Lifelink Health Providers, Inc.

“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, an organization that provides skilled nursing and therapeutic services, such as physical, occupational or speech therapy, to individuals in their homes) failed to provide written information regarding the plan of care (POC, a mandatory, written, and patient-specific document that outlines necessary medical, rehabilitative, and supportive services to treat an injury or illness at home) for two of 13 sample patients (Patient 1 and Patient 2). This failure had resulted in patients and their representatives not knowing their care team or their treatment course. a. During a record review of Patient 1’s POC dated 11/25/2025 to 1/23/2026, indicated a start of care date of 9/26/2025 with a diagnosis of multi-system degeneration (progressive brain disorder that affects movement and balance and disrupts the function). During a joint home visit on 1/14/2026 at 10:30 a.m. with the Physical Therapy Assistant (PTA) at Patient 1’s residence, Patient 1 was observed sitting down on a chair in the living room. There was no POC identified in Patient 1’s home. b. During a review of Patient 2’s POC dated 11/28/2025 to 1/26/2026, indicated a start of care date of 6/1/2025 with a primary diagnosis of intrahepatic bile duct carcinoma (a rare, aggressive cancer that forms in the bile ducts located inside the liver). During a joint home visit, on 1/14/2026 at 12:35 p.m. with the Certified Occupational Therapy Assistant 1 (COTA 1) at Patient 2’s residence, Patient 2 was observed ambulating (walking) and sitting down in the dining room. There was no POC identified in Patient 2’s home. During an interview on 1/16/2026 at 10:21 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated a copy of POC and medication profile should be available at the patient’s home. The DPCS stated that it is important to have the POC in patient’s home to make sure patients and their families are aware of the care and services patients are receiving. During a review of the agency’s policy and procedure titled, “Care Planning Process” not dated, the policy and procedure indicated the organization shall provide the patient and caregiver with a copy of written instructions outlining: any treatments, to be administered by the organization, including therapy services and any other pertinent instructions related to the patient’s care and treatments that the organization will provide, specific to the patient’s care needs.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that provides skilled nursing and therapeutic services, such as physical, occupational or speech therapy, to individuals in their homes) failed to review and document medications and treatments the patients were receiving for three of 13 sampled patients (Patient 2, Patient 3 and Patient 7). These failures had the potential to place the patients at risk for drug-to-drug interaction, medication errors and medication adverse effects that could cause harm to patient’s health. c. During a record review of Patient 7’s Patient Profile sheet indicated a start of care date of 11/10/2025, with diagnoses including presence of right artificial acute post procedure reverse total shoulder arthroplasty ( right shoulder replacement surgery with artificial device). During a concurrent interview and record review on 1/14/2026 at 10:55 am with physical therapy assistant 2 (PTA 2), at Patient 7’s residence, PTA 2 reviewed the medication Patient 7 was taking using record titled, Medication Profile, dated 11/10/2025. PTA 2 stated the following medications were at home, patient reported taking, but was not listed: -Tylenol 650mg, take 1 tablet by mouth every 4 hours daily as needed for arthritic pain -Losartan 50mg (a medication to lower elevated blood pressure) take 1 tablet by mouth daily -Loratadine 10mg (for allergies) 1 tablet daily -Raloxifene 60mg (used for postmenopausal women to prevent and treat osteoporosis and reduce the risk of invasive breast cancer) 1 tablet daily . -Rosuvastatin 20mg (medication for high cholesterol) 1 tablet daily -Wegovy 0.25mg (a medication for weight loss) 1 injection subcutaneous weekly. -ascorbic acid 1000mg tablet (vitamin C ) 2 tables twice daily. PTA 2 stated, “this was missed by the physical therapist and the nurse. Medication reconciliation needs to be done on every visit by physical therapists, occupational therapists and nurses. This is very important so we can keep track of all the current medications the patient has and communicate with the physician.” During an interview and record review on 1/15/2026 at 11:00 am., with DPCS, DPCS stated “medication reconciliation is supposed to be done every visit, this includes physical therapists as well nurses. They are supposed to do it on every visit. This was missed for these patients.” a. During a record review of Patient 2’s “Plan of Care” dated 11/28/2025 to 1/26/2026, indicated a start of care date of 6/1/2025 with a primary diagnosis of intrahepatic bile duct carcinoma (a rare, aggressive cancer that forms in the bile ducts located inside the liver). During a joint home visit, on 1/14/2026 at 12:35 p.m. with the Certified Occupational Therapy Assistant (COTA 1) at Patient 2’s residence. Patient 2 was observed ambulating and sitting down in the dining room. During a review of Patient 2’s current medication, on 1/14/2026 at 12:53 p.m. with COTA 1, the following medications were available in Patient 2’s residence but not listed in Patient 2’s medication profile provided by the HHA: Tylenol (used to treat pain reliever and a fever reducer )500 milligrams (mg – unit of measurement) – 1000 mg every 6 hoursIbuprofen (used to treat mild to moderate pain, and helps to relieve symptoms of arthritis) 800 mg – take one tablet three times daily as neededFamotidine (used to decrease stomach acid for treating ulcers) 20 mg – take one tablet twice dailyFurosemide (help treat fluid retention and swelling) 20 mg – take 1 tablet dailyb. During a record review of Patient 3’s “Plan of Care” dated 11/18/2025 to 1/16/2026, indicated a start of care date of 11/18/2025 with a diagnosis of fracture of lower end of femur (thigh bone). During a review of Patient 3’s current medication, on 1/14/2026 at 2:10 p.m. with the Director of Patient Care Services (DPCS), the following medications were not available in Patient 1’s residence but was listed in Patient 3’s medication profile provided by the HHA: Doxycycline Monohydrate (used to treat bacterial infections in many different parts of the body) 100 mg – 1 tablet twice dailyNitrofurantoin Monohydrate/Macrocrystals (used to treat urinary tract infections) 100 mg – 1 capsule twice dailyDuring a review of Patient 3’s current medication, on 1/14/2026 at 2:10 p.m. with the DPCS, the following medications were available in Patient 3’s residence but not listed in Patient 3’s medication profile provided by the HHA: Furosemide 20 mg – take 1 tablet dailyDocusate Sodium (used to relieve occasional constipation ) 100 mg – Take 1 capsule two times daily as neededThera Tears eye drops (used to relieve dry, irritated eyes by restoring moisture)Advance Eye Relief eye drops (used to provide temporary relief from dry, irritated, red, or burning eyes)During an interview on 1/16/2026 at 10:21 a.m. with Director of Patient Care Services (DPCS), the DPCS stated that all disciples need to do medication reconciliation every visit. DPCS stated that it is important to do medication reconciliation every visit to make sure patients are taking the right medications and making sure agency is updated on new medications. During a record review of the agency’s policy and procedure, titled “Medication Profile” undated, the policy and procedure indicated, patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record and medication profile will be updated for each change to reflect medications, new, and/or discontinued medications.”

“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, an organization that provides skilled nursing and therapeutic services, such as physical, occupational or speech therapy, to individuals in their homes) failed to include information required in the plan of care (POC, a mandatory, written, and patient-specific document that outlines necessary medical, rehabilitative, and supportive services to treat an injury or illness at home) for three of 13 sampled patients (Patient 1, Patient 7 and Patient 9). This failure had the potential to result in patients not receiving the identified needs and services which could cause decline in health status and well-being. b. During a record review of Patient 7’s Patient Profile sheet indicated a start of care date of 11/10/2025, with diagnoses including presence of right artificial acute post procedure reverse total shoulder arthroplasty. During a record review of Patient 7’s POC dated 01/09/2026to 3/09/2026, recertified on 1/09/2026, the POC did not indicate any blood pressure or oxygen parameters to report to the physician. During an interview on 1/15/2026 at 11:15 am with DPCS, DPCS stated,” there are no physician reportable parameters for vital signs and oxygen in Patient 7’s plan of care. This was missed. It is important to have the physician reportable parameters for vital signs and oxygen because it guides the patient care for the clinicians, and they know what to report to the physician.” c. During a record review of Patient 9’s Patient Profile sheet indicated a start of care date of 8/21/2025, with diagnoses including pressure ulcer of left buttock ( break in the skin due to pressure injury), hypertensive heart disease (disease that caused high blood pressure), and chronic obstructive pulmonary artery ( a progressive group of lung conditions, primary emphysema and chronic bronchitis, that block airflow, making it hard to breath, cough and wheezing, and is mainly caused by long-term exposure to irritants like tobacco smoke . During a record review of Patient 9’s POC dated 12/19/2025 to 2/16/2026, recertified on 12/16/2025, the POC did not indicate any blood pressure or oxygen parameters to report to the physician. During an interview on 1/15/2026 at 11:20 am with DPCS, DPCS stated,” there are no physician reportable parameters for vital signs and oxygen in Patient 9’s plan of care. This was missed. It is important to have the physician reportable parameters for vital signs and oxygen because it guides the patient care for the clinicians, and they know what to report to the physician.” a. During a record review of Patient 1’s “Plan of Care” dated 11/25/2025 to 1/23/2026, indicated a start of care date of 9/26/2025 with a diagnosis of multi-system degeneration (progressive brain disorder that affects movement and balance and disrupts the function). The “Plan of Care” indicated that there was no documented vital sign parameter. During a concurrent interview and record review on 1/15/2026 at 11:20 a.m. with Director of Patient Care Services (DPCS), the DPCS stated that the plan of care should have had vital sign parameters. DPCS stated that it is important to have vital sign parameters so that staff are aware what to report to the physician. During a record review of the agency’s policy and procedure, titled “Care Planning Process” undated, the policy and procedure indicated, the purpose of the policy and procedure is to provide clinical direction to the clinician providing direct patient care.”