Infinite Home Health, Inc.

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The Home Health agency (HHA) failed to ensure the comprehensive assessment included the patients respiratory/lung status, foot care, blood pressure assessment and blood sugar monitoring as indicated in the plan of care (POC) for four of seventeen sampled patients (Patient 1, Patient 2, Patient 3, and Patient 10). This deficient practice resulted in patients’ current health status or medical problems are not monitored and not assessed that could lead to complications and delayed treatment and intervention. (Refer to G 528). 2. The HHA failed to review and document all the medications and treatments the patient was currently using for five of seventeen sampled patients (Patient 1, Patient 2, Patient 3, Patient 11, Patient 12). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. (Refer to G536). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Comprehensive Assessment of patients to ensure home health care benefits are verified for eligibility to patients provided home health services.”

“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 interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Care Planning, Coordination, and Quality of Care was met as follows: 1. The HHA failed to ensure the Plan of Care (POC) was followed for four of seventeen sampled patients (Patient 2, Patient 10, Patient 11, Patient 12). This failure placed patients at risk for health status decline by not providing the services as indicated in the POC (Refer to G572). 2. The HHA failed to include information required in the plan of care for one of seventeen sampled patients (Patient 2). This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. (Refer to G574). 3. The HHA failed to ensure the physician reviewed and revised four of seventeen sample patients (Patient 1, Patient 2, Patient 12, Patient 15) individualized plan of care. This failure had the potential to result in Patient receiving inappropriate or lacking appropriate services. (Refer to G588). 4. The HHA failed to ensure care coordination was done between agency clinicians to ensure appropriate equipment was available for one of 17 sampled patients (Patient 12). The deficient practice had the potential to result in delayed care and impact the health and safety of Patient 12. (Refer to G608). 5. The HHA failed to provide written information regarding the plan of care and medication list for six of seventeen sample patients (Patient 1, Patient 2, Patient 3, Patient 10, Patient 11, Patient 12). This deficient practice resulted in patients and their representatives not knowing their care team or their treatment course. (Refer to G612). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care are provided to patients assessed and certified to receive the home health benefits.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on observation, interview and record review the Home Health agency (HHA) failed to follow the written Plans of Care (POC) for four of seventeen sampled patients (Patient 2, Patient 10, Patient 11, Patient 12). This deficient practice placed patients at risk for health status decline by not providing the services as indicated in the POC. A.During a record review of Patient 10’s Patient Information sheet indicated Patient 1’s start of care was 11/26/2024, with a primary diagnosis of unspecified open wound of scalp. During a record review of Patient 10’s medical record form titled “Plan of Care” dated from 11/21/2025 to 01/29/2026, indicated the SN was to notify physician if: Blood pressure; systolic (the top number in blood pressure reading, Representing the pressure in your arteries when your heart contracts and pushes blood out) of the is greater than 160mm HG (millimeters of mercury representing a measurement) or less than 90mm HG; diastolic (The second number of your blood pressure reading which measures the pressure your blood is pushing against your artery walls while the heart muscle rests between beats) is greater than 90mm HG or less than 55mm HG pulse (heart beats per minute) is greater than 100 or less than 55. During an observation on 12/04/2025 at 10:20 a.m., a joint home visit with Licensed Vocational Nurse 1 (LVN 1) at Patient 10’s residence LVN 1 was observed taking patient 10’s vital signs. Patient 10’s blood pressure reading on the right upper arm was 93/43 mm HG. LVN 1 immediately repeated the blood pressure reading on the same arm, getting a second reading of 105/50 mm HG. LVN 1 then placed the blood pressure cuff on the left upper arm and got a reading of 95/50 mm HG with a pulse of 52 beats per minute. During an interview on 12/04/2025 at 10: 30 a.m., with LVN 1, LVN 1 was asked if there are any reportable findings to the MD, LVN 1 stated, “no all of Patient 10’s vitals were okay, the blood pressure was a bit lower but I will keep the reading of 106/50 mm HG.” During a concurrent record review and interview on 12/08/2025 at 1:35 p.m., with DPCS, of Patient 10’s Skilled Nurse visit note dated 12/04/2025, the document indicated a blood pressure reading of 106/50 mm HG with a pulse rate of 54. DPCS stated, “LVN 1 needed to report the blood pressure and heart rate for Patient 10 to the physician because the diastolic and the heart rate are below the reportable parameter range.” When asked after taking a blood pressure reading how long do you have to wait to take the blood pressure on the same arm, DPCS stated, “usually 5 to 10 minutes or you will get a false higher reading.” B. During a record review of Patient 11’s Patient Information sheet indicated Patient 11’s start of care was 11/25/2025, with a primary diagnosis of acute embolism and thrombosis of left popliteal vein (a blockage of the left hollow in the back of the knee.) During a record review of Patient 11’s medical record form titled “Plan of Care” dated from 11/25/2025 to 01/23/2026, indicated SN to evaluate only and discharge same day effective 11/25/2025, PT (Physical therapy) to evaluate and treat effective 11/25/2025, OT (Occupational Therapy) to evaluate and treat effective 11/25/2025. During an interview on 12/04/2025 at 12:10 pm with Physical Therapist 1 (PT 1) and Occupational Therapy (OT 1), at Patient 11’s residence, PT 1 and OT 1 stated they never look at or follow the Plan of Care that’s for nursing. When asked how they know what parameters to report to the physician and what to educate the patient, PT 1 and OT 1 stated nursing does that. During an interview on 12/08/2025 at 1:18 pm with DPCS, DPCS stated, “ all clinicians need to follow the plan of care including physical therapy and occupational therapy. The plan of care drives the care for the patient. Patient 11 is physical therapy and occupational therapy only, skilled nurse was evaluation only. The other clinicians are supposed to follow the plan of care to implement all physician orders.” C. During a record review of Patient 12’s Patient Information sheet indicated Patient 1’s start of care was 11/07/2025, with a primary diagnosis of essential hypertension. During a record review of Patient 12’s medical record form titled “Plan of Care” dated from 11/07/2025 to 01/05/2026, indicated the assess medication compliance and instruct patient/patient caregiver medication name, dose, frequency, route, desired effect. During an interview on 12/04/2025 at 2:30 pm with PR 1(Patient Representative 1), PR 1 stated, “I give all the medications for Patient 12, and none of the agency staff has ever educated me on the medications Patient 12 is receiving or how much to give.” During an interview on 12/08/2025 at 1:20 pm with DPCS, DPCS stated, “nurses are supposed to educate all patients and family members and staff that take care of the patients on all aspects of medication management. “ Findings: a. During a record review of Patient 2’s “Plan of Care” dated 11/5/2025 to 1/3/2026, indicated a start of care date of 11/5/2025 with a diagnosis of pressure ulcer of sacral region (a wound on the tailbone from prolonged pressure that cuts off blood flow, causing skin breakdown), stage 2 (the wound extends into the bottom layers of the skin) and type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood causing high blood sugar) with other specified complications. The plan of care indicated blood sugar will be within physician-established parameters throughout the next month. A review of Patient 2’s clinical record indicated that there is no documentation during visits regarding Patient 2’s blood sugar being checked and monitored. During a concurrent interview and record review on 12/5/2025 at 12:40 p.m. with Director of Patient Care Services (DPCS), the DPCS stated that nursing staff should be documenting patients blood sugar and the plan of care should have parameters on the blood sugar. A record review of the HHA’s undated document titled, Care Planning Process, indicated, “Based on the assessment and conclusions, the plan of care will include, but not limited to…Specific services and treatment to be provided…Actions to be taken to meet the patient goals…”.”

“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 written information regarding the plan of care and medication list for six of seventeen sample patients (Patient 1, Patient 2, Patient 3, Patient 10, Patient 11, Patient 12). This deficient practice resulted in patients and their representatives not knowing their care team or their treatment course. a.During a record review of Patient 10’s Patient Information sheet indicated Patient 10’s start of care was 11/26/2024, with a primary diagnosis of unspecified open wound of scalp. During a joint home visit, on 12/04/2025 at 10:45 a.m. with the LNV 1 at Patient 10’s residence, Patient 10 was observed sitting down in by the living room couch. During a concurrent observation and interview at the home visit on 12/04/2025, at 11:00 a.m., with , LVN 1 reviewed the contents of Patient 10’s agency folder (information required to be given to the patient). There was no plan of care (POC) and medication profile found in Patient 10’s home. During an interview, on 12/08/2025 at 2:13 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that an updated copy of the plan of care and medication profile should be in the patient’s home. DPCS stated that it is important to have a copy of the updated plan of care and medication profile in the patient’s home so that the patient and family are aware of any new orders. b.During a record review of Patient 11’s Patient Information sheet indicated Patient 11’s start of care was 11/25/2025, with a primary diagnosis of acute embolism and thrombosis of left popliteal vein (a blockage of the left hollow in the back of the knee.) During a joint home visit, on 12/04/2025 at 11:55 a.m. with the Physical Therapist 1(PT 1) at Patient 11’s residence, Patient 11 was observed sitting down in by the dining table. During a concurrent observation and interview at the home visit on 12/04/2025, at 11:40 a.m., with PT 1, PT 1 reviewed the contents of Patient 11’s agency folder (information required to be given to the patient). There was no plan of care (POC) and medication profile found in Patient 11’s home. During an interview, on 12/08/2025 at 2:17 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that an updated copy of the plan of care and medication profile should be in the patient’s home. DPCS stated that it is important to have a copy of the updated plan of care and medication profile in the patient’s home so that the patient and family are aware of any new orders. c.During a record review of Patient 12’s Patient Information sheet indicated Patient 12’s start of care was 11/07/2025, with a primary diagnosis of essential hypertension. During a joint home visit, on 12/04/2025 at 1:55 p.m. with the RN 1 at Patient 12’s residence, Patient 12 was observed laying down in hospital bed. During a concurrent observation and interview at the home visit on 12/04/2025, at 1:57 p.m., with RN 1, RN 1 reviewed the contents of Patient 12’s agency folder (information required to be given to the patient). There was no plan of care (POC) and medication profile found in Patient 12’s home. During an interview, on 12/08/2025 at 2:20 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that an updated copy of the plan of care and medication profile should be in the patient’s home. DPCS stated that it is important to have a copy of the updated plan of care and medication profile in the patient’s home so that the patient and family are aware of any new orders. A record review of the HHA’s undated document titled, Care Planning Process, indicated, “The organization shall provide the patient and caregiver with a copy of written instructions outlining: A. Visit schedule, including frequency of visits…Patient medication schedule/instructions, including medication name…” a. During a record review of Patient 1’s “Plan of Care” dated 10/17/2025 to 12/15/2025, indicated a start of care date of 2/19/2025 with a primary diagnosis of obstructive and reflux uropathy (a condition in which the flow of urine is blocked). During a joint home visit, on 12/4/2025 at 9:35 a.m. with the Licensed Vocational Nurse (LVN 2) at Patient 1’s residence, Patient 1 was observed lying down in the bed watching television. There was no plan of care (POC) and medication profile found in Patient 1’s home. b. During a record review of Patient 2’s “Plan of Care” dated 11/5/2025 to 1/3/2026, indicated a start of care date of 11/5/2025 with a diagnosis of pressure ulcer of sacral region (a wound on the tailbone from prolonged pressure that cuts off blood flow, causing skin breakdown), stage 2 (the wound extends into the bottom layers of the skin) and type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood causing high blood sugar) with other specified complications. During a joint home visit, on 12/4/2025 at 11:57 a.m. with the Licensed Vocational Nurse (LVN 3) at Patient 2’s residence, Patient 2 was observed answering the door and walking with a walker to the bed. There was no plan of care (POC) and medication profile found in Patient 2’s home. c. During a record review of Patient 3’s “Plan of Care” dated 11/13/2025 to 1/11/2026, indicated a start of care date of 7/16/2025 with a primary diagnosis type 2 diabetes mellitus with foot ulcer. During a joint home visit, on 12/4/2025 at 1:36 p.m. with the Licensed Vocational Nurse (LVN 1) at Patient 3’s residence, Patient 3 was observed sitting on the couch. There was no plan of care (POC) and medication profile found in Patient 2’s home. During an interview on 12/5/2025 at 12:40 pm with Director of Patient Care Services (DPCS), the DPCS stated a copy of the plan of care and medication profile should be available at the patient’s home. DPCS stated that it is important to have the plan of care and medication profile in the home to make sure the patient and family are aware of the care patient is receiving.”

“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 agency failed to ensure proper infection control practices were implemented by clinicians for two of 17 sampled patients (Patient 3 and Patient 10). The failure had the potential to result in cross contamination and jeopardize the health and safety of the patients. B. During a record review of Patient 10’s Patient Information sheet indicated Patient 10’s start of care was 11/26/2024, with a primary diagnosis of unspecified open wound of scalp. During a record review of Patient 10’s medical record form titled “Plan of Care” dated from 11/21/2025 to 01/29/2026, indicated the SN wound care orders: Wound #1 at scalp; SN to perform wound care to wound, using aseptic technique, as follows: cleanse wound with normal saline (rinsing solution), pat dry. Apply 3m ( a skin protectant that creates a long lasting waterproof and flexible barrier on the skin) skin protectant to peri-wound. Cover wound with Aquacel AG (a wound healing agent with silver). Secure with mepilex (a type of foam skin protectant) border lite. During a concurrent observation and interview on 12/04/2025 at 10:20 am with LVN 1 at Patient 10’s residence, LVN 1 was observed putting on gloves, removing the old dressing from Patient 10’s scalp, cleansing the wound with skin protectant, covering the wound with Aquacel AG and covering the wound with mepilex dressing. During the whole wound care procedure, LVN 1 did not change her gloves. LVN 1 stated, “ I should have changed my gloves and preformed hand hygiene after I removed the old dressing. I was nervous.” During an interview on 12/08/2025 at 1:00 pm with DPCS, DPCS stated, “during every wound care, when you go from dirty to clean you are supposed to change your gloves and do hand hygiene.” During a record review of the agency’s policy and procedure, titled, “Hand Hygiene” revised November 2020, the policy and procedure indicated, “3. Hand decontamination using an alcohol-based hand rub should be performed: A. Before having direct contact with patients B. Before donning sterile gloves when performing sterile procedures; before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices C. After contact with a patient’s intact skin (when taking a pulse, blood pressure, or lifting a patient) D. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated E. When moving from a contaminated body site to a clean body site during patient care F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient G. After removing gloves”. a. During a record review of Patient 3’s “Plan of Care” dated 11/13/2025 to 1/11/2026, indicated a start of care date of 7/16/2025 with a primary diagnosis type 2 diabetes mellitus with foot ulcer. During a joint home visit, on 12/4/2025 at 1:36 p.m. with the Licensed Vocational Nurse (LVN 1) at Patient 3’s residence, Patient 3 was observed sitting on the couch. Observed that LVN 1 did not clean the equipment used after the patient assessment. During a concurrent interview and record review on 12/8/2025 at 2:05 pm with Director of Patient Care Services (DPCS), the DPCS stated that equipment used for assessments are to be cleaned before and after patient interaction. DPCS stated that it is important to clean the equipment after patient interaction in order to prevent infection control. During a record review of the agency’s policy and procedure, titled “Bag Technique” , dated 11/2020, the policy and procedure indicated, “when the visit is completed, reusable equipment will be cleaned using alcohol and/or soap and water as appropriate, hands will be washed, and equipment and supplies will be returned to the bag.””

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure patient health records were completed and authenticated for three of seventeen sampled patients (Patient 9, Patient 12, and Patient 15). This failure has the potential risk to result in patients’ health records being modified by an unauthorized staff not involved in patients’ care. A.During a record review of Patient 9’s Patient Information sheet indicated Patient 9’s start of care was 11/03/2025, with a primary diagnosis of malignant neoplasm of the endometrium (a disease where cancerous cells form in the endometrium, the inner lining of the uterus). During a concurrent interview and record review on 12/08/2025 at 12:45 pm with DPCS Patient 9’s medical record was reviewed and physicians order dated 11/03/2025 was not signed. The DPCS stated, “the MD has 30 days to sign the Plan of Care and Physician orders. It is important for the physician to see the plan of care and sign it because the physician needs to be aware and approve of the plan of care and orders. b. During a record review of Patient 12’s Patient Information sheet indicated Patient 12’s start of care was 11/07/2025, with a primary diagnosis of essential hypertension. During a concurrent interview and record review on 12/08/2025 at 12:50 pm with DPCS Patient 12’s medical record was reviewed and physicians order dated 11/07/2025 was not signed. The DPCS stated, “the MD has 30 days to sign the Plan of Care and Physician orders. It is important for the physician to see the plan of care and sign it because the physician needs to be aware and approve of the plan of care and orders. c. During a record review of Patient 15’s Patient Information sheet indicated Patient 15’s start of care was 10/19/2025, with a primary diagnosis of urinary tract infection ( bacterial infection in any part of your urinary system (kidneys, bladder, ureters, urethra). During a concurrent interview and record review on 12/08/2025 at 12:55 pm with DPCS Patient 15’s medical record was reviewed and physicians order dated 10/19/2025, 10/20/2025, and 10/31/2025 were not signed. The DPCS stated, “the MD has 30 days to sign the Plan of Care and Physician orders. It is important for the physician to see the plan of care and sign it because the physician needs to be aware and approve of the plan of care and orders. During a record review of the agency’s policy and procedure titled, “Entries in the Clinical Record” undated, the policy and procedure indicated, “Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided...” The policy and procedure further indicated, “Clinical notes shall be signed and incorporated into the patient’s health record within seven working days. The clinical note will include: A. Care that was provided B. Treatment and/or invasive procedures performed C. Patient response to treatment and/or procedures D. The date the service was provided (month, day, year) E. Signature of clinician and his/her credentials Signature authorization of clinical documentation will include the staff member’s name and credentials (as specified on professional licenses and/or certification documents). Initials will be used on forms where authentication signature space is designated on the form. All entries into the clinical record will reflect the date care was provided, including the month, day, and year...””

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on observation, interview and record review the Home Health agency (HHA) failed to ensure the comprehensive assessment included the patients respiratory/lung status, foot care, blood pressure assessment and blood sugar monitoring as indicated in the plan of care (POC) for four of seventeen sampled patients (Patient 1, Patient 2, Patient 3, and Patient 10). This deficient practice resulted in patients’ current health status or medical problems not monitored, and assessed which could lead to complication, delayed intervention, and treatment. Findings: a. During a record review of Patient 1’s “Plan of Care” dated 10/17/2025 to 12/15/2025, indicated a start of care date of 2/19/2025 with a primary diagnosis of obstructive and reflux uropathy (a condition in which the flow of urine is blocked). The “Plan of Care” indicated that the Skilled Nurse (SN) was to assess the respiratory status, and lung sounds of the patient. During a joint home visit, on 12/4/2025 at 9:35 a.m. with the Licensed Vocational Nurse (LVN 2) at Patient 1’s residence, Patient 1 was observed lying down in the bed watching television. It was observed LVN 2 completing the patient assessment without assessing Patient 1’s lung sounds. b. During a record review of Patient 2’s “Plan of Care” dated 11/5/2025 to 1/3/2026, indicated a start of care date of 11/5/2025 with a diagnosis of pressure ulcer of sacral region (a wound on the tailbone from prolonged pressure that cuts off blood flow, causing skin breakdown), stage 2 (the wound extends into the bottom layers of the skin) and type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood causing high blood sugar) with other specified complications. The “Plan of Care” indicated that the Skilled Nurse (SN) was to assess the respiratory status, and lung sounds of the patient. The “Plan of Care” further indicated that the Skilled Nurse (SN) is to assess, perform and instruct patient and caregiver skin and diabetic foot care. During a joint home visit, on 12/4/2025 at 11:57 a.m. with the Licensed Vocational Nurse (LVN 3) at Patient 2’s residence, Patient 2 was observed answering the door and walking with a walker to the bed. Observed LVN 3 completing patient assessment without assessing Patient 2’s lung sounds or foot. Patient 2’s “Plan of Care” dated 11/5/2025 to 1/3/2026, also indicated pressure ulcer of sacral region (a wound on the tailbone from prolonged pressure that cuts off blood flow, causing skin breakdown), stage 2 (the wound extends into the bottom layers of the skin) and type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood causing high blood sugar) with other specified complications. The plan of care indicated blood sugar will be within physician-established parameters throughout the next month. A review of Patient 2’s clinical record indicated that there was no documentation of Patient 2’s blood sugar being checked and monitored. During a concurrent interview and record review on 12/5/2025 at 12:40 p.m., with Director of Patient Care Services (DPCS), the DPCS stated that nursing staff should be documenting the patients blood sugar and the plan of care should have included parameters on the blood sugar monitoring. c. During a record review of Patient 3’s “Plan of Care” dated 11/13/2025 to 1/11/2026, indicated a start of care date of 7/16/2025 with a primary diagnosis type 2 diabetes mellitus with foot ulcer. The “Plan of Care” indicated that the Skilled Nurse (SN) was to assess the respiratory status, and lung sounds of the patient. The “Plan of Care” further indicated that the Skilled Nurse (SN) is to assess, perform and instruct patient and caregiver skin and diabetic foot care. During a joint home visit, on 12/4/2025 at 1:36 p.m. with the Licensed Vocational Nurse (LVN 1) at Patient 3’s residence, Patient 3 was observed sitting on the couch. Observed LVN 1 completing patient assessment without assessing Patient 3’s lung sounds or left foot. During a concurrent interview and record review on 12/8/2025 at 2:05 pm with Director of Patient Care Services (DPCS), the DPCS stated that Patient1, Patient 2 and Patient 3’s lung sounds should have been assessed during the home visit. DPCS stated that Patient 2 and Patient 3’s feet should have been assessed during the home visits. DPCS stated that it is important to assess the patients to make sure that patients are doing okay and that staff are following the plan of care. d. During a record review of Patient 10’s Patient Information sheet indicated Patient 1’s start of care was 11/26/2024, with a primary diagnosis of unspecified open wound of scalp. During a record review of Patient 10’s medical record form titled “Plan of Care” dated from 11/21/2025 to 01/29/2026, indicated the SN was to notify physician if: Blood pressure; systolic (the top number in blood pressure reading, Representing the pressure in your arteries when your heart contracts and pushes blood out) of the is greater than 160mm HG (millimeters of mercury representing a measurement) or less than 90mm HG; diastolic (The second number of your blood pressure reading which measures the pressure your blood is pushing against your artery walls while the heart muscle rests between beats) is greater than 90mm HG or less than 55mm HG pulse (heart beats per minute) is greater than 100 or less than 55. During an observation on 12/04/2025 at 10:20 a.m., a joint home visit with Licensed Vocational Nurse 1 (LVN 1) at Patient 10’s residence LVN 1 was observed taking Patient 10’s vital signs. Patient 10’s blood pressure reading on the right upper arm was 93/43 mm HG. LVN 1 immediately repeated the blood pressure reading on the same arm, getting a second reading of 105/50 mm HG. LVN 1 then placed the blood pressure cuff on the left upper arm and got a reading of 95/50 mm HG with a pulse of 52 beats per minute. During an interview on 12/04/2025 at 10: 30 a.m., with LVN 1, LVN 1 was asked if there are any reportable findings to the MD, LVN 1 stated, “no all of Patient 10’s vitals were okay, the blood pressure was a bit lower but I will keep the reading of 106/50 mm HG.” During a concurrent record review and interview on 12/08/2025 at 1:35 p.m., with DPCS, of Patient 10’s Skilled Nurse visit note dated 12/04/2025, the document indicated a blood pressure reading of 106/50 mm HG with a pulse rate of 54. DPCS stated, “LVN 1 needed to report the blood pressure and heart rate for Patient 10 to the physician because the diastolic and the heart rate are below the reportable parameter range.” When asked after taking a blood pressure reading how long do you have to wait to take the blood pressure on the same arm, DPCS stated, “usually 5 to 10 minutes or you will get a false higher reading. During a record review of the agency’s policy and procedure, titled “Ongoing Assessment” dated 11/2020, the policy and procedure indicated, “During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for: A. Blood pressure, pulse, respirations, temperature B. Weight (once each week, if indicated by disease) C. Pain status, when applicable, 1. Responses to pain intervention(s) 2. Progress toward pain management goals, including functional ability 3. Side effects of treatment 4. Risk factors for adverse events caused by the treatment D. Breath sounds E. Skin integrity F. Bowel sounds; elimination (urinary arid bowel) G. Appetite/diet, nutritional status H. Mental status I. Functional status J. Safety/home environment K. Patient and family/caregiver support”.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review the Home Health agency (HHA) failed to review and document all the medications and treatments the patient was currently using for five of seventeen sampled patients (Patient 1, Patient 2, Patient 3, Patient 11, Patient 12). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. A. During a record review of Patient 11’s Patient Information sheet indicated Patient 11’s start of care was 11/25/2025, with a primary diagnosis of acute embolism and thrombosis of left popliteal vein (a blockage of the left hollow in the back of the knee.) During a concurrent observation and record review on 12/04/2025 at 12:20 pm of Patient 11’s Medication Profile dated 11/25/2025, at Patient 11’s residence the following medications were not observed in the patient’s home but listed on the medication profile; Enoxaparin 120mg/0.8ml (a blood thinner injection), Timolol Maleate PF 0.5 % ml (an eye drop to lower high pressure inside the eye). During an interview on 12/04/2025 at 12:25 pm with FM 3 (Family member 3), FM 3 stated, “Enoxaparin and Timolol were just in the hospital, Patient 11 hasn’t been taking those medications.” During an interview on 12/08/2025 at 1:30 pm with DPCS, DPCS stated, “all clinicians are supposed to do medication reconciliation on every visit.” B. During a record review of Patient 12’s Patient Information sheet indicated Patient 12’s start of care was 11/07/2025, with a primary diagnosis of essential hypertension. During a concurrent observation and record review on 12/04/2025 at 2:20 pm of Patient 12’s Medication Profile dated 11/07/2025, at Patient 12’s residence the following medications were observed in the patient’s home but not listed on the medication profile; amlodipine 5mg ( blood pressure lowing medication), take one tablet by mouth daily, Meloxicam 7.5 mg (pain medication) take one tablet by mouth as needed for pain, Magnesium glycinate ( mineral, no label), multi collagen protein. The following medications had different doses listed on the medication profile versus medication label; Ascorbic acid 500mg (vitamin) take 1 tablet by mouth daily and Urea 40% ml (a topical moisturizer) apply to affected area 2 times a day listed on the medication profile, but the medication label available at Patient 12’s home indicated Ascorbic acid 1000mg take 1 tablet once a day, and Urea 40% ml cream apply once a day to affected area. During an interview on 12/04/2025 at 2:30 pm with PR 1(Patient Representative 1), PR 1 stated, “I give all the medications for Patient 12, and none of the agency staff has ever educated me on the medications Patient 12 is receiving or how much to give.” During an interview on 12/08/2025 at 1:10 pm with DPCS, DPCS stated, “all clinicians are supposed to do medications reconciliation on every visit.” During a record review of the agency’s policy and procedure, titled “Medication Profile” , undated, the policy and procedure indicated, “ Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen, including name, drug classification, date prescribed/discontinued, dose, strength, route, frequency, date and time of administration and any drug or food allergies. 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. A. The review will be performed by qualified personnel and will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicative drug therapy, and noncompliance with drug therapy. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile, in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting...” Findings: a. During a record review of Patient 1’s “Plan of Care” dated 10/17/2025 to 12/15/2025, indicated a start of care date of 2/19/2025 with a primary diagnosis of obstructive and reflux uropathy (a condition in which the flow of urine is blocked). During a review of Patient 1’s current medication, on 12/4/2025 at 10:06 a.m. with LVN 2, the following medications were not available in Patient 1’s residence but listed in Patient 1’s medication profile provided by the HHA: - Multi Vitamins-Minerals - Ondansetron HCL ( used to prevent nausea and vomiting) 4 milligrams (mg – unit of measurement) - Miralax (prevents and treats occasional constipation) - Cetrizine(used to treat common allergy symptoms and hives) 10 mg tablet - Calcium Carbonate-Vitamin D - Bisacodyl (used on a short-term basis to treat constipation) 10 mg suppository b. During a record review of Patient 2’s “Plan of Care” dated 11/5/2025 to 1/3/2026, indicated a start of care date of 11/5/2025 with a diagnosis of pressure ulcer of sacral region (a wound on the tailbone from prolonged pressure that cuts off blood flow, causing skin breakdown), stage 2 (the wound extends into the bottom layers of the skin) and type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood causing high blood sugar) with other specified complications. During a review of Patient 2’s current medication, on 12/4/2025 at 1:01 p.m. with LVN 2, the following medications were not available in Patient 2’s residence but listed in Patient 2’s medication profile provided by the HHA: - Cetrizine HCL - Folic Acid 400 microgram (mcg – unit of measurement) - Dexamethasone (treats inflammation of the skin, joints, lungs and other organs) - Albuterol Sulfate (used to treat or prevent wheezing, shortness of breath, coughing, and chest tightness in patients with reversible obstructive airway diseases) - Isosorbide Mononitrate Extended Release (ER) (used to prevent chest pain caused by coronary artery disease) 30 mg - Amlodipine Besylate (used to treat high blood pressureand certain types of chest pain) 5 mg tablet - Insulin NPH (Neutral Protamine Hagedorn) (used primarily to manage blood sugar levels in individuals with diabetes mellitus) 100units per milliliter (ml – unit of measurement) - Diclofenac Sodium (to treat pain and inflammation) 1 percent - Prochlorperazine Maleate (treats nausea and vomiting) 5 mg tablet - Olanzapine (treat schizophrenia and bipolar disorder) 5 mg tablet c. During a record review of Patient 3’s “Plan of Care” dated 11/13/2025 to 1/11/2026, indicated a start of care date of 7/16/2025 with a primary diagnosis type 2 diabetes mellitus with foot ulcer. During a review of Patient 3’s current medication, on 12/4/2025 at 1:50 p.m. with LVN 1, the following medications were not available in Patient 3’s residence but listed in Patient 3’s medication profile provided by the HHA: - Losartan HCL (used to treat high blood pressure)1000mg tablet - Furosemide (used to treat high blood pressure) 20 mg tablet - Clopidogrel Bisulfate (used to prevent blood clots ) 75 mg tablet - Lactobacillus-Insulin (improving insulin sensitivity, lowering blood sugar) - Metronidazole (treats infections caused by bacteria) 500 mg - Cetrizine HCL 10 mg tblet - Insulin Glargine(used to control high blood sugar in people with diabetes mellitus) 100 unit/ml During a review of Patient 3’s current medication, on 12/4/2025 at 1:50 p.m. with LVN 1, the following medication was available in Patient 3’s residence but not listed in Patient 3’s medication profile provided by the HHA: - Humilin N (a type of insulin used to control blood sugar ) 100 units/ml vial 10 ml, injected 38 units subcutaneously (beneath the skin) every morning and inject 30 units every evening During an interview on 12/5/2025 at 12:40 pm with Director of Patient Care Services (DPCS), the DPCS stated medication reconciliation is done every patient visit and supervisory visit. DPCS stated that it is important to do a medication reconciliation every visit to make sure that the patients are getting the right medications and also to make sure patients are safe. Findings:a. During a record review of Patient 1’s “Plan of Care” dated 10/17/2025 to 12/15/2025, indicated a start of care date of 2/19/2025 with a primary diagnosis of obstructive and reflux uropathy (a condition in which the flow of urine is blocked). During a review of Patient 1’s current medication, on 12/4/2025 at 10:06 a.m. with LVN 2, the following medications were not available in Patient 1’s residence but listed in Patient 1’s medication profile provided by the HHA: - Multi Vitamins-Minerals - Ondansetron HCL ( used to prevent nausea and vomiting) 4 milligrams (mg – unit of measurement) - Miralax (prevents and treats occasional constipation) - Cetrizine(used to treat common allergy symptoms and hives) 10 mg tablet - Calcium Carbonate-Vitamin D - Bisacodyl (used on a short-term basis to treat constipation) 10 mg suppository b. During a record review of Patient 2’s “Plan of Care” dated 11/5/2025 to 1/3/2026, indicated a start of care date of 11/5/2025 with a diagnosis of pressure ulcer of sacral region (a wound on the tailbone from prolonged pressure that cuts off blood flow, causing skin breakdown), stage 2 (the wound extends into the bottom layers of the skin) and type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood causing high blood sugar) with other specified complications. During a review of Patient 2’s current medication, on 12/4/2025 at 1:01 p.m. with LVN 2, the following medications were not available in Patient 2’s residence but listed in Patient 2’s medication profile provided by the HHA: - Cetrizine HCL - Folic Acid 400 microgram (mcg – unit of measurement) - Dexamethasone (treats inflammation of the skin, joints, lungs and other organs) - Albuterol Sulfate (used to treat or prevent wheezing, shortness of breath, coughing, and chest tightness in patients with reversible obstructive airway diseases) - Isosorbide Mononitrate Extended Release (ER) (used to prevent chest pain caused by coronary artery disease) 30 mg - Amlodipine Besylate (used to treat high blood pressureand certain types of chest pain) 5 mg tablet - Insulin NPH (Neutral Protamine Hagedorn) (used primarily to manage blood sugar levels in individuals with diabetes mellitus) 100units per milliliter (ml – unit of measurement) - Diclofenac Sodium (to treat pain and inflammation) 1 percent - Prochlorperazine Maleate (treats nausea and vomiting) 5 mg tablet - Olanzapine (treat schizophrenia and bipolar disorder) 5 mg tablet c. During a record review of Patient 3’s “Plan of Care” dated 11/13/2025 to 1/11/2026, indicated a start of care date of 7/16/2025 with a primary diagnosis type 2 diabetes mellitus with foot ulcer. During a review of Patient 3’s current medication, on 12/4/2025 at 1:50 p.m. with LVN 1, the following medications were not available in Patient 3’s residence but listed in Patient 3’s medication profile provided by the HHA: - Losartan HCL (used to treat high blood pressure)1000mg tablet - Furosemide (used to treat high blood pressure) 20 mg tablet - Clopidogrel Bisulfate (used to prevent blood clots ) 75 mg tablet - Lactobacillus-Insulin (improving insulin sensitivity, lowering blood sugar) - Metronidazole (treats infections caused by bacteria) 500 mg - Cetrizine HCL 10 mg tblet - Insulin Glargine(used to control high blood sugar in people with diabetes mellitus) 100 unit/ml During a review of Patient 3’s current medication, on 12/4/2025 at 1:50 p.m. with LVN 1, the following medication was available in Patient 3’s residence but not listed in Patient 3’s medication profile provided by the HHA: - Humilin N (a type of insulin used to control blood sugar ) 100 units/ml vial 10 ml, injected 38 units subcutaneously (beneath the skin) every morning and inject 30 units every evening During an interview on 12/5/2025 at 12:40 pm with Director of Patient Care Services (DPCS), the DPCS stated medication reconciliation is done every patient visit and supervisory visit. DPCS stated that it is important to do a medication reconciliation every visit to make sure that the patients are getting the right medications and also to make sure patients are safe. d. During a record review of Patient 11’s Patient Information sheet indicated Patient 11’s start of care was 11/25/2025, with a primary diagnosis of acute embolism and thrombosis of left popliteal vein (a blockage of the left hollow in the back of the knee.) During a concurrent observation and record review on 12/04/2025 at 12:20 pm of Patient 11’s Medication Profile dated 11/25/2025, at Patient 11’s residence the following medications were not observed in the patient’s home but listed on the medication profile; Enoxaparin 120mg/0.8ml (a blood thinner injection), Timolol Maleate PF 0.5 % ml (an eye drop to lower high pressure inside the eye). During an interview on 12/04/2025 at 12:25 pm with FM 3 (Family member 3), FM 3 stated, “Enoxaparin and Timolol were just in the hospital, Patient 11 hasn’t been taking those medications.” During an interview on 12/08/2025 at 1:30 pm with DPCS, DPCS stated, “all clinicians are supposed to do medication reconciliation on every visit.” e. During a record review of Patient 12’s Patient Information sheet indicated Patient 12’s start of care was 11/07/2025, with a primary diagnosis of essential hypertension. During a concurrent observation and record review on 12/04/2025 at 2:20 pm of Patient 12’s Medication Profile dated 11/07/2025, at Patient 12’s residence the following medications were observed in the patient’s home but not listed on the medication profile; amlodipine 5mg ( blood pressure lowing medication), take one tablet by mouth daily, Meloxicam 7.5 mg (pain medication) take one tablet by mouth as needed for pain, Magnesium glycinate ( mineral, no label), multi collagen protein. The following medications had different doses listed on the medication profile versus medication label; Ascorbic acid 500mg (vitamin) take 1 tablet by mouth daily and Urea 40% ml (a topical moisturizer) apply to affected area 2 times a day listed on the medication profile, but the medication label available at Patient 12’s home indicated Ascorbic acid 1000mg take 1 tablet once a day, and Urea 40% ml cream apply once a day to affected area. During an interview on 12/04/2025 at 2:30 pm with PR 1(Patient Representative 1), PR 1 stated, “I give all the medications for Patient 12, and none of the agency staff has ever educated me on the medications Patient 12 is receiving or how much to give.” During an interview on 12/08/2025 at 1:10 pm with DPCS, DPCS stated, “all clinicians are supposed to do medications reconciliation on every visit.” During a record review of the agency’s policy and procedure, titled “Medication Profile” , undated, the policy and procedure indicated, “ Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen, including name, drug classification, date prescribed/discontinued, dose, strength, route, frequency, date and time of administration and any drug or food allergies. 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. A. The review will be performed by qualified personnel and will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicative drug therapy, and noncompliance with drug therapy. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile, in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting...””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to include information required in the plan of care (POC) for one of seventeen sampled patients (Patient 2). This deficient practice had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. During a record review of Patient 2’s “Plan of Care” dated 11/5/2025 to 1/3/2026, indicated a start of care date of 11/5/2025 with a diagnosis of pressure ulcer of sacral region (a wound on the tailbone from prolonged pressure that cuts off blood flow, causing skin breakdown), stage 2 (the wound extends into the bottom layers of the skin) and type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood causing high blood sugar) with other specified complications. The “Plan of Care” indicated that the Skilled Nurse (SN) was to assess, perform and instruct patient and caregiver nephrostomy (a medical procedure to create a new opening from the back, directly into the kidney, to drain urine when the normal urinary tract is blocked, using a tube to divert urine into a bag outside the body, protecting the kidney from damage and infection) care weekly. The “Plan of Care” further indicated that there was no documented evidence in the POC regarding how the nephrostomy care needs to be done, what supplies need to be used during nephrostomy care, or what signs and symptoms needs to be assessed for the nephrostomy. Additionally, the “Plan of Care” did not have blood sugar parameters for Patient 2. During a concurrent interview and record review on 12/8/2025 at 2:05 pm with Director of Patient Care Services (DPCS), the DPCS stated that the plan of care should have a more detailed information regarding the procedure for nephrostomy care. DPCS stated that it is important to have more information in the plan of care so that the nurses know what they are doing and that different physicians have different requirements regarding nephrostomy care. DPCS stated that there should be blood sugar parameter in the plan of care. During a record review of the agency’s policy and procedure, titled “Care Planning Process” dated 11/2024, the policy and procedure indicated, the purpose of the policy and procedure is to provide clinical direction to the clinician providing direct patient care.”

“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 ensure the physician reviewed and revised the plans of care for four of seventeen sample patients (Patient 1, Patient 2, Patient 12, Patient 15). This deficient practice had the potential to result in patients plans of care will be developed not identifying the updated needs of the patients including patient care goals achieved throughout the certification period. A.During a record review of Patient 9’s Patient Information sheet indicated Patient 9’s start of care was 11/03/2025, with a primary diagnosis of malignant neoplasm of the endometrium (a disease where cancerous cells form in the endometrium, the inner lining of the uterus). During a concurrent interview and record review with the DPCS, on 12/08/2025, at 2:05 p.m., the DPCS reviewed Patient 9’s records titled, Plan of Care, dated 11/03/2025 to 01/01/2026. The records did not indicate a doctor’s signature. The DPCS stated the documents were supposed to be signed by the doctor because of the rules and regulations. The signature indicated the doctor acknowledged was the primary doctor and responsible for the care of the patient. The doctor signature validated the specific treatment needed for the patient. The DPCS stated the plan of care was supposed to be signed within 30 days of admission. The risk of not signing the plan of care was the doctor not knowing what services had been provided to the patient. b. During a record review of Patient 12’s Patient Information sheet indicated Patient 12’s start of care was 11/07/2025, with a primary diagnosis of essential hypertension. During a concurrent interview and record review with the DPCS, on 12/08/2025, at 2:10 p.m., the DPCS reviewed Patient 12’s records titled, Plan of Care, dated 11/07/2025 to 01/05/2026. The records did not indicate a doctor’s signature. The DPCS stated the documents were supposed to be signed by the doctor because of the rules and regulations. The signature indicated the doctor acknowledged was the primary doctor and responsible for the care of the patient. The doctor signature validated the specific treatment needed for the patient. The DPCS stated the plan of care was supposed to be signed within 30 days of admission. The risk of not signing the plan of care was the doctor not knowing what services had been provided to the patient. c. During a record review of Patient 15’s Patient Information sheet indicated Patient 15’s start of care was 10/19/2025, with a primary diagnosis of urinary tract infection ( bacterial infection in any part of your urinary system (kidneys, bladder, ureters, urethra). During a concurrent interview and record review with the DPCS, on 12/08/2025, at 2:15 p.m., the DPCS reviewed Patient 15’s records titled, Plan of Care, dated 10/19/2025 to 12/17/2025. The records did not indicate a doctor’s signature. The DPCS stated the documents were supposed to be signed by the doctor because of the rules and regulations. The signature indicated the doctor acknowledged was the primary doctor and responsible for the care of the patient. The doctor signature validated the specific treatment needed for the patient. The DPCS stated the plan of care was supposed to be signed within 30 days of admission. The risk of not signing the plan of care was the doctor not knowing what services had been provided to the patient. During a record review of the agency’s policy and procedure, titled “Care Planning Process” undated, the policy and procedure indicated, “All clinicians including the physician (or allowed practitioner} involved in the patient’s care, either directly or indirectly, will contribute to the plan of care. The plan of care shall be signed by a Doctor of Medicine, osteopathy, or podiatric medicine, or an allowed practitioner acting within the scope of a state license, certification or registration.” Finding: a. During a record review of Patient 1’s “Plan of Care” dated 10/17/2025 to 12/15/2025, indicated a start of care date of 2/19/2025 with a primary diagnosis of obstructive and reflux uropathy (a condition in which the flow of urine is blocked). The “Plan of Care” indicated that there was no signature from the physician. b. During a record review of Patient 2’s “Plan of Care” dated 11/5/2025 to 1/3/2026, indicated a start of care date of 11/5/2025 with a diagnosis of pressure ulcer of sacral region (a wound on the tailbone from prolonged pressure that cuts off blood flow, causing skin breakdown), stage 2 (the wound extends into the bottom layers of the skin) and type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood causing high blood sugar) with other specified complications. The “Plan of Care” indicated that there was no signature from the physician. During a concurrent interview and record review on 12/8/2025 at 2:05 p.m. with Director of Patient Care Services (DPCS), the DPCS stated that Patient 1 and Patient 2’s plan of care were not signed. DPCS stated that the plan of care should be signed by the physician within 30 days. DPCS stated that it is important that the plan of care is signed by the physician with in 30 days so that the physician is aware regarding the care being provided.”

“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 agency failed to ensure care coordination was conducted between agency clinicians to ensure appropriate equipment was available for one of 17 sampled patients (Patient 12). The deficient practice had the potential to result in delayed care and impact the health and safety of Patient 12. During a record review of Patient 12’s Patient Information sheet indicated Patient 12’s start of care was 11/07/2025, with a primary diagnosis of essential hypertension. During a record review of Patient 12’s medical record form titled “Plan of Care” dated from 11/07/2025 to 01/05/2026, indicated under supplies walker effective 11/7/2025, indicated to assess for DME (Durable medical equipment). During a record review of Patient 12’s medical record document titled Call Center Telephone Encounter, dated 11/28/2025 indicated “Member requested per physical therapist from Infinite Home Health patient needs bariatric (heavy duty mobility aid with wider, deeper frame, high weight capacity (350 -750 lbs.) front wheel walker, wide one, and a three in one commode. Chart review indicated, the DME item last ordered was too narrow for PT. No previous order for a three in one commode. During a concurrent observation and interview on 12/04/2025 at 2:30 pm with RN 1 at Patient 12’s residence, a standard size walker and a standard size commode was observed. Patient 12 stated, “I have been asking the physical therapists and the occupational therapists ever since my admission that I need a wider walker and a commode. They delivered the one here, which I can’t use. How can they discharge me from service if they haven’t helped me use the walker or the commode. I need the right size here first so they can train me on it before they discharge me from service. It is not my fault the right equipment was never delivered to me.” During an interview on 12/08/2025 at 1:05 pm with the DPCS stated, “there has to be better care coordination. Before Patient 12 was discharged from physical therapy and occupational therapy services, the proper equipment needed to be delivered, and Patient 12 needed to be able to use it.” During a record review of the agency’s policy and procedure, titled, “Coordination of Services with Other Providers” revised November 2020, the policy and procedure indicated, “A Case Manager will be assigned to be responsible for coordinating services provided to the patient by the organization, including services provided directly and through contract. The Case Manager will act as liaison with other organizations or individuals also providing care to the patient to assure effective coordination of related services.”