Assured 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 interviews and record reviews, the Home Health Agency (HHA) failed to ensure two of ten sampled patients (Patients 6 and 10) received home health services in accordance with their Physician‑ordered plan of care (POC) when: 1. Patient 6 missed one Physical Therapy visit and two Medical Social Worker (MSW) visits as ordered on the POC. 2. The Physical Therapist (PT) did not provide Patient 9 with any of the home health services that were identified on the POC. This failure to provide services as ordered had the potential to delay needed interventions, negatively affect the patients’ health status, and limit the effectiveness of the Physician‑directed plan of care. 2. A review of the “Referral Details,” dated 4/28/26, indicated, Patient 9 required the PT to provide home health visits due to a history of repeated falls and neck pain. A review of the facility’s P&P titled, “Physician Orders,” dated 3/1/26, indicated, “Services are provided according to the most recent orders updating the patient’s Plan of care.” A review of Patient 9’s “Home Health Certification and Plan of Care” (Admission POC), dated 4/30/26, indicated admission to the HHA on 4/30/26 with the diagnoses of torticollis (a condition that caused the neck muscles to tighten) and social exclusion and rejection (when a person suffered because others left them out, ignored them, or treated them poorly). The Admission POC indicated Patient 9 required PT for instruction and assessment related to safe transfers, training for safe ambulation, and education to decrease falls. The Admission POC further indicated Patient 9 required the assistance of one person for transfers, was on fall precautions, and would be discharged once all goals had been met. A review of the “Discharge Report,” dated 7/21/25 through 7/21/26, indicated Patient 9 was admitted to the HHA on 4/30/26 and discharged on 6/28/26. During a concurrent interview and record review on 7/22/26 at 3:54 pm, with PT, Patient 9’s “Coordination Note,” dated 5/4/26 was reviewed. PT confirmed performing a drive-by (when the patient does not answer the phone and someone from the HHA drove to the patient’s home) on 4/30/26 and had admitted Patient 9 for home health services. PT confirmed, the “Coordination Note,” indicated, Patient 9’s home was unsanitary, contained more than 90 cats, and that the PT had found a flea on their person believed to have come from the patient’s home. PT indicated that due to safety concerns, home health services would be discontinued and confirmed that no additional home visits were provided. During a concurrent interview and record review on 7/24/26 at 11:43 am, with ED, Patient 9’s Admission POC, dated 4/30/26 was reviewed. ED confirmed that Patient 9 was admitted to the HHA on 4/30/26, but indicated the home was unsanitary due to a flea infestation, and Patient 9 was made into a non-admit (reversing the admission to the HHA). ED reviewed Patient 9’s “Physician Order,” dated 5/1/26 and confirmed, a verbal order was obtained for PT to provide home health services two times during the first week then one time a week for seven more weeks. ED confirmed, Patient 9’s Admission POC had been signed by the Physician on 5/13/26 which indicated the Physician agreed to the Admission POC that was developed by PT on 4/30/26 and was the most current signed Physician’s order.. ED confirmed, Patient 9 did not receive home health services in accordance with the Physician’s signed POC. A review of the facility’s policy and procedure titled “Plan of Care (POC),” dated 3/1/26, indicated that the POC included the type and frequency of home visits and any alteration to the POC required Physician notification and approval. A review of the facility’s P&P titled, “Coordination of Care, From Admit Through Discharge,” dated 12/1/25, indicated, care would be coordinated with the patient’s Physician when a missed visit occurred, altering the POC. 1. A review of Patient 6’s “Home Health Certification and Plan of Care” (Admission POC), dated 5/8/26, indicated Patient 6 had been admitted to the Home Health Agency (HHA) with diagnoses that included high blood pressure, heart disease, and diabetes. The record for Patient 6 was reviewed. A physician’s order, dated 5/10/26 indicated “MSW (Medical Social Worker) 1 wk 3 (once a week for 3 weeks).” A physician’s order, dated 5/18/26 indicated “Request additional 2 social work visits to assist the patient with activating appropriate community resources.” (A total of 5 visits by the social worker) The calendar (documentation of visits with agency staff) was reviewed for Patient 6. The calendar indicated Patient 6 received a home visit with MSW on 5/14/26, 5/22/26, and 5/28/26. (a total of 3 visits) A physician’s order, dated 5/10/26 indicated “Physical therapy 1 wk 2” A physician’s order, dated 5/24/26 indicated “Physical therapy 1 wk 1, 2 wk 5” The calendar was reviewed for Patient 6. The calendar indicated Patient 6 had not been seen by a physical therapist from 5/14/26 until 6/9/26 when he received a home visit from a physical therapy aid (one missed visit by physical therapy resulting in 19 days without physical therapy staff interventions or assessments). During an interview and concurrent record review on 7/24/26 at 10:40 am with Schedule Specialist (SSP,) she reviewed the record for Patient 6. SSP confirmed that Patient 6 had not received one scheduled visit for physical therapy. SSP confirmed that Patient 6 had not received the two additional visits from the medical social worker. SSP was unable to find documentation that these missed visits had been reported to the physician or orders to alter the Plan of Care had been obtained.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on observation, interview and record review, the facility failed to remove remove expired patient care supplies from inventory in one out of two storage rooms. This had the potential to negatively impact patient health status and cause infections. Findings: The facility’s policy and procedure titled, “Infection Control Plan,” dated 10/1/25, indicated, patients would receive quality care that was safe and the facility would decrease the risk of patient infections. During a concurrent observation and interview on 7/23/26 at 3:18 pm, with the facility’s Patient Care Manager (PCM), the patient care supplies, located in two separate storage rooms were observed. In the second storage room, there were two wound culture swabs (used to collect pus from a wound and identify the bacteria responsible for the infection) that had expired on 6/25/26 available for use. There were six safety needles (inserted through the skin into the vein to obtain a blood sample) that had expired on 7/10/25 available for use. There were two bottles of Sodium Chloride Irrigation (salty water used to clean wounds) that had expired on 5/9/26 available for use. PCM confirmed the expired patient care supplies were available for staff use and indicated it was the responsibility of the PCM and Executive Director to ensure there were no expired supplies available for use.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on interview and record review, the facility did not attempt to resolve identified issues before discharging one out of 10 sampled patients (Patient 9) when the home environment was potentially unsafe for the Home Health Agency’s (HHA) staff. This had the potential for Patient 9 to not attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings: A review of the facility’s policies and procedures (P&P) titled, “Patient Discharge/Transfer Process,” dated 5/1/26, indicated, “The medical record will reflect identification of the problems encountered, assessment of the situation, communication with the Physician responsible for the plan of care, a plan to resolve the issues and results of the plan implementation.” The P&P indicated that the patient’s medical record would indicate that the patient was notified when the home health agency could not meet their needs and that patients were notified prior to discharge. A review of the facility’s P&P titled, “Coordination of Care, From Admit through Discharge,” dated, 12/1/25, indicated, “Only admitting those patents whose health care needs can be met by the agency and making appropriate referrals to other organizations capable of meeting patient needs when the agency is unable to do so.” A review of the “Referral Details,” dated 4/28/26, indicated, Patient 9 required a Physical Therapist (PT) to provide home health visits due to a history of repeated falls and neck pain. A review of Patient 9’s “Home Health Certification and Plan of Care” (Admission POC), dated 4/30/26, indicated admission to the HHA on 4/30/26 with diagnoses of torticollis (a condition that caused the neck muscles to tighten) and social exclusion and rejection (when a person suffered because others left them out, ignored them, or treated them poorly). The Admission POC indicated that Patient 9 required a PT for instruction and assessment for safe transfers, training for safe ambulation (walking), and education to decrease falls. The Admission POC indicated Patient 9 required the assistance of one person for transfers and was on fall precautions. The Admission POC indicated Patient 9 would be discharged from the HHA when all goals had been met. During a concurrent interview and record review on 7/21/26 at 3:39 pm, with Executive Director (ED), Resident 10’s Admission POC, dated 4/30/26 was reviewed. ED indicated that there was no phone service where Patient 9 lived, the HHA attempted to contact Patient 9 by phone five times, and PT was required to drive to Patient 9’s home first without speaking to Patient 9 in order to admit Patient 9 to home health services. ED confirmed that the Admission POC indicated that Patient 9’s home was a cat sanctuary, unsanitary, and there were more than 90 cats present. ED confirmed, PT admitted Patient 9 to the HHA on 4/30/26, developed a plan of care, and planned to provide additional visits. ED reviewed the “Coordination Note,” dated 5/4/26, and confirmed, the “Coordination Note” indicated, ED called Patient 9 to alert of the HHA’s inability to provide services due to safety concerns regarding fleas. ED confirmed that Patient 9 did not answer the phone, Patient 9 never called the HHA back, and did not know the HHA had planned to discharge Patient 9. During a concurrent interview and record review on 7/22/26 at 3:54 pm, with PT, Patient 9’s “Coordination Note,” dated 5/4/26 was reviewed. PT confirmed, the “Coordination Note,” indicated, Patient 9’s home was unsanitary, had more than 90 cats, had found a flea on PT’s person, and believed it to be from Patient 9’s home. PT confirmed that on 4/30/26 PT had admitted Patient 9 to the HHA. PT could not verbalize if the HHA had attempted to resolve the issues regarding Patient 9’s living situation or if a plan had been developed to safely discharge Patient 9. During an interview on 7/24/26 at 11:43 am, ED confirmed, there was no plan put into place to resolve concerns regarding Patient 9’s unsanitary living situation or safety concerns regarding fleas. ED indicated the HHA should have involved their Medical Social Worker and did not. ED indicated a report to Adult Protective Services (an agency that protected the rights of older adults) should have been made and was not. ED confirmed the HHA did not attempt to resolve any issues regarding Patient 9’s unsanitary living conditions prior to discontinuing home health services.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure one out of 10 sampled patients (Patient 4) received a comprehensive assessment from the Physical Therapist within five days. This failure had the potential to delay the identification of patient needs, delay care planning, and negatively affect the coordination and delivery of services. Findings: A review of the facility’s policy and procedure (P&P) titled, “Coordination of Care, From Admit Through Discharge,” dated 12/1/25, indicated the Executive Director (ED) was responsible for coordinating patient care and services. The P&P indicated HHA staff would schedule the projected date of anticipated therapy services. A review of Patient 4’s “Home Health Certification and Plan of Care” (Admission POC), dated 6/10/26, indicated Patient 4 was admitted to the HHA on 6/10/26 with the diagnosis of acute on chronic (a sudden flare up that caused an ongoing condition to worsen) systolic, congestive heart failure (the heart was weak and could not pump blood effectively). A review of the document titled, “Face-to-Face Encounter/Attestation Orders Home Health Care Eligibility,” dated 7/1/26, indicated, the Physician ordered the HHA to resume services that included Skilled Nursing and Physical Therapy. During a concurrent interview and record review on 7/24/26 at 10:45 am, with ED, Patient 4’s “Resumption of Care Visit Note Report” (ROC), dated 7/2/26, was reviewed. The ED confirmed that comprehensive assessments performed by all ordered disciplines were required to be completed within five days of the first visit. ED confirmed the ROC indicated the patient had been discharged from the hospital and home health services were being resumed. ED confirmed the Skilled Nurse who completed the ROC did not include the Physician‑ordered Physical Therapy comprehensive assessment in the POC and should have. ED reviewed the “Add On Discipline” order, dated 7/15/26, and confirmed that the Physical Therapist completed the comprehensive assessment on 7/15/26, thirteen days after the ROC, making it nine days late.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure that a complete review of all current medications occurred during every home visit for three of four patients (Patients 2, 3 and 4) when: 1 Patient 2’s Lasix (a medication that assists a patient to urinate excess body fluids that can also cause dehydration and low blood pressure) medication was omitted. 2. Patient 3’s physician orders did not include Milk of Magnesia ( a medication to treat constipation). 3. Patient 4’s physician orders did not include Tylenol (medication for pain) and Silver Centrum ( a multivitamin). These failures had the potential for medication related issues to be undiscovered or unresolved leading to negative medical outcomes. 3. A review of Patient 4’s “Home Health Certification and Plan of Care” (Admission POC), dated 6/10/26, indicated Patient 4 was admitted to the Home Health Agency (HHA) on 6/10/26 with the diagnosis of acute on chronic (a sudden flare up that caused an ongoing condition to worsen) systolic, congestive heart failure (the heart was weak and could not pump blood effectively). During a concurrent observation and interview, on 7/23/26 at 10:05 am, located in Patient 4’s home, SN A was observed performing a home visit that included a medication reconciliation (visual observation and documentation of all current medication bottles located in the home). During the observation, Patient 4’s family member (FM) indicated Patient 4 had experienced a headache the night before and had been given Tylenol (OTC pain reliever). SN A used a medication list created by the FM, a basket containing the patient’s current prescribed medications, and the HHA’s medication list during the reconciliation. A bottle of Tylenol 325 mg and Centrum Silver (OTC multivitamin) were observed in the medication basket. A review of the HHA’s Medication List, printed 7/23/26, did not include Tylenol or Centrum Silver. During an interview on 7/23/26 at 11:57 am, SN A confirmed, the medication reconciliation was performed at each home visit to ensure medication compliance and to identify potential drug‑to‑drug interactions. During an interview on 7/23/26 at 2:10 pm, Patient 4’s FM confirmed that Patient 4 took Tylenol 325 mg, two tablets, once a day if needed for headaches and stated, “[Patient 4] had taken Tylenol, his whole life.” FM confirmed that Patient 4 took Centrum Silver, one tablet a day and stated, “[Patient 4] had been taking Centrum Silver once a day for a year.” During an interview on 7/24/26 at 10:42 am, ED confirmed that clinicians were required to update the medication list during each home visit. After reviewing the observations made during Patient 4’s visit on 7/23/26, the ED confirmed, SN A did not perform a complete or thorough medication reconciliation. The ED indicated the purpose of medication reconciliation was to coordinate care among multiple prescribers and ensure the accuracy of the patient’s medication regimen. The agency policy titled “Monitoring Medications”, revised 4/1/26, indicated; “A drug regimen review will be performed on all patients... with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager... The physician is contacted immediately if any discrepancies between agency information and patient medications are found... The discipline responsible for the drug regimen review will: Compare medication list... or physician orders to actual medications the patient is taking. Review all medications including over the counter (OTC) medications, vitamins, herbs, and herbal products.” 1. A review of Patient 2’s “Home Health Certification and Plan of Care” (Admission POC), dated 4/28/26, indicated Patient 2 was admitted to the Home Health Agency (HHA) on 4/28/26 with diagnoses that included cellulitis (a deep bacterial infection) of the abdominal wall and abscess (painful pocket of pus) of the abdominal wall. The record for Patient 2 was reviewed. Her physician’s orders, dated 4/28/26 indicated she was taking two medications with elevated health risks; “Warfarin (medication that decreases the ability of blood to clot, placing a patient at risk for bleeding) 7.5 milligrams (mg) daily and Lasix (a medication that assists a patient to urinate excess body fluids that can also cause dehydration and low blood pressure) 20 mg every other day.” During an observation on 7/22/26 begun at 10 am, during a home visit for Patient 2, she reported that she had not taken her dose of Lasix that was scheduled for the morning. Skilled Nurse (SN) D asked Patient 2 if she needed a refill and if that was why the patient hadn’t taken the medication. Patient 2 stated she had a sufficient amount of the medication. SN D asked Patient 2 where her medication bottles were located. The patient responded that her medications were in multiple areas of the house including the kitchen, bathroom, and the bedroom. Patient 2 asked, “Would it be easier to look at the list?” SN D assisted Patient 2 to retrieve a hand written list of medications from the patient’s purse. SN D reviewed the patient provided list. In a follow up interview with Patient 2 she was asked if staff physically review her medication bottles, Patient 2 stated, “I’m sure they do it when you’re not here. She was just nervous.” 2. A review of Patient 3’s “Home Health Certification and Plan of Care” (Admission POC), dated 5/28/26, indicated Patient 3 was admitted to the Home Health Agency (HHA) on 5/28/26 with diagnoses that included chronic kidney disease and emphysema (difficulty breathing). Constipation was not listed as a diagnosis. The record for Patient 3 was reviewed, his physician’s orders did not include an order for Milk of Magnesia (MOM an OTC laxative) or “Smooth Move” laxative tea. Both are sold without a physician’s prescription. During an observation on 7/23/26 at 8:45 am Patient 3’s wife was standing outside her home. Patient 3’s wife spoke to Physical Therapy Assistant (PTA) and declined a visit at this time, stating Patient 3 was having a bowel movement after taking MOM due to constipation. PTA asked if Patient 3’s visit could be rescheduled for later in the day and the Patient’s wife stated she would follow up with agency staff. During an observation on 7/23/26 at 11:30 am Patient 3 and his wife agreed to a home observation visit with PTA. Patient 3’s wife reported to PTA that Patient 3 usually drinks one or one half of a cup of a laxative herbal tea called “Smooth Move” each morning to prevent constipation. Patient 3’s wife reported that the tea had been ineffective so Patient 3 took MOM to induce a bowel movement this morning. During an interview on 7/23/26 at 12:15 pm with PTA she was asked if she physically reviews patient medications during her home visits. PTA confirmed that she does not and stated she had been informed that if nursing was involved in the patient’s care, that therapies could just verify verbally any changes or reported concerns. PTA clarified she would only physically review the medications if no nursing care had been ordered. During an interview and concurrent record review on 7/23/26 at 2:30 pm with Executive Director (ED) she was asked to clarify the agency’s expectation for staff to monitor patient medications during home visits. ED stated that all staff should physically review the patient’s medications (in bottles) with the most current physician’s orders. Any discrepancies or changes should be noted in the chart, reported to the agency and physician, and medication related documentation updated. ED confirmed that this expectation was for all staff, not just nurses. ED confirmed that over the counter medications and herbs or supplements should also be reviewed and reported by staff as part of the medication review process. ED was asked to review the documentation for Patient 3’s home visit on 7/23/26 with PTA. ED confirmed that there was no documentation that PTA had reported to nursing staff or the physician Patient 3’s reported use of MOM or the use of a laxative tea daily. ED confirmed that there was no documentation to indicate the physician, agency, or nursing staff had been notified of the use of MOM or laxative tea, and Patient 3’s record had not been updated to reflect this information. ED confirmed that over the counter medications and herbal supplements should be included in medication review. Findings: The agency policy titled, “Monitoring Medications”, revised 4/1/26, indicated; “A drug regimen review will be performed on all patients... with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager... The physician is contacted immediately if any discrepancies between agency information and patient medications are found... The discipline responsible for the drug regimen review will: Compare medication list... or physician orders to actual medications the patient is taking. Review all medications including over the counter (OTC) medications, vitamins, herbs, and herbal products.” 1. A review of Patient 2’s “Home Health Certification and Plan of Care” (Admission POC), dated 4/28/26, indicated Patient 2 was admitted to the Home Health Agency (HHA) on 4/28/26 with diagnoses that included cellulitis (a deep bacterial infection) of the abdominal wall and abscess (painful pocket of pus) of the abdominal wall. A review of Patient 2’s “Physician’s Orders,” dated 4/28/26 indicated she was taking two medications with elevated health risks; “Warfarin (medication that decreases the ability of blood to clot, placing a patient at risk for bleeding) 7.5 milligrams (mg) daily and Lasix (a medication that assists a patient to urinate excess body fluids that can also cause dehydration and low blood pressure) 20 mg every other day.” During a home visit observation on 7/22/26 that started at 10 am, Patient 2, reported that she had not taken her dose of Lasix that was scheduled for the morning. Skilled Nurse (SN) D asked Patient 2 if she needed a refill and if that was why the patient hadn’t taken the medication. Patient 2 stated she had a sufficient amount of the medication. SN D asked Patient 2 where her medication bottles were located. The patient responded that her medications were in multiple areas of the house including the kitchen, bathroom, and the bedroom. Patient 2 asked, “Would it be easier to look at the list?” SN D assisted Patient 2 to retrieve a hand written list of medications from the patient’s purse. SN D reviewed the patient provided list. In a follow up interview with Patient 2 she was asked if staff physically review her medication bottles, Patient 2 stated, “I’m sure they do it when you’re not here. She was just nervous.” 2. A review of Patient 3’s “Home Health Certification and Plan of Care” (Admission POC), dated 5/28/26, indicated Patient 3 was admitted to the HHA on 5/28/26 with diagnoses that included chronic kidney disease and emphysema (difficulty breathing). Constipation was not listed as a diagnosis. A review of Patient 3’s “Physician’s Orders” did not include an order for Milk of Magnesia (MOM an OTC laxative) or “Smooth Move” laxative tea. Both are sold without a physician’s prescription. During an observation on 7/23/26 at 8:45 am Patient 3’s wife was standing outside her home. Patient 3’s wife spoke to Physical Therapy Assistant (PTA) and declined a visit at this time, stating Patient 3 was having a bowel movement after taking MOM due to constipation. PTA asked if Patient 3’s visit could be rescheduled for later in the day and the Patient’s wife stated she would follow up with agency staff. During an observation on 7/23/26 at 11:30 am, Patient 3 and his wife agreed to a home observation visit with PTA. Patient 3’s wife reported to PTA that Patient 3 usually drinks one or one half of a cup of a laxative herbal tea called “Smooth Move” each morning to prevent constipation. Patient 3’s wife reported that the tea had been ineffective so Patient 3 took MOM to induce a bowel movement this morning. During an interview on 7/23/26 at 12:15 pm with PTA, she was asked if she physically reviews patient medications during her home visits. PTA confirmed that she does not and stated she had been informed that if nursing was involved in the patient’s care, that therapies could just verify verbally any changes or reported concerns. PTA clarified she would only physically review the medications if no nursing care had been ordered. During an interview and concurrent record review on 7/23/26 at 2:30 pm with Executive Director (ED), she was asked to clarify the agency’s expectation for staff to monitor patient medications during home visits. ED stated that all staff should physically review the patient’s medications (in bottles) with the most current physician’s orders. Any discrepancies or changes should be noted in the chart, reported to the agency and physician, and medication related documentation updated. ED confirmed that this expectation was for all staff, not just nurses. ED confirmed that over the counter medications and herbs or supplements should also be reviewed and reported by staff as part of the medication review process. ED was asked to review the documentation for Patient 3’s home visit on 7/23/26 with PTA. ED confirmed that there was no documentation that PTA had reported to nursing staff or the physician Patient 3’s reported use of MOM or the use of a laxative tea daily. ED confirmed that there was no documentation to indicate the physician, agency, or nursing staff had been notified of the use of MOM or laxative tea, ED confirmed that Patient 3’s record had not been updated to reflect this information. ED confirmed that over the counter medications and herbal supplements should be included in medication review. 3. A review of Patient 4’s “Home Health Certification and Plan of Care” (Admission POC), dated 6/10/26, indicated Patient 4 was admitted to the HHA on 6/10/26 with the diagnosis of acute on chronic (a sudden flare up that caused an ongoing condition to worsen) systolic, congestive heart failure (the heart was weak and could not pump blood effectively). During a concurrent observation and interview, on 7/23/26 at 10:05 am, located in Patient 4’s home, SN A was observed performing a home visit that included a medication reconciliation (visual observation and documentation of all current medication bottles located in the home). During the observation, Patient 4’s family member (FM) indicated Patient 4 had experienced a headache the night before and had been given Tylenol (OTC pain reliever). SN A used a medication list created by the FM, a basket containing the patient’s current prescribed medications, and the HHA’s medication list during the reconciliation. A bottle of Tylenol 325 mg and Centrum Silver (OTC multivitamin) were observed in the medication basket. A review of the HHA’s Medication List, printed 7/23/26, did not include Tylenol or Centrum Silver. During an interview on 7/23/26 at 11:57 am, SN A confirmed, the medication reconciliation was performed at each home visit to ensure medication compliance and to identify potential drug‑to‑drug interactions. During an interview on 7/23/26 at 2:10 pm, Patient 4’s FM confirmed that Patient 4 took Tylenol 325 mg, two tablets, once a day if needed for headaches and stated, “[Patient 4] had taken Tylenol, his whole life.” FM confirmed that Patient 4 took Centrum Silver, one tablet a day and stated, “[Patient 4] had been taking Centrum Silver once a day for a year.” During an interview on 7/24/26 at 10:42 am, ED confirmed that clinicians were required to update the medication list during each home visit. After reviewing the observations made during Patient 4’s visit on 7/23/26, the ED confirmed, SN A did not perform a complete or thorough medication reconciliation. The ED indicated the purpose of medication reconciliation was to coordinate care among multiple prescribers and ensure the accuracy of the patient’s medication regimen.”

“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 (HHA) failed to ensure three of ten sampled patients (Patients 1, 5, and 7) had complete and individualized plans of care (POC, which also served as the physician’s orders) that were developed in accordance with their specific needs when: 1a. Patient 1 had a diagnosis of depression, and the HHA did not develop a POC describing how the agency planned to manage, monitor, or support Patient 1’s mental health needs. 1b. Patient 1’s supplemental oxygen (a medical treatment that provides extra oxygen when the body can’t get enough from breathing normal air) order was incomplete. 2. Patient 5 had a diagnosis of problems related to health literacy, and the HHA did not develop a POC describing how staff would address or assist Patient 5’s with understanding health information or making informed decisions about care. 3. Patient 7 had a diagnosis of depression, and the HHA did not develop a POC describing how the agency planned to manage, monitor, or support Patient 7’s mental health needs. These failures had the potential to result in unmet patient needs, inadequate care planning, and ineffective coordination of services, which could negatively impact patient outcomes. Findings: 1a. A review of the facility’s policies and procedures (P&P) titled, “Plan of Care (POC),” dated 3/1/26, indicated the purpose of the P&P was to ensure an appropriate, individualized POC was developed for each patient. The P&P indicated the POC would address patient problems, needs, and the specific services to be provided, and would include pertinent diagnoses. During a concurrent interview and record review on 7/24/26 at 12:37 pm, with the Executive Director (ED), Patient 1’s “Home Health Certification And Plan Of Care” (Admission POC), dated 12/29/25 was reviewed. ED confirmed, the Admission POC indicated Patient 1 was admitted to the HHA on 12/29/25 with the diagnosis of depression that had exacerbated (worsened) on the same date of admission. ED confirmed, the Admission POC was not individualized and did not describe how the HHA planned to manage, monitor, or support Patient 1’s mental health needs. 1b. During a concurrent interview and record review on 7/24/26 at 12:37 pm, with ED, Patient 1’s Admission POC, dated 4/25/25, was reviewed. ED confirmed that Patient 1’s oxygen order, located on the Admission POC, indicated Patient 1 would receive oxygen at two liters per minute as needed. ED confirmed the order was incomplete and was missing information regarding how the oxygen would be administered (for example, through a nasal cannula, which was a tube that delivered the oxygen through the nose). 2. During a concurrent interview and record review on 7/24/26 at 12:35 pm, with ED, Patient 5’s Admission POC dated 10/17/25 was reviewed. ED confirmed the Admission POC indicated Patient 5 was admitted to the HHA on 10/17/25 with the diagnosis of problems related to health literacy that had exacerbated on the same date of admission. ED confirmed the Admission POC was not individualized and did not describe how staff would address or assist Patient 5 with understanding health information or making informed decisions about care. 3. During a concurrent interview and record review on 7/24/26 at 12:30 pm, with ED, Patient 7’s Admission POC dated 6/18/26 was reviewed. ED confirmed the Admission POC indicated Patient 7 was admitted to the HHA on 6/18/26 with the diagnosis of depression that had exacerbated on the same date of admission. ED confirmed, the Admission POC was not individualized and did not describe how the HHA planned to manage, monitor, or support Patient 7’s mental health needs.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure that Skilled Nursing home visits provided had a Physician’s order for one out of 10 sampled patients (Patient 1) when a visit occurred prior to the order was obtained. This had the potential to negatively affect the patient’s physical, mental, and psychosocial well-being. Findings: A review of the facility’s policies and procedures (P&P) titled, “Plan of Care (POC),” dated 3/1/26, indicated, the POC would be developed and revised under the direction of the Physician prior to providing services. A review of the facility’s P&P titled, “Physician Orders,” dated 3/1/26, indicated, “Services are provided according to the most recent orders updating the patient’s Plan of care.” A review of Patient 1’s “Home Health Certification and Plan of Care” (Admission POC), dated 4/25/25, indicated admission to the Home Health Agency on 4/25/25 with the diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that made breathing difficult) and hypertension (high blood pressure). The Admission POC indicated that Skilled Nursing would perform weekly visits that included a comprehensive physical assessment (a head-to-toe assessment that included all body parts), perform a medication review that included medication education, and that the Admission POC was developed with Patient 1’s Physician. During a concurrent interview and record review on 7/24/26 at 11:04 am with the facility’s Executive Director (ED), Patient 1’s “Visit Note Report,” dated 5/1/25 and 5/6/25 were reviewed. ED confirmed the visit notes indicated that a Skilled Nurse performed a comprehensive assessment and provided Patient 1 with medication education. Patient 1’s “Physician Order,” dated 5/7/25 was reviewed. ED confirmed, the “Physician Order” indicated, Skilled Nursing would provide nursing visits once a week for nine weeks and the Physician’s order for Skilled Nursing visits was not obtained until after the 5/1/26 or 5/6/26 visits had occurred .”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to follow its Quality Assessment and Performance Improvement (QAPI) policy and procedure (P&P) when the HHA did not maintain documentation showing that it implemented the performance improvement actions it identified. This failure to document implemented improvements prevented the agency from demonstrating that it carried out its QAPI Plan as required. Findings: A review of the facility’s P&P titled, “Quality Assessment and Performance Improvement (QAPI) Plan,” dated 4/6/23, indicated the goal of the QAPI program was to identify performance issues and implement improvements that enhanced the quality of patient care services. The P&P further indicated that identified areas requiring improvement would be monitored. During a concurrent interview and record review on 7/24/26 at 2:44 pm, with the Executive Director (ED), the facility’s Quarter 1 QAPI Plan, dated 6/30/26, was reviewed. ED indicated the “HHA’s Patient Perception of Care Survey” (HHCAHPS), reflected patient concerns related to medication teaching. ED indicated the HHA conducted an audit and identified that staff performance of medication reconciliation (a review of all patient medications, including visual inspection of medication bottles in the home) was inconsistent. ED indicated the QAPI improvement plan required weekly supervisory visits to ensure staff completed medication reconciliation during every home visit. ED indicated supervisory visits had been performed and documented. However, ED was unable to provide documentation demonstrating the HHA monitored the effectiveness of the identified QAPI improvement actions.”

“Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This Element is not met as evidenced by: Based on interview and record review, the agency failed to coordinate referrals for one of ten sampled patients (Patient 3) when the physician’s order for a consult with a registered dietician (RD) was not acted upon. This resulted in Patient 3 not receiving a specialized assessment and interventions for their nutritional needs. This had the potential to negatively impact Patient 3’s health and recovery. Findings: A review of the facility’s Policy and Procedure titled, “Coordination of Care, From Admit Through Discharge,” dated 12/1/25, indicated, care would be coordinated with the patient’s Physician when a missed visit occurred, altering the POC. A review of Patient 6’s “Home Health Certification and Plan of Care” (Admission POC), dated 5/8/26, indicated Patient 6 was admitted with diagnoses that included high blood pressure, heart disease, and diabetes. A physician’s order, dated 5/8/26 indicated “Patient to benefit from nutritionist consult.” During an interview and concurrent record review on 7/24/26 at 9:20 am with Executive Director (ED) she reviewed the plan of care for Patient 6 and confirmed the physician ordered a nutritional consult. ED stated that the agency does not have an RD on staff in the office. Instead when this was ordered the visit occurred through telehealth (visit occurs using technology such as computer or phone) and the patient was provided educational materials in print. ED stated this was a new process and she was uncertain at this time how and where this would be documented. During an interview on 7/24/26 at 9:28 am with ED, stated she had reviewed the process but was unable to find documentation that Patient 6 had received a consult from the RD. ED confirmed this should have been done and it was not.”

“Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure that all branch personnel training requirements were met for one of ten reviewed employees when documentation to indicate the agency’s Medical Social Worker (MSW) had completed mandated reporter training was not in his employee file. (A mandated reporter is a person who is required by law to report any known or suspected abuse or neglect of children, older adults, or vulnerable people.) This had the potential for this staff member to not know the most accurate and up to date information regarding the recognition and reporting for suspected abuse. Findings: During an interview and concurrent record review on 7/24/26 at 11:30 am with Business Manager (BM), the agency’s employee file for MSW was reviewed. BM confirmed that, on 3/1/13 MSW was hired but the agency did not have documentation to indicate they had completed the training on being a mandated reporter. BM confirmed that having this training was an expectation for all staff. BM stated he would need to follow up with the corporate office, as this employee had been with the agency for quite a few years. During an interview on 7/24/26 at 3 pm, BM confirmed that the agency was unable to locate documentation that MSW had completed the required training.”