Unison Health Services, Inc.

“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 delivers skilled nursing and other therapeutics service to a patient at home) did not develop an individualized plan of care (POC, an individualized plan of care that summarizes the patients’ health condition, specific care needs, current treatments, and the disciplines providing the services) that included management of potential problems, interventions, and goals for two of 17 sampled patients (Patient 8 and Patient 13). 1. For Patient 8, the HHA did not develop an individualized Plan of Care (POC) that addressed the potential or existing problems, interventions, and goals related to the diagnosis of seizure (a sudden, brief surge of abnormal electrical activity in the brain that can cause changes in movement, behavior, awareness, or sensations), including the safety precautions needed during seizure episodes. 2. For Patient 13, the HHA did not develop an individualized POC that identified potential problems, interventions, and goals related to dysphagia (difficulty swallowing). These failures had potential for Patient 8 to experience unrecognized seizure activity and a lack of guidance for staff and caregivers during a seizure episode, which resulted in potential for injury during seizure episode. For Patient 13, the absence of dysphagia‑related problems, goals, interventions, and aspiration precautions resulted in a potential for undetected swallowing difficulties, aspiration of food or liquids, and reduced nutritional intake. Findings: a. During a review of Patient 8’s clinical record titled “Patient Information,” Patient Information indicated Patient 8’s start of care (SOC) date of with a primary diagnosis of other complications of procedures and secondary diagnoses which include spinal stenosis lumbar region (the narrowing of the spaces within the spine in the lower back) and epilepsy (a lasting brain condition that causes repeated, sudden bursts of uncontrolled electrical activity), without status epilepticus (defined as a continuous seizure lasting longer than 5 minutes, or having multiple seizures back-to-back without fully waking up or recovering in between). During a concurrent interview and record review on 7/14/2026 at 12:06 p.m. with the ADM, Patient 8’s clinical record titled “Home Health Certification and Plan of Care” (POC) for the certification period 5/29/2026 to 7/27/2026 was reviewed. When asked to verify the missing documentation, the ADM confirmed that the Plan of Care did not contain seizure precautions, problems, interventions, goals, or expected outcomes related to seizure. The ADM stated that a POC for a patient diagnosed with epilepsy must include an identifiable problem, corresponding goals, a defined time frame, and specific interventions to appropriately address the patient’s diagnosis. The ADM indicated that the POC is established to ensure Patient 8’s epilepsy is managed appropriately and to ensure the healthcare team is aware of the required safety precautions, patient and caregiver education, and interventions being provided. The ADM stated that without seizure‑related elements in the POC, Patient 8 would lack needed guidance on seizure safety precautions, which presented the potential for harm during a seizure episode. b. During a review of Patient 13’s clinical record titled “Patient Information”, the “Patient Information” indicated Patient 13 had a start of care (SOC) of 7/2/2026, with diagnoses stage 4 pressure ulcer (deep wound where the skin is completely destroyed, exposing the underlying muscle or bone) in sacrum (bone area located at the base of spine). During a review on Patient 13’s clinical record titled “Physical Therapy (PT) Evaluation” dated 6/5/2026 and 7/10/2026 was reviewed. The “PT Evaluation” indicated that Patient 13 has dysphagia (difficulty swallowing). During an interview on 7/10/2026 at 10:20 a.m. with Patient 13’s caregiver (PCG 1), conducted during a joint home visit with Licensed Vocational Nurse 2 (LVN 2), PCG 1 stated that Patient 13 had been awaiting a speech therapist to perform a speech and swallow evaluation. PCG 1 further reported that Patient 13 exhibited poor appetite and episodes of food pocketing, which resulted in a potential for decreased nutritional intake. During a concurrent interview and record review on 7/14/2026 at 1:03 pm with the ADM, Patient 13’s clinical record titled “Resumption of Care” (a head -to -toe comprehensive assessment) dated 6/29/2026 was reviewed. The “Resumption of Care” indicated that Patient 13 has dysphagia and Patient 13’s caregiver reported Patient 13 exhibited poor appetite and difficult swallowing. The ADM stated aspiration precautions were indicated for Patient 13 but not included in the POC. During a concurrent interview and record review on 7/14/2026 at 1:06 pm with the ADM, Patient 13’s clinical record titled “Home Health Certification and Plan of Care” (POC) for the certification period 6/2/2026 to 7/31/2026 was reviewed. The POC did not contain aspiration precautions or address dysphagia. The ADM stated a POC for Patient 13’s dysphagia and should include an identifiable goal, a defined time frame, and specific interventions to address the patient’s swallowing difficulties. The ADM stated POC is established to ensure Patient 13’s swallowing impairment is appropriately managed and to ensure the healthcare team are aware of the interventions being provided. The ADM stated that without a POC for dysphagia for Patient 13 created the potential for aspiration and poor nutrition. During a review of HHA’s policies and procedures (P&P), titled “Care Planning Process”, undated. The P&P indicated: The plan of care will be reviewed more frequently than every 60 days when a significant change occurs in the patient’s condition.Based on the assessment and conclusion, the plan of care will include identified patient problems and needs, specific services and treatments to be provided, patient and caregivers education and training to facilitate timely discharge.The plan of care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Comprehensive Assessment of Patients was met as follows: The HHA failed to conduct a complete and accurate review of all medications and failed to update the medication profile with the medications currently being used by one of seventeen sampled patients (Patient 7). This deficient practice placed Patient 7 at risk for medication errors, omissions, duplications, and serious adverse effects (an undesired, harmful response to a medication or treatment) such as severe hypotension (low blood pressure), worsening heart failure (when heart muscle is unable to pump enough blood to meet the body’s needs for blood and oxygen) symptoms (fatigue, palpitations, shortness of breath, and fainting), and hospitalization. (Refer to G536). 2. The HHA failed to conduct consistent and accurate wound reassessments that reflected the patients’ actual wound status for two of seventeen sampled patients (Patient 7 and Patient 12). -For Patient 7, the HHA Skilled Nurse failed to perform consistent wound reassessments of the patient’s surgical wounds (a cut made by a doctor during an operation; after the surgery, this cut is closed and needs time to heal) located at the mid chest area (middle chest), mid epigastric region (is the upper middle part of the abdomen, just below the breastbone), left mid epigastric region, right mid epigastric region, and left medial (inner side) lower leg. -For Patient 12, the HHA Skilled Nurse failed to perform accurate and consistent wound reassessments of the patient’s sacral (bone area located at the base of spine) and right heel pressure injury (bedsore, a localized damage to the skin and/or underlying soft tissue caused by prolonged pressure). (Refer to G544). This deficient practice of not being properly evaluated placed Patient 7 and Patient 12 at risk for delayed wound healing, worsening conditions such as increase in wound size and tissue deterioration, and infection. The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulation for Comprehensive Assessments of the patients to ensure the highest quality of care were being provided to patients certified to receive the HHA benefits.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for care planning, coordination of services, and quality of care was met as follows: 1. The HHA failed to ensure that the patient received the home health services as written in the individualized plan of care (POC, an individualized plan of care that summarizes the patients’ health condition, specific care needs, current treatments, and the disciplines providing the services) for one of seventeen sampled patients (Patient 7), by: Failing to ensure that the required skilled nursing services, including scheduled home visits dated 5/4/2026, 5/13/2026 and 5/18/2026, were consistently provided to Patient 7.Failing to ensure that necessary wound care supplies (including dressing materials, normal saline (a sterile mixture of water and salt, used to gently wash out wounds), and betadine (a brand name for povidone-iodine, a common topical antiseptic, and is primarily used on the skin to kill germs, clean wounds, and help prevent infections in minor cuts, scrapes, and burns) required by the wound treatment orders were delivered to the Patient 7’s residence.Failing to ensure that the HHA Skilled Nurse provided education to Patient 7 and Patient 7’s family/caregivers regarding post‑surgical care.Failing to ensure that the HHA Skilled Nurse performed consistent wound reassessments for Patient 7’s documented surgical wounds (is a cut made by a doctor through an operation, after the surgery, this cut is closed and needs time to heal) as indicated in the home health certification and POC with certification period from 4/24/2026 to 6/22/2026, located at the mid chest area (middle area of chest), mid-epigastric region (is the upper middle part of the abdomen, just below the breastbone), left mid-epigastric region (left upper part of the abdomen), right mid-epigastric region (right upper part of the abdomen), and left medial (the inner side of the left lower leg, the part facing toward the other leg) lower leg. This failure had the potential to delay wound healing and clinical intervention and place Patient 7 at risk for unmet care needs and deterioration in health status. (Refer to G572). 2. The HHA failed to ensure HHA staff notified the physician of a change of condition for one of seventeen sampled patients (Patient 12) by: Failing to ensure Patient 12’s physician was notified of Patient 12’s worsening sacral (bone area located at the base of spine) pressure ulcer (bedsore, damage to skin and underlying tissue cause by sustained pressure) from 3/17/2026 to 4/12/2026.Failing to ensure Patient 12’s physician was informed of Patient 12’s newly developed right heel wound on 4/8/2026. This failure resulted in Patient 12 was hospitalized for 33 days, from 4/12/2026 to 5/15/2026, due to worsening wounds that required antibiotics (medications that fight bacterial infections by either killing bacteria or stopping them from reproducing) treatment, surgical debridement (medical procedure of cleaning the wound by removing dead, damaged or infected tissue) and wound vac (negative pressure wound therapy to help complex wound to heal faster) placement for the sacral wound, and Patient 12 was also placed at increased risk for worsening of pressure ulcer and complications of pressure ulcers of the right heel. (Refer to G590). 3. The HHA failed to ensure that the patient’s individualized plan of care (POC) was promptly reviewed and updated to reflect significant changes in the patient’s condition for one (1) of seventeen sampled patients (Patient 12) by failing to update Patient 12’s POC to include a newly identified wound on Patient 12’s right heel. This failure placed Patient 12 at increased risk for delayed wound treatment, inadequate monitoring, and worsening of wound. (Refer to G592). 4. The HHA failed to ensure effective coordination of care among all the clinicians involved in the patient’s treatment for one of seventeen sampled patients (Patient 12) by: Failing to coordinate with the independent Nurse Practitioner (NP, a Registered Nurse (RN) with advanced graduate education and clinical training and provide high-quality, primary, acute, and specialty healthcare) regarding the patient’s wound care needs and wound related services for the sacral pressure injury (commonly called a pressure ulcer or bedsore, is localized damage to the skin and underlying soft tissue). This failure placed Patient 12 at increased risk for delayed treatment decisions, inconsistent wound management, and potential worsening of Patient 12 sacral pressure injury and delayed healing. (Refer to G606). 5. The HHA failed to ensure that required patient education was provided as part of the individualized plan of care for one of seventeen sampled patients (Patient 7) by: Failing to ensure that Patient 7 and Patient 7’s family/caregiver received teaching related to the care and monitoring of the patient’s surgical wounds located at located at the mid‑chest area (middle area of chest), mid-epigastric region (is the upper middle part of the abdomen, just below the breastbone), left mid-epigastric region (left upper part of the abdomen), right mid-epigastric region (right upper part of the abdomen ), and left medial (the inner side of the left lower leg, the part facing toward the other leg) lower leg. This failure placed Patient 7 at risk for inadequate understanding of wound‑care needs, improper home management, delayed identification of complications, and potential decline in health status. (Refer to G610). The cumulative effect of these systemic problems resulted in the failure of the HHA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance of Federal regulations for care planning, coordination of services, and quality of care to ensure provision of highest quality patient care and services to patients certified to receive home health services.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for clinical records was met as follows: 1. The Home Health Agency failed to ensure patients’ clinical record contained complete, timely, and authenticated physician orders and assessment for three out of seventeen sampled patients (Patient 1, Patient 2, Patient 12). 1a. For Patient 1, the Initial Order dated 11/27/2024, the Physician Order dated 11/29/2024, the Recertification Order dated 01/24/2025, and the Discharge Order dated 05/08/2025 were not uploaded into the electronic health record (EHR) until 05/27/2026 and 06/01/2026, more than one year after the orders were completed. 1b. For Patient 2, the Initial Order dated 06/01/2025, the Physician Order dated 06/03/2025, and the Discharge Order dated 07/02/2025 were not uploaded into the electronic health record (EHR), approximately one year after the orders were issued. This failure resulted in Patient 1 and Patient 2 with incomplete orders in the EHR which had the potential to compromise the patient’s safety and continuity of care. 1c. For Patient 12, the HHA failed to provide documented evidence of accurate sacral (bone area located at the base of spine) and right heel pressure injury (bedsore, damage to skin and underlying tissue caused by sustained pressure assessment from 3/17/2026 to 4/12/2026. This deficient practice placed Patient 12 at risk of not being properly evaluated and receiving delayed or inconsistent care, which could hinder wound healing and result in the worsening of the patient’s pressure injuries (bedsores, shallow open sores where the top layer of skin has broken away). (Refer to G1012) 2. For Patient 12, The HHA failed to ensure all entries in patients’ clinical records were authentic, identified original content and modified content to one of seventeen sampled patients (Patient 12). This failure had a potential for the healthcare team not having access to accurate clinical information and place Patient 12 risk for delay or inconsistent care that may contribute to worsening contribute to the worsening of the patient’s pressure injuries (bedsore, shallow open sore where the top layer of the skin have broken away). (Refer to G1024). 3. The HHA failed to ensure that all interventions, including missed skilled nursing visits, outreach attempts to patients/patient’s caregiver, coordination of care in regards with the wound care treatment supplies, services, and responses to those interventions were documented and followed to one of seventeen sampled patients (Patient 7). This failure prevented verification that required services were delivered, impaired continuity of care, and placed the patient at risk for delayed wound healing, infection, sepsis, and potential rehospitalization. (Refer to G1014). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulation for clinical records to ensure the highest quality of care were being provided to patients certified to receive the HHA benefits.”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on observation, interview and record review, the HHA failed to conduct consistent and accurate wound reassessments that reflected the patients’ actual wound status for two of seventeen sampled patients (Patient 7 and Patient 12). -For Patient 7, the HHA Skilled Nurse failed to perform consistent wound reassessments of the patient’s surgical wounds (a cut made by a doctor during an operation; after the surgery, this cut is closed and needs time to heal) located at the mid chest area (middle chest), mid epigastric region (is the upper middle part of the abdomen, just below the breastbone), left mid epigastric region, right mid epigastric region, and left medial (the inner side) lower leg. -For Patient 12, the HHA Skilled Nurse failed to perform accurate and consistent wound reassessments of the patient’s sacral (bone area located at the base of spine) and right heel pressure injury (bedsore, damage to skin and underlying tissue caused by sustained pressure). This deficient practice of not being properly evaluated placed Patient 7 and Patient 12 at risk for delayed wound healing, worsening conditions such as increase in wound size and tissue deterioration, and infection. Findings: During a review of Patient 12’s clinical record titled “Patient Information”, the “Patient Information” (summary of patient’s basic information) indicated Patient 12 had a start of care (SOC) on 3/3/2026 with diagnoses including Stage 2 pressure injury (bedsore, shallow open sore where the top layer of the skin have broken away) on sacrum (bone area located at the base of spine), hemiplegia (the paralysis of one entire side of the body) following cerebral infarction (a condition where a blood clot or fatty buildup blocks an artery, cutting off blood and oxygen to a part of the brain, without oxygen, those brain cells die, which can lead to permanent damage or loss of function) and respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). During a concurrent interview and record review on 5/29/2026 at 1:56 pm with the Director of Patient Care Services (DPCS), Patient 12’s clinical record titled “OASIS - Resumption of Care”, dated 3/17/2026 was reviewed. The “OASIS - Resumption of Care” indicated Patient 12 had a right sacral Stage 2 pressure injury that measured 5 cm x 3 cm x 0.1 cm with 50% slough (yellow layer of dead tissue and delays wound healing process) and 50% red tissue, and a left sacral Stage 2 pressure injury that measured 2 cm x 2 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that the treatment for Patient 12’s left and right sacral wounds included the application of Triad cream twice a week. The DPCS stated that based on the sacral wound photo attached on “OASIS - resumption of care” dated 3/17/2026, the right sacral pressure injury appears to have 10% slough, 40 % maroon discoloration and 50% red granulation tissue. During a concurrent interview and record review on 5/29/2026 at 1:57 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – LVN”, dated 3/20/2026 was reviewed. The “Wound Care” note indicated Patient 12 had a right sacral Stage 2 pressure injury that measured 4.9 cm x 2.9 cm x 0.1 cm with 50% slough and 50% red tissue, and a left sacral Stage 2 pressure injury that measured 1.9 cm x 1.8 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached to the “Wound Care” entry, the right sacral pressure injury was worsening, as manifested by 50% eschar and 50 % red granulation tissue. The DPCS stated that the “Wound Care” note assessment did not accurately reflect the actual pressure injury shown in the photo. During a concurrent interview and record review on 5/29/2026 at 1:58 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – LVN”, dated 3/23/2026 was reviewed. The “Wound Care” indicated Patient 12 had a right sacral Stage 2 pressure injury measuring 4.9 cm x 2.9 cm x 0.1 cm with 50% slough and 50% red tissue, and a left sacral Stage 2 pressure injury measuring 1.9 cm x 1.8 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached on “Wound Care” entry dated 3/23/2026, the right sacral pressure injury was getting worse as manifested by approximately 50 % eschar, 40% slough, and 10 % red granulation tissue. The DPCS stated that based on the photo the right sacral pressure injury was unstageable (the extent of the injury was undetermined as the depth of the wound was covered by dead tissue) because the depth of the pressure injury was undetermined due to the presence of slough and eschar (thick layer of dried out dead tissue). The DPCS stated the sacral pressure injury appeared worse compared to the previous visit and the “Wound Care” note assessment did not accurately reflect the actual pressure injury shown in the photo. During a concurrent interview and record review on 5/29/2026 at 1:59 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – LVN”, dated 4/3/2026 was reviewed. The “Wound Care” notes indicated Patient 12 had a right sacral Stage 2 pressure injury measuring 4.9 cm x 2.9 cm x 0.1 cm with 50% slough and 50% red tissue, and a left sacral pressure injury measuring 1.9 cm x 1.8 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached on “Wound Care” entry dated 4/3/2026, the right sacral pressure injury was getting worse as manifested by 90-95 % slough and 10 % pink granulation tissue. The DPCS stated that Patient 12’s sacral pressure injury continued to worsen from the previous visit and the “Wound Care” note assessment does not accurately reflect the actual pressure injury shown in the photo. During an interview on 5/29/2026 at 2 pm with the DPCS, the DPCS stated that having an accurate wound assessment for Patient 12’s sacral pressure injury was essential to determine whether Patient 12 pressure injury was deteriorating and to ensure Patient 12 received appropriate treatment to prevent further decline, including the risk of infection, sepsis, avoidable pain, and potential hospitalization. During a concurrent interview and record review on 5/29/2026 at 2:02 pm with the DPCS, Patient 12’s clinical record titled “History and Physical” (H&P), dated 5/15/2026, was reviewed. The “H&P” indicated Patient 12 was admitted to General Acute Care Hospital 1 (GACH 1) from 4/12/2026 to 5/14/2026 for a Stage 4 sacral pressure injury (deep wound where the skin is destroyed, exposing the underlying muscle or bone) and an unstageable right heel pressure injury. The DPCS stated that Patient 12 was hospitalized for surgical wound debridement (medical procedure of cleaning the wound by removing dead, damaged or infected tissue) of the sacral and right heel pressure injuries, received antibiotic treatment, and had a wound vacuum machine (wound vac, negative pressure wound therapy to help complex wound to heal faster) initiated for the sacral pressure injury. During a concurrent interview and record review on 6/1/2026 at 10:54 am with Licensed Vocational Nurse 1 (LVN 1), Patient 12’s clinical record titled “Wound Care – LVN”, dated 3/23/2026 and 4/3/2026 was reviewed. LVN 1 stated the assessments documented in the “Wound Care” note did not accurately reflect actual appearance of Patient 12’s sacral pressure injury shown in the photo. LVN 1 stated when completing the “Wound Care” assessment, the electronic clinical record automatically populated the previous wound measurements and wound information, and LVN 1 did not update the notes to reflect the actual assessment during the visits. LVN 1 stated accurate assessment ensures the healthcare team were aware if Patient 12’s pressure injury had worsened and to ensure Patient 12 is receiving the appropriate wound treatment. During a review of the HHA’s policies and procedures (P&P), titled “Home Health Wound Care Assessment Policy”, revised on 2025. The P&P indicated: Each skilled nursing visit, the clinical will reassess wound status, measure wounds, evaluate progress toward healing goals, monitor for complications or infections and notify the physician of significant changes.Documentation must be objective and measurable.The HHA shall audit wound documentation periodically.During a review of the HHA’s P&P, titled “Ongoing Assessment”, undated, the P&P indicated during each home visit the appropriate clinician will re-evaluate the patient according to the problems identified the initial visit and thereafter. During a review of HHA’s P&P, titled “Clinical/Service Data Collection”, undated, the P&P indicated documentation in the clinical/service record will be timely, detailed, accurate and reflect the care or services provided. During a review of Patient 7’s clinical record titled “Patient Information,” Patient Information indicated Patient 10’s start of care (SOC) date of 4/24/2026 with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (a heart condition which a plaque buildup in the heart’s original blood vessels, which restricts blood flow but does not cause chest pain) and secondary diagnosis of encounter for surgical aftercare following surgery on the circulatory system (an after surgical procedure or hospital stay specifically intended to monitor recovery, change bandages, and manage healing for procedures done on the heart or blood vessels). During a concurrent observation and interview on 5/27/2026 at 10:30 a.m., Registered Nurse (RN) 2 was observed conducting a joint home visit at Patient 7’s residence. Patient 7 was alert, awake, and oriented to name, time, place, and event, and ambulated independently without assistive devices. RN 2 performed hand hygiene and completed a head‑to‑toe assessment. Patient 7 had healed surgical wounds located at the mid‑chest area, midepigastric region, left midepigastric region, right midepigastric region, and left medial lower leg. RN 2 stated and confirmed that all surgical wounds were healed and showed no signs or symptoms of infection. During an interview on 5/27/2026 at 10:45 a.m. with Patient 7 and Patient 7’s wife/family member (FM2), both stated that nurses visited Patient 7 only twice: once at the start of care on 4/24/2026 and once on 4/27/2026. FM2 stated she contacted the HHA on two occasions regarding the lack of skilled nursing visits and to follow up on the wound‑care supplies needed for Patient 7. • FM2 stated she called the HHA office on 5/11/2026 and spoke with the HHA Care Coordinator (CC). FM2 stated the CC told her she would look into why no skilled nursing visits had occurred and would call her back. FM2 stated she did not receive a return call. • FM2 stated she called the HHA office again on 5/18/2026; however, no staff were available to speak with her. She stated she left a message but did not receive a call back. FM2 stated that the next skilled nurse visit after 4/27/2026 was the joint visit today (5/27/2026). During an interview on 5/27/2026 at 11:39 a.m. with RN 2, RN 2 stated that wound reassessments are important for subsequent nursing visits to determine whether the wound is improving or worsening and to assess whether the current wound‑care treatment order remains appropriate. RN 2 stated that all interventions provided to the patient, including supplies left in the home, missed visits and reasons for the missed visits, outreach to the patient and the family or caregiver, patient teaching, and wound assessments, should be documented in the patient’s chart to validate that the interventions were completed. During an interview on 5/28/2026 at 12:00 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that she visited Patient 7 once on 4/27/2026 and that the other scheduled visit resulted in a missed visit. LVN 2 stated that during her visit on 4/27/2026, she checked Patient 7’s vital signs, completed the surgical wound assessment, and performed the wound‑care treatment order. LVN 2 stated she cleansed the surgical wounds using normal saline, applied betadine, and left the wounds open to air. She stated she used wound‑care supplies she carried with her that were provided by the HHA. During a concurrent record review and interview on 5/28/2026 at 12:35 p.m. with the DPCS, The DPCS stated that skilled nurses are expected to ensure that Patient 7 had an adequate supply of wound care treatment supplied, sufficient for 3–5 days, pending the supplier’s delivery. The DPCS stated and confirmed that Patient 7’s EMR contained no documentation indicating that wound care supplies were provided to Patient 7 or FM2 during the period while awaiting delivery. The DPCS stated and confirmed that Patient 7’s EMR did not include documentation of outreach call outcomes or follow‑up actions related to the missed visits on 5/4/2026, 5/13/2026, and 5/18/2026, nor did it reflect efforts to arrange substitute or rescheduled visits. The DPCS stated and confirmed that Patient 7’s EMR did not contain documented evidence of skilled nursing wound assessments or wound care treatment for the dates 5/4/2026, 5/13/2026, and 5/18/2026, for Patient 7’s surgical wound sites located at the mid‑chest area, midepigastric region, left midepigastric region, right midepigastric region, and left medial lower leg. During an interview and concurrent record review on 5/28/2026 at 12:58 p.m. with the DPCS, Patient 7’s clinical record titled “Home Health Certification and Plan of Care (POC, a written documented created by healthcare professionals and the patient to manage health needs),” with certification period from 4/24/2026 to 6/22/2026, was reviewed. The DPCS confirmed and stated that Patient 7’s Home Health Certification and POC dated 4/24/2026 to 6/2/2026, include the following orders: DME (Durable Medical Equipment, refers to reusable, long-lasting medical devices prescribed by a doctor for everyday use at home to help you manage an injury, disability, or chronic health condition) and Supplies includes normal saline, betadineTreatments: Betadine External 10% for wound care on mid chest, mid epigastric, right epigastric and left medial lower leg daily.SN (Skilled Nurse) 1w1 (one visit for week 1), 2w8 (two visits per week for 8 weeks)Skilled nurse to perform on every visit: SN to perform assessment/observation of each body system cardiovascular (refers to heat and blood vessels) system, Integumentary (refers to skin) system, neurosensory (describes the connection between the nerves and physical senses (touch, sight, hearing, hearing, hearing, hearing, hearing, smell, and taste) system.SN to instruct the patient and caregiver (FM2) on all aspects of post-surgical care to include incision care, infection prevention, medication compliance, activity as tolerated, monitoring for complications, and signs and symptoms of infection. The DPCS stated that it is essential for all staff involved in Patient 7’s care to adhere to the individualized care plan to ensure services are delivered as ordered and to prevent any lapses in care. During an interview on 5/28/2026 at 12:45 p.m., the DPCS stated that complete and accurate documentation of all wound assessments and reassessments is essential to validate that required services were provided and to determine whether the wound is healing appropriately or worsening. The DPCS stated that failure to perform and document consistent wound assessments may delay wound healing and increase the risk of infection, which, if untreated, may result in potential sepsis or rehospitalization.”

“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 delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure that the patient received the home health services as written in the individualized plan of care (POC, an individualized plan of care that summarizes the patients’ health condition, specific care needs, current treatments, and the disciplines providing the services) for one of seventeen sampled patients (Patient 7), by: Failing to ensure that the required skilled nursing services, including scheduled home visits dated 5/4/2026, 5/13/2026 and 5/18/2026, were provided to Patient 7. Failing to ensure wound‑care supplies (including dressing materials, normal saline [a sterile mixture of water and salt, used to gently wash out wounds], and betadine [used on the skin to kill germs, clean wounds, and help prevent infections in minor cuts, scrapes, and burns]) required by the wound treatment orders were delivered to the Patient 7’s residence. Failing to ensure that the HHA Skilled Nurse provided education to Patient 7 and Patient 7’s family/caregivers regarding post‑surgical care. Failing to ensure that the HHA Skilled Nurse performed consistent wound reassessments for Patient 7’s documented surgical wounds (is a cut made by a doctor through an operation, after the surgery, this cut is closed and needs time to heal) as indicated in the home health certification and POC with certification period from 4/24/2026 to 6/22/2026, located at the mid‑chest area (middle area of chest), mid epigastric region (is the upper middle part of the abdomen, just below the breastbone), left mid epigastric region (left upper part of the abdomen), right mid epigastric region (right upper part of the abdomen ), and left medial (the inner side of the left lower leg, the part facing toward the other leg) lower leg. These failures had the potential to delay wound healing and clinical intervention and place Patient 7 at risk for unmet care needs and deterioration in health status. Findings: During a review of Patient 7’s clinical record titled “Patient Information,” indicated Patient 10’s start of care (SOC) date of 4/24/2026 with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (a heart condition which a plaque buildup in the heart’s original blood vessels, which restricts blood flow but does not cause chest pain) and secondary diagnosis of encounter for surgical aftercare following surgery on the circulatory system (an after surgical procedure or hospital stay specifically intended to monitor recovery, change bandages, and manage healing for procedures done on the heart or blood vessels). During a concurrent observation and interview on 5/27/2026 at 10:30 a.m., Registered Nurse (RN) 2 was observed conducting a joint home visit at Patient 7’s residence. Patient 7 was alert, awake, and oriented to name, time, place, and event, and ambulated independently without assistive devices. RN 2 performed hand hygiene and completed a head‑to‑toe assessment. Patient 7 had healed surgical wounds located at the mid‑chest area, mid epigastric region, left mid epigastric region, right mid epigastric region, and left medial lower leg. RN 2 stated and confirmed that all surgical wounds were healed and showed no signs or symptoms of infection. During an interview on 5/27/2026 at 10:45 a.m. with Patient 7 and Patient 7’s wife/family member (FM2), both stated that nurses visited Patient 7 only twice: once at the start of care on 4/24/2026 and once on 4/27/2026. FM2 stated she contacted the HHA on two occasions regarding the lack of skilled nursing visits and to follow up on the wound‑care supplies needed for Patient 7. FM2 stated she called the HHA office on 5/11/2026 and spoke with the HHA Care Coordinator (CC). FM2 stated the CC told her she would look into why no skilled nursing visits had occurred and would call her back. FM2 stated she did not receive a return call. FM2 stated she called the HHA office again on 5/18/2026; however, no staff were available to speak with her. She stated she left a message but did not receive a call back. FM2 stated that the next skilled nurse visit after 4/27/2026 was the joint visit today (5/27/2026). Patient 7 and FM2 both stated they did not remember receiving teaching from the visiting nurses regarding how to perform wound care for Patient 7’s surgical wounds or being instructed on what signs or symptoms of complications to monitor for. FM2 stated that because no wound‑care supplies were available, she gently washed Patient 7’s surgical wounds with soap and water, following the surgeon’s discharge instructions. Patient 7 and FM2 stated the surgical wounds improved and had healed, and they did not observe any signs or symptoms of infection, such as redness, swelling, yellow drainage, or warmth to touch. Patient 7 stated he felt well and did not experience fever, chills, or pain at the surgical wound sites. During an interview on 5/27/2026 at 11:35 a.m. with RN 2, RN 2 stated that when a patient has a wound‑care treatment order and supplies have not yet been delivered, she leaves any available supplies on hand at the patient’s residence for use until vendor‑provided supplies arrive. RN 2 stated that if a patient has a missed visit, she typically reaches out to the patient and the patient’s family or caregiver to reschedule and determine the reason for the missed visit. During an interview on 5/27/2026 at 11:37 a.m. with RN 2, RN 2 stated that she ensures the patient and caregiver understand and feel comfortable performing the wound‑care treatment independently on days when no nurse is scheduled to visit. RN 2 stated she verifies understanding through return demonstration and encourages them to ask questions if any steps are unclear. During an interview on 5/27/2026 at 11:39 a.m. with RN 2, RN 2 stated that wound reassessments are important for subsequent nursing visits to determine whether the wound is improving or worsening and to assess whether the current wound‑care treatment order remains appropriate. RN 2 stated that all interventions provided to the patient, including supplies left in the home, missed visits and reasons for the missed visits, outreach to the patient and the family or caregiver, patient teaching, and wound assessments, should be documented in the patient’s chart to validate that the interventions were completed. During an interview on 5/28/2026 at 12 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that she visited Patient 7 once on 4/27/2026 and that the other scheduled visit resulted in a missed visit. LVN 2 stated that during her visit on 4/27/2026, she checked Patient 7’s vital signs, completed the surgical wound assessment, and performed the wound‑care treatment order. LVN 2 stated she cleansed the surgical wounds using normal saline, applied betadine, and left the wounds open to air. She stated she used wound‑care supplies she carried with her that were provided by the HHA. During an interview on 5/28/2026 at 12:02 p.m. with LVN 2, LVN 2 stated that Patient 7 did not have any wound‑care supplies available during the 4/27/2026 visit. LVN 2 stated she called the HHA office to notify them that supplies were needed and had not been delivered by the vendor. LVN 2 stated that the admitting RN was responsible for ensuring that the patient had appropriate wound‑care supplies at the start of care and that the RN should have placed the supply order during the start‑of‑care visit on 4/24/2026. LVN 2 stated that the admitting RN should have submitted the request for Patient 7’s wound‑care supplies. During an interview on 5/28/2026 at 12:05 p.m. with LVN 2, LVN 2 stated did not remember whether she left extra wound‑care supplies for Patient 7 because she only had enough supplies for that day’s visit. LVN 2 stated she knew the patient did not have supplies for the following days before next visit, which was why she contacted the HHA office to follow up on the supply delivery. LVN 2 stated the HHA office told her they would follow up with the vendor and Patient 7’s health insurance. LVN 2 stated she reminded Patient 7 and FM2 to contact the HHA as well regarding the missing wound‑care supplies. During an interview on 5/28/2026 at 12:07 p.m. with LVN 2, LVN 2 stated she did not remember whether she documented her interventions regarding the follow‑up for the wound‑care supplies or her attempted outreach call to reschedule Patient 7’s missed visit. LVN 2 stated that inconsistent or incomplete wound care treatment, may affect wound healing and may cause infection, sepsis, or rehospitalization. During a concurrent record review and interview on 5/28/2026 at 1:42 p.m. with the Care Coordinator (CC), Patient 7’s electronic medical record (EMR, a comprehensive, digital version of a patient’s medical history and chart) was reviewed. CC stated that one of her responsibilities is ensuring that authorizations from the patient’s health insurance are approved, including wound‑care treatment supplies and skilled nursing visits. CC stated she coordinates with Patient 7 and FM2 regarding nurse visits and wound‑care supplies. CC stated and confirmed that there was no documentation in Patient 7’s EMR reflecting outreach calls regarding wound‑care supply delivery, follow‑up on missed visits, or resolution of those issues. CC stated that all involved staff should document outreach attempts, communication efforts, resolutions, and rescheduling of missed visits to validate that interventions were completed. During an interview on 5/28/2026 at 1:45 p.m. with the CC, CC stated she should have followed up with Patient 7 and FM2 regarding wound‑care treatment supplies and any missed visits and should have documented this information in the EMR communication log so all involved staff would be aware of the situation. CC stated that if actions are not documented, it means nothing, and if it is not documented, then it did not happen. During an interview on 5/28/2026 at 1:49 p.m. with the CC, CC stated that both skilled nurses and the care coordinator share responsibility for ensuring that wound‑care supplies and other necessary supplies are provided to patients. CC stated that once a supply request is approved by the patient’s insurance, she coordinates with the patient to provide an update. CC confirmed that Patient 7’s health insurance authorized wound‑care supplies and skilled nursing visits on 4/24/2026 and that the authorization was sent to the supplier/vendor immediately for processing. During a concurrent record review and interview on 5/28/2026 at 1:52 p.m. with the CC, Patient 7’s EMR was reviewed. CC stated that documentation should reflect that patients have the necessary supplies for non‑visit days and stated that skilled nurses should ensure patients have sufficient supplies between visits. CC stated and confirmed that during the week of 5/14/2026, she provided an update to Patient 7 and FM2 regarding the wound‑care supplies but did not document the communication in Patient 7’s EMR. During a concurrent record review and interview on 5/28/2026 at 1:57 p.m. with CC, Patient 7’s EMR was reviewed. CC stated and confirmed that Patient 7’s EMR did not contain any documentation of attempted outreach calls to Patient 7 or FM2 after 5/4/2026. CC stated that the EMR reflected that LVN 2 attempted to reach Patient 7 on 5/13/2026 but did not document the outcome of the outreach call when there was no answer. CC stated that LVN 2 should have documented in the EMR that the patient could not be reached. During a concurrent record review and interview on 5/28/2026 at 2:07 p.m. with CC, Patient 7’s EMR was reviewed CC stated that she attempted to reach Patient 7 and FM2 during the week of 5/14/2026 to verify whether wound‑care supplies had been delivered and to follow up on missed visits but received no answer. CC stated and confirmed that she did not document her attempted outreach call in Patient 7’s EMR. During a concurrent record review and interview on 5/28/2026 at 2:10 p.m. with CC, Patient 7’s EMR was reviewed. CC stated that she enters the nursing visit frequency onto the schedule for Patient 7. She stated that skilled nurses are responsible for scheduling appointments directly with the patient and that missed appointments should be reported to the HHA office and to her. CC stated that after two missed visits, all involved staff should attempt to contact the patient and FM2 and document these attempts in the communication log. CC stated and confirmed that Patient 7’s EMR did not indicate any documentation regarding outcomes of the outreach calls, rescheduling of missed visits and follow -ups of wound care treatment supplies. During a concurrent record review and interview on 5/28/2026 at 12:28 p.m. with the Director of Patient Care Services (DPCS), Patient 7’s electronic medical record (EMR) was reviewed. The DPCS stated and confirmed that Patient 7’s EMR lacked documented evidence explaining the reasons for the missed skilled nursing visits scheduled for 5/4/2026, 5/13/2026, and 5/18/2026. The DPCS stated that skilled nursing staff need to document, in the EMR, the reason for each missed visit, the circumstances leading to the missed visit, the outcome of outreach calls to the patient or the patient’s family/caregiver, and any attempts to reschedule the missed visits. During a concurrent record review and interview on 5/28/2026 at 12:35 p.m. with the DPCS, The DPCS stated that skilled nurses are expected to ensure that Patient 7 had an adequate supply of wound care treatment supplied, sufficient for 3–5 days, pending the supplier’s delivery. The DPCS stated and confirmed that Patient 7’s EMR contained no documentation indicating that wound care supplies were provided to Patient 7 or FM2 during the period while awaiting delivery. The DPCS stated and confirmed that Patient 7’s EMR did not include documentation of outreach call outcomes or follow‑up actions related to the missed visits on 5/4/2026, 5/13/2026, and 5/18/2026, nor did it reflect efforts to arrange substitute or rescheduled visits. The DPCS stated and confirmed that Patient 7’s EMR did not contain documented evidence of skilled nursing wound assessments or wound care treatment for the dates 5/4/2026, 5/13/2026, and 5/18/2026, for Patient 7’s surgical wound sites located at the mid‑chest area, midepigastric region, left midepigastric region, right midepigastric region, and left medial lower leg. During an interview on 5/28/2026 at 12:45 p.m. with the DPCS, the DPCS stated that complete and accurate documentation of all interventions is essential to validate that the services required were provided. The DPCS stated that missed visits, insufficient wound care supplies in the home, or the patient’s or family’s inability or lack of confidence in performing wound care during non‑visit days could result in wound care not being completed. The DPCS stated that failure to perform required wound treatment may delay healing and increase the risk of infection, and if untreated, may lead to potential sepsis or rehospitalization. During an interview and concurrent record review on 5/28/2026 at 12:58 p.m. with the DPCS, Patient 7’s clinical record titled “Home Health Certification and Plan of Care (POC, a written documented created by healthcare professionals and the patient to manage health needs),” with certification period from 4/24/2026 to 6/22/2026, was reviewed. The DPCS confirmed and stated that Patient 7’s Home Health Certification and POC dated 4/24/2026 to 6/2/2026, include the following orders: DME (Durable Medical Equipment, refers to reusable, long-lasting medical devices prescribed by a doctor for everyday use at home to help you manage an injury, disability, or chronic health condition) and Supplies includes normal saline, betadineTreatments: Betadine External 10% for wound care on mid chest, mid epigastric, right epigastric and left medial lower leg daily.SN (Skilled Nurse) 1w1 (one visit for week 1), 2w8 (two visits per week for 8 weeks)Skilled nurse to perform on every visit: SN to perform assessment/observation of each body system cardiovascular (refers to heat and blood vessels) system, Integumentary (refers to skin) system, neurosensory (describes the connection between the nerves and physical senses (touch, sight, hearing, smell, and taste) system.SN to instruct the patient and caregiver (FM2) on all aspects of post-surgical care to include incision care, infection prevention, medication compliance, activity as tolerated, monitoring for complications, and signs and symptoms of infection. The DPCS stated that it is essential for all staff involved in Patient 7’s care to adhere to the individualized care plan to ensure services are delivered as ordered and to prevent any lapses in care. During an interview on 6/1/2026 at 10:58 a.m. with the Administrator/Director of Patient Care Services Designee (ADM/DPCSD), ADM stated that any missed visits, insufficient wound care supplies in the home, or the patient’s or family’s inability or lack of confidence in performing wound care during non‑visit days could result in wound care not being completed. The ADM stated that skilled nurses need to document or open an encounter to the nurse visit documentation to include the reason for missed visits. The ADM stated that skilled nursing staff need to document, in the EMR, the reason for each missed visit, the circumstances leading to the missed visit, the outcome of outreach calls to the patient or the patient’s family/caregiver, and any attempts to reschedule the missed visits. The ADM stated that education provided to patient and patient’s family/caregiver needs to be documented in Patient EMR and the response of it. The ADM stated that HHA process is to provide HHA’s available supplies to patients for 3-5 days until the vendor delivered the supplies. The ADM stated that nurses can come to the HHA office to get available supplies if they do not have supplies on hand to provide for patients. The ADM stated that failure to perform required wound treatment may delay healing and increase the risk of infection, and if untreated, may lead to potential sepsis or rehospitalization. During a review of HHA’s Policy & Procedure, titled “Care Planning Process,” undated. The P&P indicated the following: The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.Problems and/or needs related to patient’s condition, desires, abilities, family/caregiver support systems, and relevant medication monitoring will be included in the plan of care. Services to be provided will be based on the prioritized needs of the patient. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to determine if goals have been achieved. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing assessments, and analysis of patient response to care against goals and outcomes.”

“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 (HHA, an organization that delivers skilled nursing and other therapeutics services to a patient at home) failed to ensure that entries in patients’ clinical records were signed, dated, and clearly identified as original or modified for one of seventeen sampled patients (Patient 12). This failure had the potential to prevent the healthcare team from accessing accurate clinical information and placed Patient 12 at risk for delayed or inconsistent care, which could result in worsening pressure injuries (bedsores, shallow open sores where the top layer of skin has broken away). Findings: During a review of Patient 12’s clinical record titled “Patient Information (summary of patient’s basic information)”, the “Patient Information” indicated Patient 12 had a start of care (SOC) on 3/3/2026 with diagnoses including Stage 2 pressure injury (bedsore, shallow open sore where the top layer of the skin have broken away) on sacrum (bone area located at the base of spine), hemiplegia (the paralysis of one entire side of the body) following cerebral infarction (a condition where a blood clot or fatty buildup blocks an artery, cutting off blood and oxygen to a part of the brain, without oxygen, those brain cells die, which can lead to permanent damage or loss of function) and respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). During a review of Patient 12’s clinical record on 5/28/2026 at 2:55pm, Patient 12’s “Missed Visit Form”, dated 5/22/2026 was reviewed. The “Missed Visit Form” indicated Patient 12’s family member requested that Licensed Vocation Nurse 1 (LVN 1) not to complete the home visit for Patient 12 if LVN 1 would not bring wound care supplies. The “Missed Visit Form” indicated LVN 1 signed and completed the note on 5/22/2026. During a concurrent interview and record review on 5/29/2026 at 2:10 pm with the Director of Patient Care Services (DPCS), Patient 12’s clinical record titled “Missed Visit Form”, dated 5/22/2026 was reviewed. The “Missed Visit Form” indicated Patient 12’s family member requested Licensed Vocational Nurse 1 (LVN 1) not complete the home visit on 5/22/2026 because a wound care specialist was scheduled to see Patient 12 that same day. The “Missed Visit Form” indicated LVN 1 signed and completed the note on 5/22/2026 with no indication that the “Missed Visit Form” was revised. The DPCS stated LVN 1 revised the “Missed Visit Form” on 5/28/2026 to include additional information but did not indicate the original entry had been modified. The DPCS stated that the “Missed Visit Form” should have been signed by LVN 1 on the date the note was actually completed (5/28/2026) and should have indicated that revisions were made. The DPCS stated that accurate documentation in Patient 12’s clinical record is essential to ensure the healthcare team is aware of the patient’s current condition and can provide consistent care. The DPCS stated that making changes to clinical notes without notifying the healthcare team may result in delays or inconsistencies in Patient 12’s care, which could contribute to the worsening of the patient’s pressure injuries. During a review of HHA’s policies and procedures (P&P), titled “Clinical/Service Data Collection”, undated, the P&P indicated: Entries into the clinical record will be made on the day care/service provided to the patient.Late entries and amendments will be documented by stating “late entry” or “amendment for visit of (date and time of visit)” and include the date the entry was made, the date and documentation that was originally omitted or amended and the signature and title of the staff making the late entry or amendment.”

“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 delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure The HHA failed to conduct a complete and accurate review of all medications and failed to update the medication profile with the medications currently being used by one of seventeen sampled patients (Patient 7). This deficient practice placed Patient 7 at risk for medication errors, omissions, duplications, and serious adverse effects (an undesired, harmful response to a medication or treatment) such as severe hypotension (low blood pressure), worsening heart failure (when heart muscle is unable to pump enough blood to meet the body’s needs for blood and oxygen) symptoms (fatigue, palpitations, shortness of breath, and fainting), and hospitalization. Findings: During a review of Patient 7’s clinical record titled “Patient Information,” Patient Information indicated Patient 10’s start of care (SOC) date of 4/24/2026 with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (a heart condition which a plaque buildup in the heart’s original blood vessels, which restricts blood flow but does not cause chest pain) and secondary diagnosis of encounter for surgical aftercare following surgery on the circulatory system (an after surgical procedure or hospital stay specifically intended to monitor recovery, change bandages, and manage healing for procedures done on the heart or blood vessels). During a review of Patient 7’s clinical record titled, “Home Health Certification and Plan of Care (POC, a written documented created by healthcare professionals and the patient to manage health needs),” with certification period from 4/24/2026 to 6/22/2026, the POC indicated the following orders: -DME (Durable Medical Equipment, refers to reusable, long-lasting medical devices prescribed by a doctor for everyday use at home to help you manage an injury, disability, or chronic health condition) and Supplies includes normal saline, betadine -Treatments: Cleanse with Saline 0.9% then paint with Betadine External 10% for wound care on mid chest, mid epigastric, right epigastric and left medial lower leg daily. -SN (Skilled Nurse) 1w1 (one visit for week 1), 2w8 (two visits per week for 8 weeks) -Skilled nurse to perform on every visit: SN to perform assessment/observation of each body system cardiovascular (refers to heat and blood vessels) system, Integumentary (refers to skin) system, neurosensory (describes the connection between the nerves and physical senses (touch, sight, hearing, hearing, hearing, hearing, hearing, smell, and taste) system. -SN to instruct the patient and caregiver (FM2) on all aspects of post-surgical care to include incision care, infection prevention, medication compliance, activity as tolerated, monitoring for complications, and signs and symptoms of infection. During a concurrent observation and record review on 5/27/2026 at 10:30 a.m. with Registered Nurse (RN) 2 at Patient 7’s residence during a joint home visit, Patient 10’s clinical record titled “Patient Medication Record (medication list),” dated 4/27/2026, was reviewed. During a reconciliation review of Patient 7’s medications with RN 2, RN 2 stated and confirmed that the following medications were in the patient medication list but were not available: -Saline wound wash (a sterile mixture of water and salt, used to gently wash out wounds) external 0.9 % for wound care mid chest (middle chest area), mid epigastric region (the upper middle part of the abdomen, just below the breastbone), left epigastric (left upper part of the abdomen), right epigastric (right upper part of the abdomen) and left medial (the inner side) lower leg. -Betadine external 10% (a brand name for povidone-iodine, a common topical antiseptic, and is primarily used on the skin to kill germs, clean wounds, and help prevent infections in minor cuts, scrapes, and burns) for wound care on mid chest, mid epigastric, left epigastric, right epigastric and left medial lower leg daily. RN 2 stated and confirmed that the following prescribed medications were in Patient 7’s possession but were not documented in the medication profile: -Metoprolol Succinate (a once-daily prescription medication that belongs to a class of drugs called beta-blockers, It works by slowing the heart rate and relaxing the blood vessels, which lowers blood pressure and reduces the strain on the heart) ER (extended release,) 25 milligrams (mg, unit of weight), take one tablet by mouth every day for 90 days. -Rosuvastatin calcium (a medication used to lower “bad” cholesterol [LDL, low-density lipoprotein] and triglycerides [fat in the blood] while raising “good” cholesterol [HDL, high density lipoprotein] in the blood) 20 mg tablet, take 1 tablet by mouth every day. -Aspirin (nonsteroidal anti-inflammatory drug [NSAID] used to relieve mild-to-moderate pain, reduce fever, and decrease inflammation) 81 mg. Per Patient 7, he was taking it by mouth daily per his doctor’s instructions. During an interview on 5/8/2026 at 10:48 a.m. with Patient 7, Patient 7 stated he had been taking metoprolol, rosuvastatin and aspirin medications even before he was admitted to HHA. During an interview on 5/27/2026 at 11:15 a.m., RN 2 stated that medication reconciliation should be completed at the start of care and during subsequent visits, and that she (RN 2) should ask the patient whether any medications have been added or discontinued by the primary care physician. During an interview on 6/1/2026 at 12:10 p.m., the Administrator/Director of Patient Care Designee (ADM/DPCSD) stated that it is standard practice for HHA nurses to ensure that patients’ medications are current, unexpired, and accurately reconciled. The ADM stated that nurses are expected to conduct medication reconciliation at each visit and, when patients report new medications, to coordinate with the HHA or the physician so the current medication list can be updated, thereby preventing the continuation of discontinued medications and avoiding confusion among the healthcare team and the patient. During a review of HHA’s Policy & Procedure, titled “Medication Profile,” undated. The P&P indicated the following: Patients receiving medications will have a current, accurate medication profile in the clinical record.Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics services to a patient at home) failed to ensure HHA staff notified the physician for a change of condition for one of seventeen sampled patients (Patient 12) by: 1. Failing to ensure Patient 12’s physician was notified of Patient 12’s worsening sacral (bone area located at the base of spine) pressure ulcer (bedsore, damage to skin and underlying tissue cause by sustained pressure) from 3/17/2026 to 4/12/2026. 2. Failing to ensure Patient 12’s physician was informed of Patient 12’s newly developed right heel wound on 4/8/2026. This failure resulted in Patient 12 was hospitalized for 33 days, from 4/12/2026 to 5/15/2026, due to worsening wounds that required antibiotics (medications that fight bacterial infections by either killing bacteria or stopping them from reproducing) treatment, surgical debridement (medical procedure of cleaning the wound by removing dead, damaged or infected tissue) and wound vac (negative pressure wound therapy to help complex wound to heal faster) placement for the sacral wound, and Patient 12 was also placed at increased risk for worsening of pressure ulcer and complications of pressure ulcers of the right heel. On 6/2/2026 at 10:52 a.m. the California Department of Public Health called an Immediate Jeopardy (IJ, a situation in which the provider’s non-compliance with one or more requirements of participation has caused, serious injury, harm impairment, or death to a patient) while onsite, in the presence of the Administrator (ADM) and Director of Patient Care services (DPCS) related to the home health agency’s failure to ensure HHA staff notified the physician for a change of condition for Patient 12 for two significant changes in the patient’s condition: The worsening of Patient 12’s sacral pressure ulcer from March 17, 2026, to April 12, 2026.The development of a new right heel wound identified on April 8, 2026. On 6/3/2026 at 9:48 am, the agency provided an Immediate Jeopardy Removal Plan (IJRP, includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death of a patient likely) to the survey team. On 6/3/2026 at 9:50 am., the survey team reviewed IJRP#1 and was not accepted. On 6/3/2026 at 10:51 am, the agency provided an IJRP #2 to the survey team, was reviewed and accepted. On 6/3/2026 at 1:15 pm, while onsite, the IJ was removed in the presence of the HHA’s ADM and DPCS after the survey team verified and confirmed the implementation of the IJRP. On 6/3/2026 at 1:30 pm, the survey team conducted an exit conference while onsite, in the presence of the HHA’s ADM and DPCS. Findings: During a review of Patient 12’s clinical record titled “Patient Information”, the “Patient Information” (summary of patient’s basic information) indicated Patient 12 had a start of care (SOC) on 3/3/2026 with diagnoses including Stage 2 pressure injury (bedsore, shallow open sore where the top layer of the skin have broken away) on sacrum (bone area located at the base of spine), hemiplegia (the paralysis of one entire side of the body) following cerebral infarction (a condition where a blood clot or fatty buildup blocks an artery, cutting off blood and oxygen to a part of the brain, without oxygen, those brain cells die, which can lead to permanent damage or loss of function) and respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). During a review of Patient 12’s clinical record “Outcome and Assessment Information Set (OASIS) - Start of Care”, dated 3/3/2026, the “OASIS - Start of Care” indicated Patient 12 had a right sacral Stage 2 pressure that measured 5 centimeters (cm, unit of measurement) x 3 cm x 0.1 cm with 100 % red tissue (healthy tissue), and a left sacral Stage 2 pressure injury that measured 2 cm x 2 cm x 0.1 cm with 100 % granulation tissue (the new, healthy tissue that form at the base of a healing wound). During a review of Patient 12’s clinical record titled “Home Health Certification and Plan of Care”, for the certification period from 3/3/2026 to 5/1/2026, indicated that the treatment for Patient 12’s left and right sacral Stage 2 pressure injuries included the application of Triad cream (specialized wound product to act as protective barrier and promote wound healing) daily and as needed. During a concurrent interview and record review on 5/29/2026 at 1:56 pm with the Director of Patient Care Services (DPCS), Patient 12’s clinical record titled “OASIS - Resumption of Care”, dated 3/17/2026 was reviewed. The “OASIS - Resumption of Care” indicated Patient 12 had a right sacral Stage 2 pressure injury that measured 5 cm x 3 cm x 0.1 cm with 50% slough (yellow layer of dead tissue and delays wound healing process) and 50% red tissue, and a left sacral Stage 2 pressure injury that measured 2 cm x 2 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that the treatment for Patient 12’s left and right sacral wounds included the application of Triad cream twice a week. The DPCS stated that based on the sacral wound photo attached on “OASIS - resumption of care” dated 3/17/2026, the right sacral pressure injury appears to have 10% slough, 40 % maroon discoloration and 50% red granulation tissue. During a concurrent interview and record review on 5/29/2026 at 1:57 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – Licensed Vocational Nurse (LVN)”, dated 3/20/2026 was reviewed. The “Wound Care” note indicated Patient 12 had a right sacral Stage 2 pressure injury that measured 4.9 cm x 2.9 cm x 0.1 cm with 50% slough and 50% red tissue, and a left sacral Stage 2 pressure injury that measured 1.9 cm x 1.8 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached to the “Wound Care” entry, the right sacral pressure injury was worsening, as manifested by 50% eschar and 50 % red granulation tissue. The DPCS stated the physician should have been notified of the worsening change in condition of the right sacral pressure injury. During a concurrent interview and record review on 5/29/2026 at 1:58 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – LVN”, dated 3/23/2026 was reviewed. The “Wound Care” indicated Patient 12 had a right sacral Stage 2 pressure injury measuring 4.9 cm x 2.9 cm x 0.1 cm with 50% slough and 50% red tissue, and a left sacral Stage 2 pressure injury measuring 1.9 cm x 1.8 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached on “Wound Care” entry dated 3/23/2026, the right sacral pressure injury was getting worse as manifested by approximately 50 % eschar, 40% slough, and 10 % red granulation tissue. The DPCS stated that based on the photo the right sacral pressure injury was unstageable (the extent of the injury was undetermined as the depth of the wound was covered by dead tissue) because the depth of the pressure injury was undetermined due to the presence of slough and eschar (thick layer of dried out dead tissue). The DPCS stated the sacral pressure injury appeared worse compared to the previous visit and that the physician should have been notified for appropriate wound treatment and possible referral to a wound specialist. During a concurrent interview and record review on 5/29/2026 at 1:59 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – LVN”, dated 4/3/2026 was reviewed. The “Wound Care” notes indicated Patient 12 had a right sacral Stage 2 pressure injury measuring 4.9 cm x 2.9 cm x 0.1 cm with 50% slough and 50% red tissue, and a left sacral pressure injury measuring 1.9 cm x 1.8 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached on “Wound Care” entry dated 4/3/2026, the right sacral pressure injury was getting worse as manifested by 90-95 % slough and 10 % pink granulation tissue. The DPCS stated that Patient 12’s sacral pressure injury continued to worsen from the previous visit and the licensed nurse should have notified the physician to obtain an appropriate wound treatment order. During a concurrent interview and record review on 5/29/2026 at 1:59 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – LVN”, dated 4/8/2026 was reviewed. The “Wound Care” included a photo of Patient 12’s right heel. The DPCS stated that based on the photo of the right heel it appears to be an unstageable pressure injury as manifested by 90 % eschar and 10% pink granulation tissue. The DPCS stated the LVN should have notified the registered nurse (RN) and the physician regarding the new pressure injury in right heel and the worsening right sacral pressure injury. During a concurrent interview and record review on 5/29/2026 at 2 pm with the DPCS, Patient 12’s clinical record titled “Orders” and “Communication Log” from 3/3/2026 to 4/26/2026 was reviewed. The DPCS was unable to provide documented evidence that the physician or the registered nurse was notified of the worsening right sacral wound. The DPCS stated that having an accurate wound assessment for Patient 12’s sacral pressure injury was essential to determine whether Patient 12 pressure injury was deteriorating and to ensure the patient received appropriate treatment to prevent further decline, including the risk of infection, sepsis, avoidable pain, and potential hospitalization. During a concurrent interview and record review on 5/29/2026 at 2:02 pm with the DPCS, Patient 12’s clinical record titled “History and Physical” (H&P), dated 5/15/2026, was reviewed. The “H&P” indicated Patient 12 was admitted to General Acute Care Hospital 1 (GACH 1) from 4/12/2026 to 5/14/2026 for a Stage 4 sacral pressure injury (deep wound where the skin is completely destroyed, exposing the underlying muscle or bone) and an unstageable right heel pressure injury. The DPCS stated that Patient 12 was hospitalized for surgical wound debridement (medical procedure of cleaning the wound by removing dead, damaged or infected tissue) of the sacral and right heel pressure injuries, received antibiotic treatment, and had a wound vacuum machine(wound vac, negative pressure wound therapy to help complex wound to heal faster) initiated for the sacral pressure injury. During an interview on 6/1/2026 at 10:54 am with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she did not notify Patient 12’s physician regarding the worsening right sacral pressure injury or the newly developed right heel pressure injury identified on 4/8/2026. LVN 1 stated that any changes in a patient’s condition, including the progression of a wound, should be reported to the physician and documented in the clinical note. During a review of the HHA’s policy and procedure (P&P) titled “Physician Participation in Plan of Care,” undated, the P&P indicated orders will be reviewed and revised by the physician or other authorized licensed independent practitioner based on changes in diagnosis or treatment, including procedures, medications and equipment. During a review of the HHA’s P&P titled “Continuity of Care,” undated, indicated the following: Continuity of care will be ensured by periodic communication between team members concerning the patient’s progress and special needs as evidenced in conference reports and clinical notes. This communication will support the objectives outlined in the plan of care. The clinician will be responsible for communicating will all personnel caring for the patient including the physician, updating the plan of care, communicating changes in orders and findings to the clinical supervisor or designee, or other team members as necessary. During a review of the HHA’s P&P titled “Monitoring Patient’s Response/Reporting to Physician,” undated, indicated the following: Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit. Progress of goals will be measured at regular intervals. Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient. During each home visit, the clinician will monitor the patient’s response to care against the established goals including, but not limited to care interventions/treatments, medications and teachings. The patient’s physician will be contacted on the same day when any of the following occur: significant changes in the patient’s condition, changes that have occurred regarding diagnosis, prognosis, or treatment (including procedures, medications, precautions, and limitations). All conferences or attempts to communicate with physician will be documented in the clinical record.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient 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 delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure that the patient’s individualized plan of care (POC) was promptly reviewed and updated to reflect significant changes in the patient’s condition for one (1) of seventeen sampled patients (Patient 12) by failing to update Patient 12’s POC to include a newly identified wound on Patient 12’s right heel. This failure placed Patient 12 at increased risk for delayed wound treatment, inadequate monitoring, and worsening of wound. Findings: During a review of Patient 12’s clinical record titled “Patient Information”, the “Patient Information” (summary of patient’s basic information) indicated Patient 12 had a start of care (SOC) on 3/3/2026 with diagnoses including Stage 2 pressure injury (bedsore, shallow open sore where the top layer of the skin have broken away) on sacrum (bone area located at the base of spine), hemiplegia (the paralysis of one entire side of the body) following cerebral infarction (a condition where a blood clot or fatty buildup blocks an artery, cutting off blood and oxygen to a part of the brain, without oxygen, those brain cells die, which can lead to permanent damage or loss of function) and respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). During a review of Patient 12’s clinical record titled “Home Health Certification and Plan of Care”, for the certification period from 3/3/2026 to 5/1/2026, indicated that the treatment for Patient 12’s left and right sacral Stage 2 pressure injuries included the application of Triad cream (specialized wound product to act as protective barrier and promote wound healing) daily and as needed. During a concurrent interview and record review on 5/29/2026 at 1:59 pm, with the Director of Patient Care Services (DPCS), Patient 12’s clinical record titled “Wound Care – LVN”, dated 4/8/2026 was reviewed. The “Wound Care” included a photo of Patient 12’s right heel. The DPCS stated that based on the photo of the right heel it appeared to be unstageable (the extent of the injury was undetermined as the depth of the wound was covered by dead tissue) pressure injury as manifested by 90% (Percent, a part out of every hundred ) eschar and 10% pink granulation tissue. The DPCS stated that the “Wound Care” note did not indicate the assessment and interventions provided by the nurse related to Patient 12’s right heel pressure injury. The DPCS stated when nurses identified new wounds on a patient, the nurses should notify the DPCS and the physician to obtain pressure injury treatment order and to update the plan of care. During a concurrent interview and record on 5/29/2026 at 2:15 pm with the DPCS, Patient 12’s clinical record for the certification period 3/3/2026 to 5/1/2026 was reviewed. Patient 12’s clinical record did not contain an updated plan of care that included Patient 12’s right heel pressure injury. The DPCS stated Patient 12’s plan of care should be updated to reflect goals and intervention for Patient 12’s right heel pressure injury such as caregiver education and right heel pressure injury treatments. The DPCS stated updating the plan of care to reflect Patient 12’s current pressure injuries and ensure the healthcare team are aware of the new and ongoing treatments provided to Patient 12 to prevent infection and further wound deterioration. During a review of HHA’s policies and procedures (P&P), titled “Care Planning Process”, undated. The P&P indicated: The plan of care will be reviewed more frequently than every 60 days when a significant change occurs in the patient’s condition.Based on the assessment and conclusion, the plan of care will include identified patient problems and needs, specific services and treatments to be provided, patient and caregivers education and training to facilitate timely discharge.The plan of care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure effective coordination of care among all the clinicians involved in the patient’s treatment for one of seventeen sampled patients (Patient 12) by: Failing to coordinate with the independent Nurse Practitioner (NP, a Registered Nurse (RN) with advanced graduate education and clinical training and provide high-quality, primary, acute, and specialty healthcare) regarding the patient’s wound care needs and wound related services for the sacral pressure injury (commonly called a pressure ulcer or bedsore, is localized damage to the skin and underlying soft tissue). This failure placed Patient 12 at increased risk for delayed treatment decisions, inconsistent wound management, and potential worsening of Patient 12 sacral pressure injury and delayed healing. Findings: During a review of Patient 12’s clinical record titled “Patient Information”, the “Patient Information” (summary of patient’s basic information) indicated Patient 12 had a start of care (SOC) on 3/3/2026 with diagnoses including Stage 2 pressure injury (bedsore, shallow open sore where the top layer of the skin have broken away) on sacrum (bone area located at the base of spine), hemiplegia (the paralysis of one entire side of the body) following cerebral infarction (a condition where a blood clot or fatty buildup blocks an artery, cutting off blood and oxygen to a part of the brain, without oxygen, those brain cells die, which can lead to permanent damage or loss of function) and respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). During an interview on 5/28/2026 at 12:36 pm with Patient 12’s primary caregiver (PCG 1) at Patient 12’s joint home visit. PCG 1 stated that after Patient 12 was discharged in the General Acute Care Hospital 1 (GACH 1) on 5/15/2026 for pressure injury debridement (medical procedure of cleaning the wound by removing dead, damaged or infected tissue) and antibiotic treatment, Patient 12 was being seen by Nurse Practitioner (NP) at least weekly to assess Patient 12’s sacral (bone area located at the base of spine) pressure injury and change the wound vac (negative pressure wound therapy to help complex wound to heal faster) and Patient 12’s right heel pressure injury. PCG 1 stated the NP visited Patient 12 last 5/22/2026, NP changed the treatment to Patient 12’s right heel to apply medi-honey (medical grade honey used to promote wound healing). During an interview on 5/28/2026 at 12:54 pm with Licensed Vocation Nurse 2 (LVN 2), LVN 2 stated not being aware that Patient 12 was being seen by. LVN 2 stated he will notify the HHA regarding the NP that visits Patient 12 to coordinate the services being provided to Patient 12. During an interview on 5/29/2026 at 1:32 pm with the NP. The NP stated she is under a wound specialist group and was assigned to Patient 12 after being discharged from GACH 1 on 5/15/2026. The NP stated she was aware that Patient 12 was receiving HHA services and stated having no communication with the HHA regarding treatment for Patient 12’s pressure injuries. The NP stated that multiple attempts were made to contact the HHA but were unsuccessful. The NP stated that the treatment order for Patient 12’s right heel pressure injury was changed to medi‑honey daily starting on 5/22/2026 because a thin layer of slough (yellow, dead tissue that delays the wound‑healing process) was present in the wound bed. The NP stated the new treatment order for the right heel pressure injury was not coordinated to the HHA. During a concurrent interview and record review on 5/29/2026 at 2:08 pm with the Director of Patient Care Services (DPCS), Patient 12’s clinical record titled “Missed Visit Form”, dated 5/22/2026 was reviewed. The “Missed Visit Form” indicated that Patient 12’s family member requested not be seen on 5/22/2026 because the NP was scheduled to visit Patient 12 on that day. The DPCS stated not aware that Patient 12 was seen by NP from an outside wound specialist group. The DPCS was unable to provide documented evidence that coordination of services or any form of communication occurred with the NP or the wound specialist group. The DPCS stated that coordinating with the NP is essential to ensure that Patient 12 receives appropriate wound treatment to prevent worsening of the pressure injury or delays in wound healing. During a review of HHA’s policies and procedures (P&P), titled “Care/Service Coordination”, undated, the P&P indicated: Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group and will be appropriate to the needs and abilities of the patient, and relevant to the care/services provided.Care coordination will include integration of services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness.HHA personnel will communicate changes in a timely manner via telephone, one-on-one meeting, case conference and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure that required patient education was provided as part of the individualized plan of care for one of seventeen sampled patients (Patient 7) by: Failing to ensure that Patient 7 and Patient 7’s family/caregiver received teaching related to the care and monitoring of the patient’s surgical wounds located at located at the mid‑chest area (middle area of chest), midepigastric region (is the upper middle part of the abdomen, just below the breastbone), left midepigastric region (left upper part of the abdomen), right midepigastric region (right upper part of the abdomen ), and left medial (the inner side of the left lower leg, the part facing toward the other leg) lower leg. This failure placed Patient 7 at risk for inadequate understanding of wound‑care needs, improper home management, delayed identification of complications, and potential decline in health status. Findings: During a review of Patient 7’s clinical record titled “Patient Information,” Patient Information indicated Patient 10’s start of care (SOC) date of 4/24/2026 with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (a heart condition which a plaque buildup in the heart’s original blood vessels, which restricts blood flow but does not cause chest pain) and secondary diagnosis of encounter for surgical aftercare following surgery on the circulatory system (an after surgical procedure or hospital stay specifically intended to monitor recovery, change bandages, and manage healing for procedures done on the heart or blood vessels). During a concurrent observation and interview on 5/27/2026 at 10:30 a.m., Registered Nurse (RN) 2 was observed conducting a joint home visit at Patient 7’s residence. Patient 7 was alert, awake, and oriented to name, time, place, and event, and ambulated independently without assistive devices. RN 2 performed hand hygiene and completed a head‑to‑toe assessment. Patient 7 had healed surgical wounds located at the mid‑chest area, midepigastric region, left midepigastric region, right midepigastric region, and left medial lower leg. RN 2 stated and confirmed that all surgical wounds were healed and showed no signs or symptoms of infection. During an interview on 5/27/2026 at 10:45 a.m. with Patient 7 and Patient 7’s wife/family member (FM2), both stated that nurses visited Patient 7 only twice: once at the start of care on 4/24/2026 and once on 4/27/2026. FM2 stated she contacted the HHA on two occasions regarding the lack of skilled nursing visits and to follow up on the wound‑care supplies needed for Patient 7. • FM2 stated she called the HHA office on 5/11/2026 and spoke with the HHA Care Coordinator (CC). FM2 stated the CC told her she would look into why no skilled nursing visits had occurred and would call her back. FM2 stated she did not receive a return call. • FM2 stated she called the HHA office again on 5/18/2026; however, no staff were available to speak with her. She stated she left a message but did not receive a call back. FM2 stated that the next skilled nurse visit after 4/27/2026 was the joint visit today (5/27/2026). Patient 7 and FM2 both stated they did not remember receiving teaching from the visiting nurses regarding how to perform wound care for Patient 7’s surgical wounds or being instructed on what signs or symptoms of complications to monitor for. FM2 stated that because no wound‑care supplies were available, she gently washed Patient 7’s surgical wounds with soap and water, following the surgeon’s discharge instructions. Patient 7 and FM2 stated the surgical wounds improved and had healed, and they did not observe any signs or symptoms of infection, such as redness, swelling, yellow drainage, or warmth to touch. Patient 7 stated he felt well and did not experience fever, chills, or pain at the surgical wound sites. During an interview on 5/27/2026 at 11:35 a.m. with RN 2, RN 2 stated that when a patient has an active wound care treatment order and the ordered supplies have not yet been delivered, she provides any available wound care supplies on hand at the patient’s residence for use until the vendor‑supplied materials arrive. RN 2 stated that wound care treatment supplies must be available during patient and caregiver teaching to ensure the patient and the patient’s family/caregiver can be properly instructed on how to perform the wound care treatment. RN 2 stated that it is difficult for both the nurse and the patient or caregiver to complete teaching effectively when the necessary wound care supplies are not available, as the absence of supplies limits the ability to demonstrate and practice the required steps of the wound care procedure. During an interview on 6/1/2026 at 10:58 p.m. with the Administrator/Director of Patient Care Services Designee (ADM/DPCSD), the ADM stated that missed visits, lack of wound care supplies in the home, or the patient’s or family’s inability or lack of confidence in performing wound care during non‑visit days could result in wound care not being completed. The ADM stated that all outreach efforts, attempts to reschedule missed visits, and patient/caregiver education—including the patient’s or caregiver’s response—must be documented in the EMR. The ADM stated that the HHA process is to provide available wound care supplies to the patient for 3–5 days until vendor delivery is received, and that nurses may obtain supplies from the agency office when supplies are not immediately available in the home. The ADM stated that failure to perform and document required wound care may delay wound healing and increase the risk of infection, and if left untreated, may lead to potential sepsis or rehospitalization. During a review of HHA’s Policy & Procedure, titled “Patient Education Process,” undated. The P&P indicated the following: Patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate. Documentation of patient and family/caregiver education will consist of: Describing what was taught to the patient (if using preprinted materials, documenting the name of the handout, Describing the patient’s response to the teaching, including the level of understanding and the ability to repeat or demonstrate what was taught. Describing any additional learning needs not currently met and Describing teaching planned for subsequent visits.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current 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 delivers skilled nursing and other therapeutics services to a patient at home) failed to ensure Licensed Vocational Nurse 1 (LVN 1) notified the healthcare team (physician, Director of Patient Care Services [DPCS] and Registered Nurse [RN]) of worsening sacral (bone area located at the base of spine) pressure ulcer (bedsore, damage to skin and underlying tissue cause by sustained pressure) and a newly developed right heel wound to one of seventeen sampled patients (Patient 12). This failure placed Patient 12 at risk for further deterioration of the sacral pressure injury and complications related to the pressure ulcer on the right heel. Findings: During a review of Patient 12’s clinical record titled “Patient Information (summary of patient’s basic information)”, the “Patient Information” indicated Patient 12 had a start of care (SOC) on 3/3/2026 with diagnoses including Stage 2 pressure injury (bedsore, shallow open sore where the top layer of the skin have broken away) on sacrum (bone area located at the base of spine), hemiplegia (the paralysis of one entire side of the body) following cerebral infarction (a condition where a blood clot or fatty buildup blocks an artery, cutting off blood and oxygen to a part of the brain, without oxygen, those brain cells die, which can lead to permanent damage or loss of function) and respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). During a concurrent interview and record review on 5/29/2026 at 1:56 pm, with the Director of Patient Care Services (DPCS), Patient 12’s clinical record titled “OASIS (Outcome and Assessment Information Set, a standardized clinical assessment tool used in home health to evaluate patient status)- Resumption of Care”, dated 3/17/2026 was reviewed. The “OASIS - Resumption of Care” indicated Patient 12 had a right sacral Stage 2 pressure injury that measured 5 cm (centimeter, unit of length) x 3 cm x 0.1 cm with 50% slough (yellow layer of dead tissue and delays wound healing process) and 50% red tissue, and a left sacral Stage 2 pressure injury that measured 2 cm x 2 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that the treatment for Patient 12’s left and right sacral wounds included the application of Triad cream (a wound‑care topical treatment used for pressure injuries and skin protection) twice a week. The DPCS stated that based on the sacral wound photo attached on “OASIS - resumption of care” dated 3/17/2026, the right sacral pressure injury appears to have 10% slough, 40 % maroon discoloration and 50% red granulation tissue. During a concurrent interview and record review on 5/29/2026 at 1:57 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – Licensed Vocational Nurse (LVN)”, dated 3/20/2026 was reviewed. The “Wound Care” note indicated Patient 12 had a right sacral Stage 2 pressure injury that measured 4.9 cm x 2.9 cm x 0.1 cm with 50% slough and 50% red tissue, and a left sacral Stage 2 pressure injury that measured 1.9 cm x 1.8 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached to the “Wound Care” entry, the right sacral pressure injury was worsening, as manifested by 50% eschar (dead [necrotic] tissue that forms on a wound and is thick, leathery, tan, brown, or black colored) and 50 % red granulation tissue. The DPCS stated the healthcare team (physician, DPCS and Registered Nurse [RN]) should have been notified of the worsening change in condition of the right sacral pressure injury. During a concurrent interview and record review on 5/29/2026 at 1:58 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – LVN”, dated 3/23/2026 was reviewed. The “Wound Care” indicated Patient 12 had a right sacral Stage 2 pressure injury measuring 4.9 cm x 2.9 cm x 0.1 cm with 50% slough and 50% red tissue, and a left sacral Stage 2 pressure injury measuring 1.9 cm x 1.8 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached on “Wound Care” entry dated 3/23/2026, the right sacral pressure injury was getting worse as manifested by approximately 50 % eschar, 40% slough, and 10 % red granulation tissue. The DPCS stated that based on the photo the right sacral pressure injury was unstageable (the extent of the injury was undetermined as the depth of the wound was covered by dead tissue) because the depth of the pressure injury was undetermined due to the presence of slough and eschar (thick layer of dried out dead tissue). The DPCS stated the sacral pressure injury appeared worse compared to the previous visit and that the healthcare team should have been notified for appropriate wound treatment, assessment, intervention follow-up and possible referral to a wound specialist. During a concurrent interview and record review on 5/29/2026 at 1:59 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – LVN”, dated 4/3/2026 was reviewed. The “Wound Care” notes indicated Patient 12 had a right sacral Stage 2 pressure injury measuring 4.9 cm x 2.9 cm x 0.1 cm with 50% slough and 50% red tissue, and a left sacral pressure injury measuring 1.9 cm x 1.8 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached on “Wound Care” entry dated 4/3/2026, the right sacral pressure injury was getting worse as manifested by 90-95 % slough and 10 % pink granulation tissue. The DPCS stated that Patient 12’s sacral pressure injury continued to worsen from the previous visit and the licensed nurse should have notified the healthcare team to obtain an appropriate wound treatment order. During a concurrent interview and record review on 5/29/2026 at 1:59 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – LVN”, dated 4/8/2026 was reviewed. The “Wound Care” included a photo of Patient 12’s right heel. The DPCS stated that based on the photo of the right heel it appears to be an unstageable pressure injury as manifested by 90 % eschar and 10% pink granulation tissue. The DPCS stated the LVN should have notified the registered nurse (RN) and the physician regarding the new pressure injury in right heel and the worsening right sacral pressure injury. During a concurrent interview and record review on 5/29/2026 at 2 pm with the DPCS, Patient 12’s clinical record titled “Orders” and “Communication Log” from 3/3/2026 to 4/26/2026 was reviewed. The DPCS was unable to provide documented evidence that the physician or the registered nurse was notified of the worsening right sacral wound. The DPCS stated she was not informed of Patient 12’s worsening pressure injury. The DPCS stated the visiting nurse should notify the DPCS and the healthcare team with changes in condition to ensure the patient receives appropriate treatment to prevent further decline, including the risk of infection, sepsis, avoidable pain, and potential hospitalization. During an interview on 6/1/2026 at 10:54 am with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she did not notify Patient 12’s physician or the DPCS regarding the worsening right sacral pressure injury or the newly developed right heel pressure injury identified on 4/8/2026. LVN 1 stated that any changes in a patient’s condition, including the progression of a wound, should be reported to the physician and the DPCS to ensure Patient 12’s pressure injury has an appropriate clinical oversight and receives appropriate treatment. During a review of the HHA’s P&P titled “Continuity of Care,” undated, indicated the following: Continuity of care will be ensured by periodic communication between team members concerning the patient’s progress and special needs as evidenced in conference reports and clinical notes. This communication will support the objectives outlined in the plan of care. The clinician will be responsible for communicating will all personnel caring for the patient including the physician, updating the plan of care, communicating changes in orders and findings to the clinical supervisor or designee, or other team members as necessary. During a review of HHA’s policies and procedures (P&P), titled “Care/Service Coordination”, undated, the P&P indicated: Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group and will be appropriate to the needs and abilities of the patient, and relevant to the care/services provided.HHA personnel will communicate changes in a timely manner via telephone, one-on-one meeting, case conference and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure patients’ clinical record contained complete, timely, and authenticated physician orders and assessment for three out of seventeen sampled patients (Patient 1, Patient 2, Patient 12). 1a. For Patient 1, the Initial Order dated 11/27/2024, the Physician Order dated 11/29/2024, the Recertification Order dated 01/24/2025, and the Discharge Order dated 05/08/2025 were not uploaded into the electronic health record (EHR) until 05/27/2026 and 06/01/2026, more than one year after the orders were completed. 1b. For Patient 2, the Initial Order dated 06/01/2025, the Physician Order dated 06/03/2025, and the Discharge Order dated 07/02/2025 were not uploaded into the electronic health record (EHR), approximately one year after the orders were issued. This failure resulted in Patient 1 and Patient 2 with incomplete orders in the EHR which had the potential to compromise the patient’s safety and continuity of care. 1c. For Patient 12, the HHA failed to provide documented evidence of accurate sacral (bone area located at the base of spine) and right heel pressure injury (bedsore, damage to skin and underlying tissue caused by sustained pressure assessment from 3/17/2026 to 4/12/2026. This deficient practice placed Patient 12 at risk of not being properly evaluated and receiving delayed or inconsistent care, which could hinder wound healing and result in the worsening of the patient’s pressure injuries (bedsores, shallow open sores where the top layer of skin has broken away). Findings: 2. During a review of Patient 12’s clinical record titled “Patient Information”, the “Patient Information” (summary of patient’s basic information) indicated Patient 12 had a start of care (SOC) on 3/3/2026 with diagnoses including Stage 2 pressure injury (bedsore, shallow open sore where the top layer of the skin have broken away) on sacrum (bone area located at the base of spine), hemiplegia (the paralysis of one entire side of the body) following cerebral infarction (a condition where a blood clot or fatty buildup blocks an artery, cutting off blood and oxygen to a part of the brain, without oxygen, those brain cells die, which can lead to permanent damage or loss of function) and respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). During a concurrent interview and record review on 5/29/2026 at 1:56 pm with the Director of Patient Care Services (DPCS), Patient 12’s clinical record titled “Outcome and Assessment Information Set (OASIS)- Resumption of Care”, dated 3/17/2026 was reviewed. The “OASIS - Resumption of Care” indicated Patient 12 had a right sacral Stage 2 pressure injury that measured 5 cm x 3 cm x 0.1 cm with 50% slough (yellow layer of dead tissue and delays wound healing process) and 50% red tissue, and a left sacral Stage 2 pressure injury that measured 2 cm x 2 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached on “OASIS - resumption of care” dated 3/17/2026, the right sacral pressure injury appears to have 10% slough, 40 % maroon discoloration and 50% red granulation tissue. The DPCS stated the assessment indicated in “OASIS - Resumption of Care” does not accurately reflect the appearance of the sacral pressure injury based on the photo. During a concurrent interview and record review on 5/29/2026 at 1:57 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – Licensed Vocational Nurse (LVN)”, dated 3/20/2026 was reviewed. The “Wound Care” note indicated Patient 12 had a right sacral Stage 2 pressure injury that measured 4.9 cm x 2.9 cm x 0.1 cm with 50% slough and 50% red tissue, and a left sacral Stage 2 pressure injury that measured 1.9 cm x 1.8 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached to the “Wound Care” entry, the right sacral pressure injury was worsening, as manifested by 50% eschar and 50 % red granulation tissue. The DPCS stated the assessment indicated in “Wound Care” does not accurately reflect the appearance of the sacral pressure injury based on the photo. During a concurrent interview and record review on 5/29/2026 at 1:58 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – LVN”, dated 3/23/2026 was reviewed. The “Wound Care” indicated Patient 12 had a right sacral Stage 2 pressure injury measuring 4.9 cm x 2.9 cm x 0.1 cm with 50% slough and 50% red tissue, and a left sacral Stage 2 pressure injury measuring 1.9 cm x 1.8 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached on “Wound Care” entry dated 3/23/2026, the right sacral pressure injury was getting worse as manifested by approximately 50 % eschar, 40% slough, and 10 % red granulation tissue. The DPCS stated that based on the photo the right sacral pressure injury was unstageable (the extent of the injury was undetermined as the depth of the wound was covered by dead tissue) because the depth of the pressure injury was undetermined due to the presence of slough and eschar (thick layer of dried out dead tissue). The DPCS stated the assessment indicated in “Wound Care” does not accurately reflect the appearance of the sacral pressure injury based on the photo. During a concurrent interview and record review on 5/29/2026 at 1:59 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – LVN”, dated 4/3/2026 was reviewed. The “Wound Care” notes indicated Patient 12 had a right sacral Stage 2 pressure injury measuring 4.9 cm x 2.9 cm x 0.1 cm with 50% slough and 50% red tissue, and a left sacral pressure injury measuring 1.9 cm x 1.8 cm x 0.1 cm with 70 % slough and 20 % granulation tissue. The DPCS stated that based on the sacral wound photo attached on “Wound Care” entry dated 4/3/2026, the right sacral pressure injury was getting worse as manifested by 90-95 % slough and 10 % pink granulation tissue. The DPCS stated the assessment indicated in “Wound Care” does not accurately reflect the appearance of the sacral pressure injury based on the photo. During a concurrent interview and record review on 5/29/2026 at 1:59 pm with the DPCS, Patient 12’s clinical record titled “Wound Care – LVN”, dated 4/8/2026 was reviewed. The “Wound Care” included a photo of Patient 12’s right heel. The DPCS stated that based on the photo of the right heel it appears to be an unstageable pressure injury as manifested by 90 % eschar and 10% pink granulation tissue. The DPCS stated the assessment indicated in “Wound Care” does not accurately reflect the appearance of the sacral pressure injury based on the photo. During a concurrent interview and record review on 5/29/2026 at 2 pm with the DPCS, Patient 12’s clinical record titled “Orders” and “Communication Log” from 3/3/2026 to 4/26/2026 was reviewed. The DPCS was unable to provide documented evidence that the physician or the registered nurse was notified of the worsening right sacral wound. The DPCS stated that having an accurate wound assessment for Patient 12’s sacral pressure injury was essential to determine whether Patient 12 pressure injury was deteriorating and to ensure the patient received appropriate treatment to prevent further decline, including the risk of infection, sepsis, avoidable pain, and potential hospitalization. During a concurrent interview and record review on 6/1/2026 at 10:54 am with Licensed Vocational Nurse 1 (LVN 1), Patient 12’s clinical record titled “Wound Care – LVN”, dated 3/23/2026 and 4/3/2026 was reviewed. LVN 1 stated the assessments documented in the “Wound Care” note did not accurately reflect actual appearance of Patient 12’s sacral pressure injury shown in the photo. LVN 1 stated when completing the “Wound Care” assessment, the electronic clinical record automatically populated the previous wound measurements and wound information, and LVN 1 did not update the notes to reflect the actual assessment during the visits. LVN 1 stated accurate assessment ensures the healthcare team were aware if Patient 12’s pressure injury had worsened and to ensure Patient 12 is receiving the appropriate wound treatment. During a review of HHA’s policies and procedure (P&P), titled “Contents of Clinical Record”, undated, the P&P indicated the clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs. Justify care, accurate documents care provided and results in detail and facilitate continuity of care among organization and contract personnel. During a HHA’s P&P, titled “Clinical Record Review”, undated, the P&P indicated that each clinical record will be reviewed on an ongoing basis by the Clinical Supervisor, Performance improvement Coordinator, Clinical Director or designee for compliance with the established plan of care, the accuracy of clinical records and the need of continued care. 1a. During a review of Patient 1’s “Patient Information”, undated, the Patient information indicated, Patient 1, a 100-year-old female with Start of Care (SOC) of 11/29/2024, with diagnoses but not limited to hypertensive heart disease (HHD – a collection of structural and functional changes in the heart caused by chronic, unmanaged high blood pressure) without heart failure (a serious chronic condition where the heart cannot pump enough oxygen-rich blood to meet the body’s demands), hypothyroidism ([or underactive thyroid] – happens when the thyroid gland-a small butterfly-shaped organ in the neck-doesn’t make enough hormones which acts as the body’s energy dial, a lack of them means the metabolism slows down, making you feel exhausted and sluggish), unspecified, and mixed hyperlipidemia (also called mixed hyperlipidemia or familial combined hyperlipidemia – is a condition characterized by abnormally high levels of both cholesterol and triglycerides in the blood). During a record review of Patient 1’s “Initial Order” dated 11/27/2024, the Initial Order had no physician signature. During a record review of Patient 1’s “Physician Order”, dated 11/29/2024, the Physician Order had no physician signature. During a record review of Patient 1’s “Recertification Order”, dated 01/24/2025, the Recertification Order had no physician signature. During a record review of Patient 1’s “D/C (Discharge) Order”, dated 05/08/2025, the D/C Order had no physician signature. During a review of Patient 1’s (Electronic Health Records (EHR), the signed documents, Initial Order signed on 12/04/2024, Physician Order signed on 12/6/2024, Recertification Order signed on 1/31/2025, and the D/C Order were all uploaded on 5/27/2026. 1b. During a review of Patient 2’s “Patient Information”, undated, the Patient information indicated, Patient 2, a 75-year-old male with Start of Care (SOC) of 6/3/2025, with diagnoses but not limited to unilateral primary osteoarthritis, right knee (a generative, age related condition where the cartilage in just the right knee joints wears down), and aftercare following joint replacement surgery (focuses on pain management, swelling reduction through icing and elevation, blood clot prevention, and strict physical therapy), hypertensive heart disease (HHD – a collection of structural and functional changes in the heart caused by chronic, unmanaged high blood pressure) without heart failure (a serious chronic condition where the heart cannot pump enough oxygen-rich blood to meet the body’s demands), mixed hyperlipidemia (also called mixed hyperlipidemia or familial combined hyperlipidemia – is a condition characterized by abnormally high levels of both cholesterol and triglycerides in the blood.) and long term (current) use of aspirin (acetylsalicylic acid – is a versatile, non-steroidal anti-inflammatory drug used primarily to relieve minor aches and pains, reduce fever, and decrease inflammation. Additionally, in low doses, it acts as blood thinner to prevent dangerous blood clots). During a record review of Patient 2’s “Initial Order” dated 06/01/2025, the Initial Order had no physician signature. During a record review of Patient 2’s “Physician Order”, dated 06/03/2025, the Physician Order had no physician signature. During a record review of Patient 2’s “D/C Order”, dated 07/02/2025, the D/C (Discharge) Order had no physician signature. During a review of Patient 2’s EHR (Electronic Health Record), the Initial Order and the Physician Order were signed on 6/18/2025, and the D/C Order signed on 7/9/2025 and were all uploaded on 6/1/2026. During an interview with the DPCS (Director of Patient Care Services) on 5/29/2026 at 3:35 p.m., DPCS will provide signed copies on Monday, 6/1/2026. DPCS stated physicians signed these documents on time within 30 days of the order date. During an interview with the Administrator (ADM), on 6/2/2026 at 10:15 a.m., the ADM stated that Patient 1’s and Patient 2’s Initial Order, Physician Order, and D/C Order were signed within 30 days from the date the orders were written and should be uploaded as soon as received from the physician or the next business day but were uploaded into Patient 1’s EHR one year later and Patient 2’s EHR almost one year later. Incomplete During a review of the facility’s P&P (Policy & Procedure) titled “Clinical Record Review”, undated, the Policy indicated, “Clinical records will be reviewed at least quarterly by qualified organization personnel to assure that documentation entered are reliable, timely, valid, and accurate”. The Procedure indicated, “Ongoing review…. 1. Each clinical record will be reviewed on an ongoing basis by the Clinical Supervisor. Performance Improvement Coordinator, Clinical Director, or designees for: E. Completeness of clinical records and F. The accuracy of clinical records”.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure that all interventions, including missed skilled nursing visits, outreach attempts to patients/patient’s caregiver, coordination of care in regards with the wound care treatment supplies, services, and responses to those interventions were documented and followed to one of seventeen sampled patients (Patient 7). This failure prevented verification that required services were delivered, impaired continuity of care, and placed the patient at risk for delayed wound healing, infection, sepsis, and potential rehospitalization. Findings: During a review of Patient 7’s clinical record titled “Patient Information,” Patient Information indicated Patient 10’s start of care (SOC) date of 4/24/2026 with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (a heart condition which a plaque buildup in the heart’s original blood vessels, which restricts blood flow but does not cause chest pain) and secondary diagnosis of encounter for surgical aftercare following surgery on the circulatory system (an after surgical procedure or hospital stay specifically intended to monitor recovery, change bandages, and manage healing for procedures done on the heart or blood vessels). During a concurrent observation and interview on 5/27/2026 at 10:30 a.m., Registered Nurse (RN) 2 was observed conducting a joint home visit at Patient 7’s residence. Patient 7 was alert, awake, and oriented to name, time, place, and event, and ambulated independently without assistive devices. RN 2 performed hand hygiene and completed a head‑to‑toe assessment. Patient 7 had healed surgical wounds located at the mid‑chest area, midepigastric region, left midepigastric region, right midepigastric region, and left medial lower leg. RN 2 stated and confirmed that all surgical wounds were healed and showed no signs or symptoms of infection. During an interview on 5/27/2026 at 10:45 a.m. with Patient 7 and Patient 7’s wife/family member (FM2), both stated that nurses visited Patient 7 only twice: first, at the start of care on 4/24/2026 and second, on 4/27/2026. FM2 stated she contacted the HHA on two occasions regarding the lack of skilled nursing visits and to follow up on the wound‑care supplies needed for Patient 7. -FM2 stated she called the HHA office on 5/11/2026 and spoke with the HHA Care Coordinator (CC). FM2 stated the CC told her she would look into why no skilled nursing visits had occurred and would call her back. FM2 stated she did not receive a return call after leaving a message. -FM2 stated she called the HHA office again on 5/18/2026; however, no staff were available to speak with her. She stated she left a message but did not receive a call back. FM2 stated that the next skilled nurse visit after 4/27/2026 was the joint visit today (5/27/2026). During an interview on 5/27/2026 at 11:35 a.m. with Registered Nurse (RN) 2, RN 2 stated that when a patient has a wound‑care treatment order and the ordered supplies have not yet been delivered, she leaves any available supplies on hand at the patient’s residence for use until the vendor‑provided supplies arrive. RN 2 further stated that when a patient has a missed visit, she typically contacts the patient and the patient’s family or caregiver to determine the reason for the missed visit and to reschedule the appointment. During an interview on 5/27/2026 at 11:39 a.m. with RN 2, RN 2 stated that wound reassessments are important for subsequent nursing visits to determine whether the wound is improving or worsening and to assess whether the current wound‑care treatment order remains appropriate. RN 2 stated that all interventions provided to the patient, including supplies left in the home, missed visits and reasons for the missed visits, outreach to the patient and the family or caregiver, patient teaching, and wound assessments, should be documented in the patient’s chart to validate that the interventions were completed. During an interview on 5/28/2026 at 12:00 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that she visited Patient 7 once on 4/27/2026 and that the other scheduled visits on 5/4/2026, 5/13/2026, and 5/18/2026 resulted in a missed visit. LVN 2 stated that during her visit on 4/27/2026, she checked Patient 7’s vital signs, completed the surgical wound assessment, and performed the wound‑care treatment order. LVN 2 stated she cleansed the surgical wounds using normal saline, applied betadine, and left the wounds open to air. She stated she used wound‑care supplies she carried with her that were provided by the HHA. During an interview on 5/28/2026 at 12:02 p.m. with LVN 2, LVN 2 stated that Patient 7 did not have any wound‑care supplies available during the 4/27/2026 visit. LVN 2 stated she called the HHA office to notify them that supplies were needed and had not been delivered by the vendor. LVN 2 stated that the admitting RN is responsible for ensuring that the patient has appropriate wound‑care supplies at the start of care and that the RN should have placed the supply order during the start‑of‑care visit on 4/24/2026. LVN 2 stated that the admitting RN should have submitted the request for Patient 7’s wound‑care supplies. During an interview on 5/28/2026 at 12:05 p.m. with LVN 2, LVN 2 stated did not remember whether she left extra wound‑care supplies for Patient 7 because she only had enough supplies for that day’s visit. LVN 2 stated she knew the patient did not have supplies for the following days before next visit, which was why she contacted the HHA office to follow up on the supply delivery. LVN 2 stated the HHA office told her they would follow up with the vendor and Patient 7’s health insurance. LVN 2 stated she reminded Patient 7 and FM2 to contact the HHA as well regarding the missing wound‑care supplies. During an interview on 5/28/2026 at 12:07 p.m. with LVN 2, LVN 2 stated she did not remember whether she documented her interventions regarding the follow‑up for the wound‑care supplies or her attempted outreach call to reschedule Patient 7’s missed visit. LVN 2 stated that if the wound‑care treatment is not performed properly and consistently, it could result in delayed wound healing and may cause infection, sepsis, or rehospitalization. During a concurrent record review and interview on 5/28/2026 at 1:42 p.m. with the Care Coordinator (CC), Patient 7’s electronic medical record (EMR, a comprehensive, digital version of a patient’s medical history and chart) was reviewed. CC stated that one of her responsibilities is ensuring that authorizations from the patient’s health insurance are approved, including wound‑care treatment supplies and skilled nursing visits. CC stated she coordinates with Patient 7 and FM2 regarding nurse visits and wound‑care supplies. CC stated and confirmed that there was no documentation in Patient 7’s EMR reflecting outreach calls regarding wound‑care supply delivery, follow‑up on missed visits, or resolution of those issues. CC stated that all involved staff should document outreach attempts, communication efforts, resolutions, and rescheduling of missed visits to validate that interventions were completed. During an interview on 5/28/2026 at 1:45 p.m. with the CC, CC stated she should have followed up with Patient 7 and FM2 regarding wound‑care treatment supplies and any missed visits and should have documented this information in the EMR communication log so all involved staff would be aware of the situation. CC stated that if actions are not documented, it means nothing, and if it is not documented, then it did not happen. During an interview on 5/28/2026 at 1:49 p.m. with the CC, CC stated that both skilled nurses and the care coordinator share responsibility for ensuring that wound‑care supplies and other necessary supplies are provided to patients. CC stated that once a supply request is approved by the patient’s insurance, she coordinates with the patient to provide an update. CC confirmed that Patient 7’s health insurance authorized wound‑care supplies and skilled nursing visits on 4/24/2026 and that the authorization was sent to the supplier/vendor immediately for processing. During a concurrent interview and record review on 5/28/2026 at 1:52 p.m. with the CC, Patient 7’s EMR was reviewed. CC stated that documentation should reflect that patients have the necessary supplies for non‑visit days and stated that skilled nurses should ensure patients have sufficient supplies between visits. CC stated and confirmed that during the week of 5/14/2026, she provided an update to Patient 7 and FM2 regarding the wound‑care supplies but did not document the communication in Patient 7’s EMR. During a concurrent interview and record review on 5/28/2026 at 1:57 p.m. with CC, Patient 7’s EMR was reviewed. CC stated and confirmed that Patient 7’s EMR did not contain any documentation of attempted outreach calls to Patient 7 or FM2 after 5/4/2026. CC stated that the EMR reflected that LVN 2 attempted to reach Patient 7 on 5/13/2026 but did not document the outcome of the outreach call when there was no answer. CC stated that LVN 2 should have documented in the EMR that the patient could not be reached. During a concurrent interview and record review on 5/28/2026 at 2:07 p.m., with CC, Patient 7’s EMR was reviewed. CC stated that she attempted to reach Patient 7 and FM2 during the week of 5/14/2026 to verify whether wound‑care supplies had been delivered and to follow up on missed visits but received no answer. CC stated and confirmed that she did not document her attempted outreach call in Patient 7’s EMR. During a concurrent interview and record review on 5/28/2026 at 2:10 p.m. with CC, Patient 7’s EMR was reviewed. CC stated that she enters the nursing visit frequency onto the schedule for Patient 7. CC stated that skilled nurses are responsible for scheduling appointments directly with the patient and that missed appointments should be reported to the HHA office and to her. CC stated that after two missed visits, all involved staff should attempt to contact the patient and FM2 and document these attempts in the communication log. CC stated and confirmed that Patient 7’s EMR did not indicate any documentation regarding outcomes of the outreach calls, rescheduling of missed visits and follow -ups of wound care treatment supplies. During a concurrent interview and record review on 5/28/2026 at 12:28 p.m., with the Director of Patient Care Services (DPCS), Patient 7’s electronic medical record (EMR) was reviewed. The DPCS stated and confirmed that Patient 7’s EMR lacked documented evidence explaining the reasons for the missed skilled nursing visits scheduled for 5/4/2026, 5/13/2026, and 5/18/2026. The DPCS stated that skilled nursing staff need to document, in the EMR, the reason for each missed visit, the circumstances leading to the missed visit, the outcome of outreach calls to the patient or the patient’s family/caregiver, and any attempts to reschedule the missed visits. During a concurrent interview and record review on 5/28/2026 at 12:35 p.m. with the DPCS, the DPCS stated that skilled nurses were expected to ensure that Patient 7 had an adequate supply of wound care treatment supplied, sufficient for 3–5 days, pending the supplier’s delivery. The DPCS stated and confirmed that Patient 7’s EMR contained no documentation indicating that wound care supplies were provided to Patient 7 or FM2 during the period while awaiting delivery. The DPCS stated and confirmed that Patient 7’s EMR did not include documentation of outreach call outcomes or follow‑up actions related to the missed visits on 5/4/2026, 5/13/2026, and 5/18/2026, nor did it reflect efforts to arrange substitute or rescheduled visits. The DPCS stated and confirmed that Patient 7’s EMR did not contain documented evidence of skilled nursing wound assessments or wound care treatment for the dates 5/4/2026, 5/13/2026, and 5/18/2026, for Patient 7’s surgical wound sites located at the mid‑chest area, midepigastric region, left midepigastric region, right midepigastric region, and left medial lower leg. During an interview on 5/28/2026 at 12:45 p.m. with the DPCS, the DPCS stated that complete and accurate documentation of all interventions is essential to validate that the services required were provided. The DPCS stated that missed visits, insufficient wound care supplies in the home, or the patient’s or family’s inability or lack of confidence in performing wound care during non‑visit days could result in wound care not being completed. The DPCS stated that failure to perform required wound treatment may delay healing and increase the risk of infection, and if untreated, may lead to potential sepsis or rehospitalization. During an interview and concurrent record review on 5/28/2026 at 12:58 p.m. with the DPCS, Patient 7’s clinical record titled “Home Health Certification and Plan of Care (POC, a written documented created by healthcare professionals and the patient to manage health needs),” with certification period from 4/24/2026 to 6/22/2026, was reviewed. The DPCS confirmed and stated that Patient 7’s Home Health Certification and POC dated 4/24/2026 to 6/2/2026, include the following orders: DME (Durable Medical Equipment, refers to reusable, long-lasting medical devices prescribed by a doctor for everyday use at home to help you manage an injury, disability, or chronic health condition) and Supplies includes normal saline, betadineTreatments: Betadine External 10% for wound care on mid chest, mid epigastric, right epigastric and left medial lower leg daily.SN (Skilled Nurse) 1w1 (one visit for week 1), 2w8 (two visits per week for 8 weeks)Skilled nurse to perform on every visit: SN to perform assessment/observation of each body system cardiovascular (refers to heat and blood vessels) system, Integumentary (refers to skin) system, neurosensory (describes the connection between the nerves and physical senses (touch, sight, hearing, hearing, hearing, hearing, hearing, smell, and taste) system.SN to instruct the patient and caregiver (FM2) on all aspects of post-surgical care to include incision care, infection prevention, medication compliance, activity as tolerated, monitoring for complications, and signs and symptoms of infection. The DPCS stated that it is essential for all staff involved in Patient 7’s care to adhere to the individualized care plan to ensure services are delivered as ordered and to prevent any lapses in care. During an interview on 6/1/2026 at 10:58 a.m. with the Administrator/Director of Patient Care Services Designee (ADM/DPCSD), ADM stated that any missed visits, insufficient wound care supplies in the home, or the patient’s or family’s inability or lack of confidence in performing wound care during non‑visit days could result in wound care not being completed. The ADM stated that skilled nurses need to document or open an encounter to the nurse visit documentation to include the reason for missed visits. The ADM stated that skilled nursing staff need to document, in the EMR, the reason for each missed visit, the circumstances leading to the missed visit, the outcome of outreach calls to the patient or the patient’s family/caregiver, and any attempts to reschedule the missed visits. The ADM stated that education provided to patient and patient’s family/caregiver needs to be documented in Patient EMR and the response of it. The ADM stated that the HHA process is to provide HHA’s available supplies to patients for 3-5 days until the vendor delivered the supplies. The ADM stated that nurses can come to the HHA office to get available supplies if they do not have supplies on hand to provide for patients. The ADM stated that failure to perform required wound treatment may delay healing and increase the risk of infection, and if untreated, may lead to potential sepsis or rehospitalization. During a review of HHA’s Policy & Procedure (P & P), titled “Care Planning Process,” undated. The P&P indicated the following: The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. Problems and/or needs related to patient’s condition, desires, abilities, family/caregiver support systems, and relevant medication monitoring will be included in the plan of care. Services to be provided will be based on the prioritized needs of the patient. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to determine if goals have been achieved. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing assessments, and analysis of patient response to care against goals and outcomes. During a review of HHA’s P&P titled “Clinical Record Review,” undated, the P & P indicated the following: Clinical records will be reviewed at least quarterly by qualified organization personnel to assure that documentation entered are reliable, timely, valid, and accurate. Each clinical record will be reviewed on an ongoing basis by the Clinical Supervisor. Performance Improvement Coordinator, Clinical Director, or designees for completeness of clinical records and the accuracy of clinical records.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the home health agency failed to perform hand hygiene after removing pair of gloves used to remove soiled dressing, and prior to providing wound care for two of 17 sample patients (Patients 1 and 2). This deficient practice placed the patient at a potential risk in the delay in wound healing or cause a wound infection. a. A review of Patient 1’s Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 1 on 12/3/23, with a diagnosis that included left hip punctured wound without foreign body. During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for certification period from 12/3/2023 to 1/31/2023, indicated the frequency of visits of SN (skilled Nurse) to three times a week for one week, two times a week for eight weeks, to provide wound care treatment at Stage II right buttocks as follows: to cleanse with Normal Saline, pat dry, apply Hydrogel ointment and covered with 4x4 dressing daily. On 12/20/23, at 12 p.m., during a joint home visit with Licensed Vocational Nurse (LVN) 2, Patient 1 was observed lying in a bed with dressing on his right buttocks. During a wound care observation on 12/20/2023, at 12:10 p.m., LVN 2 was observed washing his hands, donned (put on) new gloves and removed the old dressing on the right buttocks. LVN 2 cleansed the Stage II pressure ulcer with 4 x 4 gauze wet with normal saline, patted dry and repeated the procedure two times. LVN 2 removed the gloves that touched the open wound. LVN 2 donned a new pair of gloves, applied Hydrogel ointment and covered with gauze. LVN 2 did not wash hands or performed hand hygiene prior to donning new pair of gloves. b. A review of Patient 2’s Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 2 on 12/13/2023, with a diagnosis that included subdural hematoma. During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for certification period from 12/13/2023 to 2/10/2024, indicated the frequency of visits of SN (skilled Nurse) to two times a week for one week, two times a week for eight weeks, to provide wound care treatment at surgical site on top of head as follows: to cleanse with Normal Saline, pat dry, apply Betadine ointment and covered with 4x4 dressing daily. On 12/20/2023, at 1:30 p.m., during a joint home visit with Licensed Vocational Nurse (LVN) 2, Patient 21 was observed sitting on a couch at the family room. Patient 2 had a dressing on top part of her head. During a wound care observation on 12/20/2023, at 1:50 p.m., LVN 2 was observed washing his hands, donned new gloves and removed the old dressing on top part of patient’s head. LVN 2 cleansed the surgical incision wound with 4x4 gauze wet with normal saline and repeated the procedure three times. LVN 2 took off the gloves that touched the open wound, donned a new pair of gloves and applied Betadine ointment. LVN 2 did not wash hands or performed hand hygiene prior to donning new pair of gloves. On 12/20/2023, at 2 p.m., during an interview with LVN 2, he stated he forgot to wash or sanitize his hands after removing his soiled gloves after cleaning the open wounds for both Patient 1 and 2. On 12/22/2023, at 2 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated, “ LVN 2 should have washed or sanitized the hands after removing the gloves that touched the soiled dressing.” A review of the agency’s undated policy of “Hand Hygiene “, indicated a hand decontamination with an alcohol-based hand rub should be used after removing gloves.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency failed to ensure patient rights and responsibilities information were provided in a language easily understood by one of 17 patients (Patient10). Patient 10 spoke other language besides English. Patient 10 was provided a Patient Handbook and an informed consent in a language not preferred and understood by the patient. This failure had the potential to result in the patient/family member not fully understand their rights and responsibilities, and other pertinent information contained in the Patient Handbook. A review of Patient 10’s clinical record indicated a start of care date (SOC) of 12/15/2023 with a primary diagnosis of type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar or glucose; with type 2 diabetes, the body either doesn’t produce enough insulin, or it resists insulin) and diabetic neuropathy (a type of nerve damage that can occur when a person has diabetes. High blood sugar (glucose) can injure nerves throughout the body and sciatica-Pain originates in the spine and radiates down the back of the leg. Sciatica typically affects only one side of the body). During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 12/20/2023, at 11 a.m., Patient 10 was observed walking with assistive device, alert, and oriented and communicated with LVN 1 and Family Member 1 (FM 1) solely in Spanish. During a review of Patient 10’s home folder provided by the home health agency (HHA), it was noted the Patient Handbook was written entirely in English. During an interview with Family Member 1 (FM 1) on 12/22/2023, at 11:30 a.m., FM 1 stated Patient 2 only spoke Spanish. FM 1 stated he remembered Patient 10 signed consents written in English language during admission. According to both FM 1 and Patient 10, both did not understand what was in the consent or the Patient Handbook. During an interview with the Director of Nursing (DON) on 12/18/2023, at 10:30 a.m., the DON stated the admissions nurse could have provided the consents and Handbook in Spanish to Patient 10. It’s better for the patient because that’s the language that the patient understands.” A review of the agency’s policy, titled “Informed Consent/Refusal of Treatment,” revised April 2018, indicated that upon admission and throughout the course of care, the patient, family/caregiver and/or patient representative would be given information in an understandable language, to make informed decisions regarding the care being provided.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to document an alleged complaint of patient neglect (an act or failure to act which presents an imminent risk of serious harm), and the resolution (decision) of the complaint for one out of 17 sampled patients (Patient 8). This deficient practice had the potential for the patient’s complaint or grievances presented to the HHA will not be addressed and resolved promptly and could affect the quality of care and wellbeing of the patient. On 12/19/2023, at 1 p.m., a complaint validation survey was conducted at the home health agency (HHA) regarding alleged patient neglect indicating LVN 1 did not perform Patient 8’s wound care treatment during LVN 1’s home visit on 12/22/2023. As a result, Patient 17 was transported to the emergency room on 12/22/23, for further evaluation and treatment of the wounds. A review of Patient 8’s Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 8 on 8/17/23, with a diagnosis that included fracture at superior rim of left pelvis. During a review of Patient 8’s Initial Comprehensive Assessment, dated 8/17/2023, indicated under the Integumentary Section the patient had a Stage III mid back pressure injury with wound measurements of 6 cm (centimeters) in length by 2 cm in width without drainage and a Stage three left heel pressure injury with wound measurements of 4.5 cm in length by 2.8 cm in width without drainage. A wound care was provided by the visiting nurse for both wound sites as follows: cleansed with Normal Saline, patted dry, applied Hydrogel and covered with 4x4 dressing. During a review of Patient 8’s Home Health Certification and Plan of Care (POC) for certification period from 8/17/2023 to 10/15/2023, indicated the frequency of visits of SN (skilled Nurse) to one visit per week for one week, twice a week for eight weeks, to provide wound care treatment at Stage III mid back and left heel as follows: to cleanse with Normal Saline, pat dry, apply Hydrogel ointment and covered with 4x4 dressing daily. A review of Patient 8’s Communication Note dated 8/22/2023, indicated FM 1 (family member) called the HHA (home health agency) and reported that LVN 1 came in on 8/22/2023 but did not clean the wounds nor provide wound treatment. FM 1 stated he was very anxious and upset and kept saying that LVN 1 was neglecting the patient. During an interview on 12/19/2023, at 2 p.m., with the DPCS (director of patient care services), she stated she was aware that FM 1 filed a grievance regarding an alleged neglect by LVN 1 for not providing wound treatment as ordered during her visit for Patient 8. The DPCS further stated the agency failed to document the complaint in their grievance book in order to find a resolution to the issue as per their agency’s policy. During a review of the agency’s undated policy and procedure titled, “Grievances and Complaints”, indicated at the time of admission, and as needed, patient/client and/or family/caregiver shall be informed of their rights to voice grievances regarding treatment or care, lack of respect of property, or recommend changes in policy, staff, or service/care without restraint, interference, coercion, discrimination, or reprisal. Grievances received from a patient/client and/or family/caregiver will be promptly reported to Office Leadership/Designee for assessment determination.”

“Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This Element is not met as evidenced by: Based on interview, and record review, the home health agency failed to complete the comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) for one of 17 patients (Patients 10), in order to determine eligibility to receive home health benefit, including homebound status. This deficient practice resulted for the patient being provided home health services whose eligibility status was not determined in coordination with the patient’s attending physician in order to receive the Medicare home health benefits. A review of Patient 10’s clinical record indicated a start of care date (SOC) of 12/15/2023 with a primary diagnosis of type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar or glucose; with type 2 diabetes, the body either doesn’t produce enough insulin, or it resists insulin) and diabetic neuropathy (a type of nerve damage that can occur when a person has diabetes. High blood sugar (glucose) can injure nerves throughout the body and sciatica (Pain originates in the spine and radiates down the back of the leg. Sciatica typically affects only one side of the body). During a joint home visit conducted at Patient 10’s residence with the licensed vocational nurse 1 (LVN 1) on 12/20/2023, at 11 a.m., Patient 10 was observed alert, oriented to name, person, place and time. Walked independently without assistive device. Not in any respiratory distress. Speaks fluent Spanish only. During an interview with Patient 10 and her husband stated that Patient 10 received hospice care before. Patient 10 stated that she received a call from a person identified self from “Medi-cal” and asked if she was dying or had 6 months to live. Patient 10 stated, “No” I am not dying and that she only has high blood pressure, diabetes and sciatica pain. Patient 10 also stated that the person who called her will discharge her from hospice and will be transferred to home health. Patient 10 stated that she was not able to get the name of the person who called her. Patient 10 stated the nurse from the home health agency came and had her sign papers. When asked when the last time she saw the referring doctor listed on the plan of care, Patient 10 stated she had not seen any doctor from the hospice agency. When asked if she went to the clinic of the doctor who referred her to the home health agency, Patient 10 stated in Spanish “ No I don’t know who that doctor was”. During an interview with the Director of Nursing (DON) on 12/22/2023, at 10:30 a.m., DON stated that Patient 10 was referred from a hospice agency. DON stated they received the order from the nurse practitioner (NP) who was working in the same medical group. When asked who the referring doctor was for Patient 10, DON stated it was the doctor from the hospice agency. DON stated that the doctor of the hospice agency will also be the attending doctor for Patient 10. A phone call attempt on 12/22/2023, at 12:12 p.m., to the attending and referring doctor for Patient 10. The DON from another hospice facility called back and confirmed that Patient 10 was a former patient of theirs and was discharged from their services. When asked if the doctor who referred Patient 10 to this home health agency will continue to follow up Patient 10, she stated “ No, he is our medical director and he will not continue to follow up on her care after discharge.” During an interview with the DON on 12/22/2023, at 1:23 p.m., DON stated that it was their policy for the patient to be seen by their referring doctor first before admission to home health. DON stated that the field staff should have called the agency first when they encounter problems or issues in the field. DON further stated that before they even admitted Patient 10, they should have confirmed who was the referring doctor and which doctor will follow up with the patient first before admission. A review of Patient 10’s “Home health Certification and Plan of Care” for the period of 12/15/2023 to 2/12/2023 indicated orders and treatments that included skilled nurse (SN) services once a week for one week and twice a week for 8 weeks (20 authorized visits from health plan, will request for more). SN was to perform assessment /observation of each body system cardiovascular, endocrine, respiratory, gastrointestinal, genito-urinary, integumentary, musculoskeletal, neurosensory, lymphatic system, mental/emotional status. SN was to take vital signs (blood pressure/ temperature/ heart rate/ respiration), pulse oximetry (device that measures saturation of oxygen in the blood), monitor weight and edema (swelling caused by too much fluid in the body’s tissues) weekly, assess pain level using pain scale, implement pain relief measures and evaluate its effectiveness, and to instruct patient and PCG to check the blood sugar daily. The POC included for the SN to instruct patient and caregiver as follows: -Disease process of DM type 2, sciatica, pain management, infection control management, prevention of disease exacerbation and potential complications and importance of prompt reporting to MD, measures to recognize endocrine and cardiac dysfunction. SN to instruct the patient/caregiver on diabetes is a common disorder in which the body cannot properly use the carbohydrates (starches and simple sugars), fats and proteins in foods. Testing blood sugar regularly, eating well and exercising daily are all important aspects of diabetes management. Notify physician for random blood sugar greater than(>) 300 or less than() 250 or less than() 3 lbs. or less than() 100 or less than () 26 or less than () 160 or less than()90 or less than () 101 or less than (<) 96. Pain scale of 7/10 and greater not relieved with pain medications. There was no documented evidence the agency conducted a comprehensive assessment for Patient 10 in coordination with the attending or referring physician. There was no documented evidence the attending physician participated in the development of the POC for certification period of 12/15/2023 to 2/12/2023. There was no documented evidence Patient 10’s admission for home health was accurately assessed to determine patient’s eligibility for Medicare home health benefits. A review of the HHA’s policy titled “ Physician Participation in the Plan of Care” revised April 2018 indicated to provide guidelines for the physician’s participation in home health services. A physician will direct the care of every home health patient admitted for service. The attending physician will certify that medical, skilled, rehabilitation, and social services provided by the organization are medically necessary and meets the requirements to be covered by Medicare. The attending physician (or other authorized licensed independent practitioner) will participate in the care planning process by reviewing and revising the plan of care (therapeutic and diagnostic orders). The care will be provided in compliance with his/her therapeutic and diagnostic orders and accepted standards and practice. When services are provided on the basis of a physician’s verbal orders, a registered nurse, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law shall document the orders in the patient’s clinical record, and sign, date, and time the orders. Orders are reviewed for appropriateness and accuracy before care, treatment, and services are provided. The organization may assist the physician in determining medical necessity and formulating an appropriate plan of care, if requested by the physician.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to maintain an accurate, and current medication profiles for 2 of 17 sampled patients (Patients 9 and 10). This failure had placed the patients at risk for medication errors and adverse drug reactions. 1. A review of Patient 9’s clinical record indicated a start of care date of 12/8/2023 with a primary diagnosis of puncture wound right upper arm fracture (upper arm bone id broken) and type 2 diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur when a person has diabetes). SN frequency once a week for one week and twice a week for eight weeks to assess medication compliance, knowledge, and medication effectiveness. SN to educate patient on medication usage, route, dosage, side effects, interactions and administration. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 12/21/2023 at 10:45 a.m., Patient 9 was observed walking with assistance from the daughter, alert and oriented to name, place, person and time. Patient 9 was moaning in pain at the time of home visit, extremely guarded but was not in any respiratory distress noted. During the medication review with the LVN 1 at the same date and time, the following medication discrepancies were noted: Glimepiride 4mg 1 daily was changed to twice daily Carvedilol 25mg daily was changed to 12.5mg twice daily Missing medications on the medication profile were: 1. Clonidine 0.1 mg 1 tab as needed for High Blood pressure 2. Atorvastatin 80 mg daily for cholesterol 3. Gabapentin 100 mg three times daily for neuropathy 4. Hydroxyzine 25 mg as needed for itching 5. Jardiance 10 mg daily for diabetes 6. Amlodipine 2.5 mg daily for high blood pressure 7. Ondansentron 4 mg 1-2 mg three times daily for three days for nausea 8. Fish Oil 1000 mg daily for supplement 9. Tramadol 50 mg every 8 hours was changed to every 4 hours as needed for pain 10. New order for oxycontin was mentioned but she does not know the dose and frequency yet. 11. Vit. B12 1000 mcg (micrograms-unit of measurement) daily as supplement 12. Urocholine 25 mg every 6 hours for urination 13. Vit C 500 mg daily as supplement During an interview with Patient 9 on 12/21/2023, Patient 9 stated she has a lot of medications, and this is her first time under home health services and she did not know that she had to give the complete medication list to the nurse who admitted her at the time. During an interview with the Director of Nursing (DON on 12/22/2023 at 10:30 a.m., DON stated that the nurse should review patient’s medications and compare it with the bottles at home and update the medication profile for any changes during the home visit and update the plan of care. 2. A review of Patient 10’s clinical record indicated a start of care date (SOC) of 12/15/2023 with a primary diagnosis of type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar or glucose; with type 2 diabetes, the body either doesn’t produce enough insulin, or it resists insulin) and diabetic neuropathy (a type of nerve damage that can occur when a person has diabetes. High blood sugar (glucose) can injure nerves throughout the body and sciatica (Pain originates in the spine and radiates down the back of the leg. Sciatica typically affects only one side of the body). Skilled nursing (SN) frequency once a week for one week and twice a week for eight weeks to assess medication compliance, knowledge, and medication effectiveness. SN to educate patient on medication usage, route, dosage, side effects, interactions and administration. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 12/20/2023, at 11 a.m., Patient 10 was observed walking with assistive device, alert and oriented to name, place, person and time. Walking without assistive device and was not in any respiratory distress noted. During the medication review for Patient 10 at the same date and time, the following medication discrepancies were noted: There were only 2 bottles of medications found at the patient’s home. Patient 10 stated these were new medications delivered to her. Metformin 1000 milligrams (mg- a unit of measurement) 1 tablet twice daily for diabetes and Lisinopril 20 mg-hydrochlorothiazide 12.5 mg 1 tablet daily for high blood pressure. Amlodipine Besylate 10 mg 1 tablet daily for high blood pressure was not at the patient’s home. There were 4 medications listed in the medication profile that needs to be picked up from the pharmacy. During an interview with LVN 1 stated that it is important to verify and list all the medications that the patient takes during the home visit to know how they can update the plan of care every visit. A review of the HHA’s policy titled Identification of Medication for Administration” revised January 2018 indicated that to provide general guidelines for the safe administration of medications in the home. Orders for the administration of patient medications must be given by a physician (or other authorized licensed independent practitioner) and will include patient name, patient identifier, the name of the medication, dosage, dilution, route, frequency of administration, and rate of infusion, if applicable. Orders for anaphylaxis, laboratory work and indications for drug use will be obtained when appropriate. Correct identification of the patient is also critical for patient safety with medication administration. All clinicians will use two identifies to ensure the patient is the correct patient for medication administration, blood draws, and other treatments. Medications will be properly labeled with the patient’s name, an additional patient identifier, name of drug, dosage, diluent, date of preparation, expiration date, initials of preparer, and any special instructions, as applicable. A complete list of the patient’s medications is communicated to the next provider of service when a patient is transferred or referred to another setting, service, practitioner, or level of care within or outside of the organization. A review of the HHA’s policy titled “Medication Profile” revised November 2018, indicated that Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient’s current medications upon the patient’s entry to the organization. A comparison of the medications ordered for the patient while under the organization’s care will be made to those on the list. The admitting nurse will initiate a medication profile to document the current medication regimen, including name, strength, dose, route, frequency, date and time of administration and a diagnosis, condition, or indication for use for each medication ordered.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to coordinate care and delivery of services from the skilled nursing facility (SNF) in reference to the severity of the patient’s wounds for one of 17 sampled patients ( Patient 8). This deficient practice resulted in Patient 8’s wounds not identified for immediate care, treatment, and intervention leading to the patient’s admission to the acute hospital emergency room. A review of Patient 8’s clinical record indicated a start of care (SOC) date of 8/17/2023, with a diagnoses of fracture of the rim of left pubis (generally the result of a direct blow, often in elderly patients, and are the result of minimal traumatic force) and hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). A review of Patient 8’s Plan of Care (POC) for the certification period of 8/17/2023 to 10/15/2023, included an order for Skilled Nursing (SN) to visit once a week for one week and twice a week for 8 weeks. The SN was to perform wound care treatment to: Wound #1: Mid back; Pressure ulcer Stage 3; measuring 6.0 cm x 2.0 cm x O cm. with normal saline, pad dry, apply hydrogel, cover with 4x4 gauze daily. Left Heel; Pressure ulcer Stage 3; measuring 4.5.0 cm x 2.0 cm x O cm. SN to perform wound care as follows: cleanse with normal saline, pad dry, apply hydrogel, cover with 4x4 gauze daily. Patient/caregiver was able and willing to perform wound care safely during non-SN visits as validated by skilled nurse. The POC further indicated for SN to perform on every visit Vital signs: blood pressure/ temperature/ heart rate/ respiration/pulse oximetry wound monitoring weekly. SN to demonstrate to patient/caregiver measures for infection prevention control such as proper hand washing and proper disposal of soaked dressing to infectious waste. SN to assess medication compliance, knowledge, and medication effectiveness. SN to educate patient on medication usage, route, dosage, side effects, interactions and administration. Occupational Therapy evaluation and treatment (5 authorized visits from health plan) and Speech Therapy evaluation and treatment (5 authorized visits form health plan). A review of Patient 8’s POC included “Goals and Outcomes” for the same period indicated Patient will remain in the home setting & not require unplanned medical care, emergent care or hospitalization for complications of disease exacerbation in 9 weeks (Goal Term: long, Target Date: 10/15/23) Patient/Caregiver will verbalize understanding and will call 911/MD within 4 weeks if heart attack symptoms arises (Goal Term: long, Target Date: 9/15/23) During an interview with the Patient 8’s family member on 12/21/2023 at 12:28 p.m., stated that Patient 8 fell at home and was sent to the hospital last June 2023 for her right hip surgery. Patient 8 was discharged to a skilled nursing facility (SNF) for rehab in 7/22/2023 and stayed there till 8/14/2023. Patient was discharged to home when the SNF told him that they cannot care for the patient and will be discharged to the care of a home health agency. Patient 8’s family member stated the SNF did not inform him of the severity of her wounds and filed a complaint against them. Patient 8’s family member stated the SNF told him that she only had tiny wounds that the home health agency can take care of. Family member further stated that two nurses came from the HHA on 8/17/2023 and 8/22/2023, but he was not satisfied with the wound care provided. Family member stated that when the 2nd nurse took pictures of the wound, he thought it was very bad and was afraid to have infection. Family member requested something to be done but the nurses kept on telling him they were waiting for authorization from the patient’s insurance for wound care supplies. Family member stated no one explained to him what it meant and why they have to wait for authorization Family member stated when the nurse left, he called the patient’s insurance and doctor to notify them of what happened. Family member stated he received a phone call from the patient’s doctor and told him to call 911 and bring the patient to the nearest hospital for possible infection. Family member stated patient received a dose of intravenous antibiotics and was discharged to another rehab facility and then discharged to home under another HHA. During a phone interview with Licensed Vocational Nurse 2 (LVN 2) on 12/22/2023 at 2:34 p.m., LVN 2 stated that “Technically I would try to explain my side that, but the family member kept on insisting that this should’ve been done when things like this happens, I would tell them I will call my case manager and call the doctor.” LVN 2 stated “I was caught off-guard about this patient because on my end I would ask them about their health plan. The family member was very upset at that time.” LVN 2 stated “I should have spent more time with the son explaining that the HHA was still getting authorization for the approval of the supplies.” During a concurrent interview with the Director of Nursing (DON) at the same date and time while on the call with the LVN 2, DON stated as a field staff, the staff should have called the agency while she was there and informed us of the situation and the concern should have been dealt with the patient’s family properly. A review of the HHA’s policy titled “ Care Coordination” revised April 2018 indicated that Care coordination will include, but not be limited to: Clearly outlining each clinician’s responsibilities to avoid duplication of services, Developing complementary actions and goals, Regularly occurring telephone or e-mail communication among team members, Planned face-to-face conferences, Timely documentation of coordination of care activities, Appropriate involvement of the patient and caregivers, Limiting the number of personnel assigned to a case, when possible, Proper communication upon “hand-off’ of patient, including the opportunity for questions between the giver and receiver of patient information. Coordinate communication with all physicians involved in the plan of care. Integrate orders from all physicians involved in the plan of care so that all services and interventions are coordinated. Integration of services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. Coordination of care delivery to meet the patient’s needs, and involve the patient, representative, and caregivers, as appropriate, in the coordination of care activities. Ensuring that each patient, and their caregiver(s), where applicable, receive ongoing education and training provided by the organization regarding the care and services identified in the plan of care. The organization shall provide training, as necessary, to ensure a timely discharge. All organization personnel involved in patient care, including those providing contracted services, will have access to the plan of care and all other relevant patient information to ensure coordination and continuity of care. All personnel will be knowledgeable regarding patient needs, goals of care and services.”