Compassionate Care Home Health Agency, LLC

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to conduct a comprehensive assessment within five days of the start of care for one of five sampled patients (Patient (Pt)) 1, when there was a physical therapy (PT) evaluation appointment made on 8/5/26, which was 12 days after the start of care date on 7/24/26. This failure had the potential to place Pt 1 at risk for delayed care, falls, safety issues and hospitalization. Findings: During a review of Pt 1’s “Home Health Certification (physician’s or allowed practitioner’s (a Nurse Practitioner or Physician Assistant) attestation that a Medicare beneficiary is eligible for home health services and Plan of Care (document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home (HHCPC),” undated was reviewed. The “HHCPC” indicated, Pt 1’s start of care was dated 7/24/26 with a primary diagnosis of cellulitis (a skin infection that causes swelling and redness), open wound left lower leg, chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), retention of urine, and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and the PT evaluation was scheduled from 8/1/26-8/31/26. During a concurrent interview and record review on 7/30/26 at 11:14 a.m. with the Director of Patient Care Services (DPCS), Pt 1’s referral documentation titled, “Home Health Packet,” undated was reviewed. The referral documentation indicated Pt 1 was to start HHA services for nursing and physical therapy. The DPCS stated Pt 1 started services with the agency on 7/24/26 and was admitted to services by a registered nurse (RN). The DPCS stated an RN put an evaluation for one time a month. The DPCS stated, “We did not have an available PT until that date.” The DPCS stated the intake coordinators were responsible for ensuring the visit was scheduled. The DPCS stated the intake coordinator plotted a visit for Pt 1’s PT evaluation on 8/5/26. The DPCS stated the PT should have been scheduled to make an initial visit within five days. The DPCS stated the PT evaluation was needed to prevent delays in care and could have placed Pt 1 at risk for falls and injuries and returning to the hospital. During an interview on 7/30/26 at 2:30 p.m. with the Intake Coordinator Supervisor (ICS), the ICS stated Pt 1’s start of care was on 7/24/26. The ICS stated Pt 1 was admitted by an RN on 7/24/26. The ICS stated the PT evaluation should have been scheduled within five days after the start of care. The ICS stated the PT appointment was scheduled by Intake Coordinator (IC) 2. The ICS stated IC 2 scheduled the initial evaluation visit for Pt 1’s PT evaluation on 8/5/26. The ICS stated, “I am not sure why the PT did not go out within five days.” The ICS stated the PT should have been scheduled for PT evaluation within five days for patient safety and could place patients at risk for falls and injuries. During an interview on 7/30/26 at 3:01 p.m. with IC 1, IC 1 stated Pt 1 was admitted on 7/24/26. IC 1 stated she was responsible for ensuring the initial start of care visit was scheduled by the RN. IC 1 stated she did not make the initial schedule for the PT evaluation and that was done by another IC. IC 1 stated patients need to be seen within five days to ensure they received proper care and safe discharge. IC 1 stated a delay in care could have caused wounds (an injury to living tissue caused by a cut, blow, or other impact) to become infected, missed medications and could have affected the quality of care. IC 1 stated patients should have been seen by all disciplines within five days to prevent them from going back to the emergency room and be re-admitted to the hospital. During an interview on 7/30/26 at 3:13 p.m. with IC 2, IC 2 stated she was responsible for scheduling all types of disciplines for the HHA for multiples counties. IC 2 stated the HHA received the referral for Pt 1 on 7/21/26 for PT and nursing services. IC 2 stated “We will then check for the clinician availability.” IC 2 stated, “We have a spreadsheet and what days the clinicians were available.” IC 2 stated Pt 1’s start of care was on 7/24/26 with nursing services. IC 2 stated Pt 1 was scheduled to start PT on 7/31/26. IC 2 stated she checked and confirmed Pt 1 was scheduled for PT evaluation on 7/31/26. IC 2 was asked if there was a certain amount of days that PT should have been scheduled after start of care services with the HHA. IC 2 stated there was no amount of days that the PT needs to see Pt 1 after start of care. IC 2 stated it was dependent on availability. IC 2 stated “There was no PT available for 7/25/26 and the soonest PT we had available was on 7/31/26 and we schedule one for 7/31/26.” IC 2 stated she coordinated the visits with the Physical Therapist Codirector (PTC) to check for availability for the PT (s). IC 2 stated, “It was important to schedule all disciplines visits to ensure the care won’t be delayed.” During an interview on 7/30/26 at 3:30 p.m. with the ICS, the ICS stated whoever is doing the portal ( a system that is used for referrals) was responsible for ensuring the PT evaluation was scheduled for Pt 1. The ICS stated she was not sure how IC 2 got the date of 7/31/26 for the PT evaluation and it should have been on 8/5/26.. The ICS stated IC 2 was the one who set up the appointment on 8/5/26. The ICS stated the PTC was responsible for the scheduling along with the IC. During an interview on 7/30/26 at 3:50 p.m. with the Physical Therapist Codirector (PTC), the PTC stated patients should have been seen within five days after the start of care. The PTC stated, “It was important for coordination of care.” The PTC stated the PT does not schedule the initial evaluation visit. The PTC stated, “We do not plot visit frequencies, and we do not see our schedules.” The PTC stated, “We should not delay care due to availability of the therapist.” The PTC stated, “We need to meet their needs.” The PTC stated, “Patients are expecting us to be there, and we want to make sure the patient is safe.” The PTC stated, “We need to facilitate timely evaluations.” The PTC stated, “We do teach patients who are a risk for falls and teach how to reduce them.” The PTC stated the PT evaluation would help with safety issues. During an interview on 7/30/26 at 4:19 p.m. with the Administrator (ADM), the ADM stated it was important to see Pt 1 within 5 days to prevent a delay in care. The ADM stated, a comprehensive care was not done for Pt 1. The ADM stated the PT evaluation should have been scheduled within five days after the start of care and not seeing Pt 1 within five days could have placed Pt 1 at risk for falls, delay in care, decline in health and rehospitalization. During an interview 7/31/26 at 8:35 a.m. with Family Member (FM) 1, FM 1 stated Pt 1 and FM 1 were trying to get Pt 1’s balance and exercise to have core strength for Pt 1 to pull up when he fell. FM 1 stated, “We did not know anything about the PT evaluation, and we never got that far.” FM 1 stated Pt 1 fell while at a cardiologist’ s (a doctor who specializes in the study or treatment of heart diseases and heart abnormalities) appointment and was admitted to the hospital on 7/29/26. FM 1 stated, “We had no idea PT was ordered and did not know about the PT evaluation.” During a record review of the agency’s policy and procedures (P&P) titled, “Initial and Comprehensive Patient Assessment,” dated 1/1/2024, the P&P indicated, “[Home Health Agency Name] will ensure that all patients referral for care/services will receive an initial assessment… the Home Health agency (HHA) will then provide each patient with a patient-specific comprehensive assessment that accurately reflects the patient’s current health. The comprehensive assessment must be conducted in a timely manner, consistent with the patient’s immediate needs, but no later than five calendar days after the start of care…all patients with physician-ordered Therapy…will have a discipline-specific assessment conducted. When these care/services are ordered, the therapist…will perform the initial evaluation within a time established by the agency unless the physician or patient specifies differently…the patient-specific comprehensive…””

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interviews and record reviews, the Home Health Agency (HHA) failed to coordinate care delivery for one of five sampled patients (Pt 2), when Pt 2’s start of care (SOC) appointment was scheduled five days after the referral date and was not completed within the required 48 hours after referral, and staff did not document communication with the physician regarding the delay. This failure limited the physician’s ability to make an informed clinical decision regarding Pt 2’s care and placed Pt 2 at risk for delayed care, injury, rehospitalization, infection, and decline in health. Findings: During a review of Pt 2’s “Home Health Certification (physician’s or allowed practitioner’s (a Nurse Practitioner or Physician Assistant) attestation that a Medicare beneficiary is eligible for home health services and Plan of Care (document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home (HHCPC),” undated was reviewed. The “HHCPC” indicated, Pt 2’s start of care was dated 7/28/26 with a primary diagnosis of hemiplegia following cerebral infarction affecting right dominate side (paralysis that affects only one side of your body), history of falling, hypertension (high blood pressure), and anxiety. During a concurrent interview and record review on 7/30/26 at 1 p.m. with the Director of Patient Care Services (DPCS), Pt 2’s “Referral Order (RO),” dated 7/23/26 was reviewed. The “RO” indicated, “Physical Therapist Referral…Notes…had stroke (medical emergency that happens when blood flow to part of the brain is blocked or when a blood vessel in the brain bursts), not driving needs home health PT…” The DPCS stated Pt 2’s SOC was on 7/28/26. The DPCS stated the SOC should have been done within 48 hours after the referral. The DPCS stated he spoke with Intake Coordinator Supervisor (ICS) and she did not notify the physician about the admission starting past 48 hours. The DPCS stated the ICS should have documented the communication between her and the physician when there was a delay in the SOC. The DPCS stated the clinical documentation should be justified for the delay in the SOC. During a concurrent interview and record review on 7/30/26 at 1:53 p.m. with the ICS, Pt 2’s “RO,” dated 7/23/26 was reviewed. The ICS stated, “I got the referral on 7/23/26.” The ICS stated Pt 2 had a stroke and needed PT. The ICS stated Pt 2’s SOC was scheduled for 7/28/26. The ICS stated, “It was pushed for three days past the 48 hours.” The ICS stated Pt 2 should have a SOC appointment within 48 hours after the referral. The ICS stated the agency had issues with insurance. The ICS stated, “We should have informed the patient and referral source (physician office) about the delay in start of care.” The ICS stated there should have been a note to in the clinical record about notifying the physician when the admission went past 48 hours. The ICS stated, “No communication note was done.” The ICS stated patients could have injuries, delayed care and rehospitalization when they were not admitted within 48 hours. The ICS stated she should have informed the physician for coordination of care. The ICS stated the physician would not know about what was happening with the care and would not be able to help the agency guide Pt 2’s care when they were not informed of the delay in SOC. During an interview on 7/30/26 at 2:30 p.m. with the Administrator (ADM), the ADM stated the SOC should have been done within 48 hours after receiving the referral. The ADM stated, “When the SOC was delayed by the patient there should have been a note stating who they communicated with and it should be documented in the clinical note.” The ADM stated it was important to admit patient within 48 hours for patient safety. The ADM stated clinicians should have been out there within 48 hours to develop a care plan to prevent patients from injuries and hospitalization. The ADM stated patients were at risk for infection, injuries and decline in health. The ADM stated, “It should be documented to ensure paper trail and to ensure we all have the same information.” The ADM stated, “We need to have all the information together and provide information to all parties involved.” The ADM stated that the physician should have been notified. The ADM stated the physician would not know the status of the patients and would not be able to do follow-up when they were not informed. During an interview on 7/31/26 at 9:30 a.m. with the DPCS, the DPC stated patients were at risk for injuries, delayed care and rehospitalization when there was a delay in the SOC. The DPCS stated the home health agency should have informed the physician for coordination of care. The DPCS stated the physician should have been notified about the delay in care so they can be involved in the care and could have guided the home health agency. The DPCS stated the physician should have been notified to ensure coordinated care and informed clinical decisions. During a record review of the agency policy and procedure (P&P) titled, “Initial and Comprehensive Patient Assessment” dated 1/1/2024, the P&P indicated, “[Home Health Agency Name] will ensure that all patients referred for care/service will receive an initial assessment. The initial assessment will be conducted within 48 hours of referral or within 48 hours of the patient’s return home, or on the physician’s ordered start-of-care date…The therapist will perform the initial evaluation within the time frame established by the organization unless the physician or allow practitioner or patient specifics differently. Documentation of any such delayed will be conducted in the clinical record including the physician or allowed practitioner’s awareness/approval of such delayed…””

“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 Condition of Participation (COP) for Care planning, coordination of services, and quality of care was not followed when: 1. Home health agency failed to follow their policy and procedure titled, “Plan of Care” for one of four sampled patients (Patient (Pt)) 3, when drainage dressing changes were completed without a physician order for treatment of Pt 3’s diverticulitis (inflammation or infection of the large intestine) abscess (localized collection of pus). (Refer to G0580) 2. Physical Therapist Co- director (PTC) 2 failed to notify the physician promptly when Occupational Therapy (OT) services were discontinued for one of four sampled patients (Patient (Pt) 4).(Refer to G0588). 3. The Physical Therapist did not coordinate a meeting time for the home visit on 6/16/26 for one of three sampled patients (Pt 3). (Refer to G0608). 4. A copy of the CMS 485 (standardized document used by the Centers for Medicare & Medicaid Services (CMS) for the Home Health Certification and Plan of Care containing written instructions for visit schedules, medications, treatments to be administered, and other pertinent information) documents and the name of the clinical manager was not provided for one of three sampled patients (Pt 3) during a home visit. (Refer to G0612) 5. The clinical manager’s name was not provided to three of three sampled patients (Patient (Pt) 1, 2, and 3) during home visits (Refer to G0622). The cumulative effects of these systemic failures resulted in the agency’s substantial non-compliance in providing care in a quality and safe setting.”

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to provide a copy of the CMS 485 (standardized document used by the Centers for Medicare & Medicaid Services (CMS) for the Home Health Certification and Plan of Care containing written instructions for visit schedules, medications, treatments to be administered, and other pertinent information) documents and the name of the clinical manager for one of three sampled patients (Patient (Pt) 3), when the admission booklet and folder did not contain the information during a home visit on 6/16/26. This failure caused confusion for Pt 3 and Family Members (FM) had the potential for gaps in care coordination, medication errors, and unsafe outcomes. Findings: During a concurrent interview and record review on 6/16/26 at 1:46 p.m. with Pt 3, FM 2, and FM 3, Pt 3’s “folder containing the home health agency written documents,” undated were reviewed. The folder did not contain written instructions outlining visit frequency, medications, treatments and clinical managers information. The admission booklet did not contain the clinical manager’s name. FM 2 stated they did not receive a printout of the agency documentation containing the information. FM 2 stated she did not know “what was going on.” FM 2 stated the family felt confused and frustrated and wanted written information to understand the care provided to Pt 3. FM 3 stated Registered Nurse (RN) 1 performed dressing changes for Pt 3’s diverticulitis (inflammation or infection of the large intestine) abscess (localized collection of pus) drainage, while RN 2 did not. FM 2 stated written instructions would have helped the family understand coordination of care between the family and agency staff and clarify the nurses’ responsibilities. FM 2 stated they did not know the name of the clinical manager and would like to know who to contact for concerns regarding the care. During an interview on 6/17/26 at 1:27 p.m. with RN 2, RN 2 stated, “I should have printed out the plan of care and brought it to the patient.” RN 2 stated, “I never got one for her and she did not get one.” RN 2 stated there was no written information for this patient, and she did not realize it was not there. RN 2 stated, “The CMS 485 has everything we discussed, and they can look at it to see what our plan of care and to see what the goals were.” RN 2 stated, “It’s patient’s right to know what was going on.” RN 2 stated, “It was good information to provide for the rest of the family so they would know what was going on.” RN 2 stated that not providing the written plan could cause confusion and affect patient safety. During an interview on 6/18/26 at 9:39 a.m. with the Assistant Director of Nursing (ADON), the ADON stated Pt 3 and her family should have been provided with the information at the start of care. The ADON stated disciplines should have explained what was being provided by the home health agency and the patients should have been provided the CMS 485 at the next scheduled visit. The ADON stated providing the CMS 485 was important for patients and families to be involved in the care and better outcomes. The ADON stated the written instructions provided coordination of care and services being provided. The ADON stated patients and families could have refused treatment if they were not involved and patients could have had bad outcomes. The ADON stated, “Patients and families would not know what was going on and the patient would not know what to expected.” The ADON state the clinical manager’s name should have been provided. The ADON stated the nurses were expected to review the care plans and update care plans when there were any changes to the patients’ plan of care. The ADON stated licensed staff should update medication changes on the CMS‑485 or medication list and that failing to do so increased the risk of medication errors or cause harm when taking incorrectly. . During a review of the HHA’s policy and procedures (P&P) titled, “Patient Written Instructions,” dated 1/1/2026, the P&P indicated, “[Name of Home Health agency] will provide the patient and caregiver with a copy of written instructions regarding the care/services to be provided. Clear written communication between the Home Health Agency (HHA) and the patient, patient’s caregiver, the representative, if any, helps ensure that patients and families understand what services to expect from the HHA, the purpose of each service, and when to expect these services…procedure… written instructions/documents will be provided to the patient and/or his/her caregiver and/or representative…if any, no later than the next visit after the plan of care has been approved… a visit schedule including the frequency of visits by all home health disciplines and others… medication schedule/instructions…any treatments to be administered by the home health clinician… wound treatment…therapy… other pertinent instruction such as equipment…HHA clinical manager, including the clinical manager’s telephone number…””

“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 use standard precautions to prevent transmission of infections for two of three sampled home visit patients (Patient [Pt]1 and Pt 2) when Registered Nurse Supervisor (RNS) and Registered Nurse (RN) 3 did not follow standards of practice for Pt 1 and Pt 2’s peripherally inserted central catheter (PICC-a long, thin, flexible tube inserted into a vein in your upper arm used for delivering medications, fluids, or nutrition, and for drawing blood) line dressing change during home visits. This failure placed Pt 1 and Pt 2 at risk for cross-contamination, infections, sepsis (a life-threatening response to an infection), hospitalization and death. Findings: During an observation on 6/10/26 at 10:32 p.m. in Pt 2’s living room, the RNS prepared a sterile field for a PICC line dressing change. The RNS donned clean gloves, removed the old dressing, and swabbed the PICC line insertion site from left to right with an alcohol swab. While still wearing the same gloves the RNS searched for the patient’s supply box for additional items. After gathering the items, the RNS returned to the procedure, removed the glove without performing hand hygiene and applied new clean gloves. The RNS swabbed the insertion site with chlorhexidine swab (CHG- a broad-spectrum antiseptic used to kill and prevent the growth of bacteria, fungi, and viruses) removed the gloves without performing hand hygiene and then donned (put on) sterile gloves. The RNS applied a CHG‑impregnated bio‑patch (a specialized, absorptive foam dressing) to the insertion site, obtained a clear dressing, and applied it over the bio‑patch and PICC line. With sterile gloves still on, the RNS obtained items for laboratory collection. The RNS then removed the sterile gloves, performed hand hygiene, and applied new gloves to collect blood from the PICC line. During an interview on 6/11/26 at 11:36 a.m., the RNS stated she received training on PICC line dressing changes prior to going on maternity leave but did not recall the date. The RNS stated she did not apply sterile gloves before providing the cleansing of the insertion site. The RNS stated she donned sterile gloves prior to applying the bio‑patch and dressing because the bio‑patch contacts the insertion site. The RNS stated all clinician with direct contact with patients should have performed hand hygiene at the beginning of the procedure and again after removing gloves and before donning new gloves. The RNS stated that hand hygiene is essential to prevent infections and that patients are at risk for sepsis and hospitalization. The RNS also stated they [who] are responsible for completing skills check‑offs for new hires. During an observation on 6/15/26 at 11:00 a.m. in Pt 1’s room, Registered Nurse (RN) 3, RN 3 performed hand hygiene, retrieved a blue barrier pad, placed the barrier pad on the patient’s right side, gathered the procedure tray, obtained supplies from the closet, performed hand hygiene, and applied gloves. RN 3 then opened packages of supplies, placed items on the barrier pad, opened the sterile field, checked the adapter with normal saline, donned a mask, cleansed the lumen tip with an alcohol pad, flushed the line, removed the old adapter, applied a new adapter cap, and removed gloves. RN 3 did not perform hand hygiene prior to donning sterile gloves. During an interview at 6/15/26 at 12:25 p.m. with RN 3, RN 3 stated, “We should always performed hand hygiene before applying gloves.” RN 3 stated she should have performed hand hygiene before applying the sterile gloves. RN 3 stated it was important to prevent cross-contamination. RN 3 stated the failure to perform hand hygiene before donning sterile gloves places patients at risk for infection, sepsis, hospitalization, and death. During an interview on 6/18/26 at 11:50 a.m. with the Assistant Director of Nursing (ADON), the ADON stated RNs were trained by being paired with nurses, and RNs were provided with a skills check‑off list. The ADON stated it was important to follow the standard of practice for cleaning a PICC line to prevent infection. The ADON stated patients could develop an infection, become septic, require hospitalization, or die when proper procedures were not followed. The ADON stated the process should always be performed the same way. ADON stated nurses should perform hand hygiene between glove changes because it is necessary to prevent infection. During a review of Pt 1’s “Home Health Certification (physician’s or allowed practitioner’s [like a Nurse Practitioner or Physician Assistant] attestation that a Medicare beneficiary is eligible for home health services and Plan of Care [document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home [HHCPC[),” dated 5/6/26, the “HHCPC” indicated, “[Pt 1] Interventions: [Skilled Nurse] to perform central line dressing change…use clean technique remove and discard old dressing. Perform hand hygiene. Using sterile technique, open sterile PICC line dressing kit, don sterile gloves and face mask. Using friction, cleanse the site. Apply surrounding areas with chlorhexidine for 30 seconds. Place bio patch on the insertion site. Apply skin prep to the surrounding areas. Apply securement device, cover with a transparent dressing, follow by the date of dressing change and initials. Change out alcohol impregnated caps to lumen…” During a review of Pt 2’s “HHCPC,” dated 5/25/26, the “HHCPC” indicated, “…Interventions: [Skilled Nurse] to perform central line dressing change…use clean technique remove and discard old dressing. Perform hand hygiene. Using sterile technique, open sterile PICC line dressing kit, don sterile gloves and face mask. Using friction, cleanse the site. Apply surrounding areas with chlorhexidine for 30 seconds. Place bio patch on the insertion site. Apply skin prep to the surrounding areas. Apply securement device, cover with a transparent dressing, follow by the date of dressing change and initials. Change out alcohol impregnated caps to lumen…” During a review of the agency’s policy and procedure (P&P) titled, “Infection Control,” dated 1/1/24, the “P&P” indicated, “[Name of home health agency] will maintain and document an infection control that aims to prevent and control the spread of infections and communicable diseases…conform to the acceptable standards of infection control pertaining to home health services issued by Centers for Disease Control (CDC), the Agency for Healthcare Research and Quality, state practice act, commonly acceptable stands established by national organizations…hand hygiene must be performed at least in the following instances: …prior to donning sterile or non-sterile gloves…after removing gloves… During a review of the agency’s skills list titled, “Peripherally Inserted Central Catheter: Dressing change (Home Health Care)” undated, the skills list indicated, “…Prepare a work area in a clean, accessible location and assemble the necessary supplies…9. clean hands and put on clean gloves… 19. remove gloves and clean hands and put on sterile gloves. 20. cleanse the insertion site with a single -se sterile application with an alcohol-based chlorhexidine solution…apply sterile alcohol…23. Place a sterile dressing on the site.”

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on interviews and record review the home health agency failed to ensure one of four sampled patients (Patient (Pt)) 1, was provided with a timely response for a complaint investigation when Family Member (FM) 1 complained on 4/28/26 and no follow up investigation was provided. This failure resulted in Pt 1 and FM 1 feeling dismissed and upset and had the potential to cause illness and hospitalization when for Pt 1 when home health services were requested to be discontinued. Findings: During a review of Pt 1’s “Home Health Certification (physician’s or allowed practitioner’s (like a Nurse Practitioner or Physician Assistant) attestation that a Medicare beneficiary is eligible for home health services and Plan of Care (document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home (HHCPC),” dated 5/6/26, the “HHCPC” indicated, “[Pt 1] services period was on 4/19/26 -6/17/26…Skilled nursing visit 4/19/2026-4/24/26…1 visit per week for 8 weeks…Narrative: stated/order details: Central line dressing change, labs, wound care, infection prevention and control education…” During an interview on 6/15/26 at 12:49 p.m. with FM 1, FM 1 stated he called the home health agency on 4/27/26 and spoke to the front desk to file a complaint regarding Pt 1’s peripherally inserted central catheter (PICC line- a long, thin, flexible tube inserted into a vein in the upper arm used for long-term intravenous treatments, including chemotherapy, antibiotics, blood transfusions, and frequent blood draws) treatment visit on 4/20/26 by a registered nurse supervisor. FM 1 stated he wanted to make a complaint about the Registered Nurse Supervisor. FM 1 stated the RNS left the lumen adapter ( also called a needleless connector, hub, or extension set) is the small, specialized plastic valve attached to the external end of each tube (lumen) of a PICC line) out and caused Pt 1 to get an infection. FM 1 stated he spoke with the Director of Patient Care Services (DPCS) and exchanged emails regarding their conversation regarding the visit. FM 1 stated on 5/17/26, he sent an email to the home health agency for an update regarding the investigation. FM 1 stated he has not gotten an email reply from the home health agency. FM 1 stated he felt the home health agency did not do their “due diligence” and “did not do what they were supposed to do.” FM 1 stated he would like to hear from the home health agency and felt dismissed. FM 1 stated he felt angry. During an interview on 6/18/26 at 12:07 p.m. with the ADON, the ADON stated we should have notified Pt 1 and FM 1 to update them about our investigation. The ADON stated it was important to provide coordination of care for Pt 1. The ADON stated the home health agency provided an education for the staff involved in the complaint. The ADON stated FM 1 wanted a copy of the home health agency’s resolution and should have gotten one. The ADON stated FM 1 and Pt 1 had the right to find out what happened with the investigation for patient satisfaction and for the nurse’s accountability. The ADON stated FM 1 and Pt 1’s rights would have been violated when they did not get a complaint resolution, and Pt 1 and FM 1 could have been upset. The ADON stated FM 1 wanted to speak to the DPCS and she notified him of the request. The ADON stated the DPCS was responsible for notifying FM 1 regarding the outcome. The ADON stated she expected the family to be notified timely and it was not done timely since it has been past 50 days. During an interview and record review on 6/18/26 at 3:32 p.m. with the DPCS, FM 1 and the DPCS’s the “Email Record (ER),” dated 6/18/26 was reviewed. The “ER” indicated on 5/17/26 at 11:08 a.m. FM 1 requested an update on the investigation. The DPCS stated he had not seen the email. The DPCS stated FM 1 called the office and the call was routed to the ADON because the complaint was about a supervisor. The DPCS stated the ADON reached out to him. The DPCS stated FM 1 called to complain about a treatment done by the registered nurse supervisor. The DPCS stated he told FM 1 he would follow up on the complaint. The DPCS stated the ADON started the complaint investigation and training, but he has not investigated any further. The DPCS stated he has not respond to FM 1’s complaint investigation. The DPCS stated, “It was not common practice, and it took longer for us to determine the outcome because of the circumstances.” The DPCS stated the home health agency has not come up with the “objective determination.” The DPCS stated, “This complaint warranted more time.” The DPCS stated he should have replied to the email the same day. The DPCS stated, “I should have responded in a more timely manner.” The DPCS stated the Administrator (ADM), the ADON, the director of therapy and himself should have addressed the complaint during their Quality Assurance Performance Improvement meeting. The DPCS stated the investigation took a long time due to incomplete documentation from the hospital. The DPCS stated the investigation was not finalized. The DPCS stated, “I have been training the new nurses in San Luis Obispo” and had not looked into the issue. The DPCS stated he would handle it when he got back. The DPCS stated the complaint should have been investigated. The DPCS stated the allegation was regarding infection control. The DPCS stated it was important to complete the investigation to prevent patients at risk for infection. The DPCS stated he understood “why the complainant could have been upset when they did not get a follow up on the investigation.” During an interview on 6/18/26 at 4:21 p.m. with the ADM, the ADM stated, “When a patient call to file a complaint they could call the office to speak to the supervisor.” The ADM stated, “The supervisor’s responsibility is to follow and document about the complaint and what occurred.” The ADM stated the complaint should have the investigation done timely. The ADM stated, “We should have responded to the complaint within 24 hours.” The ADM stated, “Some complaints take longer and you should keep the patient in the loop.” The ADM stated, “It was important to not interrupt in patient care, and it should be addressed appropriately.” The ADM stated FM 1 and Pt 1 could have requested to discontinue services from the agency and it could have caused her to become ill and hospitalized. The ADM stated, “It could have been detrimental to their care.” The ADM stated it could have caused damage in relationships with the patient and the agency. The ADM stated FM 1 and Pt 1 had the right to receive follow up in a timely manner. During a review of the agency’s policy and procedure (P&P) titled, “Patient Grievance/Complaint,” dated 1/1/2024, the P&P indicated, “…[ Home Health Agency name] will investigate complaints made by a patient, the patient’s representative…including but not limited to treatment or care…[Home Health Agency name] investigates and attempts to resolve all patient grievances/complaints and document the results within a described time frames as defined…report status of activities to the patient within 5 days following receipt of the complaint…a written notification of the results of the investigation and the response to the investigation will be provided to the patient/complainant within 10 days of completing the investigation…” During a review of the home health agency’s admission booklet titled, “Patient Orientation for Home Health Care,” undated, the admission booklet indicated, “…Section 3. Patient Rights and Responsibilities…Your rights…you have the right to…have your complaints as well as your family’s or your representatives’ complaints heard, investigated and …. resolved…Receive information on our complaint resolution process and know about the results of complaint investigation…””

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview and record review the home health agency failed to follow their policy and procedure (P&P) titled, “Plan of Care,” for one of four sampled patients (Patient (Pt)) 3 when the drainage dressing changes were completed without a physician order for treatment of Pt 3’s diverticulitis (inflammation or infection of the large intestine) abscess (localized collection of pus). This failure placed Pt 3 at risk for improper treatment, missed signs of infection, and potential complications. Findings: During a review of Pt 3’s “Home Health Certification (physician’s or allowed practitioner’s [a Nurse Practitioner or Physician Assistant] attestation that a Medicare beneficiary is eligible for home health services and Plan of Care [document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home] [HHCPC]),” resume dated 6/1/26 was reviewed. The “HHCPC” indicated, “[Pt 3] episode period was on 4/22/26-6/20/26... primary diagnosis: [diverticulitis of large intestine with perforation (hole) and abscess without bleeding…Orders and Treatment…5/23/36-6/20/26…drain management… interventions: SN to educate/instruct patient/caregiver regarding colonic diverticular abscess management…” The HHCPC indicated no treatment interventions and no physician orders for dressing changes for the diverticular abscess. During an observation on 6/16/26 at 11:57 a.m. with Pt 3, Pt 3 had a drainage bag hooked to a white tube that was covered by a white gauze with a clear dressing. Registered Nurse (RN) 1 was observed changing the dressing to the diverticulitis drainage site and told the family the suture (medical device used to hold body tissues together and close wound edges after an injury or surgery) was torn and Pt 3 needed to go to the emergency room to make sure it was in the correct place. During an interview on 6/16/26 at 1:17 p.m. with RN 1, RN 1 stated this was his second time seeing Pt 3. RN 1 stated he provided dressing changes for Pt 3 in the past. RN 1 stated it was important to have a physician order to have the right treatment. During an interview on 6/16/26 at 1:49 p.m. with FM 3, FM 3 stated Pt 3 had her diverticulitis drainage placed on 4/11/2026 before starting services with home health agency. FM 3 stated she asked RN 1 to change the diverticulitis dressing. FM 3 stated RN 1 provided the dressing change for Pt 3 when he made his visits, but RN 2 did not. FM 3 stated she wanted to make sure the treatment was done correctly and Pt 3 did not have complications to the site. FM 3 stated no one informed her about the suture and what to look for. During an interview on 6/17/26 at 1:27 p.m. with RN 2, RN 2 stated Pt 3 had a diverticulitis abscess drain and there was a dressing at the start of care. RN 2 stated she was under the impression she did not have to provide any treatment since Pt 3’s family members were managing the dressing. RN3 stated “The original plan was for the patient to get it removed and so we did not put it in the plan of care to managed it.” RN 3 stated, RN 1 had an order for the diverticulitis dressing treatment which was started on 6/14/26. RN 2 stated the diverticulitis treatment order should have been added in the plan of care at the start of services. RN 2 stated it was important to inform the team members to monitor signs and symptoms of infection. RN 2 stated the patient could have been at risk for infection and rehospitalization without dressing changes performed or site monitored. During an interview on 6/17/26 at 4:32 p.m. with FM 2, FM 2 stated Pt 3’s family members were confused about what treatments was being provided. FM 2 stated RN 2 had provided treatment for the diverticulitis abscess drainage site at the start of care but then stopped and now family members were managing it. FM 2 stated, “We were confused and wondering what was going on.” FM 2 stated she would like the nurse to provide the diverticulitis dressing treatment when they made visits. FM 2 stated Pt 3’s family members were not educated on signs and symptoms of infections to the surgical diverticulitis abscess drainage site. During a concurrent interview and record review on 6/18/26 at 10:44 a.m. with the Assistant Director of Nursing (ADON) Pt 3’s “HHCPC”, resume dated 6/1/26 was reviewed. The ADON stated Pt 3 was admitted on 4/22/26 and RN 2 admitted the patient. The ADON stated RN 2 did not mention Pt 3 had the diverticulitis abscess dressing on her admission note. The ADON stated on 4/28/26 RN 2 mentioned Pt 3 had a diverticulitis abscess drainage dressing and Pt 3’s family was managing it. The ADON stated Pt 3 resumed care with the home health agency on 5/23/26 after being hospitalized. The ADON stated RN 1 provided a dressing change on 5/23/26. The ADON stated RN 1 and RN 2 should have reached out to the physician to obtain a treatment order for the diverticulitis abscess drainage since they were doing the dressing change. The ADON stated having a diverticulitis treatment order was important for coordination of care and updating the physician for changes in condition. The ADON stated not having a physician order could have placed Pt 3 at risk for hospitalized due to inappropriate care. ADON stated the Nurse Practitioner (NP, an allowed practitioner who signed for the home health services) should have been involved in providing proper care. ADON stated Pt 3 could have mistreatment, hospitalization, treatment errors and patients might have declined in heath without a physician order for treatment. The ADON stated Pt 3 did not have a physician order for treatment for her diverticulitis wound at the start of care and it was not done when she resumed services. The ADON read the policy for Plan of Care and stated, “Our plan of care policy was not followed.” During an interview on 6/22/25 at 2:09 p.m. with the NP, the NP stated Pt 3 was referred to the home health agency for management of the diverticulitis abscess drainage. The NP stated treatment to the surgical site should have been part of the plan of care. The NP stated Pt 3’s diverticulitis abscess drainage dressing should have been addressed, changed, and managed by the home health agency nurses. The NP stated the nurses should look at the diverticulitis abscess site and make sure there were no signs and symptoms of infections or complications. The NP stated the nurses could have called him and he would have advised the home health agency on changes in treatment orders when there were any complications. The NP stated it was important to have the treatment orders placed to ensure the care was being provided and to have him involved in the plan of care. The NP stated. “I expect the agency to reach out to us after the visit to update us about the care.” The NP stated, “We need to be updated so we would know what was happening to the patient. The NP stated, without a physician order, we would not know what treatment was being done and it could have affected the quality of care. During a review of the agency policy and procedures (P&P) titled, “Plan of Care” dated 1/1/2024, the P&P indicated, “…[Name of Home Health Agency] will obtain physician or allowed practitioner orders prior to initiation of the care or service…drugs, care/services, and treatments will be administered only as ordered by the physician or allowed practitioner…”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to notify the physician promptly when Occupational Therapy (OT) services were discontinued for one of four sampled patients (Patient [Pt] 4). This failure had the potential to place Pt 4 at risk for declined health, missed services, and possible hospitalization, and prevented timely updates to the plan of care. Findings: During a review of Pt 4’s “Home Health Certification (physician’s or allowed practitioner’s (a Nurse Practitioner or Physician Assistant) attestation that a Medicare beneficiary is eligible for home health services and Plan of Care (document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home (HHCPC), dated 5/11/26 was reviewed. The “HHCPC” indicated, Pt 4’s start of care was dated 5/11/26 with a primary diagnosis of “[Other mechanical complication of internal fixation device of right femur (thigh bone)….Orders and Treatment:…Occupation Therapy: 5/11/26-5/31/26…” During a record review of Pt 4’s “physician order (PO),” dated 5/20/26, the physician order indicated, clinical signature [PTC 2]…date 5/19/2026…physician signature: [physician name] date: 5/21/2026…” During a concurrent interview and record review on 6/12/26 at 9:11 a.m. with the Assistant Director of Nursing (ADON), Pt 4’s “PO” dated 5/20/26 was reviewed. The ADON stated Pt 4 had a physician order for OT. The ADON stated there was no documentation showing the patient was evaluated by OT, and an OT note should have been entered within five days of the start of care. The ADON stated Physical Therapy Co-Director (PTC) 2 entered a physician order and sent the physician order for signature on 5/19/26. The physician order indicated Pt 4 declined OT, but no OT visit occurred and no documentation was entered. During a concurrent interview and record review on 5/17/26 at 10:33 a.m. with PTC 2, Pt 4’s “Medical Record (MR),” undated was reviewed. PTC 2 stated Pt 4 declined OT services and he did not document on 5/19/26 that the patient declined OT. PTC 2 stated he learned of this change on 5/13/26 from the physical therapist. PTC 2 stated the MR indicated there was no documentation and there should have been an entry in the patients note for care coordination. PTC 2 stated the documentation was not there and there should have been a note to indicate coordination as proof that the team discussed the patient’s care. PTC 2 stated the missing documentation “does not look good.” PTC 2 stated it was important to communicate with the team, so staff remained informed and updated about the patient’s care. PTC 2 stated the lack of documentation could lead to negative outcomes, affect the patient’s care, and prevent the patient from receiving the best possible care. PTC 2 stated documentation was also important in case the patient wanted to review their record. PTC 2 stated the order dated 5/19/26 reflected the day he signed and submitted it to the physician. PTC 2 stated the notification should have been completed immediately once the agency received notice the patient wanted to discontinue services. PTC 2 stated timely communication was essential for coordination of care and ensuring “we are doing right by the patient.” PTC 2 stated the physician is part of the care team and must be informed of changes, including discontinuation of services. PTC 2 stated timely notification allows the physician to agree or disagree with the change and directly affects the patient’s quality of care. During an interview on 6/18/26 at 4:42 p.m. with the ADON, the ADON stated the physician should have been notified within 24 hours of the patient declining OT. The ADON stated the lack of timely notification and documentation could result in missed services, poor coordination among disciplines, and possible patient decline or hospitalization. During a record review of the agency’s policy and procedure (P&P) titled, “Initial and Comprehensive Patient Assessment,” dated 1/1/2026, the P&P indicated, “[Home Health Agency Name]… the comprehensive assessment that accurately reflects the patient’s current health. The comprehensive assessment must be completely timely…but no more than five calendar days after start of care…All patients with physician-ordered Therapy and/or Medical Social Services will have a discipline-specific assessment conducted. When these care/services are ordered, the therapist. Will performed the initial evaluation within a time established by the agency…” During a record review of the agency’s P&P titled, “Plan of Care,” dated 1/2/26, the P&P indicated, “[Name of home health agency] will notify the physician(s) or allowed practitioners promptly to any changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered.”

“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 observation, interview, and record review, the home health agency (HHA) failed to coordinate home visits for one of three sampled patients (Patient [Pt] 3), when Physical Therapist (PT) 1 did not call Pt 3 and Family Member (FM) 2 to arrange a time for the home visit on 6/16/26. This failure resulted in FM 2 feeling annoyed and had the potential for missed visits, hospitalization, adverse events and affected the quality of care when Pt 3 was found to not be home. Findings: During a concurrent observation and interview on 6/16/26 at 10:30 a.m. with PT 1, PT 1 was observed knocking on Pt 3’s door. FM 2 opened the door and had a surprised look on her face. FM 2 stated, “What are you doing here?” FM 2 stated she was not expecting PT 1 and was expecting Registered Nurse (RN) 1. FM 2 stated Pt 3 was not home and was at her sister-in-law’s. FM 2 stated no one called her to confirm the appointment for that morning. FM 2 stated she notified RN 1 on 6/14/26 about Pt 3 being at her sister in law’s house. FM 2 stated the agency should have communicated better and felt annoyed. During an interview on 6/16/26 at 10:45 a.m. with PT 1, PT 1 stated he normally called and scheduled his own visits the day before. PT 1 stated he was responsible for seeing patients in Turlock, Modesto, Merced, Dos Palos and other areas. PT 1 stated he worked part time for the home health agency and saw patients on Tuesdays and Thursdays. PT 1 stated, “My company was supposed to call.” PT 1 stated not having the patients and families involved in the scheduling could have caused confusion. During an interview on 6/16/26 at 1:17 p.m. with RN 1, RN 1 stated he normally scheduled visits the evening before. RN 1 stated he notified his supervisor of the change in address and expected her to communicate with the team. RN 1 stated he should have notified the intake team and should have communicated by email to the team regarding the change in address. RN 1 stated it was important to communicate the change in address for coordination of care. RN 1 stated patients were at risk of missed visits when there was no coordination of care. RN 1 stated missed visits could have resulted in delayed care, which could have cause a decline in health, rehospitalization and affect the quality of care. During an interview on 6/17/26 at 11:09 a.m. with Physical Therapist Codirector (PTC) 1, PTC 1 stated RN 1 should have notified the team about the address change and he did not. PTC 1 stated, “I told PT 1 to call the family the day before.” PTC 1 stated, “My expectations were for the disciplines to call the night before to coordinate the time with the patients and families.” PTC 1 stated PT 1 should have called and spoken to the family and set the expected time. PTC 1 stated “[Name of RN 1] should have notified the intake staff, and we should have communicated among each other.” PTC 1 stated RN 1 could have sent an email, and made direct contact with each discipline to let them know of the address change. PTC 1 stated it was important to provide optimal care for the patients. PTC 1 stated, “We should be consistent and uniformed.” PTC 1 stated, “The patient’s care could have been disrupted, and the care would not be followed.” PTC 1 stated, “Patient and family could have been upset and confused.” PTC 1 stated that not coordinating among the team could have affected the plan and quality of care for the patients. During an interview on 6/17/26 at 11:55 a.m. with the Assistant Director of Nursing (ADON), the ADON stated, “My expectation is that all clinicians should be communicating with the patient and family the day before to schedule their visit.” The ADON stated RN 1 should have notified the intake coordinator. The ADON stated RN 1 should have called or sent an email to the PT 1 to communicate the change in address. The ADON stated it was important not to delay the care of the patient. The ADON stated not communication among the team could result in delays of resources. The ADON stated Pt 3 could have missed her visit when the PT 1 showed up at the wrong address. The ADON stated it was important to communicate with the family and patients so staff could make the scheduled visit. The ADON stated not communicating with the family and patient could have put patients at risk for patients not getting their care done as scheduled. The ADON stated patients faced higher risks of hospitalization and adverse events if the patients missed their visits. The ADON stated patients and families could have been upset and canceled services when there was no communication with family regarding scheduled visit times. During a review of Pt 3’s “Home Health Certification (-physician’s or allowed practitioner’s (like a Nurse Practitioner or Physician Assistant) attestation that a Medicare beneficiary is eligible for home health services and Plan of Care (document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home (HHCPC),” resume dated 6/1/26, the “HHCPC” indicated, “[Pt 3] episode period was on 4/22/26-6/20/26…Skilled nursing visit:5/23/26-6/20/26…1 visit per week for 5 weeks…Narrative: stated/order details: [peripherally inserted central catheter- is a long, thin, flexible tube inserted into a vein in the upper arm and guided to a large central vein near the heart. It is used for long-term [intravenous] treatments, frequent blood draws, and to avoid repeated needle sticks] PICC line care and Drain Management… Physical Therapy:5/24/26 (Sunday)-6/20/26 (Saturday) 1 visit per week for 4 weeks. Narrative statement/Order Details: PT/Eval/Treatment completed/skilled…for strength training, gait training, safety training. Physical Therapy Assistant will follow up…” During a record review of the agency policy and procedures (P&P) titled, “Plan of Care,” dated 1/1/2024, the P&P indicated, “…[Name of home health Agency] coordinates care by:...coordinating 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…”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency failed to provide the name of the clinical manager for three of three sampled home visit patients (Patient [Pt] 1, 2, and 3), when the admission booklet did not contain the required information. This failure had the potential to place Pt 1, 2, and 3 and their families at risk of not knowing who to call when making complaints regarding care and could have affected the quality of care. Findings: During a concurrent interview and record review on 6/11/2026 at 12:03 p.m. with Pt 2, Pt 2’s admission booklet titled, “Patient Orientation for Home Health Care,” undated was reviewed. The admission booklet indicated, “[Line] Clinical Manager: no name…” Pt 2 stated he had three admission booklets, and the name of the clinical manager was not provided in all three. Pt 2 stated he was instructed to call the main number for all issues. Pt 2 stated he did not know the name of the clinical manager. During a review of Pt 2’s “Home Health Certification (-physician’s or allowed practitioner’s (like a Nurse Practitioner or Physician Assistant) attestation that a Medicare beneficiary is eligible for home health services and Plan of Care (document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home (HHCPC), dated 5/25/26, the “HHCPC” indicated, Pt 2 services period was on 5/25/26-7/23/26...” During a concurrent interview and record review on 6/15/26 at 12:49 p.m. with Pt 1, Pt 1’s “Admission Booklet,” undated was reviewed. The Admission Booklet indicted, “[Line] Clinical Manager: no name…” Pt 1 stated she did not know the name of the clinical manager. Family Member (FM) 1 stated he had to make a complaint about Pt 1’s Peripherally Inserted Central Catheter (PICC- a long, thin, flexible tube inserted into a large vein in the upper arm functions as a long-term intravenous, sparing patients from repeated needle sticks and protecting veins from irritating medications) and he had to use the internet to look up the information. FM 1 stated, “It would have been nice if the information was provided.” During a review of Pt 1’s “Home Health Certification (physician’s or allowed practitioner’s (like a Nurse Practitioner or Physician Assistant) attestation that a Medicare beneficiary is eligible for home health services and Plan of Care (document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home (HHCPC), dated 5/6/26, the “HHCP” indicated, Pt 1 services period was on 4/19/26 -6/17/26…Skilled nursing visit 4/19/2026-4/24/26…1 visit per week for 8 weeks…Narrative: stated/order details: Central line dressing change, labs, wound care, infection prevention and control education…” During a concurrent interview and record review on 6/16/26 at 1:10 p.m. with Pt 3, Pt 3’s admission booklet, undated was reviewed. The Admission Booklet indicated, “[Line] Clinical Manager: no name…” FM 3 stated she did not know the name of the clinical manager. FM 3 stated the agency should have the information when she wanted to make a complaint about care. During a review of Pt 3’s “HHCPC,” dated 6/1/26, the “HHCPC” indicated, “[Pt 3] episode period was on 4/22/26-6/20/26...” During an interview on 6/18/26 at 9:56 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the name of the clinical manager should have been provided to the patients and families and written in the booklet. The ADON stated the clinicians should have written the name in the front or back of the booklet. The ADON stated providing the name of the clinical manager was important for patients to be aware of who was involved in their care and who to escalate their complaint to. The ADON stated patients and families could feel they did not know who to complain to and who to elevate their complaints to. The ADON stated the patient should have been given the information to provide better quality. The ADON stated the name of the clinical manager would have provided the patients and families a contact person in case they needed to know about coordination of care. The ADON stated, “We should be going out and checking the admission booklet to ensure the names were provided. During an interview on 6/18/26 at 3:32 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the nurses should write the name of the clinical manager and go over the expectations. The DPCS stated the clinical staff should be putting their names and the clinical manager’s name on the back of the admission booklet. The DPCS stated it was important for patients’ rights, and the patients and family who may need to be involved in their plan of care. The DPCS stated patients have the right to know who to contact and should not have to go through the home health agency to obtain the direct name of the manager. The DPCS stated patients and families would not know who to express their concerns to when they were not given the name of the clinical manager. The DPCS stated it could delay the patient’s ability to contact the agency, and the patient should have the ability to contact the clinical manager for anything that involve patient care. The DPCS stated, “It could have affected the patient’s quality of care, and we should have provided better quality of care with the information provided.” The DPCS stated, “It would give the patients assurance that their needs were heard.” During a review of the agency admission booklet titled, “Patient Orientation for Home Health Care,” undated, the admission booklet indicated, “…The role of the clinical Manager…Your manager coordinates your home health care and referral to additional services, contact information for your clinical manager is provided on the back cover of this booklet…” During a review of the home health agency’s policy and procedure titled, “Patient Written Instructions,” dated 1/1/2024, the P&P indicated, “...The HHA will provide each patient/caregiver with written instructions no later than the next visit after the plan of care has been approved by the physician or allowed practitioner-specifically, the name and contact information of the HHA’s clinical Manager, including the clinical Manager’s telephone number...””

“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 agency failed to ensure communication between disciplines was done for one of four sampled patients (Patient 1) when Physical Therapy (PT) 1 did not call Patient 1’s Registered Nurse (RN) 1 to inform RN 1 of Patient 1’s low blood pressure and fatigue during her home visit. This failure resulted in Patient 1 not receiving necessary nursing assessment, intervention and education by RN 1 prior to her next scheduled home visit. Findings: During a review of Patient 1’s “Patient Communication” note, dated 2/25/24, written by PT 1, the note indicated, “Initially, it was difficult to obtain the patient’s blood pressure and it appeared that it may have been 81/64 or 88/64 (normal range 120/80). It was hard to hear the blood pressure. The patient was instructed to drink water and lay down and then it came in at 90/64. The patient reported that he did not feel up for therapy, but he was willing to stand up one time then due to fatigue and pain he was unable to ambulate and required moderate assistance to stand up. The patient was trained regarding what to do if his blood pressure is low and if he felt dizzy, not ambulating but using a wheelchair and the patient was trained how to remove the armrest of the wheelchair and scoot from his couch onto the wheelchair and back again. The patient verbalized understanding of the training provided. A phone call was placed to the doctor’s office and a voicemail message was left regarding the patient’s blood pressure and that the patient has had a decline in his mobility. The patient does not want to continue physical therapy services at this time.” There was no documented evidence that PT 1 notified RN 1(the case manager) regarding the Patient 1’s low blood pressure and fatigue during her visit. During a review of Patient 1’s “Physical Therapy” note, dated 2/26/24, the note indicated Patient 1 was discharged from the therapy per patient/family request. There was no documented evidence that PT 1 informed RN 1 about unexpected discharge from Physical Therapy. During a review of Patient 1’s “Communication Note” dated 3/5/24, the note indicated Patient 1 was hospitalized on 3/5/24 due to sepsis. During a phone interview on 6/20/24 at 3:15 p.m., with PT 1, PT 1 stated she did not call RN 1 about Patient 1’s change of condition she encountered during her home visit. PT 1 stated Patient 1 was alert, oriented and capable of verbalizing his needs without any difficulty. PT 1 stated she did not know Patient 1 had a drainage tube on his abdomen. PT 1 stated she communicated with other disciplines by communication note. PT 1 stated everyone who was assigned to Patient 1’s case had access to read the communication note. PT 1 stated it was not her standard of practice to call case manager directly to notify change of condition. PT 1 stated she always called the physician but not the case manager. PT 1 stated she expected RN 1 to read the communication note. RN 1 was no longer employed with the agency and unable to interview. During an interview on 6/20/24 at 3:53 p.m., with Physical Therapy Assistant (PTA) 1, PTA 1 stated he reported any change of condition to his supervisor by phone call during home visit followed by communication note for record keeping. During an interview on 6/24/24 at 9:15 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated any change of condition, such as out of the range vital signs, severe pain, or fatigue she called the case manager. LVN 1 stated the communication note was utilized for record keeping but not to replace a call. During an interview on 8/24/24 at 11:30 a.m., with RN 2, RN 2 stated the communication note did not replace the need for a direct phone call. RN 2 stated the agency’s standard of practice was to call the case manager for any change of condition or change of POC. RN 2 stated it was very important to communicate any change of conditions between disciplines to provide patients continuous care and provide the necessary assessment and treatment in timely manner. RN 2 stated the communication note was for tracking and record keeping. During an interview on 6/24/24 at 2:30 p.m., with the Clinical Supervisor (CS), the CS stated she did not know PT 1 did not call to notify RN 1 of Patient 1’s change of condition. The CS stated her expectation was for PT 1 to call RN 1 for Patient 1’s low BP and fatigue during her visit so RN 1 could assess the situation and arrange a visit sooner than scheduled (SN scheduled visit was three days later) if necessary. The CS stated communication note did not replace the call to the case manager. The CS stated when SN was ordered PT must communicate with RN case manager and if no SN was ordered PT must report any medical concerns to the CS. The CS stated she requested the visit note from [Hospital] but could not get the note of Patient 1’s visit to IR to validate the reason for RN 1 not changing the dressing on 2/22/24. The CS stated Patient 1 was able to speak out if RN 1 omitted the dressing change for no reason. During a review of the agency’s Policy and Procedure (P&P) titled “Care/Service Coordination” dated 11/20, the P&P indicated, “… the clinician will be responsible for facilitating communication about changes in the patient’s status among the assigned personnel …” During a review of the agency’s job description for “Physical Therapist”, undated, the job description indicated, “… communicate with other team members, as appropriate, regarding the patient’s plan of care, and updates team members when there are changes ...””

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on interview and record review, the agency ‘s Registered Nurse (RN) 1 failed to provide patient care giver education regarding wound care to the common bile (a liquid made by the liver, helps digest fats) duct drain (allows bile to flow out from a blocked bile duct into a collection bag outside the body) and disease process for one of four sampled patients (Patient 1) when RN 1 did not identify the primary caregiver to educate during the entire certification period (60 days). This failure placed Patient 1 at risk for pain and infection which could prevent Patient 1 from achieving the plan of care (POC-a document that outline the health conditions, specific care needs and current treatments of a patient) due to lack of education to the primary caregiver. Findings: During a review of Patient 1’s POC, dated 1/10/24 to 3/9/24, the POC indicated, “Skilled nursing (SN): 1 visit per week for 9 weeks: SN for wound care to common bile duct drain, disease process education … SN to assess skin for breakdown each visit. SN to instruct on and perform common bile duct dressing change weekly as follows: using sterile technique, remove old dressing, cleanse area with [brand name sterile antiseptic solution], cover site with split drainage sponge and [brand name transparent medical dressing], add securement device as needed.” During a concurrent interview and record review on 6/20/24 at 10 a.m., with the Clinical Supervisor, Patient 1’s skilled nursing visit notes were reviewed. RN 1 performed the initial assessment on 1/10/24. There was no documented evidence that who was Patient 1’s primary caregiver and what education was provided upon her visit. SN visit note dated 1/24/24, 1/31/24, 2/12/24, 2/22/24 and 2/28/24 were reviewed. There was no documented evidence indicating who was the primary caregiver and what education was provided in the visit notes. The CS stated RN 1 should have identified Patient 1’s primary caregiver to educate Patient 1 and the caregiver. The CS stated RN 1 did check marks on each visit indicating she did education but unable to locate narrative documentation to whom and what was taught throughout the entire certification period. The CS stated it was her expectation for RN 1 to assess the availability of caregiver and document the content of education no later than the first week from the start of care. RN 1 was no longer employed with the agency and unable to interview. During a review of the agency’s job description for “Registered Nurse”, undated, the job description indicated, “... Provides education and information to the patient and/or family members as appropriate to their plan of care …””

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the agency‘s Registered Nurse (RN) 1 failed to prepare the clinical record accurately to reflect the actual services provided for one of four sampled patients (Patient 1) when RN 1 did minimal and generic documentation about wound care and caregiver education in her visit notes. This failure placed Patient 1 at risk for not receiving service as indicated in the plan of care (POC-a document that outline the health conditions, specific care needs and current treatments of a patient) due to an inaccurate documentation of service provided. Findings: During a concurrent interview and record review on 6/20/24 at 10 a.m., with the Clinical Supervisor (CS), Patient 1’s POC dated 1/10/24 to 3/9/24 was reviewed. The POC indicated, “Skilled nursing (SN): 1 visit per week for 9 weeks: SN for wound care to common bile duct drain, disease process education … SN to assess skin for breakdown each visit. SN to instruct on and perform common bile duct dressing change weekly as follows: using sterile technique, remove old dressing, cleanse area with [brand name sterile antiseptic solution], cover site with split drainage sponge and [brand name transparent medical dressing], add securement device as needed.” During a concurrent interview and record review of Patient 1’s Skilled Nursing visit notes, dated 1/10/24, the note indicated RN 1 performed the initial assessment on 1/10/24. There was no documented evidence of who was Patient 1’s primary caregiver and what education was provided upon visit. SN visit notes dated 1/24/24, 1/31/24, 2/12/24, 2/22/24 and 2/28/24 were reviewed. The wound care note had minimal information with check marks and the narrative document was entered in a form copied and pasted from previous visit notes. In each visit note, there was no documentation of feedback from the caregiver. The CS stated she expected each visit notes should not be identical for each visit. The CS stated it was her expectation for RN 1’s wound care and caregiver education to be more comprehensive and reflected progress or decline determining the need for more education. RN 1 was no longer employed with the agency and unable to interview. During a review of the agency’s job description for “Registered Nurse”, undated, the job description indicated, “… maintains accurate and timely documentation of care/services provided ...””