Focus Health

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Outcome and Assessment Information Set (OASIS, a group of standard data elements home health agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services, (CMS)) data was transmitted within 30 days of completing the OASIS data sets. This failure created the risk of not reporting and coordinating patient care assessments timely for the patients receiving care and services at the HHA. Findings: During a review on 6/23/26 of the agency’s “OASIS Error Detail Report, validation report period dated March 1, 2026, to May 31, 2026, the following was identified: The agency’s “OASIS Error Detail Report,” indicated, two of two data sets were submitted more than 30 days from the assessment completion date in January 2026. The agency’s “OASIS Error Detail Report,” indicated, five of five data sets were submitted more than 30 days from the assessment completion date in February 2026. The agency’s “OASIS Error Detail Report,” indicated, thirteen of thirteen data sets were submitted more than 30 days from the assessment completion date in March 2026. The agency’s “OASIS Error Detail Report,” indicated, thirteen of thirteen data sets were submitted more than 30 days from the assessment completion date in April 2026. During an interview and concurrent record review with the Billing Supervisor (Biller) on 6/25/26 at 9:12 a.m., the “OASIS Error Detail Report,” was reviewed. The Biller stated that the OASIS data flowed into the workflow list in the electronic medical record (EMR) of the patient. The Biller stated that the workflow list was then put into an online file, then the file was uploaded into the Internet Quality Improvement and Evaluation System (iQIES). The Biller confirmed that she uploaded the file into iQIES for the agency. The Biller stated that once she uploaded the file into iQIES, she waited to see if the file was accepted. The Biller stated that if the file was rejected, she sent an email to the agency Administrator/Executive Director (ADM/ED) and the agency clinical team to fix the errors in the file. The Biller stated that if the agency received 3330 error codes and other codes, she forwarded the codes to the ADM/ED so that she was aware. The Biller acknowledged that sometimes the files were uploaded late. The Biller acknowledged that the files needed to be submitted to iQIES within 30 days. The Biller stated that she had to wait for the corrections to be made before she could resubmit the files to iQIES. The Biller stated that when she sent the emails to the ADM/ED regarding corrections that were needed, the ADM/ED replied back when the corrections were made. The Biller stated that when she resubmitted the files she waited to see if the files would be accepted, rejected, or if error codes were sent. During an interview and concurrent record review with the ADM/ED on 6/25/26 at 3:30 p.m., the “OASIS Error Detail Report,” was reviewed. The ADM/ED stated that the agency had 30 days to submit the OASIS data before it was late. The ADM/ED acknowledged that she received emails from the Biller if the data was submitted late. The ADM/ED stated that she was new to the process. The ADM/ED stated that the Biller owned the process. The ADM/ED stated that the agency had 30 calendar days to submit the data to OASIS per the agency policy. A review of an agency policy and procedure (P&P) titled, “OASIS DATA TRANSMISSION,” revised April 2021, the P&P indicated, “…PURPOSE…to outline the OASIS data transmission requirements…POLICY…The organization will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation, Reporting of OASIS Information 42 CFR 484.45. OASIS data will be reported electronically, (in accordance with 42 CFR 484.45) using data communication software that complies with the Federal Information Processing Standard…PROCEDURE…The organization will encode and transmit completed OASIS data for each applicable patient within thirty (30) days of the…date assessment completed…The organization must electronically transmit accurate, complete and encoded OASIS data for each patient to the iQIES (Internet Quality Improvement and Evaluation System) …at least monthly…””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the home health agency failed to ensure that it followed accepted standards of practice to prevent the transmission of infections and communicable diseases for two of seventeen sampled patients (Patient 1 and Patient 2) when: Licensed Nurse (LN) 1 did not perform hand hygiene (the process of cleaning hands with soap and water or using alcohol-based rubs [hand sanitizer] to prevent the spread of germs) in between glove changes while providing care for Patient 1;LN 1 did not sanitize or clean a pulse oximeter (a painless, non-invasive electronic device used to measure the oxygen saturation [measures the percentage of hemoglobin in your red blood cells carrying oxygen] levels of blood and pulse rate [the speed at which the heart beats, measured in beats per minute]) after it was placed directly on a sofa after being used for Patient 1;LN 1 did not perform hand hygiene or change gloves when going from a dirty area to a clean area while providing wound care for Patient 1; andThe Occupational Therapist (OT- A licensed healthcare professional who helps individuals across the lifespan participate in the “occupations” [everyday activities] they need and want to do) did not wash hands prior to opening the equipment bag while doing a home visit for Patient 2.These failures could lead to the spread of infection and cause health problems for Patient 1 and Patient 2 and other patients whose homes staff visit. Findings: 1. A review of Patient 1’s “Patient Information Report,” indicated that Patient 1 started care with diagnoses which included chronic osteomyelitis (a persistent, progressive infection and inflammation of the bone and surrounding tissues that typically lasts longer than 4 weeks), and a history of methicillin resistant staph infection (a contagious type of staph bacteria that is resistant to many common antibiotics). A review of Patient 1’s “HOME HEALTH CERTIFICATION AND PLAN OF CARE,” dated 6/23/26, indicated, “…Orders of Discipline and Treatments: …SKILLED NURSE TO PERFORM/TEACH INCISION SITE WOUND CARE TO RIGHT GREAT TOE: CLEANSE WITH NORMAL SALINE [salt water], PAT DRY, APPLY XEROFORM [non-adhering gauze], 4X4 GAUZE, ABD [abdominal] PAD, WRAP WITH KERLIX [100% cotton gauze bandage], SECURE WITH TAPE. USE CLEAN...TECHNIQUE WOUND CARE TO BE PROVIDED Q (every) 2 DAYS...OR PRN (as needed) IF SOILED OR DISLODGED …” During an observation on 6/24/26 at 8:55 AM, LN 1 was observed doing an assessment and wound care for Patient 1. During the course of the assessment and wound care, LN 1 changed gloves two times (changed gloves after disinfecting the blood pressure cuff but did not do hand hygiene and then changed gloves after taking pictures of the wound but did not do hand hygiene) and did not sanitize or wash hands in between glove changes. During an interview on 6/24/26 at 9:35 AM, LN 1 stated that he should have washed his hands in between glove changes to prevent the spread of infection from potentially occurring. During an interview on 6/25/26 at 11:40 AM with the Administrator (ADM), the ADM stated that her expectation was for the staff members to either do hand hygiene or hand washing in between glove changes. The ADM also stated that there could be a risk of infection and that the staff members could recontaminate (to make something dirty, infected, or poisonous again, particularly after it has already been cleaned, sterilized, or decontaminated) their hands even after changing gloves. During a review of the facility’s policy and procedure (P&P) titled, “HAND HYGIENE Policy No. 7-009,” revised 4/21, the P&P indicated, “…PURPOSE …To prevent cross-contamination and home care-acquired infections …Personnel providing care in the home setting will regularly wash their hands …Hand decontamination using an alcohol-based hand rub should be performed: …After removing gloves …” 2. During an observation on 6/24/26 at 8:55 AM, LN 1 was observed doing an assessment and wound care for Patient 1. During the course of the assessment and wound care, LN 1 used a pulse oximeter to check the pulse rate and oxygen saturation of Patient 1. LN 1 proceeded to place the pulse oximeter on Patient 1’s living room sofa in between his equipment bag and other vital signs (an assessment of the body’s basic functions including body temperature, heart rate, blood pressure, and respiratory rate [the number of breaths taken in one minute]) equipment. After LN 1 completed his care for Patient 1, LN 1 proceeded to place his equipment and supplies back into his bag. LN 1 did not sanitize or clean the pulse oximeter used for Patient 1. During an interview on 6/24/26 at 9:35 AM, LN 1 stated that he should have cleaned all his equipment before placing it back in his bag. LN 1 also stated that germs could be transferred from his bag to another patient. During an interview on 6/25/26 at 11:40 AM with the ADM, the ADM stated that all staff members should properly clean their equipment before being placed back into the equipment bag. The ADM also stated that cross-contamination (the physical transfer of harmful bacteria, viruses, or other microorganisms from one substance, surface, or person to another) between the patient and their home environment could have occurred. During a review of the facility’s P&P titled, “BAG TECHNIQUE Policy No. 7-016,” revised 4/21, the P&P indicated, “…PURPOSE …To describe the procedure for maintaining a clean nursing bag/computer bag and preventing cross-contamination …The bag will contain a designated clean and dirty area. The clean area contains unused or cleaned supplies/equipment, and the dirty area is designated for contaminated materials (i.e., used equipment, etc.) …When the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag …” 3. During an observation on 6/24/26 at 8:55 AM, LN 1 was observed doing an assessment and wound care for Patient 1. During the course of the assessment and wound care, LN 1 proceeded to go from a dirty area of the wound care procedure to a clean area without changing his gloves or washing his hands. LN 1 failed to follow the doctor’s orders of performing wound care using aseptic technique (a set of strict, mandatory practices used in medical, clinical, and laboratory settings to prevent the spread of harmful germs) by not cleaning his hands or changing gloves during the wound care treatment. During an interview on 6/24/26 at 9:35 AM, LN 1 stated that he should have changed his gloves and performed hand hygiene to protect Patient 1 from getting germs back onto a clean wound site. LN 1 also stated that infections could occur if a wound site was to get dirty and it could contaminate the wound site. During an interview on 6/25/26 at 11:40 AM with the ADM, the ADM stated that she wanted the staff to change their gloves and wash their hands when going from a dirty wound site to a clean wound site. The ADM also stated that germs could be reintroduced back into a clean wound site by not changing gloves or washing hands. During a review of the facility’s P&P titled, “HAND HYGIENE Policy No. 7-009,” revised 4/21, the P&P indicated, “…Hand decontamination using an alcohol-based hand rub should be performed: …After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings …When moving from a contaminated body site to a clean body site during patient care …” During a review of the facility’s P&P titled, “WOUND ASSESSMENT & CARE Policy No. 1-017A,” dated 2/25/25, the P&P indicated, “…POLICY …Wound care orders will be obtained from certifying provider and delivered according to the order/ prescribed treatment …” 4. A review of Patient 2’s “Patient Information Report,” indicated that Patient 2 started care with a diagnosis of asthma (a chronic [long-term] lung disease that inflames and narrows the airways). During an observation on 6/24/26 at 2:05 PM, the OT was observed placing her equipment bag on a dresser in Patient 2’s bedroom. The OT did not wash hands prior to obtaining supplies and equipment from the equipment bag. The OT then proceeded to start her care for Patient 2. During an interview on 6/24/26 at 2:35 PM with the OT, the OT stated that she was more focused on doing hand hygiene as opposed to hand washing. The OT also stated that she would have normally washed her hands before opening supplies from the equipment bag and that it was her expectation to do so. During an interview on 6/25/26 at 11:40 AM with the ADM, the ADM stated that the equipment bag is considered a clean environment. The ADM also stated the staff should have washed their hands before opening and getting supplies from the bag to prevent making a clean environment dirty. During a review of the facility’s P&P titled, “BAG TECHNIQUE Policy No. 7-016,” revised 4/21, the P&P indicated, “…Prior to administering care, alcohol-based hand rub or soap and paper towels will be removed, and hands will be washed …Hand washing will always be completed before opening the bag …After hand washing, the supplies and/or equipment needed for the visit will be removed from the bag …””

“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 facility failed to ensure an accurate review of all medication orders was performed to ensure safe medication use for 3 out of 18 sampled patients (Patient 1, Patient 3 and Patient 4) when: 1. Patient 1’s Medication list did not match her current medication regimen and the plan of care; and, 2. Patient 3’s Medications were not reviewed for frequency of PRN medications use; and, 3. Patient 4’s pain medication order did not indicate specific time frames for administration. These failures had the potential to result in unsafe medication use and decreased well-being for Patient 1, Patient 3 and Patient 4. Findings: 3. During a review of Patient 4’s clinical document titled, “HOME HEALTH CERTIFICATION AND PLAN OF CARE,” the document indicated Patient 4 was admitted to the agency with diagnoses which included acute and chronic respiratory failure (illness that can cause severe shortness of breath and ongoing breathing difficulties) and chronic pain. During a concurrent interview and record review on 6/25/26 at 3:08 PM, with the Administrator (ADM), Patient 4’s clinical document titled, “Client Medication Report” was reviewed. The document indicated, “…Hydrocodone [potent pain medication used to treat moderate to severe pain] 7.5 mg [milligram, unit of measure] – acetaminophen [over the counter pain medication used to treat mild to moderate pain] 325 mg tablet [each tablet contained both medications]…Take one tablet by mouth three times daily as needed…” The ADM confirmed “three times daily” did not provide clear direction for administration of the pain medication. The ADM stated it was her expectation that the order would indicate the number of hours between doses. The ADM further stated if the directions were not specific there was the potential for Patient 4 to overmedicate herself which could result in slow, shallow breathing and an insufficient supply of oxygen to her body. During a review of a facility policy and procedure (P&P) titled, “IDENTIFICATION OF MEDICATION FOR ADMINISTRATION,” revised April 2021, the P&P indicated “…PURPOSE…To provide general guidelines for the safe administration of medications…POLICY…Orders for the administration of medications must be given by the physician…and include…the name of the medication, dosage, dilution, route, frequency of administration…It is the nurses responsibility to be knowledgeable of the medication to be administered, including indications, normal dosage range…side effects, expected therapeutic effect, proper antidote and incompatibilities…” During a review of a P&P titled, “MEDICATION PROFILE,” revised April 2021, the P&P indicated, “…PROCEDURE…Patient receiving medications administered by the organization will have current, accurate medication profile in the clinical record…Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications…a drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication…” 2.A review of Patient 3’s “Patient Information Sheet,” indicated that Patient 3 started care with diagnoses which included Cerebral Infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also known as a stroke). A review of Patient 3’s “Client Medication Report,” on 6/23/26 at 9:30 a.m. indicated, “…HYDROCODONE 5MG-ACETAMINOPHEN 325MG TABLET [a medication prescribed for pain] …Dose…1 tablet…Frequency…AS NEEDED…Route…ORAL…Instructions…2 TIMES DAILY AS NEEDED FOR PAIN…” A review of Patient 3’s “Client Medication Report,” on 6/23/26 at 9:30 a.m. indicated, “…TRAZODONE 50MG TABLET [a medication prescribed for inability to sleep] …Dose…0.5 tablet…Frequency…AS NEEDED…Route…ORAL…” During an interview and concurrent record review on 6/23/26 at 11:15 a.m. with the agency Administrator/Executive Director (ADM/ED) and the agency Director of Patient Care Services (DPCS), Patient 3’s “Client Medication Report,” and “Skilled Nurse Visit Notes,” were reviewed. The ADM/ED acknowledged that Patient 3 was prescribed Hydrocodone 5mg/Acetaminophen 325mg tablet one tablet orally as needed for pain. The ADM/ED stated that the risk of Patient 3 taking the pain medication without a time interval was drowsiness. The ADM/ED acknowledged that Patient 3 was prescribed Trazadone 50mg tablet 0.5 tablet orally as needed for inability to sleep. The ADM/ED stated that the risk of Patient 3 taking the medication without a time interval was drowsiness. The ADM/ED stated that the as needed medication orders should have a time interval. The ADM/ED acknowledged that the facility policy was not followed. A review of an agency policy and procedure (P&P) titled, “ADMINISTRATION AND DOCUMENTATION OF MEDICATIONS,” revised April 2021, the P&P indicated, “…As part of the assessment process, a drug history will be taken…A comparison will be made between the physician’s…orders and the current medication the patient is taking…Any discrepancies…should be reported to the physician for resolution…” A review of an agency P&P titled, “MEDICATION PROFILE,” revised April 2021, the P&P indicated, “…PURPOSE…To define the use of the medication profile in evaluating a patient’s medication regimen…POLICY…Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record…” Findings: 1. A review of Patient 1’s “Patient Information Report,” indicated that Patient 1 was admitted to the home health agency (HHA) with diagnoses which included chronic osteomyelitis (a persistent, progressive infection and inflammation of the bone and surrounding tissues that typically lasts longer than 4 weeks), heart failure (a condition where the heart muscle is too weak or too stiff to pump enough oxygen-rich blood to meet the body’s needs), and personal history of methicillin resistant staph infection (a contagious type of staph bacteria that is resistant to many common antibiotics). During a concurrent observation, interview, and record review, on 6/24/26 at 9:25 AM, at Patient 1’s home, Patient 1’s medication bottles were reviewed with Licensed Nurse (LN) 1. The following discrepancies were observed when compared to the medications Patient 1 was taking versus what the HHA documents titled, “Client Medication Report,” dated 5/13/2026, and the “HOME HEALTH CERTIFICATION AND PLAN OF CARE (POC -a written, doctor-approved roadmap outlining the specific medical services you will receive at home),” dated 4/25/26 and 6/24/26 indicated: a. Furosemide (a water pill used to remove excess water from the body) 40 mg (mg -milligrams, a unit of measure equal to 1/1000th of a gram) 1 tablet three times daily by mouth. -The Furosemide bottle was reviewed with LN 1, and the bottle indicated the directions were to take 1 tablet twice a day. Family Member (FM) 1 confirmed that Patient 1 was taking the medication twice a day and not three times per day and stated Patient 1 had been taking this medication twice a day for over a month. b. Hydroxyzine (an allergy medication used for sleep) HCL (hydrochloride) 10 mg 1 tablet by mouth at bedtime. -The Hydroxyzine bottle was reviewed with LN 1 and confirmed the difference was the bottle indicated 1-2 tablets as needed at bedtime. FM 1 confirmed that Patient 1 had been taking 2 tablets at bedtime for several months. c. Linezolid (an antibiotic used to treat serious lung and skin infections) 600 mg 1 tablet every 12 hours by mouth for 10 days. -Patient 1 no longer had the medication bottle because the medication was finished on 5/6/26. LN 1 confirmed the medication needed to be removed from Patient 1’s medication report and should have been removed during the last assessment for the recertification on 6/19/26. d. Metoprolol (a blood pressure medication that works by slowing your heart rate and relaxing your blood vessels, making it easier for your heart to pump blood throughout your body) 25 mg, 1 tablet once daily by mouth. -The Metoprolol medication bottle was reviewed with LN 1 and confirmed that the bottle indicated take 1 tablet twice daily. FM 1 stated that Patient 1 had been on the twice daily dose for over 18 years. During an interview on 6/24/25 at 9:29 AM with LN 1, LN 1 confirmed the discrepancies on Patient 1’s mediation report and POC and stated that it was important for the information to be accurate. LN 1 added they were supposed to complete the medication reconciliation and were required to review the bottles during each visit. LN 1 explained that Patient 1 had a recent recertification for services with a comprehensive assessment on 6/19/26 and the medications should have been updated on the medication report and POC dated 6/24/26. LN 1 stated it was important to review the medication bottles so that the HHA staff knew exactly what the patients were taking and could help prevent medication errors and provide proper medication education to the patients. During an interview on 6/24/26 at 4:11 PM with the Executive Director (ED), the ED stated it was her expectation that the nurses completed the medication reconciliation during the admission assessment and the recertification comprehensive assessments. The ED stated it was important for the nurses to review the bottles during reconciliation so they can educate the patients on their medications with the correct medication orders. A review of a facility provided policy and procedure (P&P) titled, “MEDICAITON PROFILE,” revised April 2021, indicated. “…Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications…1. Upon admission…initiate a medication profile to document the current medication regimen, including name, dose, strength, route, frequency, date and time…2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed…””

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review the facility failed to ensure the Plan of Care (POC, a personalized, doctor-prescribed document that details the medical, rehabilitative, and support services a patient needs at home) was authenticated and signed by the physician in accordance with state law and facility policy for one of eighteen sampled patients (Patient 5) when Patient 5’s POC dated 3/18/26 was not signed by the physician within the required 30 day time frame. This failure placed Patient 5 at risk of not receiving physician directed services. Findings: A review of Patient 5’s clinical document titled, “HOME HEALTH CERTIFICATION AND PLAN OF CARE,” (POC) dated 3/18/26, indicated Patient 5 was admitted to the agency with diagnoses which included chronic venous ulcer (a slow healing wound caused by impaired blood flow) of the right lower leg and type 2 diabetes (a chronic condition in which the body has trouble controlling blood sugar levels). During a concurrent interview and record review on 6/25/26 at 2:56 PM with the Administrator (ADM), the ADM confirmed patient 5’s POC dated 3/18/26 had not been signed by the physician. The ADM stated the agency’s process was to obtain verbal orders from the physician at the start of care and send the POC to the physician within 5 days for signature. The ADM further stated the agency then followed up with the physician to make sure the POC was signed within 30 days. The ADM stated if the timeline was getting close to 30 days without a signature the agency would create an action plan which included phone calls and visits to the physician’s office. The ADM further stated without a signed POC the agency could not ensure eligibility for services and could not bill insurance. During a review of a facility policy and procedure (P&P) titled, “ PHYSICIAN PARTICIPATION IN PLAN OF CARE,” revised April 2021, the P&P indicated, “…Policy…A physician …will direct the care of every home health care patient admitted for service…The attending physician …will participate in the care planning process by initiating, reviewing and revising the plan of care…The care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards of practice…The attending physician’s…verbal orders will be obtained at the time the plan of care is established…The attending physician… will sign the plan of care/treatment within 30 days of the start of care…” According to the California Code of Regulations Title 22, section 74697 for home health agencies, the sections reads, “...A written plan of treatment (or plan of care for home health agencies participating in the Medicare and/or Medi-Cal program) shall be established for each patient whose care requires medical orders. A plan of treatment or plan of care for patients requiring medical orders shall be: (1) Approved and signed within 30 working days by the attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice...””

“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 observation, interview, and record review, the facility failed to coordinate care for recommended medical equipment in a timely manner for one of 18 sampled patients (Patient 6), when on 5/28/26 the Occupational Therapist (OT) did not contact Patient 6’s physician to request a referral for medical equipment that Patient 6 needed for safety. This failure increased the risk of injury to Patient 6 during transfers and caused a delay in the delivery of the needed equipment for a shower/tub chair, a tub transfer bench, and a bedside commode (a portable, chair-like device with a toilet seat and a removable collection bucket). Findings: A review of Patient 6’s “HOME HEALTH CERTIFICATION AND PLAN OF CARE (POC -a written, doctor-approved roadmap outlining the specific medical services you will receive at home)” dated 5/25/26 indicated that Patient 6 was admitted to the home health agency (HHA) with diagnoses that included end stage renal disease (ESRD -also known as kidney failure, it is the final, permanent stage of chronic kidney disease), heart failure (when the heart muscle does not pump blood as effectively as it should), and hemiplegia following a stroke (paralysis of the muscles on one entire side of the body, affecting the face, arm, and leg), affecting the left side of the body. A review of Patient 6’s POC dated 5/25/26, indicated under the section “DME [Durable Medical Equipment] and Supplies,” included a shower chair and a tub chair. A review of Patient 6’s “Visit Note Report,” dated 5/28/26, written by the OT, indicated, “…DURABLE MEDICAL EQUIPMENT RECOMMENDED…TUB TRANSFER BENCH…SHOWER CHAIR…PRECAUTIONS: FALL RISK…” During a concurrent observation and interview on 6/24/26 at 11:05 AM, at Patient 6’s home visit, the OT assessed the bathroom of the residence and asked family member (FM) 2 if they had received the equipment she recommended of a shower/tub chair and a tub transfer bench, and bedside commode. FM 2 stated they had not received the bedside commode or shower/tub chair, or the tub transfer bench that the OT had recommended during the initial assessment on 5/28/26 and added that it had been more than three weeks since then. The OT stated she would follow up with Patient 6’s primary physician. During a telephone interview on 6/25/26 at 12:27 PM with FM 2. FM 2 stated that Patient 6 had been recommended by the OT a need for a shower/tub chair, tub transfer board, and a bedside commode during the initial OT evaluation. FM 2 confirmed they had not received the medical equipment and added the only thing that was delivered was a hospital bed and a mechanical lift (a mechanical device that helps caregivers safely move individuals with limited mobility). FM 2 stated the equipment would be helpful for safe transfers, when the family bathed Patient 6, and when he needed to use the bathroom. During a concurrent interview and record review on 6/25/26 at 11:45 AM with the Executive Director (ED), the ED reviewed Patient 6’s medical record (comprehensive, chronological history of a person’s health and medical care) and confirmed there were no coordination of care notes documented for the order of the medical equipment of the shower/tub chair, tub transfer bench or bedside commode. The ED confirmed their process was to document any contact with the physician under the coordination of care area of the medical record that they contacted the physician. The ED explained that their office ‘does not” order medical equipment and it had to be done through Patient 6’s primary physician office. During a follow-up telephone interview on 6/25/26 at 12:48 PM, with the OT, the OT stated she had put in the order for the medical equipment. A review of Patient 6’s medical record coordination of care tab revealed a note entered by the OT on 6/25/26 at 12:40 PM that she contacted Patient 6’s physician and requested a referral for the medical equipment of a bedside commode and a shower chair with arms. The OT stated she had thought it was previously ordered and stated she should have followed up with her assistant and made sure the needed equipment was ordered after the initial assessment on 5/28/26. The OT stated it was important for Patient 6 to have the needed equipment for safety, to increase patient independence and to decrease care giver need. A review of the facility provided policy and procedure (P&P) titled, “CARE/SERVICE COORDINATION,” revised April 2021, indicated, “…Timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided…4. Care coordination will include…E. Timely documentation of coordination of care activities…I. Integration of services, whether services are provided directly…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…Documentation of all communications will be included in the clinical record on a communication note…Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication…””

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure one of three sampled patients (Patient 1) and their legal representative (someone authorized by law to act for another person’s behalf) had the opportunity to participate in the plan of care (an individualized outline of a patient’s health conditions, specific needs, and treatment goals) when the legal representative requested that nursing services (nursing services focuses on skilled assessments, pain management, and quality of life) be provided for Patient 1 and the request was not communicated to the agency staff. This failure resulted in a delay in Patient 1’s nursing evaluation (a physical assessment and assessment of needs) for nursing services and a lack of communication and understanding between Patient 1’s legal representative, Patient 1, and the agency staff. A review of Patient 1’s clinical document titled, “Patient Information Report,” indicated he was admitted to the agency with a diagnosis of primary osteoarthritis (a disease that causes joint pain and stiffness) of the left hip. A review of Patient 1’s “Patient Information Report,” indicated, “…Coordination Notes…12/18/2025 3:29:53 PM…RCVD [received] CALL FROM CAREGIVER…WHO STATED SHE WOULD LIEK (SIC) THE RN [registered nurse] TO COME OUT NOW…SHE FEELS THE PATIENT WOULD BENEFIT FROM RN SERVICES…” During a concurrent interview and record review on 1/6/26 at 2:30 PM with the Vice President of Operations (VPO), the VPO confirmed there was no documentation in Patient 1’s electronic health record (EHR) to indicate a RN had been informed of the request for nursing services or that an assessment for nursing services had been completed. The VPO stated it was her expectation that the caregiver would have been informed if nursing services was not indicated for Patient 1. The VPO further stated communication with the legal representative should have been documented in Patient 1’s EHR. A review of a facility policy and procedure titled, “Care Planning Process,” revised 4/21, indicated, “…Purpose to provide clinical direction to the clinicians providing direct patient care…At the time of the initial assessment, the clinician…will develop the patient plan of care based on patient identified needs and will review with the patient and family/caregiver…””

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on interview and record review, the agency failed to provide written instructions outlining the Physical Therapy (PT, treatment that helps improve how the body performs physical movements) visit schedule for one of three sampled patients (Patient 2). This failure resulted in Patient 2 not being aware of the days and times of her physical therapy visits which caused a disruption in her schedule and the potential for psychosocial distress. A review of an agency document titled, “Client Census Report,” the document indicated that Patient 2 was admitted to agency services with diagnosis which included a fractured left femur (break of the thigh bone). During a telephone interview on 1/6/26 at 2:56 PM with Patient 2, Patient 2 stated she had been expecting a call from PT to schedule her weekly visit, and she still had not heard from anyone. Patient 2 further stated she would have liked to be able to plan her days in advance. Patient 2 stated she did not know why the visits were not scheduled ahead of time. Patient 2 further stated her time was valuable and she should not have had to wait around to be called or have to chase the staff down. During a telephone interview on 1/16/26 at 8:11 AM with the Vice President of Operations (VPO), the VPO stated it was her expectation that the Patient 2’s visits should have been scheduled and put on the calendar ahead of time. The VPO further stated that Patient 2 should have been able to plan her day according to the pre-scheduled PT visit times. The VPO stated agency staff should have called Patient 2 the day before an appointment to confirm a visit not to schedule a visit. A review of a facility policy and procedure titled, “Care Planning Process,” revised 4/21, indicated, “…Purpose to provide clinical direction to the clinicians providing direct patient care…At the time of the initial assessment, the clinician…will develop the patient plan of care based on patient identified needs and will review with the patient and family/caregiver…The organization shall provide the patient and caregiver with a copy of written instructions outlining…Visit schedule, including frequency of visits by personnel and personnel acting on behalf of the agency…””