Gfk Home Health Care

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. 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 process for collaboration with the tribal, regional, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. This failure created the potential risk of not providing the necessary care and services to the patients of the HHA during emergency events. Findings: Review of the agency’s emergency preparedness program was conducted on 6/25/26, and showed the plan did not include a process for collaboration with the tribal, regional, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. On 6/26/26 at 1423 hours, an interview and concurrent agency document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and confirmed the finding.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness P&Ps included the procedures to inform the State and local emergency preparedness officials about the patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This failure created the risk of not providing the necessary care and services to the patients during an emergency. Findings: Review of the agency’s emergency preparedness P&P titled Emergency Management Policy revised 9/17/20, was initiated on 6/25/26. The emergency preparedness P&P failed to show the procedures to inform the State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. On 6/26/26 at 1423 hours, an interview and concurrent agency document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and confirmed the finding.”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s emergency preparedness P&P addressed a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. This failure had the potential for patient’s confidential information not to be protected. Findings: Review of the agency’s P&P on emergency preparedness was initiated on 6/25/26. The Emergency Plan did not address the system of medical documentation that preserve patient information, protect confidentiality of patient information, and secure and maintain availability of records. On 6/26/26 at 1423 hours, an interview and concurrent agency document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and confirmed the finding.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency communication plan included a primary and alternate means of communication with the Federal, State, tribal, and regional emergency management agencies. This failure had the potential for not being able to contact or request assistance in emergency events. Findings: Review of the agency’s emergency preparedness program was conducted on 6/25/26. The communication plan failed to include the primary and alternate means of communication with the Federal, State, tribal and regional emergency management agencies. On 6/26/26 at 1423 hours, an interview and concurrent agency document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and confirmed the finding.”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness communication plan included a method for sharing information and medical documentation for the patients under the HHA’s care, as necessary, with other health providers to maintain the continuity of care. This failure created the risk of not providing the necessary care and services to patients during emergency events. Findings: Review of the agency’s emergency preparedness program was conducted on 6/25/26. The emergency preparedness communication plan did not include a method for sharing the information and medical documentation for the patients under the HHA’s care, as necessary, with other health providers to maintain the continuity of care. On 6/26/26 at 1423 hours, an interview and concurrent agency document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and confirmed the finding.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to conduct exercises to test the emergency plan annually for the years of 2024 and 2025. This failure created the risk of the staff not knowing what to do in case of emergency. Findings: Review of the agency’s emergency preparedness testing program was conducted on 6/25/26 and showed no documented evidence the agency participated in a full-scale exercise that is community based or facility based functional exercises that may include mock disaster drills for the years 2024 and 2025. On 6/26/26 at 1423 hours, an interview and concurrent agency document review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and confirmed the 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 Reports from 6/1/25 to 5/31/26, was initiated on 6/23/26. The Agency Error Summary Report for 6/1/25 to 5/31/26, showed 10 OASIS data sets were submitted more than 30 days from the assessment completion date. On 6/23/26 at 0810 hours, an interview and concurrent agency document review were conducted with the CEO and Nursing Coordinator. The CEO confirmed the 10 OASIS data sets were submitted late.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the CHHA 12-hour training was completed for one of two CHHA’s reviewed (CHHA 1). This failure had the potential 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 Competency Evaluation of Home Care Staff (undated) showed the Home Health Aide must demonstrate evidence of successful completion of a training program totaling at least 75 hours. At least 16 of those hours must have been devoted to supervised practical training. The individual must complete at least 16 hours of classroom training before beginning the supervised practical training or successful completion of a competency evaluation program. The Home Health Aide will successfully complete the competency evaluation program if he/she demonstrates competency in a minimum of 11 of the 12 areas required in federal guidelines. Review of the employee file for CHHA 1 was initiated on 6/25/26. CHHA 1 was hired on 4/24/23. However, CHHA 1’s employee file showed no documented evidence CHHA 1 had completed the CHHA 12-hour training. On 6/26/26 at 1152 hours, an interview and concurrent agency document review was conducted with the Nursing Coordinator. The Nursing Coordinator was informed confirmed there was no in-service training for CHHA 1.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient’s immediate needs, but no later than five calendar days after the SOC date for three of seven sampled patients (Patients 2, 6, and 7). This failure had the potential for not identifying and addressing the care needs for these patients timely. Findings: #1. Review of Patient 6’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 1/28/26 The patient was certified for home health services during the certification periods from 3/29/26 to 5/27/26 and 5/28/26 to 7/26/26. Review of the OASIS E1 Start of Care Assessment dated 1/28/25 showed the Nursing Coordinator had performed a comprehensive assessment. The assessment included the section for the Emergency Disaster /Disaster code; Advance Directives: Living Will, Power of Attorney, Patient Legal Representative, Patient chosen caregiver, and scope they will perform, inform patient and their right in advance of providing hands on care or patient education; DNR status; Allergies; Spiritual/Cultural Needs, Community/Agencies, Interventions to include teach emergency care plan, discharge plans, skilled interventions to include visit frequency. However, the above sections were incomplete as part of the comprehensive assessment. On 6/26/26 at 1013 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. Review of the agency’s P&P titled Comprehensive Patient Assessment revised 1/9/26, showed a thorough, well organized, comprehensive and accurate assessment, consistent with the patients immediate needs will be completed for all patients in a timely manner, but no later than five calendar days after start of care. For example: 1.Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the OASIS SOC Comprehensive Assessment dated 6/18/20, failed to show documented evidence the following were completed: -Vitals assessed -Structural barriers -Safety hazards -Sanitation hazards -Hearing condition -Nasal condition -Pharyngeal (anything related to the throat) condition -Mouth condition -Pain status -Braden pressure ulcer risk -Psychological/Social -Blood sugar -Endocrine/Diabetes management -Fall risk assessment -Orders -Goals -Patient information and input -Care Plan information -Skilled intervention (procedure and teaching) On 6/26/26 at 1115 hours, an interview and concurrent clinical record review was conducted with the Nursing Coordinator. The Nursing Coordinator had provided additional documentation, however, the abovementioned components of the OASIS SOC Comprehensive Assessment were left blank. The Nursing Coordinator confirmed the findings. 2. Review of Patient 7’s clinical record was initiated on 6/23/26. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services for 30 certification periods including certification periods from 3/27/26 to 5/25/26 and 5/26/26 to 7/24/26. Review of the OASIS SOC Comprehensive Assessment dated 8/20/21, failed to show documented evidence the following were completed: -Vitals assessed -Structural barriers -Safety hazards -Sanitation hazards -Hearing condition -Nasal condition -Pharyngeal condition -Mouth condition -Musculoskeletal -Pain status -Integumentary -Braden pressure ulcer risk -Respiratory status -Elimination status -Frequency of disruptive behavior -Psychological/Social -Blood sugar -Endocrine/Diabetes management -Fall risk assessment -Patient information and input -Care Plan information -Spiritual/cultural needs -Nutritional status -Homebound reasons -Criteria for evaluating a patient’s risk following a disaster -Skilled intervention (procedure and teaching) On 6/26/26 at 1054 hours, an interview and concurrent clinical record review was conducted with the Nursing Coordinator. The Nursing Coordinator had provided additional documentation, however, the abovementioned components of the OASIS SOC Comprehensive Assessment were left blank. The Nursing Coordinator confirmed the findings.”

“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 updated to reflect the current medications and include specific indications and parameters for its use for four of seven sampled patients (Patients 1, 2, 5, and 7). 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 Patient 5’s clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. The Medication Profile from 5/1/26 to 6/29/26 showed the patient was on metoprolol tartrate (beta blocker) 25 mg GT give 0.5 mg tablet hold if HR less than 65 or SBP less than 100 and magnesium gluconate (supplement) 550 mg oral tablet GT give one tablet daily. A joint home visit with LVN 1 was conducted on 6/23/26 at 0815 hours, to the Patient 5’s home. However, the instructions in metoprolol tartrate bubble pack showed to take 1/2 tablet by mouth every morning and before bedtime instead of daily as written in the medication profile. In addition, the dosage for magnesium gluconate was 500 mg tablet instead of 550 mg as written in the medication profile. On 6/23/26 at 1038 hours, an interview was conducted with the PCG 1. PCG 1 was asked about the frequency of metoprolol. PCG 1 replied, the medication was given 1/2 tablet in AM and PM. LVN 1 was also asked if the medication profile was updated. LVN 1 did not respond. LVN 1 was informed of the findings. On 6/26/26 at 1249 hours the findings were shared with The Administrator/DPCS was informed and acknowledged the findings. Review of the agency’s P&P titled Medication Profile (undated) showed the medication profile shall include all prescription and nonprescription including regularly scheduled medications and those taken intermittently or as needed. The profile will be reviewed and updated as needed to reflect current medications the patient is taking. 1.Review of Patient 1’s clinical record was initiated on 6/18/26. The clinical record showed the SOC was 9/17/17. The patient was certified for home health services for 54 certification periods including certification periods from 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26. The Medication Profile for Patient 1 for the certification period from 5/23/26 to 7/21/26 showed Senna-Time (laxative) 8.6 mg tablet administered via GT, give two tablets daily as needed for constipation. May increase up to four tablets two times a day as needed for severe constipation. However, the bottled medication at the patient’s home showed Senna-Time (laxative) 8.6 mg tablet administered via GT, give two tablets daily as needed for constipation. May increase up to four tablets two times a day as needed for severe constipation. Hold if having loose stools. Do not exceed eight tablets in 24 hours. The Medication Profile was not updated to show the additional indications of the above medication. Furthermore, the following medications were also included in the Medication Profile for Patient 1 for the certification period from 5/23/26 to 7/21/26: -Nystop (fungal skin infection) 100,000 unit/gm topical powder, applied to skin surface/left under arm as needed. -hydrocortisone (treatment for various skin conditions) 2.5 percent topical ointment, applied to affected area two times a day as needed (for penile foreskin swelling related to allergy to foley catheter). -lactulose (laxative) 10 gm in 15 ml oral solution administered via GT, give 30 ml two times a day as needed for severe constipation. However, the above medications were not in the patient’s home. A joint visit with LVN 2 was conducted on 6/19/26 at 1430 hours, to Patient 1’s home. LVN 2 stated the medications were checked on the day of the home visit and were discontinued. In addition, the medications had not been administered for several months and were already expired. The LVN confirmed the medication profile was not updated. An interview was conducted with the CEO and Nursing Coordinator on 6/23/26 at 0810 hours. The Nursing Coordinator stated the medications were reviewed on the day of the visit. The medications were not in use for several months. The Nursing Coordinator was asked how often the nurses conduct medication reviews and reconciliation. The Nursing Coordinator stated during RN Supervisory visits, recertifications and by the nurse caring for the patient from time to time. Both the CEO and Nursing Coordinator were informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the Clinical Progress Note dated 4/28/26, showed the patient appears very restless, irritated with crying spells. The physician was notified and patient was sent to an acute hospital for evaluation. The patient was placed on the following medications: -cefdinir (antibiotics) 250/5 ml suspension 60 ml, give 6 ml via GT two times a day for 10 days. -metoclopramide hydrochloride (for nausea and vomiting) 5mg/5ml solution, give 5 ml via GT three times daily as needed. However, the patient’s Medication Profile for Certification Period 3/19/26 to 5/17/26 showed the following medications were administered: -cefpodoxime proxetil (antibiotic) 50mg/5ml powder for suspension, give 20 ml every 12 hours via GT for 10 days. -metoclopramide hydrochloride 5mg/5ml solution, give 5 ml via GT two times a day as needed. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review was conducted with the Nursing Coordinator. The Nursing Coordinator confirmed the findings. 3. Review of Patient 7’s clinical record was initiated on 6/23/26. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services for 30 certification periods including certification periods from 3/27/26 to 5/25/26 and 5/26/26 to 7/24/26. The Medication Profile for Patient 7 for certification period from 5/26/26 to 7/24/26 showed the patient’s medications included the following: -losartan potassium/hydrochlorothiazide (anti-hypertensive medication) 100 mg – 25 mg tablet, give one tablet one time a day. -Motrin (pain medication) 600 mg oral tablet, administered by mouth, give one tablet two times a day as needed for fever or pain. A joint visit with CHHA 1 was conducted on 6/23/26 at 1300 hours, to Patient 7’s home. The medication bottle for the above medications showed as: -losartan potassium/hydrochlorothiazide (anti-hypertensive medication) 100 mg – 25 mg tablet, give one tablet one time a day. Hold if SBP is less than 105 and HR is less than 55. -Motrin (pain medication) 600 mg oral tablet, take one tablet by mouth every eight hours with food or milk as needed. However, the medications were not updated to show the indication for the SBP, HR and frequency of the above medications. On 6/26/26 at 1106 hours, an interview and concurrent clinical record review was conducted with the Nursing Coordinator. The Nursing Coordinator stated the medication review and reconciliation were done during RN Supervisory visit, recertification and as needed. The Nursing Coordinator verified the findings.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7). This failure had the potential of not addressing the care needs for these patients. Findings #1. Review of Patient 5’s clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. Review of the OASIS E2 Recertification Assessment dated 3/1/26, showed the Nursing Coordinator had performed a comprehensive assessment. The assessment included the section for Spiritual/Cultural Needs, Community/Agencies, Interventions to include teach emergency care plan, discharge plans, skilled interventions to include visit frequency. However, the above sections were incomplete as part of the comprehensive assessment. In addition, review of the OASIS E2 Recertification Assessment dated 4/30/26, showed the Nursing Coordinator had performed a comprehensive assessment. The assessment included the section for Spiritual/Cultural Needs, Community/Agencies, Interventions to include teach emergency care plan, discharge plans, skilled interventions to include visit frequency. However, the above sections were incomplete as part of the comprehensive assessment. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. #2. Review of Patient 3’s closed clinical record was initiated on 6/25/25. The closed clinical record showed the SOC was 10/24/2019. The patient was certified for home health services during the certification periods from 5/25/25 to 7/23/25 and 7/24/25 to 9/21/25. The patient was discharged from the agency on 8/23/25. Review of the OASIS E2 Recertification Assessment dated and 5/24/25 and 7/23/25, showed the RN Supervisor had performed a comprehensive assessment. The assessment included the section for Advanced Directive: Living Will, Power of Attorney; Informed of Patients rights in advance of providing hands on care or patient education; DNR status; Spiritual/Cultural Needs; Community/Agencies; Interventions to include teach emergency care plan; discharge plans; skilled interventions to include visit frequency. On 6/26/256at 1120 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. #3. Review of Patient 6’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 1/28/26 The patient was certified for home health services during the certification periods from 3/29/26 to 5/27/26 and 5/28/26 to 7/26/26. Review of the OASIS E2 Recertification Assessment dated 3/28/26 and 5/27/26 showed the RN Supervisor had performed a comprehensive assessment. The assessment included the section for the Emergency Disaster /Disaster code; Advance Directives: Living Will, Power of Attorney, Patient Legal Representative, Patient chosen caregiver, and scope they will perform, inform patient and their right in advance of providing hands on care or patient education; DNR status; Allergies; Spiritual/Cultural Needs, Community/Agencies, Interventions to include teach emergency care plan, discharge plans, skilled interventions to include visit frequency. However, the above sections were incomplete as part of the comprehensive assessment. On 6/26/26 at 1013 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 1. Review of Patient 1’s clinical record was initiated on 6/18/26. The clinical record showed the SOC was 9/17/17. The patient was certified for home health services for 54 certification periods including certification periods from 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26. Review of the Recertification Assessments dated 3/23/26 and 5/22/26, failed to show documented evidence, the following were completed: -Advanced directives: Living will -Advanced directives: Power of Attorney -Patient Legal Representative -Discharge plans -Skilled Intervention (Procedure and Teaching) -Visit Frequency On 6/26/26 at 1012 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 2. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the Recertification Assessments dated 3/18/26 and 5/17/26, failed to show documented evidence, the following were completed: -Advanced directives: Living will -Advanced directives: Power of Attorney -Patient Legal Representative -Discharge plans -Skilled Intervention (Procedure and Teaching) -Visit Frequency On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 3.Review of Patient 4’s closed clinical record was initiated on 6/25/26. The clinical record showed the SOC was 6/7/11. The patient was certified for home health services for 88 certification periods including certification period from 9/21/25 to 11/19/25. The patient was discharged on 11/5/25. Review of the Recertification Assessment dated 9/20/25, failed to show documented evidence, the following were completed: -Advanced directives: Living will -Advanced directives: Power of Attorney -Patient Legal Representative -Discharge plans -Skilled Intervention (Procedure and Teaching) -Visit Frequency On 6/26/26 at 1141 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 4. Review of Patient 7’s clinical record was initiated on 6/23/26. The clinical record showed the SOC was 8/20/21. The patient was certified for home health services for 30 certification periods including certification periods from 3/27/26 to 5/25/26 and 5/26/26 to 7/24/26. Review of the Recertification Assessments dated 3/22/26 and 5/21/26, failed to show documented evidence, the following were completed: -Advanced directives: Living will -Advanced directives: Power of Attorney -Patient Legal Representative -Discharge plans -Skilled Intervention (Procedure and Teaching) -Visit Frequency On 6/26/26 at 1054 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the discharge assessment was completed for two of seven sampled patients (Patients 3 and 4). This failure had the potential for not addressing the care needs for these patients. Findings: #. Review of Patient 3’s closed clinical record was initiated on 6/25/25. The closed clinical record showed the SOC was 10/24/2019. The patient was certified for home health services during the certification periods from 5/25/25 to 7/23/25 and 7/24/25 to 9/21/25. The patient was discharged from the agency on 8/23/25. Review of the Physician Order dated 8/19/25 showed Patient 3 was discharged from the hospice service. Review of the Summary (Non- OASIS) showed check mark on the section for a discharge summary. However, review of the closed clinical record failed to show documented evidence of a discharge OASIS was completed. On 6/26/256at 1120 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if a discharge OASIS was completed for the patient. The Administrator/DPCS replied, it should be. The Administrator/DPCS was also asked as to the timeline for the completion of the discharge OASIS. The Administrator/DPCS replied, on the day of the discharge, it was missing on the electronic record. The Administrator/DPCS was informed and acknowledged the finding. Review of the agency’s P&P titled Patient Discharge Process (undated) showed discharge planning is initiated for every home care patient at the time of the patient’s admission for home care. The discharge procedure including planning for discharge is provided as part of the ongoing assessment of needs and in accordance with expected care outcomes. A discharge OASIS assessment will be completed as appropriate. 1. Review of Patient 4’s closed clinical record was initiated on 6/25/26. The clinical record showed the SOC was 6/7/11. The patient was certified for home health services for 88 certification periods including certification period from 9/21/25 to 11/19/25. The patient was discharged on 11/5/25. Review of the Physician Order dated 11/5/25, showed the PCG decided to transfer the patient to another home health agency, however, the order read back and verified with MD and patient consulted and provided consent to planned services and care provided in this order was not checked. Further review of the clinical records showed a Non-OASIS Summary was completed on 11/5/25 for Patient 4. However, there was no documented evidence a Discharge OASIS or discharge assessment was completed. On 6/26/26 at 1141 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator stated a Discharge OASIS should be completed. The Nursing Coordinator acknowledged and confirmed the findings.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the physician was notified promptly related to the changes of conditions for one of seven sampled patients (Patient 4). This failure had the potential of not providing quality of care and services to the patient receiving services from the HHA. Findings: Review of the agency’s P&P titled Change in Patient Condition revised 1/17/20, showed all licensed nursing staff are expected to assess the patient’s condition every visit and instruct the caregiver to observe and recognize the changes in patient’s condition. If the licensed nurse observes any change in patient’s condition which is not life threatening, the attending physician should be notified immediately. If the licensed nurse observes that the patient’s change in condition is serious and life threatening, she/he should call 911 immediately. He or she will then, notify the attending physician and nurse supervisor. Review of Patient 4’s closed clinical record was initiated on 6/25/26. The clinical record showed the SOC was 6/7/11. The patient was certified for home health services for 88 certification periods including certification periods from 9/21/25 to 11/19/25. The patient was discharged on 11/5/25. Review of the Clinical Progress Notes dated 10/14 and 10/15/25, showed the patient had a small boil on top of the penis. The boil was red and drained with no pus. However, there was no documented evidence the physician was notified about the patient’s boil on top of the penis. On 6/26/26 at 1141 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator was informed and stated the change in condition should be reported to the physician. The Nursing Coordinator acknowledged confirmed the finding.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the services were integrated in the POC for one of seven sampled patients (Patient 2). This failure had the potential of not providing quality care and services to the patient. Findings: Review of the agency’s P&P titled Coordination of Patient Services (undated) showed all personnel furnishing services shall maintain a liaison to assure their efforts are coordinated effectively and support the objectives outlined in the Plan of Care. This may be done through formal care conferences, maintaining complete, current care plans; and written and verbal interaction. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the Home Health Certification and Plan of Care for certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26, showed if during SN visit, the SBP less than 90 mmHg or more than 140 mmHg and DBP less than 60 mmHg and more than 95 mmHg, to notify the physician. Review of the SN visit frequency showed the SN had 56 hours of visits per week from 3/19/26 to 5/17/26 and 5/18/26 to 6/20/26. Review of the Clinical Progress Notes showed the BP was taken on 4/17 and 4/18/26; however, there was no documented evidence the BP was taken on other SN visits and coordinated with the nurse supervisor or physician for the reason why the BP was not taken during every visit. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed 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 observation, interview, and record review, the agency failed to provide written instructions outlining the visit schedule for one of seven sampled patients (Patient 5). This failure had the potential for not providing the necessary information to this patient. Findings: Review of Patient 5’s clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. The POC, for the certification period from 5/1/26 to 6/29/26, cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per the PCG’s discretions in situations where the patient required more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. A joint home visit with LVN 1 was conducted on 6/23/26 at 0815 hours, to Patient 5’s home. Review of the patient’s home folder was conducted with LVN 1. However, there was no documented evidence of the written instructions outlining the SN visit schedules on the home folder. An interview was conducted with the PCG. The PCG was asked if the agency had provided her with the visit schedule. The PCG replied she had her my own calendar. On 06/23/26 at 0941 hours, an interview and concurrent agency document review was conducted with LVN 1. LVN 1 was asked if a visit schedule was available in the home folder. LVN 1 replied none because the visit schedule was permanent, from Monday to Friday, eight hours a day from 0700 hours to 1500 hours. On 6/26/26 at 1249 hours, an interview was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding.”

“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 observation, interview, and record review, the agency failed to provide care and services as per the POC for five of seven sampled patients (Patients 1, 2, 3, 4, and 5). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. Findings: #1. Review of Patient 5’s clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. a. The POC, for the certification periods from 3/2/26 to 4/30/26 and 5/1/26 to 6/29/26, cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. *The POC showed the patient was on G-tube water flush with the following schedules. -Give 200 ml water via GT before breakfast with meds. -Give 300 ml water via GT after breakfast. -Give 125 ml water via GT before lunch. -Give 125 ml water via GT after lunch. Review of the SN visit notes for example dated 5/8, 5/12, 5/22, 5/27, 6/1, 6/9, and 6/16 /26 showed the SN had given water. However, there was no documented evidence if the water flush was given with medications as ordered in the POC. *Review of the POC showed SN to reposition the patient every two hours and PRN Q shift. Review of the Treatment Record on the following dates showed the SN had repositioned the patient for example: -on 5/1/26 - 0740, 1110 -on 5/7/27 - 0740, 1100 -on 5/8/26 - 0740, 1100 However, the SN failed to repositioned the patient every two hours as ordered in the POC. b. The POC, for the certification period from 3/2/26 to 4/30/26 cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. SN to notify MD for SBP less than 90 or more than 140 , DBP less than 60 or more than 95, Pulse less than 60 or more than 120. Review of the SN visit notes on the following for example: -On 3/4/26: BP = 156/101 -On 3/5/26: BP = 152/103 -On 3/6/26: BP = 152/103 -On 3/9/26: BP = 160/104 -On 3/10/26: BP = 160/104 -On 3/11/26: BP = 155/93 -On 3/12/26: BP = 159/106 -On 3/13/26: BP = 154/102 However, review of the clinical records failed to show documented evidence of the SN had notified the physician of the elevated BP as ordered in the POC. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. #2. Review of Patient 3’s closed clinical record was initiated on 6/25/25. The closed clinical record showed the SOC was 10/24/2019. The patient was certified for home health services during the certification periods from 5/25/25 to 7/23/25 and 7/24/25 to 9/21/25. The patient was discharged from the agency on 8/23/25. The POC, for the certification period from for the certification period from 5/25/25 to 7/23/25 cited SN visits 1 to 178 hours per month or 1 to 1068 hours per 180 days (1068 hours/180 days can be used per PCG’S discretions in situations where patient requires more than 178 hours/month) for assessment, observation, evaluation of all body systems and home safety. The POC also includes Intravenous fluids of D5W Lactated Ringers 1000 ml Intravenous two times a week on TPN off days. Review of the SN visit notes showed on Week 7 ( 7/6to 12/25) showed the RN 1 had provided the Intravenous fluids one time on 7/7/25 instead of two times as ordered in the POC. Moreover, there was no documented evidence of the RN 1 had provided the intravenous fluid from Weeks 1, 2, 3,4, 5, 6, 8 and 9 as ordered in the POC. On 6/26/26 at 1140 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if the POC was followed. The Administrator/DPCS replied, it was the PCG provides the D5LR, it was documented on the medication profile. The Administrator/DPCS was asked if there was a documented evidence to show the IV fluids was given two times a week as ordered in the POC. The Administrator/DPCS replied, no. The Administrator/DPCS was informed and acknowledged the findings. Review of the agency’s P&P titled Care Plans (undated) showed each patient will have a care plan on file that addresses their identified needs and the agency’s plan to respond to those needs. This plan is developed with the patient and family, as indicated, and is based on services needed to achieve specific measurable goals. 1. Review of Patient 1’s clinical record was initiated on 6/18/26. The clinical record showed the SOC was 9/17/17. The patient was certified for home health services for 54 certification periods including certification periods from 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26. Review of the Home Health Certification and Plan of Care for certification periods 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26 showed on Orders for Discipline and Treatment during SN visit for the following: -May dissolve medications or flush GT with up to 50 ml of water for medication administration. -Administer Peptamen Prebio (enteral nutrition formula) 1.0 (250 ml/carton) via GT pump at 55 ml/hr continuously for 22 hours a day. Can decrease GT pump rate to 40 ml/hr if patient is not tolerating. However, review of the Clinical Progress Note in the Time/Intake/Output for the certification period 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26, showed visits wherein SN had not dissolved medications or flush GT with up to 50 ml of water and had nt decreased Peptamen Prebio 1.0 via GT pump rate to 40 ml/hr which is inconsistent with the POC. For example: -On 3/27/26, at 1210 hours SN had administered medication with 120 ml of water, at 1500 hours administered Peptamen Prebio 1.0 at 35 ml/hr and at 1800 hours administered medications with 120 ml of water. -On 4/1/26, at 1210 hours SN had administered medication with 120 ml of water, at 1600 hours administered Peptamen Prebio 1.0 at 30 ml/hr and at 1800 hours administered medications with 120 ml of water. -On 5/1/26, at 1300 hours SN had administered Peptamen Prebio 1.0 at 35 ml/hr and at 1800 hours administered medications with 120 ml of water. -On 6/2/26, at 1210 hours SN had administered medication with 120 ml of water, at 1300 hours administered Peptamen Prebio 1.0 at 30 ml/hr and at 1800 hours administered medication with 120 ml of water. On 6/26/26 at 1012 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 2. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the Home Health Certification and Plan of Care for certification periods 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26 shown in Orders for Discipline and Treatment during SN visit to reposition patient every 2 hours or as needed. However, review of the Treatment Record showed Patient 2 was not repositioned every two hours or as needed which was inconsistent with the POC. For example: -On 3/19/26, SN had a 12-hour shift from 0900 hours to 2100 hours. Patient 2 was repositioned at 0934 hours. -On 4/2/26, SN had a 12-hour shift from 0900 hours to 2100 hours. Patient 2 was repositioned at 0920 hours. -On 5/1/26, SN had a 10-hour shift from 0700 hours to 1700 hours. Patient 2 was repositioned at 0720 hours. -On 6/1/26, SN had a 12-hour shift from 0800 hours to 2000 hours. Patient 2 was repositioned at 0820 hours. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 3. Review of Patient 4’s closed clinical record was initiated on 6/25/26. The clinical record showed the SOC was 6/7/11. The patient was certified for home health services for 88 certification periods including certification period from 9/21/25 to 11/19/25. The patient was discharged on 11/5/25. Review of the Home Health Certification and Plan of Care for certification period for 9/21/25 to 11/19/25, shown in the Orders for Discipline and Treatments during SN visits to check for temperature every four hours. However, review of the Treatment Record did not show temperature was checked every four hours, which was inconsistent with the POC. For example: -On 9/23/25, SN had an eight-hour shift from 1400 hours to 2200 hours. The Treatment Record showed to check temperature every two to three hours. Temperature was checked at 1400 hours then at 2200 hours. -On 10/7/25, SN had an eight-hour shift from 1400 hours to 2200 hours. The Treatment Record showed to check temperature every two to three hours. Temperature was checked at 1400 hours then at 2200 hours. -On 11/1/25, SN had a seven-hour shift from 1530 hours to 2230 hours. The Treatment Record showed to check temperature every four hours. Temperature was checked at 1540 hours then at 2113 hours. On 6/26/26 at 1141 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. Review of the agency’s P&P titled Care Plans (undated) showed each patient will have a care plan on file that addresses their identified needs and the agency’s plan to respond to those needs. This plan is developed with the patient and family, as indicated, and is based on services needed to achieve specific measurable goals. 1. Review of Patient 1’s clinical record was initiated on 6/18/26. The clinical record showed the SOC was 9/17/17. The patient was certified for home health services for 54 certification periods including certification periods from 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26. Review of the Home Health Certification and Plan of Care for certification periods 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26, showed the Orders for Discipline and Treatment included the following: -May dissolve medications or flush GT with up to 50 ml of water for medication administration. -Administer Peptamen Prebio (enteral nutrition formula) 1.0 (250 ml/carton) via GT pump at 55 ml/hr continuously for 22 hours a day. Can decrease GT pump rate to 40 ml/hr if the patient not tolerating. However, review of the Clinical Progress Note in the Time/Intake/Output for the certification period 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26, showed the SN did not followed the POC. For example: -On 3/27/26, at 1210 hours, the SN had administered medication with 120 ml of water; at 1500 hours, administered Peptamen Prebio 1.0 at 35 ml/hr; and at 1800 hours, administered medications with 120 ml of water. -On 4/1/26, at 1210 hours, the SN had administered medication with 120 ml of water; at 1600 hours, administered Peptamen Prebio 1.0 at 30 ml/hr; and at 1800 hours, administered medications with 120 ml of water. -On 5/1/26, at 1300 hours SN had administered Peptamen Prebio 1.0 at 35 ml/hr and at 1800 hours, administered medications with 120 ml of water. -On 6/2/26, at 1210 hours SN had administered medication with 120 ml of water, at 1300 hours administered Peptamen Prebio 1.0 at 30 ml/hr and at 1800 hours administered medication with 120 ml of water. On 6/26/26 at 1012 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 2. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the Home Health Certification and Plan of Care for certification periods 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26, showed the Orders for Discipline and Treatment showing during the SN visit, to reposition patient every 2 hours or as needed. However, review of the Treatment Record showed Patient 2 was not repositioned every two hours or as needed as per the POC. For example: -On 3/19/26, the SN was on duty for a 12-hour shift from 0900 hours to 2100 hours. Patient 2 was repositioned at 0934 hours. -On 4/2/26, the SN was on duty for a 12-hour shift from 0900 hours to 2100 hours. Patient 2 was repositioned at 0920 hours. -On 5/1/26, the SN was on duty for a 10-hour shift from 0700 hours to 1700 hours. Patient 2 was repositioned at 0720 hours. -On 6/1/26, the SN was on duty for a 12-hour shift from 0800 hours to 2000 hours. Patient 2 was repositioned at 0820 hours. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 3. Review of Patient 4’s closed clinical record was initiated on 6/25/26. The clinical record showed the SOC was 6/7/11. The patient was certified for home health services for 88 certification periods including certification period from 9/21/25 to 11/19/25. The patient was discharged on 11/5/25. Review of the Home Health Certification and Plan of Care for certification period for 9/21/25 to 11/19/25, shown the Orders for Discipline and Treatments showing during the SN visits, to check for temperature every four hours. However, review of the Treatment Record did not show the temperature was checked every four hours as per the POC. For example: -On 9/23/25, the SN was on duty for an eight-hour shift from 1400 hours to 2200 hours. The Treatment Record showed to check temperature every two to three hours. The patient’s temperature was checked at 1400 hours, then at 2200 hours. -On 10/7/25, the SN was on duty for an eight-hour shift from 1400 hours to 2200 hours. The Treatment Record showed to check temperature every two to three hours. The patient’s temperature was checked at 1400 hours then at 2200 hours. -On 11/1/25, the SN was on duty for a seven-hour shift from 1530 hours to 2230 hours. The Treatment Record showed to check temperature every four hours. The patient’s temperature was checked at 1540 hours then at 2113 hours. On 6/26/26 at 1141 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 4. Review of Patient 5’s clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. a. The POC, for the certification periods from 3/2/26 to 4/30/26 and 5/1/26 to 6/29/26, cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. *The POC showed the patient was on the GT water flush schedule as follows: -Give 200 ml water via GT before breakfast with medications. -Give 300 ml water via GT after breakfast. -Give 125 ml water via GT before lunch. -Give 125 ml water via GT after lunch. Review of the SN visit notes dated 5/8, 5/12, 5/22, 5/27, 6/1, 6/9, and 6/16 /26, showed the SN had given water. However, there was no documented evidence if the water flush was given with the medications as ordered in the POC. *Review of the POC showed the SN to reposition the patient every two hours and PRN Q shift. Review of the Treatment Record showed the SN did not followed the POC regarding reposition of the patient. For example: -on 5/1/26, the patient was reposition at 0740 and 1110 hours -on 5/7/27, the patient was reposition t 0740 and 1100 hours -on 5/8/26, the patient was reposition at 0740 and 1100 hours b. The POC, for the certification period from 3/2/26 to 4/30/26 cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per the PCG’s discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety; and SN to notify MD for SBP less than 90 mmHg or more than 140 mmHg , DBP less than 60 mmHg or more than 95 mmHg, Pulse less than 60 bmp or more than 120 bmp. Review of the SN visit notes showed the following: -On 3/4/26, BP = 156/101 mmHg -On 3/5/26, BP = 152/103 mmHg -On 3/6/26, BP = 152/103 mmHg -On 3/9/26, BP = 160/104 mmHg -On 3/10/26, BP = 160/104 mmHg -On 3/11/26, BP = 155/93 mmHg -On 3/12/26, BP = 159/106 mmHg -On 3/13/26, BP = 154/102 mmHg However, review of the clinical record failed to show documented evidence the SN had notified the physician of the elevated BP as ordered in the POC. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 5. Review of Patient 3’s closed clinical record was initiated on 6/25/25. The closed clinical record showed the SOC was 10/24/2019. The patient was certified for home health services during the certification periods from 5/25/25 to 7/23/25 and 7/24/25 to 9/21/25. The patient was discharged from the agency on 8/23/25.The POC, for the certification period from for the certification period from 5/25/25 to 7/23/25 cited SN visits 1 to 178 hours per month or 1 to 1068 hours per 180 days (1068 hours/180 days can be used per PCG’S discretions in situations where patient requires more than 178 hours/month) for assessment, observation, evaluation of all body systems and home safety. The POC also includes Intravenous fluids of D5W Lactated Ringers 1000 ml Intravenous two times a week on TPN off days. Review of the SN visit notes showed on Week 7 ( 7/6to 12/25) showed the RN 1 had provided the Intravenous fluids one time on 7/7/25 instead of two times as ordered in the POC. Moreover, there was no documented evidence of the RN 1 had provided the intravenous fluid from Weeks 1, 2, 3,4, 5, 6, 8 and 9 as ordered in the POC. On 6/26/26 at 1140 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if the POC was followed. The Administrator/DPCS replied, it was the PCG provides the D5LR, it was documented on the medication profile. The Administrator/DPCS was asked if there was a documented evidence to show the IV fluids was given two times a week as ordered in the POC. The Administrator/DPCS replied, no. The Administrator/DPCS was informed and acknowledged the findings.”

“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 clinical notes for three of seven sampled patients (Patients 1, 2, and 5) were accurate. This failure had the potential for substandard healthcare outcomes to these patients. Findings: #. Review of Patient 5’s clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. a. The POC, for the certification periods from 3/2/26 to 4/30/26 cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. The POC showed the patient nutritional requirements included Osmolite1.5 cal via G.Tube. Review of the SN visit notes for example dated 3/2, 3/9, 3/14, 3/23, 3/30, 4/6, 4/13, 4/20 and 4/27/26 showed the body system assessment was performed. The assessment included gastrointestinal. The gastrointestinal included a section for the administration method. However, the section for GT was left blank. In addition, further review of the SN visit notes dated 3/2, 3/9, 3/14, 3/23, 3/30, 4/6, 4/13, 4/20 and 4/27/26 on the genitourinary system assessment showed the patient was assessed to be on diaper. However, on the section for the assessment of incontinent was left blank. b. The POC, for the certification periods from 3/2/26 to 4/30/26 and 5/1/26 to 6/29/26, cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. The POC showed the patient nutritional requirements included Osmolite 1 .5 cal via G Tube. Review of the SN visit notes for example dated 5/4, 5/11, 5/18, 5/25, 6/8 and 6/18/26 showed the body system assessment was performed. The assessment included gastrointestinal. The gastrointestinal included a section for the administration method. However, the section for GT was left blank. In addition, further review of the SN visit notes dated 5/4, 5/11, 5/18, 5/25, 6/8 and 6/18/26 on the genitourinary system assessment showed the patient was assessed to be on diaper. However, on the section for the assessment of incontinent was left blank. c. Review of the SN visit note dated 3/3/26 on the section of narrative showed the wound care nurse recommended suspension of the “Thripple” antibacterial cream. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked as to what was the medication for. The Administrator/DPCS replied, it was inaccurate documentation. The Administrator/DPCS was informed and acknowledged the findings. Review of the SN visit note dated 3/3/26 on the section of narrative showed the wound care nurse recommended suspension of the “Thripple” antibacterial cream. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. Review of the agency’s P&P titled Clinical Documentation (undated) showed the agency will document each direct contact with the patient. The purpose of the clinical documentation was to ensure that there is an accurate record of the services provided, patient response and ongoing need for care. 1. Review of Patient 1’s clinical record was initiated on 6/18/26. The clinical record showed the SOC was 9/17/17. The patient was certified for home health services for 54 certification periods including certification periods from 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26. a.Review of the Recertification Assessment dated 3/23 and 5/22/26 both showed in the Bladder and Bowel Section, the patient continues to require vent GT as needed due to gas, bloated stomach. Daily insert of dover red rubber urethral catheter 16 French (5.3 mm) via anus to release abdominal air distention and as needed. However, review of the Home Health Certification Plan of Care for certification periods 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26 showed in the Orders for Discipline and Treatment for both certification periods to insert dover red rubber urethral catheter 20 French via anus to release air as needed which was inconsistent with the Recertification Assessments. b.Review of the Clinical Progress Note documented on the SN visits showed in the Gastrointestinal Section the number of times patient had a BM which was inconsistent with Intake/Output section for the stool. For example: -On 5/23/26, LVN 2 documented patient had one-time medium BM which was inconsistent with the documentation in the Output section of one large BM. -On 6/12/26, LVN documented patient had nine times BM, however, there was no documented BM in the Output section. On 6/26/26 at 1012 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 2. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. a. Review of the Clinical Progress Note documented on the SN visits shown in the Gastrointestinal Section, the number of times patient had a BM which was inconsistent with Intake/Output section for the stool. For example: -On 4/14/26, LVN 3 documented patient had BM four times which was inaccurate with the documentation in the Output section of BM six times. -On 4/24/26, LVN 3 documented patient had BM four times which was inconsistent with the documentation in the Output section of BM seven times. b. Review of the Clinical Progress Note for 4/20, 4/21, 4/23, 4/24, 4/25, and 4/27/26, showed LVN 3 assessed Patient 2 has no pain, however, grinding of teeth was checked on the behavior for pain, which was inconsistent with the pain assessment. c.Review of the Clinical Progress Note dated 6/16/26, showed Respiratory function was assessed, however, oxygen saturation was left blank. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. Review of the agency’s P&P titled Clinical Documentation (undated) showed the agency will document each direct contact with the patient. The purpose of the clinical documentation was to ensure that there is an accurate record of the services provided, patient response, and ongoing need for care. 1. Review of Patient 1’s clinical record was initiated on 6/18/26. The clinical record showed the SOC was 9/17/17. The patient was certified for home health services for 54 certification periods including certification periods from 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26. a. Review of the Recertification Assessment dated 3/23 and 5/22/26, showed the patient continued to require vent GT as needed due to gas, bloated stomach. Daily insert of dover red rubber urethral catheter 16 French (5.3 mm) via anus to release abdominal air distention and as needed. However, review of the Home Health Certification Plan of Care, for certification periods 3/24/26 to 5/22/26 and 5/23/26 to 7/21/26, showed to insert dover red rubber urethral catheter 20 French via anus to release air as needed which was inconsistent with the Recertification Assessments. b. Review of the Clinical Progress Notes showed inconsistent information on the Gastrointestinal section and Output section. For example: -On 5/23/26, the Gastrointestinal section showed the patient had one-time medium BM which was inconsistent with the Output section of one large BM. -On 6/12/26, the Gastrointestinal section showed the patient had nine times BM; however, there was no documented BM in the Output section. On 6/26/26 at 1012 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator was informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. a. Review of the Clinical Progress Notes showed inconsistent information on the Gastrointestinal section and Output section. For example: -On 4/14/26, the Gastrointestinal section showed the patient had BM four times which was inconsistent with the Output section of six times BM. -On 4/24/26, the Gastrointestinal section showed the patient had BM four times which was inconsistent with the Output section of seven times BM. b. Review of the Clinical Progress Note for 4/20, 4/21, 4/23, 4/24, 4/25, and 4/27/26, showed Patient 2 had no pain; however, grinding of teeth was checked on the behavior for pain, which was inconsistent with the pain assessment. c.Review of the Clinical Progress Note dated 6/16/26, showed Respiratory function was assessed, however, oxygen saturation was left blank. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator acknowledged and confirmed the findings. 3. Review of Patient 5’s clinical record was initiated on 6/18/26. The clinical record showed SOC was 1/16/26. The patient was certified for home health services during the certification periods from 1/6/25 to 3/6/25, 3/7/25 to 5/5/25, 5/6/25 to 7/4/25, 7/5/25 to 9/2/25, 9/3/25 to 11/1/25, 11/2/25 to 12/31/25, 1/1/16 to 3/1/26, 3/2/26 to 4/30/26, and 5/1/26 to 6/29/26. a. The POC, for the certification periods from 3/2/26 to 4/30/26 cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. The POC showed the patient nutritional requirements included Osmolite1.5 cal via G-Tube. Review of the SN visit notes for example dated 3/2, 3/9, 3/14, 3/23, 3/30, 4/6, 4/13, 4/20 and 4/27/26 showed the body system assessment was performed. The assessment included gastrointestinal. The gastrointestinal included a section for the administration method. However, the section for GT was left blank. In addition, further review of the SN visit notes dated 3/2, 3/9, 3/14, 3/23, 3/30, 4/6, 4/13, 4/20 and 4/27/26 on the genitourinary system assessment showed the patient was assessed to be on diaper. However, on the section for the assessment of incontinent was left blank. b. The POC, for the certification periods from 3/2/26 to 4/30/26 and 5/1/26 to 6/29/26, cited SN visits 1 to 46 hours per week or 1 to 1183 hours per 180 days (1183 hours/180 days can be used per PCGS discretions in situations where patient requires more than 46 hours/week) for assessment, observation, evaluation of all body systems and home safety. The POC showed the patient nutritional requirements included Osmolite 1 .5 cal via G Tube. Review of the SN visit notes for example dated 5/4, 5/11, 5/18, 5/25, 6/8 and 6/18/26 showed the body system assessment was performed. The assessment included gastrointestinal. The gastrointestinal included a section for the administration method. However, the section for GT was left blank. In addition, further review of the SN visit notes dated 5/4, 5/11, 5/18, 5/25, 6/8 and 6/18/26 on the genitourinary system assessment showed the patient was assessed to be on diaper. However, on the section for the assessment of incontinent was left blank. c. Review of the SN visit note dated 3/3/26 on the section of narrative showed the wound care nurse recommended suspension of the “Thripple” antibacterial cream. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked as to what was the medication for. The Administrator/DPCS replied, it was inaccurate documentation. The Administrator/DPCS was informed and acknowledged the findings. Review of the SN visit note dated 3/3/26 on the section of narrative showed the wound care nurse recommended suspension of the “Thripple” antibacterial cream. On 6/26/26 at 1249 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the HHA’s RN provided supervision to the LVN to ensure quality of care and services were provided for one of seven sampled patients (Patient 2). Findings: Review of the agency’s P&P titled Clinical Supervision revised 3/30/20, showed skilled nursing and other therapeutic services are provided under the supervision of a Registered Nurse to assure employee performance is appropriately supervised, that care is directed toward the achievement of goals, and that services are provided based on patient need and in accordance with the physician’s Plan of Care. Review of Patient 2’s clinical record was initiated on 6/24/26. The clinical record showed the SOC was 6/18/20. The patient was certified for home health services for 37 certification periods including certification periods from 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26. Review of the LVN Supervisory Note dated 4/17 and 5/17/26, showed the Nurse Supervisor evaluated the services of LVN 3. The evaluation showed LVN 3 exceeded requirements for adhering to the plan of treatment. LVN 3 provided excellent care and followed plan of care. Review of the Home Health Certification and Plan of Care, for certification periods 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26, showed to reposition patient every 2 hours or as needed during SN visit. Review of the Treatment Record failed to show LVN 3 had repositioned the patient every two hours or as needed. For example: -On 3/19/26, LVN 3 had a 12-hour shift from 0900 hours to 2100 hours. LVN 3 repositioned the patient at 0934 hours. -On 4/2/26, LVN 3 had a 12-hour shift from 0900 hours to 2100 hours. LVN 3 repositioned at 0920 hours. -On 5/1/26, LVN 3 had a 10-hour shift from 0700 hours to 1700 hours. LVN 3 repositioned the patient at 0720 hours. -On 6/1/26, LVN 3 had a 12-hour shift from 0800 hours to 2000 hours. LVN 3 repositioned the patient at 0820 hours. However, the RN failed to identify LVN 3 did not provide care as per the POC and ensure adequate supervision provided for the LVN. On 6/26/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the Nursing Coordinator. The Nursing Coordinator was informed and acknowledged 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 related to not implementing the P&Ps as evidenced by: -The annual TB screening was not completed for LVNs 4, 6, and CHHA 1. -The pre-employment physical was not completed for the Nurse Supervisor, LVNs 5, 6, and CHHA 1. -The orientation was not completed for RN 2. -The certification was expired for CHHA 2. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. 1. Review of the agency’s P&P titled Employee TB Screening and Prevention Policy effective 1/2/26, showed all employees shall be screened for TB infection and disease risk at the time of hire and monitored annually for TB risk factors and symptoms. Procedure for pre-employment screening includes all new employees shall complete a baseline TB infection test and TB symptom questionnaire. Review of the personnel files conducted on 6/25/26, showed the following: -LVN 4’s personnel file showed the hired date was 2/20/26. The TB symptom questionnaire was completed on 8/18/25. However, there was no documented evidence a TB infection test was completed for the pre-employment. -LVN 6’s personnel file showed the hired date was 1/22/26. However, there was no documented evidence a TB infection test was completed for the pre-employment. -CHHA 1’s personnel file showed the hired date was 4/24/23. However, there was no documented evidence an annual TB symptom questionnaire was completed for the years of 2024 and 2025. 2. Review of the agency’s P&P titled Health Screening revised 1/19/18, showed each employee having direct contact with patients must have documentation of baseline health screening prior to providing care to patients within 90 days of hire. Health screening will occur after a conditional offer of employment is made. Review of the personnel files conducted on 6/25/26, showed the following: -LVN 5’s personnel file showed the hired date was 1/22/26. However, there was no documented evidence the pre-employment physical examination was completed. -LVN 6’s personnel file showed the hired date was 1/22/26. However, there was no documented evidence the pre-employment physical examination was completed. -CHHA 1’s personnel file showed the hired date was 4/24/23. However, there was no documented evidence the pre-employment physical examination was completed. 3. Review of the agency’s P&P titled Employee Orientation (undated) showed each employee of the agency who provides direct care, supervision of direct care, or management of services, will participate in an orientation program specific to his/her educational background and experience, type of care provided, physical and mental condition of patients, and the roles and responsibilities as an employee of the agency. Review of the employee file for RN 2 was conducted on 6/25/26. RN 2’s personnel file showed the hire date was 12/2/25. However, the employee orientation was blank. 4. Review of the agency’s P&P titled Employment (undated) showed for License Certification, the agency shall obtain copies of updated licensure on an ongoing basis. Review of the employee file for CHHA 2 was conducted on 6/25/26. CHHA 2’s personnel file showed the hire date was 11/17/22. However, CHHA 2’s certification had expired on 3/9/25. On 6/26/26 at 0858 hours, an interview and concurrent record review were conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.”