St Luke’s Home Health Services, Inc.

“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 agency failed to ensure the clinical record was completed for one of four sampled patients (Patient 1). This failure created the risk of not having the accurate information in the patient’s clinical record. Review of Patient 1’s closed clinical record was initiated on 6/17/26. The closed clinical record showed the SOC was 8/18/25. The patient was certified for home health services during the certification periods from 8/18/2025 to 10/16/2025, 10/17/2025 to 12/15/2025, 12/16/2025 to 02/13/2026, 02/14/2026 to 04/14/2026, and 04/15/2026 to 06/13/2026. The patient was discharged on 6/12/26. Review of the Communication notes showed the HHA felt unsafe: -On 9/8/25, the family member visited the agency with the transportation denial letter, previous hospital papers, and pad papers with care information of the patient. The communication note included the family member verbalized that he got banned from six different hospitals due to accusation of assault to the MD and threatening to come back and packing with a gun but nothing were true as he mentioned. -On 2/11/26, received a report from RN 1 that during her visit, she felt unsafe because the family member was verbally making her feel uncomfortable with comments he was making in regards to be being banned from all Orange County hospitals. RN verbalized her hesitance to continue visiting the patient. Agency verbalized understanding and stated they will document all reports received. MD was aware and notified -On 4/17/26, the family member came by the office today to stop by and pay “us” a visit. The family member then mentioned the following, “ yes I might make you guys suffer a bit more and make you work.” The agency requested further clarification in regards to his statement but the family member laughed and walked away. The MD was notified. - On 5/26/26, received report from CHHA 1 that during the visit, CHHA 1 witnessed an argument the family member and the partner had. CHHA 1 stated the partner said, “he’s really on a role today and I might call the cops on him.” CHHA 1 wanted to inform agency of situation she experienced. The MD was notified. On 6/17/26 at 1158 hours, an interview was conducted with the CEO. The CEO was asked about Patient 1’s discharge. The CEO stated on 6/1/26, the HHA received report from LVN 1 that LVN 1 would be resigning in two weeks; and the family member and MD was informed. The CEO further stated the agency’s other licensed staff nurses were requested to render their skilled nursing services to Patient 1; however the agency’s other licensed nurses refused because they were not comfortable with the family member. The CEO added RN 1 who used to go to Patient 1 even asked for LVN 1’s presence because RN 1 felt unsafe. The CEO mentioned RN 1 already resigned because of the family member. Additionally, the CEO stated the agency had been assisting the patient for HHA referrals, and the HHA was just waiting for the decision on which HHA the family member preferred. However, review of the closed clinical record showed no documented evidence the reasons for discharge included the unsafe environment for staff. On 6/18/26 at 1610 hours, an interview was conducted with the CEO and DPCS. The CEO and DPCS were informed and verified the findings.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the written visit schedule provided to one of four sampled patients (Patient 4) was consistent with the patient’s most current plan of care. This failure had the potential of creating the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 4’s clinical record was initiated on 6/17/26. The clinical record showed the SOC was 12/22/25. The patient was certified for home health services during the certification periods from 12/22/2025 to 2/19/2025, 2/20/2026 to 4/20/2026, and 4/21/2026 to 6/19/2026. The POC, for the certification periods from 4/21/2026 to 6/19/2026, showed SN visits 1W9 (one visit a week for nine weeks). A joint home visit with LVN 1 was conducted on 6/18/26 at 0900 hours, to Patient 4’s home. Patient 4’s Admission Packet was reviewed. The Projected Home Visit Schedule Frequency Calendar was blank for the SN visit frequency and episode dates. LVN 1 was asked if it should have been filled up and completed, LVN 1 verified it was missed and should have been completed. On 6/18/26 at 1500 hours, an interview and concurrent clinical record review were conducted with the CEO and DPCS. The CEO and DPCS were informed and verified the findings.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the SN provided education to the patient/PCG as per the POC for two of four sampled patients (Patients 1 and 2). This failure created the risk of not providing the necessary care and services to these patients. Findings: 1. Review of Patient 1’s closed clinical record was initiated on 6/17/26. The closed clinical record showed the SOC was 8/18/25. The patient was certified for home health services during the certification periods from 8/18/2025 to 10/16/2025, 10/17/2025 to 12/15/2025, 12/16/2025 to 2/13/2026, 2/14/2026 to 04/14/2026, and 04/15/2026 to 06/13/2026. The patient was discharged on 6/12/26. Review of the POC for the certification period from 4/15/26 to 6/13/26, showed skilled nurse to teach/instruct the patient/patient caregiver on PEG care. Review of the SN Nursing Progress Notes dated 4/15. 4/16, 4/17, 4/18, 4/19, 4/20, 4/22, 4/27, 4/29, 5/5, 5/7, 5/11, 5/14, 5/18, 5/20, 5/21, 5/25, 5/27, 6/1, 6/3, 6/8, and 6/10/26 showed no documented evidence the SN followed the physician’s order to teach/instruct patient/caregiver on PEG tube care. On 6/18/26 at 1515 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the findings. 2. Review of Patient 2’s closed clinical record was initiated on 6/17/26. The clinical record showed the SOC was 1/15/26. The patient was certified for home health services during the certification period from 1/15/26 to 3/15/26. The patient was discharged on 2/25/26. Review of the POC, for certification period from 1/15/26 to 3/15/26, showed the following: -SN to teach/instruct/train the patient/caregiver regarding dietary regimen. -Goals/rehabilitation, potential/discharge plans/referral plan/other notes showed patient/caregiver would verbalize understanding on low salt/fat/cholesterol diet as evidenced by compliance with diet plan in four to six weeks. Review of the SN Nursing Progress Notes dated 1/19 , 1/23, 1/26, 1/30, 2/6, 2/14, and 2/18/26, showed no documented evidence the SN followed the physician’s order to teach/instruct patient/caregiver on the dietary regimen. On 6/18/26 at 1044 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the findings.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included strategies for addressing emergency events identified by the risk assessment. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency’s 2025 emergency preparedness program documents was conducted on 5/19/26, and showed the plan did not address the strategies for addressing bomb threat emergency event as identified by the risk assessment. On 5/20/26 at 0839 hours, an interview and concurrent record review was conducted with the CEO. The CEO verified the above finding.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included the communication plan that address how the facility interacts and coordinates with emergency management agencies and systems to protect patient health and safety in the event of a disaster. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Review of the agency’s 2025 emergency preparedness program documents was conducted on 5/19/26, and showed the communication plan did not address how the facility interacts and coordinates with emergency management agencies and systems to protect patient health and safety in the event of a disaster. On 5/20/26 at 0838 hours, an interview and concurrent document review was conducted with the CEO. The CEO was informed and acknowledged the above finding.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the OASIS data were transmitted within 30 days of completing the OASIS data sets. This failure had the potential for not reporting and coordinating the patient care assessment timely for the patients receiving care and services at the agency. Findings: Review of the Agency Error Summary Report for 5/5/25 to 5/5/26, was initiated on 5/15/26. The Agency Error Summary Report for 5/5/25 to 5/5/26, showed five OASIS data sets were submitted more than 30 days from the assessment completion date. On 5/15/26 at 0805 hours, an interview and concurrent document review was conducted with the CEO. The CEO confirmed the five OASIS data sets were submitted late.”

“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 agency failed to ensure the clinical records were electronically signed and dated for one out eight sampled patients (Patient 1). This failure had a potential risk on inaccuracy of the patient’s clinical records. Findings: Review of the agency’s P&P titled Entries into the Clinical Record revised 1/2004 showed the clinical note will include the date the service was provided and signature of clinician and his/her credentials. Review of Patient 1’s clinical record was initiated on 5/13/26. The clinical record showed the SOC was 2/5/26. The patient was certified for home health services during the certification period from 4/6/26 to 6/4/26. Review of Patient 1’s Recertification Assessment/ OASIS dated 4/5/26, showed RN 1 conducted complete the patient assessment documentation. However, there was no documentation showing it was electronically signed and dated. On 5/20/26 at 0818 hours, an interview and concurrent record reveiw was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the medication profiles were reviewed and updated for two of eight sampled patients (Patients 2 and 3). This failure had the potential for the patients not to receive the appropriate care and necessary services and negatively affect the patients’ well-being. Findings: Review of the agency’s P&P titled Medication Profile revised 1/2004 showed patients receiving medications will have a current accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. 1. Review of Patient 2’s clinical record was initiated on 5/14/26. The clinical record showed the SOC was 10/23/24. The patient was certified for home health services during the certification periods from 10/23/24 to 12/21/24, 12/22/24 to 2/29/25, 2/20/25 to 4/20/25, 4/21/25 to 6/19/25, 6/20/25 to 8/18/25, 8/19/25 to 10/17/25, 10/18/25 to 12/16/25, 12/17/25 to 2/14/26, 2/15/26 to 4/15/26, and 4/16/26 to 6/14/26. The Patient Medication Profile for the certification period from 4/16/26 to 6/14/26, showed the patient’s medication included ibuprofen (pain medication) 600 mg one tablet by mouth at bedtime. A joint home visit with LVN 1 was conducted on 5/14/26 at 1130 hours, to Patient 2’s home. The medication bottle at the patient’s home showed ibuprofen 600 mg one tablet by mouth three times a day with food/milk as needed. However, there was no documented evidence the medication profile was updated to show the frequency of the above medication. LVN 1 confirmed the above finding. On 5/20/26 at 0843 hours, an interview and concurrent clinical record review was conducted with the CEO. The CEO acknowledged and verified the findings. 2. Review of Patient 3’s clinical record was initiated on 5/14/26. The clinical record showed the SOC was 3/27/26. The patient was certified for home health services during the certification period from 3/27/26 to 5/25/26. The Patient Medication Profile for the certification period from 3/27/26 to 5/25/26, showed the patient’s medication included pramipexole (medication used to treat Parkinson’s disease) 0.5 mg one tablet by mouth every evening. A joint home visit with PT 1 was conducted on 5/14/26 at 1500 hours, to Patient 3’s home. The PCG stated Patient 3 was weaned off from pramipexole and it was discontinued about two weeks ago. Furthermore, the PCG stated Patient 3 started on gabapentin (medication used to treat nerve pain) a couple of months ago. Gabapentin was administered until the patient was weaned off from pramipexole. However, there was no documented evidence the medication profile was updated to reflect the patient’s current medications to include gabapentin and remove pramipexole. On 5/20/26 at 0822 hours, an interview and concurrent clinical record review was conducted with the CEO. The CEO acknowledged and verified the findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure to follow the physician’s orders for two of eight sampled patients (Patients 5 and 8). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 5’s closed clinical record was initiated on 5/13/26. The clinical record showed the SOC was 8/1/23. The patient was certified for home health services during the certification period from 8/1/23 to 9/29/23, 9/30/23 to 11/28/23, 11/29/23 to 1/27/24, 1/28/24 to 3/27/24, 3/28/24 to 5/26/24, 5/27/4 to 7/25/24, 7/26/24 to 9/23/24, 9/24/24 to 11/22/24, 11/23/24 to 1/21/25, 1/22/25 to 3/22/25, 3/23/25 to 5/21/25, 5/22/25 to 7/20/25, 7/21/25 to 9/18/25, 9/19/25 to 11/17/25, and 11/18/25 to 1/16/26. The patient was discharged on 1/8/26. Review of Physician’s Order/Telephone Order dated 11/24/25, showed to send MSW for evaluation and as needed 1-2 follow up visits. Review of the agency’s visit calendar for certification period from 11/18/25 to 1/16/26 showed no documentation of MSW visits. On 5/20/26 at 0822 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked to show MSW visits documentation as ordered by the physician. The Administrator/DPCS verified she could not find any documentation of MSW visits and further stated the physician’s order should have been followed. 2. Review of Patient 8’s clinical record was initiated on 5/13/26. The clinical record showed the SOC was 8/18/25. The patient was certified for home health services during the certification period from 8/18/25 to 10/16/25, 10/17/25 to 12/15/25, 12/16/25 to 2/13/26, 2/14/26 to 4/14/26 and 4/15/26 to 6/13/26. Review of Patient 8’s POC dated 4/15/26 for certification period from 4/15/26 to 6/13/26, showed a physician’s order for SN to teach/instruct patient/caregiver on the following: -management and treatment of disease process and wound care -signs and symptoms of infection, infection control -PEG -Foley catheter care, signs and symptoms of UTI -bleeding -medications to include action, dose, frequency, route of administration, adverse side effects. In addition, the orders for discipline and treatment showed SN to perform bladder irrigation through Foley catheter every visit. The PCG would perform bladder irrigation through Foley catheter on non SN visit days: Bladder Irrigation- 1:20 ratio of white vinegar to water and instill 60cc then aspirate 30cc through Foley catheter daily and as needed to prevent clogging. Review of the SN visits dated 4/16, 4/17, 4/18, 4/19, 4/20, 4/22, 4/27, 4/29, 5/5, and 5/7/26, showed the completed assessments from head to toe. However there was no documentation of the bladder irrigation through Foley catheter every SN visits conducted. On 5/20/26 at 0831 hours, an interview and concurrent record review was conducted with the Administrator and DPCS. The Administrator/DPCS was informed and verified the physician’s orders should have been followed.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patient and PCG were provided education regarding the care identified in the POC for five of eight sampled patients (Patients 1, 5, 6, 7, and 8). This failure has the potential for not addressing the care needs for these patients. Findings: 1. Review of Patient 7’s clinical record was initiated on 5/19/26. The clinical record showed the SOC was 3/13/26. The patient was certified for home health services during the certification periods from 3/13/26 to 5/11/26 and 5/12/26 to 7/10/26. Review of the communication note dated 3/19/26, showed Patient 7 went to GACH ER due to complaints of left arm swelling and pain. Review of the physician’s telephone order dated 3/31/26, showed Patient 7 was discharged from GACH due to left arm swelling and pain. Documentation showed the patient had complication with the fistula on the left upper extremity that required coiling. A resumption of care (after inpatient stay) was ordered. In addition, the order included teaching and training and follow up for the patency of the left forearm “AV fistula (shunt).” Review of the resumption of care assessment dated 3/31/26, showed RN 2 noted left forearm AV fistula to be patent and positive for thrill/bruit. However, there was no documented evidence the teaching and training were provided to keep the left forearm AV fistula free from any complications. On 5/20/26 at 0906 hours, an interview and concurrent clinical record review were conducted with the CEO and RNCM/QA. The RNCM/QA verified the findings. 2. Review of Patient 1’s clinical record was initiated on 5/13/26. The clinical record showed the SOC was 2/5/26. The patient was certified for home health services during the certification period from 4/6/26 to 6/4/26. Review of Patient 1’s POC for certification period from 4/6/26 to 6/4/26, showed the medications included aspirin (blood thinner) 81 mg oral tablet daily. The POC showed SN to teach/instruct patient/patient caregiver on the following: -on the management and treatment of diabetes, stroke, hypertension, and hyperlipidemia, -measures to recognize cardiac dysfunction and relieve complications, recognizing warning signs of stroke -bleeding/universal/covid-19 precautions, signs and symptoms of disease exacerbation/complications, pain management, -medications to include action, dose, frequency, route of administration, adverse side effects, Review of the SN notes dated 4/13, 4/20, 4/26, 5/7, and 5/12/26, showed Patient 1 was assessed from head to toe. *However there was no documented evidence the teaching/instructions were provided to the patient/caregiver on signs and symptoms of bleeding related to aspirin use. On 5/20/26 at 0815 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and verified the finding. 3. Review of Patient 5’s closed clinical record was initiated on 5/13/26. The clinical record showed the SOC was 8/1/23. The patient was certified for home health services during the certification period from 8/1/23 to 9/29/23, 9/30/23 to 11/28/23, 11/29/23 to 1/27/24, 1/28/24 to 3/27/24, 3/28/24 to 5/26/24, 5/27/4 to 7/25/24, 7/26/24 to 9/23/24, 9/24/24 to 11/22/24, 11/23/24 to 1/21/25, 1/22/25 to 3/22/25, 3/23/25 to 5/21/25, 5/22/25 to 7/20/25, 7/21/25 to 9/18/25, 9/19/25 to 11/17/25, and 11/18/25 to 1/16/26. The patient was discharged on 1/8/26. Review of the Physician’s Order/Telephone Order dated 12/22/26, showed a change of dosage for quetiapine (antipsychotic) from 25 mg to 50 mg, one tablet by mouth daily in the afternoon. The order showed SN to teach/instruct/train the patient/PCG on new medication (action, dose, frequency and side effects), administration, disease process, sign and symptoms of infection, complications/management, etc. Review of the SN notes dated 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/30, 12/31/25, 1/1, 1/2, and 1/3/26, showed the completed assessments on mental status, cardiovascular, respiratory, EENT, motor/musculoskeletal, pain, gastrointestinal, genitourinary, endocrine, integumentary, wound, and venous assessment. *However, there was no documented evidence of the SN following the physician’s order to teach/instruct/train patient/caregiver on the new medication order. On 5/20/26 at 0822 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed on the new medication dosage order of quetiapine and verified that education should have been provided to the patient/caregiver as ordered by the physician. 4. Review of Patient 6’s clinical record was initiated on 5/13/26. The clinical record showed the SOC was 3/23/26. The patient was certified for home health services during the certification period from 3/23/26 - 5/21/26. Review of the Medication Profile showed a physician’s order that included aspirin 81 mg one tablet oral daily for prophylaxis. Review of the POC dated 3/23/26, showed SN to teach/instruct/train the patient/PCG on the following: -disease process/management/complications, medication regimen (purpose, side effects, dosage and frequency) - signs/symptoms of bleeding. Review of the SN notes dated 3/27, 4/1/, 4/3, 4/8, 4/15, 4/22, 4/29, 5/6, and 5/13/26, showed the completed assessments on mental status, cardiovascular, respiratory, EENT, motor/musculoskeletal, pain, gastrointestinal, genitourinary, endocrine, integumentary, wound, and venous assessment. *However, there was no documented evidence of the SN following the physician’s order to teach/instruct/train the patient /caregiver on medication regimen (purpose, side effects, dosage and frequency), and signs and symptoms of bleeding. On 5/20/26 at 0825 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS acknowledged there was no documentation from the dates mentioned and verified the physician’s order to provide the patient/caregiver with education on aspirin medication and signs and symptoms of bleeding should have been followed. 5. Review of Patient 8’s clinical record was initiated on 5/13/26. The clinical record showed the SOC was 8/18/25. The patient was certified for home health services during the certification period from 8/18/25 to 10/16/25, 10/17/25 to 12/15/25, 12/16/25 to 2/13/26, 2/14/26 to 4/14/26, and 4/15/26 to 6/13/26. Review of Patient 8’s POC dated 4/15/26 for certification period from 4/15/26 to 6/13/26, showed a physician’s order for skilled nurse to teach/instruct the patient/caregiver on the following: -management and treatment of disease process and wound care -signs and symptoms of infection, infection control -PEG -foley catheter care, signs and symptoms of UTI -bleeding -medications to include action, dose, frequency, route of administration, adverse side effects. In addition, the orders for discipline and treatment showed SN to perform bladder irrigation through Foley catheter every visit. The PCG would perform bladder irrigation through Foley catheter on non SN visit days: Bladder Irrigation- 1:20 ratio of white vinegar to water and instill 60 cc then aspirate 30 cc through Foley catheter daily and as needed to prevent clogging. Review of the Medication Profile for certification period from 4/15/26 to 6/13/26, showed a physician’s order dated 8/18/25, for aspirin 81 mg one tablet via G-tube daily. a. Review of the SN notes dated 4/16, 4/17, 4/18, 4/19, and 4/20/26, showed the completed assessments on mental status, cardiovascular, respiratory, EENT, motor/musculoskeletal, pain, gastrointestinal, genitourinary, endocrine, integumentary, wound, and venous assessment. *However, there was no documented evidence the SN followed the physician’s order to provide education to the patient/caregiver on signs and symptoms of bleeding, infection, UTI, PEG care, and Foley catheter care. b. Review of the SN visits dated 4/16, 4/17, 4/18, 4/19, 4/20, 4/22, 4/27, 4/29, 5/5, and 5/7/26, showed the completed assessments from head to toe. *However there was no documentation the education was provided to the caregiver to perform bladder irrigation through Foley catheter on non-SN visit days. On 5/20/26 at 0831 hours, an interview and concurrent record review was conducted with the Administrator and DPCS. The Administrator/DPCS was informed and verified the physician’s orders should have been followed.”

“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 failed to ensure the agency’s skilled professionals prepared accurate clinical notes for two of eight sampled patients (Patient 2 and 7). This failure had the potential risk of creating a substandard healthcare outcome for these patients. Findings: 1. Review of Patient 2’s clinical record was initiated on 5/14/26. The clinical record showed the SOC was 10/23/24. The patient was certified for home health services during the certification period from 10/23/24 to 12/21/24, 12/22/24 to 2/29/25, 2/20/25 to 4/20/25, 4/21/25 to 6/19/25, 6/20/25 to 8/18/25, 8/19/25 to 10/17/25, 10/18/25 to 12/16/25, 12/17/25 to 2/14/26, 2/15/26 to 4/15/26, and 4/16/26 to 6/14/26. a. Review of the Recertification Assessment dated 4/15/26, showed Patient 2 had anemia and was taking ferrous sulfate (medication for iron deficiency) 325 mg one tablet by mouth once a day. However, review of the Patient Medication Profile for the certification period from 4/16/26 to 6/14/26, did not include the mentioned medication which was inconsistent with the Recertification Assessment. b. Review of the Nursing Progress Note dated 4/30 and 5/7/26, showed in the narrative section, LVN 1 cleansed Stage 4 sacrococcyx pressure injury with wound cleanser, patted dry with gauze, applied Skin-Prep (protective wipes) to the periwound, applied Vitastem (antibiotic spray), medical grade honey and calcium alginate with silver (antimicrobial wound dressing) to the wound bed, and covered with a foam dressing. However, review of the Wound Care Worksheet dated 4/30 and 5/7/26, showed the treatment order to cleanse Stage 4 sacrococcyx pressure injury with wound cleanser, pat dry with gauze, apply Skin-Prep to the periwound, apply Vitastem and collagen powder (topical wound care) to the wound bed, and cover with a bordered foam dressing which was inconsistent with the SN Notes. On 5/20/26 at 0843 hours, an interview and concurrent clinical record review was conducted with the CEO. The CEO confirmed the findings. 2. Review of Patient 7’s clinical record was initiated on 5/19/26. The clinical record showed the SOC was 3/13/26. The patient was certified for home health services during the certification periods from 3/13/26 to 5/11/26 and 5/12/26 to 7/10/26. a. Review of the Patient Referral and Order Form dated 2/24/26, showed an order for a Social Worker for transportation and assistance to and from dialysis. Review of the POC, for the certification period from 3/13/26 to 5/11/26, showed MSW 1-2 visits for 60 days for evaluation, psychosocial assessment, community resources/services referral, counseling, and long-term planning. However, review of the Medical Social Services Discharge Summary dated 4/1/26, the MSW did not specify information on the transportation and assistance to and from dialysis in the community referrals. b. Review of the Nursing Progress Note dated 4/7/26, showed in the narrative section, LVN 2 noted Patient 7 took losartan hydrochlorothiazide (antihypertensive) 50-12.5 mg one tablet by mouth and carvedilol (antihypertensive) 12.5 mg one tablet by mouth. However, review of the Home Health Certification and Plan of Care for the certification period from 3/13/26 to 5/11/26, did not include the abovementioned medications. On 5/20/26 at 0906 hours, an interview and concurrent clinical record review was conducted with the CEO and RNCM/QA. The CEO and RNCM/QA confirmed the findings.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on interview and record review, the agency’s Administrator failed to be responsible for the agency’s day-to-day operations which included: -The written agreements failed to address the role of the agency and the contracted individual in discharge planning for Contractors 3 and 4. -The implementation of the agency’s P&P related to the maintenance of the patient’s clinical records specifically the Patient Arbitration Agreement for four of eight sampled patients (Patients 2, 3, 4, and 7). These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: Review of the agency’s P&P titled Entries Into the Clinical Record revised 1/2004, showed documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. A clinical record will be initiated and maintained for each patient receiving care or services and include among other the client consent authorization, and elections forms, as applicable. 1.Review of Patient 2’s clinical record was initiated on 5/14/26. The clinical record showed the SOC was 10/23/24. The patient was certified for home health services during the certification period from 10/23/24 to 12/21/24, 12/22/24 to 2/29/25, 2/20/25 to 4/20/25, 4/21/25 to 6/19/25, 6/20/25 to 8/18/25, 8/19/25 to 10/17/25, 10/18/25 to 12/16/25, 12/17/25 to 2/14/26, 2/15/26 to 4/15/26 and 4/16/26 to 6/14/26. Review of the Consent/Admission/Recertification Service Agreement dated 10/23/24, showed the Patient Arbitration Agreement was left blank. On 5/20/26 at 0843 hours, an interview and concurrent clinical record review was conducted with the CEO. The CEO acknowledged and verified the findings. 2.Review of Patient 3’s clinical record was initiated on 5/14/26. The clinical record showed the SOC was 3/27/26. The patient was certified for home health services during the certification period from 3/27/26 to 5/25/26. Review of the Consent/Admission/Recertification Service Agreement dated 3/27/26, showed the Patient Arbitration Agreement was left blank. Furthermore, the consent was signed by a patient or authorized representative, however, the reason why patient did not sign was not indicated. On 5/20/26 at 0822 hours, an interview and concurrent clinical record review was conducted with the CEO. The CEO acknowledged and confirmed the findings. 3.Review of Patient 4’s closed clinical record was initiated on 5/15/26. The clinical record showed the SOC was 10/30/25. The patient was certified for home health services during the certification period from 10/30/25 to 12/28/25, 12/29/25 to 2/6/26 and 2/27/26 to 4/27/26. The patient was discharged on 4/25/26. Review of the Consent/Admission/Recertification Service Agreement dated 10/30/25, showed the Patient Arbitration Agreement and Medicare Secondary Payer Screening Form were left blank. On 5/20/26 at 0904 hours, an interview and concurrent clinical record review was conducted with the CEO and RNCM/QA. The RNCM/QA acknowledged and confirmed the findings. 4.Review of Patient 7’s clinical record was initiated on 5/19/26. The clinical record showed the SOC was 3/13/26. The patient was certified for home health services during the certification periods from 3/13/26 to 5/11/26 and 5/12/26 to 7/10/26. Review of the Consent/Admission/Recertification Service Agreement dated 3/13/26, showed the Patient Arbitration Agreement was left blank. On 5/20/26 at 0906 hours, an interview and concurrent clinical record review was conducted with the CEO and RNCM/QA. The RNCM/QA acknowledged and confirmed the findings. Review of the agency’s P&P title Administrator (undated) showed the administrator ensures quality and safe delivery of home health care services; coordinates services that reflect the Agency’s philosophy and standards of care; plans, develops, implements and evaluates Agency services; programs and activities. Review of agency’s Written Agreements for Contracted Services revised 1/2004 showed the written agreement will address discharge planning. Review of the agency’s job description for Physical Therapist copyright dated 1995 showed physical therapists participate in discharge planning for patient. Review of the agency’s job description for Occupational Therapist copyright dated 1995 showed occupational therapists participate in discharge planning for patient. Review of the agency’s job description for Speech Language Pathologist copyright dated 1995 showed occupational therapists participate in discharge planning for patient. Review of the Contractor Agreements was initiated on 5/19/26. The contractor agreements 3 and 4 failed to include discharge planning. On 5/19/26 at 1032 hours, an interview and concurrent record review was conducted with the CEO. The CEO verified the above findings and stated agency would reach out to contractor for revision of agreement.”