29/2026 with diagnoses that included urinary tract infection (UTI, an infection in any part of the urinary system) and altered mental status (an unexpected change in a person’s normal brain function or awareness). During a review of Patient 1’s medical record form titled “SN (Skilled Nursing) Direct Skilled Care Visit,” dated 1/31/2026, the document indicated Registered Nurse 7 (RN 7) was the author; however, the form was not signed by RN 7. During a review of Patient 1’s medical record form titled “SN Eval Skilled Care Visit,” dated 2/2/2026, the document indicated RN 8 was the author; however, the form was not signed by RN 8. 2). During a review of Patient 2’s undated medical record titled “Patient Information Facesheet,” the Facesheet indicated a start of care date of 12/17/2025 with a diagnosis of non-pressure chronic ulcer of other part of the right foot (a long-lasting break in the skin that is not caused by pressure). During a review of Patient 2’s medical record form titled “SN Recert Skilled Care Visit,” dated 2/13/2026, the document indicated RN 3 was the author; however, the form was not signed by RN 3. During a review of Patient 2’s medical record form titled “LVN (Licensed Vocational Nurse) Direct Skilled Care Visit,” dated 1/30/2026, the document indicated LVN 2 was the author; however, the form was not signed by LVN 2. During a review of Patient 2’s medical record form titled “LVN Direct Skilled Care Visit,” dated 1/28/2026, the document indicated LVN 3 was the author; however, the form was not signed by LVN 3. 3). During a review of Patient 3’s undated medical record titled “Patient Information Facesheet,” the Facesheet indicated a start of care date of 12/6/2025 with a diagnosis of nontraumatic subdural hemorrhage (bleeding inside the head that occurs without a significant injury or trauma). During a review of Patient 3’s medical record form titled “LVN Direct Skilled Care Visit,” dated 2/13/2026, the document indicated LVN 1 was the author; however, the form was not signed by LVN 1. During a review of Patient 3’s medical record form titled “SN Direct Skilled Care Visit,” dated 2/6/2026, the document indicated RN 3 was the author; however, the form was not signed by RN 3. During a review of Patient 3’s medical record form titled “SN Recert Skilled Care Visit,” dated 1/30/2026, the document indicated RN 6 was the author; however, the form was not signed by RN 6. 4). During a review of Patient 4’s undated medical record titled “Patient Information Facesheet,” the Facesheet indicated a start of care date of 6/25/2025 with a diagnosis of unilateral osteoarthritis of the left hip (degeneration of the hip joint affecting one side of the body). During a review of Patient 4’s medical record form titled “LVN Direct Skilled Care Visit,” dated 7/8/2025, the document indicated LVN 3 was the author; however, the form was not signed by LVN 3. During a review of Patient 4’s medical record form titled “SN Direct Skilled Care Visit,” dated 7/11/2025, the document indicated RN 9 was the author; however, the form was not signed by RN 9. During a review of Patient 4’s medical record form titled “LVN Direct Skilled Care Visit,” dated 7/17/2025, the document indicated LVN 3 was the author; however, the form was not signed by LVN 3. During a review of Patient 4’s undated medical record form titled “Discharge/Transfer Summary,” the document indicated RN 9 was the author; however, the form was not signed by RN 9. During a review of Patient 4’s medical record form titled “Non-Bill (Transfer, DC without Visit, etc.)” which included OASIS (Outcome and Assessment Information Set) documentation, dated 8/14/2025, the document indicated RN 9 was the author; however, the form was not signed by RN 9. During an interview on 2/20/2026 at 10:05 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated that use of an electronic signature is best practice and documenting the date, time, and author of the entry is important for accurate documentation. During a review of the facility’s policy and procedure titled “Medical Record Content,” dated 2/12/2025, the policy indicated: “Medical record entries shall be made and authenticated by all licensed or certified employees of the agency… Any computerized documentation will be signed with electronic signatures.” During a review of the facility’s policy and procedure titled “Documentation,” dated 8/28/2024, the policy indicated: “For electronic documentation in the electronic health record (EHR), the electronic signature shall include the clinician’s name and role.” 5). During a review of Patient 10’s undated medical record form titled “Patient Information Facesheet,” the Facesheet indicated a start of care date of 7/29/2025 with a diagnosis of pneumonia (a lung infection). During a concurrent interview and record review on 2/20/2026 at 9:45 a.m. with the DPCS, the DPCS reviewed Patient 10’s Discharge/Transfer Summary, printed 8/27/2025. The record indicated the name of the author; however, the document did not contain an electronic signature. During an interview on 2/20/2026 at 9:57 a.m. with the Electronic Medical Record Representative (EMR Representative), the representative stated that when a record is signed, the document should display a message indicating “electronically signed.” The representative stated the record becomes finalized once the document is locked and electronically signed, which requires the user to complete EVA (electronic verification access). During an interview on 2/20/2026 at 10:00 a.m. with the DPCS, the DPCS stated that authenticating or signing medical record entries is important for accurate documentation and to ensure documentation is completed within required timeframes. 6). During a review of Patient 16’s undated medical record form titled “Patient Information Facesheet,” the Facesheet indicated a start of care date of 5/10/2025 with an active diagnosis of non-pressure chronic ulcer of other part of the right foot with unspecified severity. During a review of Patient 16’s medical record form titled “SN (Skilled Nurse) Recert Skilled Care Visit,” dated 11/3/2025, the document indicated Registered Nurse 4 (RN 4) was the author; however, the form was not signed by RN 4. During a review of Patient 16’s medical record form titled “LVN (Licensed Vocational Nurse) Direct Skilled Care Visit,” dated 10/30/2025, the document indicated LVN 1 was the author; however, the form was not signed by LVN 1. During a review of Patient 16’s medical record form titled “SN Direct Skilled Care Visit,” dated 10/28/2025, the document indicated Registered Nurse 5 (RN 5) was the author; however, the form was not signed by RN 5. During a review of Patient 16’s medical record form titled “Discharge/Transfer Summary,” printed 12/11/2025, the document indicated RN 4 was the author; however, the form was not signed by RN 4. During a review of the HHA policy titled “Documentation,” dated 5/8/2004, the policy indicated: “All electronic documentation shall be signed by the end user per available functionality and can be printed by the HIM Department as needed.” During a review of the HHA policy titled “Medical Record Content,” dated 01/2025, the policy indicated: “Medical record entries shall be made and authenticated by all licensed or certified employees of the agency.””

“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 – an organization that provides skilled nursing, therapeutic services and aide services directly to patients in their homes.) failed to review and document all the current medications and treatments for six of seventeen sampled patients (Patient 1, Patient 2, Patient 6, Patient 7, Patient 12, and Patient 13). This deficient practice placed the patients at risk for drug-to-drug interaction and harm by not knowing which medications the patients were taking. 1. During a review of Patient 1’s undated medical record titled, “Patient Information Facesheet”, the Patient Information Facesheet indicated a start of care date of 1/29/2026, with a diagnosis of urinary tract infection (UTI, an infection in any part of the urinary system) and altered mental status (an unexpected change in a person’s normal brain function or awareness). During a review of Patient 1’s HHA untitled and undated medication list, the medication list indicated Patient 1 was taking the following medications: Acetaminophen (used to treat pain), Amiodarone (used to treat abnormal heart rhythms), Atorvastatin (used to treat high cholesterol), Austedo (used to treat involuntary movements),Docusate (used for constipation), Famotidine (used to treat acid reflux), Furosemide (used to treat retention of fluids in the body), Losartan (used to treat high blood pressure), Metoprolol succinate (used to treat blood pressure), MiraLAX (used to treat constipation). During a concurrent observation and interview on 2/18/2026 at 11:28 a.m. with Patient 1’s daughter/caregiver 4 (CG 4) and with Registered Nurse 1 (RN 1), while in Patient 1’s dining room, there was a medication the patient was taking which was not listed on the patient’s medication list. Patient 1 was taking Eliquis (medication used to thin the blood and prevent blood clots) 5 milligrams (mg, unit of measurement). Patient 1’s CG 4 stated that a previous visit nurse had added the Eliquis on the medication list and it should be listed on RN 1’s medication list. RN 1 stated the medication list had been printed on 2/18/2026 and did not have Eliquis listed, but that it would be added. 2. During a review of Patient 2’s undated medical record titled, “Patient Information Facesheet”, the Patient Information Facesheet indicated a start of care of 12/17/2025, with a diagnosis of non-pressure chronic ulcer of other part of right foot (a long-lasting break in skin that is not caused by pressure). During a review of Patient 2’s untitled and undated medication list, dated 2/17/2026, the medication list indicated Patient 2 was taking the following medications: Aspirin (used for blood clot prevention). Budesonide (used to help reduce inflammation in the body).EliquisFamotidineFurosemideIbuprofen (used to relieve pain). Omeprazole (used to help reduce the production of stomach acid).Valacyclovir (an antiviral medication). During a concurrent observation and interview on 2/18/2026 at 12:05 p.m. with Patient 2, while in Patient 2’s home, RN 1 was observed reviewing medications. Patient 2 stated that he takes Eye Fortin (an over-the-counter dietary supplement used for eye health) and Vinia (an over-the-counter dietary supplement used for heart health and to improve blood flow). RN 1 added the medications to the patient’s medication list. 3. During a record review of Patient 6’s undated medical record form titled “Patient Information Facesheet”, the record indicated a start of care date of 1/30/2026 with an active diagnosis Type 2 diabetes mellitus (high blood sugar) with other specified complication. During a concurrent observation, interview, and record review while at the home visit on 2/18/2026, at 11:46 a.m., with Registered Nurse 3 (RN 3), RN 3 reviewed Patient 6’s medications using the HHA’s untitled, and undated medication list. Patient 6 stated she was no longer taking “Metformin” (a medication used to treat diabetes), as this medication was discontinued when she was in the rehabilitation center. Metformin was listed. Patient 6 stated she was taking famotidine (helps with indigestion symptoms) 20 mg (mg-milligrams, unit of measurement) one tablet twice a day. Famotidine was not listed. Patient 6 also stated to RN 3 that she was taking docusate sodium (stool softener) 100 mg. Docusate sodium was not listed. During an interview on 2/18/2026, at 12:15 p.m., with RN 3, RN 3 stated the nurses are required to review medications at each visit to identify any changes and provide education regarding the purpose and importance of the medication. RN 3 stated failure to review medications at each visit could result in medication noncompliance and the patient not understanding the prescribed treatment. 4. During a record review of Patient 7’s undated medical record form titled “Patient Information Facesheet”, the record indicated a start of care date of 8/11/2026 with an active diagnosis of obstruction of bile duct. During a concurrent observation, interview, and record review while at the home visit on 2/19/2026, at 11:30 a.m., with RN 3, RN 3 reviewed Patient 7’s medications using the HHA’s untitled, and undated medication list. RN 3 stated the incorrect medication type for Ondansetron (helps control nausea) was listed as “disintegrating” (medication that dissolves). Patient 7 stated to RN 3 Ondansetron was a tablet, not a disintegrating one, but it was a medication that she swallowed. RN 3 continued to review Patient 7’s medication and stated Potassium 99 mg one tablet by mouth was being taken by Patient 7 and but was not listed on the medication list. Patient 7 stated Potassium was prescribed by her doctor three months ago because her potassium levels were really low and her legs were cramping. 5. During a record review of Patient 12’s undated, medical record form titled, “Patient Information Facesheet” the Facesheet indicated a start of care date of 1/14/2026 with an active diagnosis of sepsis (blood infection) and pneumonia (lung infection). During a record review of Patient 12’s untitled and undated, medical record form indicated Patient 12 was currently prescribed: Amiodarone (heart medication) 200 mg (milligrams – unit of measure) one tablet twice a day.Apixaban (blood thinner medication) 5 mg twice a day. Folic acid (supplement) 400 mcg (micrograms – unit of measure) one tablet daily. Glipizide (high blood sugar medication) 2.5 mg one tablet twice a day.Heparin lock flush (blood thinner medication) 10 units/ml (milliliter – unit of measure) give 5 ml every day.Metoprolol (high blood pressure medication) 25 mg one tablet twice a day.Normal saline flush (supplement) 0.9% 10ml every 48 hours.Omeprazole (stomach acid medication) 20 mg one capsule every day. During a joint home visit on 2/18/2026 at 11 a.m. with Registered Nurse 2 (RN2) to Patient 12’s home, RN2 reviewed and reconciled Patient 12’s current home medications comparing Patient 12’s medication bottles with the HHA’s medication list. There were some discrepancies noted between Patient 12’s medications bottle labels and the HHAs medication list. Patient 12’s HHA medication list was noted as follows: 1. Metoprolol (high blood pressure medication) 25 mg one tablet twice a day. 2. Heparin lock flush (blood thinner medication) 10 units/ml (milliliter – unit of measure) give 5 ml every day. 3. Omeprazole (stomach acid medication) 20 mg one capsule every day. 4. Glipizide (high blood sugar medication) 2.5 mg one tablet twice a day. 5. Apixaban (blood thinner medication) 5 mg twice a day. 6. Amiodarone (heart medication) 200 mg (milligrams – unit of measure) one tablet twice a day. 7. Folic acid (supplement) 400 mcg (micrograms – unit of measure) one tablet daily. 8. Normal saline flush (supplement) 0.9% 10ml every 48 hours. Patient 12’s medication labels were noted as follows: 1. Metoprolol 50 mg 1 tab twice per day – filled 2/5/26 2. Heparin lock flush 10u/ml 5ml, flush IV 1-5 ml as needed per SASH method – filled 2/3/26 3. Omeprazole 20 mg 1 cap daily 30 minutes before breakfast – filled 1/27/26 4. Glipizide 5 mg 2 tabs twice per day 30 minutes before meals, do not take if not eating – filled 9/26/25 5. Eliquis 5 mg 2 tabs twice per day – filled 1/13/26 6. Amiodarone 200 mg 1 tab twice per day for one week then 1 tab daily – filled 1/13/26 7. Folic Acid 400 mcg 2 tabs daily. Per Patient 12’s daughter has been taking for the past 3 months. 8. NA (normal saline flush) 09% 10ml before and after each medication – filled 1/16/26. During an interview on 2/18/2026 at 12:10 p.m. with RN2 of Patient 12’s reconciled medications, RN2 stated that it was important to check each patients medication compared with the HHA list during every skilled nurse visit in order to know what the patient was taking and to maintain updated medical records. RN2 stated it was important to reconcile each patients medications to check for any interactions between the medications. RN2 provided an example, indicating that when a patient has two bottles of the same blood pressure medications, the patient can take medication from both bottles which will cause low blood pressure and the patient may need to be taken to the hospital. 6. During a record review of Patient 13’s undated medical record form titled “Patient Information Facesheet” the Facesheet indicated a start of care date of 1/6/2026 with an active diagnosis of unspecified open wound, right ankle, and subsequent encounter. During a record review of Patient 13’s untitled and undated medical record form, the form indicated Patient 13 was currently prescribed Colace (stool softener) 100 mg 1 capsule every day as needed and Jardiance (high blood sugar medication) 25 mg ½ tab every day. During a joint home visit on 2/18/2026 at 12:30 p.m. with RN2 to Patient 13’s home, RN2 reviewed and reconciled Patient 13’s current home medications using Patient 13’s medication bottles compared with the HHA’s medication list. There were some discrepancies noted between Patient 13’s medications bottle labels and the HHAs medication list. Patient 13’s HHA medication list was noted as follows: 1. Colace (stool softener) 100 mg 1 capsule every day as needed. 2. Jardiance (high blood sugar medication) 25 mg ½ tab every day. Patient 13’s medication labels were noted as follows: 1. Colace 100 mg 1 capsule three times a day. 2. Jardiance 25 mg ½ tab AM (morning) and HS (night). During an interview on 2/18/2026 at 12:30 p.m. with Patient 13’s daughter/caregiver (CG1), CG1 stated that she (CG1) has been administering Men’s multivitamin one tablet daily and aspirin 81 mg one tablet daily to Patient 13 for the past couple of years. During an interview on 2/18/2026 at 1:30 p.m. with RN2, RN2 stated that patient medications should be reconciled to prevent medication errors, like overdosing and underdosing. During a review of the HHA’s document titled, “Medication Management and Reconciliation”, dated 2/27/2025, the record indicated “Any medication changes will be entered into the EMR (electronic medical record) and the new medications will be screened for potential adverse reactions, duplicates, or allergies.””

“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 observation, interview and record review, the Home Health Agency (HHA – an organization that provides skilled nursing, therapeutic services and aide services directly to patients in their homes.) failed to include information required in the plan of care (POC) for four of seventeen sampled patients (Patient 6, Patient 7, Patient 12, and Patient 13). This failure had the potential to result in patients not receiving the identified needs and services, and a decline in health status, that could affect their quality of care and well-being. 1. During a record review of Patient 6’s undated medical record form titled “Patient Information Facesheet”, indicated a start of care date of 1/30/2026 with an active diagnosis Type 2 Diabetes Mellitus (high blood sugar) with other specified complication. a. During a concurrent observation and interview at the home visit on 2/18/2026, at 11:15 a.m., with Registered Nurse 3 (RN 3), RN 3 assessed Patient 6’s arms to take a blood pressure reading. Patient 6 stated to RN 3 that a blood pressure could not be taken on the left arm due to an operation she had in the past, and the lymph nodes (help filter fluid, bacteria, viruses) had been removed. During a concurrent interview and record review on 2/18/2026, at 12:20 p.m., with RN 3, RN 3 reviewed Patient 6’s POC (plan of care) titled, “Home Health Certification and Plan of Care”, for certification period 1/30/2026 to 3/30/2026. RN 3 stated the POC did not have any interventions/precautions for Patient 6’s left arm. The precautions should have been no to take the blood pressure on the left arm. RN 3 stated these interventions were important to have on the POC, so the nurse knows that a blood pressure is not to be taken from the left side. Since the lymph nodes were removed, Patient 6 was at risk of getting a blood clot from the pressure of the blood pressure cuff. During a record review of Patient 6’s document titled, LVN Educ Training Visit, dated 2/4/2026, indicated a blood pressure reading was taken on Patient 6’s left arm. During a record review of Patient 6’s document titled, SN Direct Skilled Care Visit, dated 2/11/2026, indicated a blood pressure reading was taken on Patient 6’s left arm. During a record review of Patient 6’s document titled, LVN Direct Skilled Care Visit, dated 2/1/2026, indicated a blood pressure reading was taken on Patient 6’s left arm. b. During a concurrent interview and record review on 2/18/2026, at 12:17 p.m., with RN 3, RN 3 reviewed Patient 6’s POC titled, “Home Health Certification and Plan of Care”, for certification period 1/30/2026 to 3/30/2026. RN 3 stated the POC did not have the visit frequency listed. RN 3 stated the POC was supposed to have a frequency so the staff know how often the patient should be seen. c. During a concurrent observation and interview at the home visit on 2/18/2026, at 11:15 a.m., with RN 3, RN 3 assessed the catheter (a tube inserted in the vein to administer fluids and/or medications) on Patient 6’s right arm. RN 3 stated the catheter type was a midline catheter. RN 3 stated the last time the dressing on the midline catheter was changed was on 1/27/2026. During a concurrent interview and record review on 2/18/2026, at 12:18 p.m., with RN 3, RN 3 reviewed Patient 6’s POC titled, “Home Health Certification and Plan of Care”, for certification period 1/30/2026 to 3/30/2026. RN 3 stated the POC did not have interventions for the midline catheter. RN 3 stated she did not know why interventions were not prescribed. RN 3 stated the dressing on the catheter was supposed to be changed every week, every 7 days to prevent infection. RN 3 stated if the catheter was still present following the week of the start of care day, the HHA should have done an intervention. The HHA should have called the doctor for an order to change the dressing. d. During a concurrent interview and record review on 2/18/2026, at 12:17 p.m., with RN 3, RN 3 reviewed Patient 6’s POC titled, “Home Health Certification and Plan of Care”, for certification period 1/30/2026 to 3/30/2026. RN 3 stated the POC did not have any interventions for the management of Patient 6’s diabetes. During an interview on 2/19/2026, at 9:30 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she did not know if the HHA implemented blood sugar level parameters in the POC for the patients, if the doctor did not order specific blood sugar parameters. The DPCS stated it was important for the POC to have blood sugar level parameters to make sure the patients are healthy, they are not going to have any adverse events such as hypoglycemia (low blood sugar levels) and hyperglycemia (high blood sugar levels). These adverse effects could have long term effects such as damage to their organs. The HHA wants to make sure the patients remain safe in their therapeutic ranges. 2. During a record review of Patient 7’s undated medical record form titled “Patient Information Facesheet”, indicated a start of care date of 8/11/2026 with an active diagnosis of obstruction of bile duct. During a concurrent interview and record review on 2/19/2026, at 12:40 p.m., with the DPCS, the DPCS reviewed Patient 7’s POC titled, “Home Health Certification and Plan of Care”, for certification period 2/7/2026 to 4/5/2026. The record did not indicate Patient 7’s DME and supplies, safety measures, nutritional requirements, functional limitations, activities permitted, prognosis, mental, psychosocial and cognitive status. The DPCS stated the POC was not fully completed. The POC was supposed to be completed within 5 days of start of care, prior to giving care. 3. During a record review of Patient 12’s medical record form titled, “Patient Information Facesheet” undated, indicated a start of care date of 1/14/2026 with an active diagnosis of sepsis (blood infection) and pneumonia (lung infection). The form also indicated Patient 12 was ordered Peripherally Inserted Central Catheter (PIIC - is a long, thin, flexible tube inserted into a peripheral arm vein and threaded into a large, central vein near the heart) medication management. During a record review of Patient 12’s medical record form titled “Home Health Certification and Plan of Care (POC)” dated from 1/14/2026 to 3/14/2026, indicated Patient 12 had orders for Skilled Nurse (SN) visits but the form did not state the frequency the SN was to conduct the visits. The form indicated Patient 12 was ordered Daptomycin (anti-infective medication) by intravenous (administered through a vein) route. The form did not indicate Patient 12’s PICC line assessment and management. Lastly, the form also indicated section “Allergies” was marked with “N/A (not applicable)”. During a concurrent interview and record review on 2/19/2026 at 10:50 a.m. with the Director of Patient Care Services (DPCS) of Patient 12’s medical record, the DPCS stated that Patient 12’s PICC lines goals and interventions are not listed on the form. The DPCS stated that Patient 12’s POC has not been audited yet. The DPCS stated that Patient 12’s POC would spell out what the nurses need to do. The DPCS stated that the nurses do not reference the patients POC, the nurses reference the physician orders. The DPCS stated that it was important to have patients’ goals and interventions so that staff know what the parameters and procedures are, so that the correct care is performed. During a concurrent interview and record review on 2/19/2026 at 11:05 a.m. with the DPCS of Patient 12’s medical record, the DPCS stated that Patient 12’s POC did not have the Skilled Nurse (SN) visit frequency. The DPCS stated that patients SN frequency vsits should be documented so that they know when care is being provided. 4. During a record review of Patient 13’s medical record form titled “Patient Information Facesheet” undated, indicated a start of care date of 1/6/2026 with an active diagnosis of unspecified open wound, right ankle, subsequent encounter. During a record review of Patient 13’s medical record form titled “Home Health Certification and Plan of Care” dated from 1/6/2026 to 3/4/2026, indicated Patient 13 had orders for Skilled Nurse (SN) visits but the form did not state the frequency the SN was to conduct the visits. The form indicated Patient 13 was ordered to have wound and urethral catheter (soft hollow tube inserted into the urinary bladder) care. The form did not indicate Patient 13’s wound and urethral catheter assessment and management. During a concurrent interview and record review on 2/19/2026 at 12:05 p.m. with the DPCS of Patient 13’s medical record, the DPCS stated that Patient 13’s POC does not list the interventions for Patient 13s wounds and diabetes management. The DPCS stated Patient 13’s wound and diabetes interventions needed to be listed so that the nurse is able to follow the POC. The DPCS stated that nurses “don’t function under the plan of care”. During a review of the HHA’s record titled, “Plan of Care”, dated 8/28/2024, the record indicated, “The plan of care includes the following: A. Types of services, frequency and duration of visits, as determined by...safety measures to protect against injury...any other items appropriate to patient’s condition or needs.””

“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-an organization that provides skilled nursing, therapeutic services, and aides services to patients in their homes) failed to ensure physician orders were incorporated into the plan to care (POC) for two of seventeen sampled patients (Patient 6 and Patient 13). This deficient practice resulted in the POC not reflecting the most current physician orders. When the POC does not include current orders, there is the potential for inconsistency between the documented care plan and the physician-directed treatment. 1. During a record review of Patient 6’s undated medical record form titled “Patient Information Facesheet,” the record indicated a start of care date of 1/30/2026 with an active diagnosis Type 2 diabetes mellitus (high blood sugar) with other specified complications. During a concurrent interview and record review on 2/18/2026, at 12:17 p.m., with RN 3, RN 3 reviewed Patient 6’s Home Health Certification and Plan of Care” for the certification period 1/30/2026 to 3/30/2026. RN 3 stated the POC did not include interventions for the management of Patient 6’s diabetes, but the HHA did have an order for the management of Patient 6’s diabetes. A review of Patient 6’s physician’s orders dated 1/30/2026 indicated orders for diabetes management; however, these interventions were not reflected in the POC. During an interview on 2/19/2026, at 9:30 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated that once the POC was finalized, additional physician orders were maintained in the physician order section of the medical record and were not routinely transcribed into the POC. The DPCS stated nurses were expected to review and follow the most recent physician orders and document follow-up needs within the visit notes for continuity of care. 2. During a record review of Patient 13’s undated medical record form titled “Patient Information Facesheet” undated, indicated a start of care date of 1/6/2026 with an active diagnosis of unspecified open wound, right ankle, subsequent encounter. During a record review of Patient 13’s “Home Health Certification and Plan of Care” dated from 1/6/2026 to 3/4/2026, the POC indicated orders for Skilled Nurse (SN) visits, but the frequency of visits was not specified. The POC also indicated orders for wound care and ureteral care; however, the POC did not include detailed assessment or management instructions related to these conditions. During a concurrent interview and record review on 2/19/2026 at 12:05 p.m. with the DPCS, the DPCS stated the agency planned to update the POC to include the physician orders following completion of the audit process. During a review of the HHA’s policy titled, “Plan of Care,” dated 8/28/2024, the policy indicated: “The plan of care is based on an assessment of the patient by each discipline involved in the care and includes planning, intervention, evaluation, and modification of the plan for care or service.””

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an organization that provides skilled nursing, therapeutic services and aide services directly to patients in their homes) failed to ensure the plan of care (POC) for one of seventeen sampled patients (Patient 16) was reviewed and signed by the physician in a timely manner. This failure had the potential to result in services being provided without documented physician authorization, which may lead to missed, delayed, or inappropriate care. During a record review of Patient 16’s undated, medical record form titled “Patient Information Facesheet” the record indicated a start of care date of 5/10/2025 with an active diagnosis of non-pressure chronic ulcer of other part of right foot with unspecified severity. During a record review of Patient 16’s medical record form titled “Home Health Certification and Plan of Care” covering the period 7/9/22025 to 9/6/2026, the record indicated the attending provider signed the form on 2/20/2026. The form also indicated that the HHA received the signed plan of care on 2/20/2026. During a record review of Patient 16’s medical record form titled “Home Health Certification and Plan of Care,” covering the certification period 11/06/2025 to 1/4/2026, the record indicated the attending provider signed the form on 2/20/2026. The form also indicated the HHA received the signed form on 2/20/2026. The plans of care for Patient 16 were not signed by the physician during the applicable certification periods and were instead signed several months after the care periods had already occurred. During a concurrent interview and record review on 2/20/2026 at 10:15 a.m. with the Director of Patient Care services (DPCS), the DPCS stated that Patient 16’s plan of care for the certification period 7/9/2025 to 9/6/2025 had not been signed by the physician during that certification period. During an interview on 2/20/2026 at 11:10 a.m., the DPCS stated that the plan of care (POC) contains the physician’s orders, patient medications, equipment, and services required, and serves as a summary of the care the patients needs.”

“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 failed to ensure the physician for one of seventeen sample patients (Patient 16) was notified when ordered wound care visits were missed. This failure had the potential to result in delayed wound treatment and healing, and prevented the physician from evaluating the patient’s condition and revising the pan of care as necessary. During a record review of Patient 16’s undated, medical record form titled “Patient Information Facesheet” the record indicated a start of care date of 5/10/2025 with an active diagnosis of non-pressure chronic ulcer of other part of right foot with unspecified severity. During a record review of Patient 16’s medical record form titled “Home Health Certification and Plan of Care” dated 11/06/2025 to 1/4/2026, the record indicated Patient 16 was ordered to receive skilled nursing (SN) visits twice weekly for eight weeks. The plan of care also indicated wound care treatments were ordered for the right dorsal foot and the left dorsal foot/left dorsal third toe. The document further indicated that Patient 16 would be discharged once the wounds heal. During a concurrent interview and record review on 2/20/2026 at 10:15 a.m. with the Director of Patient Care Services (DPCS) of Patient 16’s medical record, the DPCS stated that Patient 16 missed four visits on November 5, November 10, November 13, and November 17. The DPCS stated documentation in the medical record included a communication note dated 2/18/2026, notifying staff of the missed visits. However, the DPCS confirmed that there was no documentation in the medical record explaining the reason the visits were missed. The DPCS further stated that Patient 16’s physician was not notified of the missed visits. The DPCS stated that the physician should have been notified so the physician could evaluate the patient’s condition and determine whether changes to the pan of care were necessary.”

“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 – an organization that provides skilled nursing, therapeutic services and aide services directly to patients in their homes) failed to send all necessary medical information to the primary care practitioner within five days of discharge for one of seventeen sampled patients (Patient 10). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. 1. During a record review of Patient 10’s undated medical record form titled, “Patient Information Facesheet”, the record indicated a start of care date of 7/29/2025, with an active diagnosis of pneumonia (lung infection). During a concurrent interview and record review on 2/20/2026, at 9:45 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 10’s record titled, Discharge/Transfer Summary (DC summary), printed on 8/27/2025. The record indicated Patient 10 was discharged from the HHA on 8/20/2025. The DPCS stated the DC summary was sent to Patient 10’s doctor on 8/26/2025, six days after the discharge. The DPCS stated the DC summary was supposed to be sent within five days of discharge, so the doctor is aware that the patient is no longer receiving HHA services, in case the doctor needs to modify the medical plan of care. During a record review of the HHA’s undated document titled, Discharge Planning, Transfer, and Continuing Care Needs, indicated, “The agency discharge summary and related documentation shall be sent to the patient’s following physician within five business days of discharge, and must be submitted or filing within thirty (30) days following discharge from service.””