Blue Sky Home Health Care, Inc.

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Condition of Participation regarding Comprehensive assessment of patients was met as follows: 1. The HHA failed to ensure three of thirteen sampled patients (Patient 9, Patient 10 and Patient 11) registered nurses (RN) initial assessments were completed within 48 hours or start of care. This failure placed the patients at risk of not receiving the care required, placing patients at risk for worsening of their condition. (Refer to G514). 2. The HHA failed to review and document all the medications and treatments the patient was currently using for four of thirteen sampled patients (Patient 2, Patient 3, Patient 8 and Patient 9). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. (Refer to G536). The cumulative effect of these systemic practices resulted in the failure of the HHA to ensure the provision of quality health care in a safe environment.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: This CONDITION is NOT MET as evidenced by: Based on interview, observation, and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Condition of Participation regarding Clinical Records was met as follows: 1.The HHA failed to ensure nine of thirteen sampled patients (Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13) clinical records included all the medical records of the care provided. This failure resulted in an incomplete clinical record. (Refer to G1012). 2. The HHA failed to send all necessary medical information to the primary care practitioner within 5 days of discharge for four of thirteen sampled patients (Patient 6, Patient 7, Patient 12, and Patient 13). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. (Refer to G1022). 3. The HHA failed to ensure patient care records were complete and authenticated for six of thirteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 10). This failure resulted in patients’ medical records being incomplete by not validating who had provided the care. (Refer to G1024). The cumulative effect of these systemic practices resulted in the failure of the HHA to ensure contents in the patient’s clinical must be accurate, adhere to current clinical record documentation, available to the physician issuing orders for the home health plans of care, and assure safe care is delivered to each certified HHA patients.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the plan of care (POC) was followed for four of thirteen sample patients (Patient 3, Patient 4, Patient 8 and Patient 9). This deficient practice resulted in patients not receiving the care ordered by the doctor. During an interview on 5/13/2026 at 2:50 p.m. with Licensed Vocational Nurse 1 (LVN1), LVN1 stated patients plans of care (POC) were patient care guides. LVN1 stated patients POCs are used to achieve patients’ goals. LVN1 stated the HHA staff are expected to follow patients POCs. LVN1 stated that without the guidance of patients POC the HHA staff would be blinded and can cause patients’ harm. 1. During a record review of Patient 3’s document titled, Patient Profile, indicated a start of care on 5/4/2026, with diagnoses including essential hypertension. During a record review of Patient 3’s document titled, Order Sheet, dated 4/28/2026, indicated Patient 3 was to have daily wound care to the left heel with normal saline (a water-salt based liquid), cover with ABD pad (a type of bandage) and kerlix (a type of bandage). During a record review of Patient 3’s document titled, Home Health Certification and Plan of Care (POC) for certification period 5/4/2026-7/2/2026, indicated, to clean the left heel with saline (a water-salt based liquid) spray, pat dry, apply Iodosorb cream (used to treat infected wounds) and cover with 4x4 gauze (a type of bandage), and secure with tape. During an observation of the wound care at the home visit on 5/13/2026, at 12:26 p.m., with the Director of Nurses (DON), the DON performed wound care on Patient 3’s left heel. The DON washed the heel with saline spray; pat dried the area and applied 2 ointments on the heel Mupirocin 2% (an ointment to treat skin infections) and Cadexomer iodine topical 0.9% gel (treats wounds/openings of the skin). The DON then applied 4x4 gauzes and wrapped the heel with Kerlix. During an interview at the home visit on 5/13/2026, at 12:30 p.m., with Patient 3, stated she had visited the wound doctor on 5/9/2026 and the wound doctor had approved her using the 2 ointments on her wound. During an interview on 5/15/2026, at 11:30 a.m., with the DON, the DON stated the wound orders to apply the 2 ointments where from the wound care doctor as Patient 3 stated. The DON stated she had put the wound orders from the wound doctor in Patient 3’s medical records, but the orders were not present. The DON stated she did not have the wound care information and needed to coordinate and organize the wound care with Patient 3’s wound care doctor so the plan of care could reflect the most current orders. 2. During a record review of Patient 4’s document titled, Patient Profile, indicated a start of care on 10/7/2025 with diagnoses including encounter for change or removal of surgical wound dressing. During a record review of Patient 4’s document titled, Home Health Certification and Plan of Care (POC) for certification period 4/5/2026-6/3/2026, the record indicated the skilled nurse (SN) was to monitor the wound care status. During an interview on 5/15/2026, at 11:09 a.m., with the DON stated, that monitoring the wound care meant the SN needed to assess the wound size, check for infection, check the wound appearance, and check the color of the wound. The DON stated pictures and wound measurements were supposed to be done every week. The importance of wound measurements and pictures were to see if the wound was being treated properly, see if the wound treatment was working, or if the patient needed a different wound treatment. The wound pictures and measurements were also used to notify the doctor of the wound progress. During a concurrent interview and record review on 5/15/2026, at 11:21 a.m., with the DON, the DON reviewed Patient 4’s SN visit notes dated 4/6/2025, 4/8/2026, 4/10/2026, 4/15/2026, 4/17/2026, 4/20/2026, 4/22/2026, 4/27/2026, 4/29/2026, 5/1/2026, 5/4/2026, 5/6/2026, and 5/8/2026. The DON stated the wound assessment, measurements and pictures were not in the record. The DON stated the nurse who visited the patient needed to document the wound assessment including the measurements. 3. During a record review of Patient 8’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 4/16/2026 with a primary diagnosis of essential (primary) hypertension (high blood pressure). During a record review of Patient 8’s medical record form titled “Reason for Assessment: Start of Care” dated 4/20/2026, indicated Patient 8’s primary diagnosis was Type 2 Diabetes Mellitus with hyperglycemia (high blood sugar). During a record review of Patient 8’s medical record form titled “Home Health Certification and Plan of Care (POC)” dated from 4/16/2026 to 6/14/2026, indicated Patient 8 was to have skilled nursing (SN) visits once a week for nine weeks. The POC also indicated the SN was to perform the following during every visit: SN to record BS (blood sugar) test results and report any significant changes to the medical doctor. SN to notify medical doctor if BS is less than 60 mg/dl (milligram per deciliter: unit of measurement) or greater than 300 mg/dl.SN to perform diabetic foot exam. Lastly, SN was to educate Patient 8 on diabetic care including BS monitoring, signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) management and preventions, accurate logging of results, and proper foot care. During a concurrent observation, interview, and record review on 5/13/2026 at 2 p.m., with Licensed Vocational Nurse 1 (LVN1) at Patient 8’s residence, LVN1 stated he had Patient 8’s POC in his folder and reviewed it before every home visit. LVN1 was not observed performing a diabetic foot examination to Patient 8. LVN 1 was not noted providing diabetic education to Patient 8 or reviewed the patient’s BS log. Patient 8 was asked how often she checked her BS: however Patient 8 was not able to provide the log for his BS results. 4. During a record review of Patient 9’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 3/29/2026 with a primary diagnosis of essential (primary) hypertension (high blood pressure). During a record review of Patient 9’s medical record form titled “Reason for Assessment: Start of Care” dated 4/02/2026, indicated Patient 9’s primary diagnosis was other sequelae of cerebral infarction (neurological, cognitive, and physical deficits left after an ischemic stroke {no blood supply to brain}). Patient 9’s other diagnoses included Type II Diabetes Mellitus. During a record review of Patient 9’s medical record form titled “Home Health Certification and Plan of Care (POC)” dated from 3/29/2026 to 5/27/2026, indicated Patient 9 was to have skilled nursing (SN) visits twice a week for one week then once a week for eight weeks. The POC also indicated the SN was to perform the following during every visit: SN to record BS test results and report any significant changes to the medical doctor. SN to notify medical doctor if BS is less than 60 mg/dl or greater than 300 mg/dl.SN to perform diabetic foot exam. SN was to educate Patient 9 on diabetic care including BS monitoring, signs and symptoms of hypoglycemia and hyperglycemia management and preventions, accurate logging of results, and proper foot care. During a concurrent observation, interview, and record review on 5/13/2026 at 12:20 p.m., with Licensed Vocational Nurse 1 (LVN1) at Patient 9’s residence, LVN1 was not observed performing a diabetic foot exam to Patient 9. LVN 1 was not noted providing diabetic education care to Patient 9 or asking to see her (Patient 9) BS log. LVN1 stated he (LVN1) had concluded Patient 9’s home visit. Patient 9 was asked by this writer how often she (Patient 9) was checking her (Patient 9) BS levels. Patient 9 could not provide her BS result log. Patient 9 stated that she has not checked her BS levels in years. Patient 9 stated that her BS levels were under control with medication and diet. During an interview on 5/13/2026 at 12:45 p.m. with LVN1 stated that he has not checked Patient 9s BS. LVN1 stated that he will inform the HHA office that Patient 9 does not have a BS monitor device, so that they (HHA) can send her one. During a record review of the HHAs form titled “Care Planning Process” revised 11/20217, indicated “The plan of care will be based upon the physicians’ orders and will encompass the equipment, supplies, and services required to meet the patient needs. At the time of the initial assessment, the clinician, along with other involved disciplines, will develop the patient plan of car based upon the patients identified needs and will review it with the patient and family/caregiver.” During a record review of the HHAs form titled “Patient Bill of Rights” revised 11/2017, indicated “The organization shall ensure that the patient receives all services outlined in the plan of care”.”

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to patients’ personal residence) failed to ensure written information regarding the patient’s care was provided for two of thirteen sampled patients (Patient 3 and Patient 8). This deficient practice placed these patients at risk of not fully understanding what services to expect from the HHA, the purpose of each service and when to expect the services. 1. During a record review of Patient 3’s document titled, Patient Profile, indicated a start of care on 5/4/2026, with diagnoses including essential hypertension. During a concurrent interview and record review at the home visit on 5/13/2026, at 12:34 p.m., with the Director of Nurses (DON), the DON reviewed Patient 3’s agency folder (a folder provided by the agency, to the patient with information). The DON stated there was no plan of care (POC) in the patient’s folder. Patient 3 stated she had not received a plan of care. The DON stated the POC should have been given to Patient 3. 2. During a record review of Patient 8’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 4/16/2026 with a primary diagnosis of essential hypertension (high blood pressure). During a concurrent observation, interview, and record review on 5/13/2026 at 2 p.m., with Licensed Vocational Nurse 1 (LVN1) at Patient 8’s residence, LVN 1 asked Patient 8 to provide her the patient’s home folder. During a review of Patient 8’s home folder did not include Patient 8’s plan of care in the folder. Patient 8 stated she did not know what her plan of care looked like. LVN1 stated that he carries Patient 8’s plan of care in his folder and reviews it before the home visits. LVN 1 showed Patient 8’s plan of care. Patient 8 stated she (Patient 8) had not seen the document before. LVN 1 informed Patient 8 what the POC was used for. During a record review of the HHAs form titled “Patient Bill of Rights” revised 11/2017, indicated “Each patient will be an active, informed participant in his/her plan of care.” During a record review of the HHAs form titled “Care Planning Process” revised 11/20217, indicated “The organization shall provide the patient and caregiver with a copy of written instructions outlining: visit schedule... frequency of visits by personnel... medication schedule /instructions... treatments to be administered...and any other pertinent instruction related to the patients care and treatments...””

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patients personal residence) failed to ensure patient care records were complete and authenticated for six of thirteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 10). This failure resulted in patients’ medical records being incomplete by not validating who had provided the care. During an interview on 5/14/2026, at 10:05 a.m., with the Director of Nurses (DON), the DON stated all visit notes should be signed by 48 hours following the visit. The signature was important because it validated the notes entered by the visiting staff. 1. During a record review of Patient 1’s document titled, Patient Profile, indicated a start of care on 5/9/2026, with diagnoses including essential hypertension (high blood pressure). During a concurrent interview and record review on 5/14/2026, at 10:05 a.m., with the DON, the DON reviewed Patient 1’s record titled, Reason for Assessment-Start of Care, dated 5/11/2026. The DON stated the record was not signed and it needed to have been signed by 5/11/2026. 2. During a record review of Patient 2’s document titled, Patient Profile, indicated a start of care date on 3/5/2026, with diagnoses including Type 2 diabetes (too much sugar in the blood). During a concurrent interview and record review on 5/14/2026, at 10:05 a.m., with the DON, the DON reviewed Patient 2’s record titled, Recertification (follow-up) assessment, dated 5/3/2026. The DON stated the record was not signed. 3. During a record review of Patient 3’s document titled, Patient Profile, indicated a start of care on 5/4/2026, with diagnoses including essential hypertension. During a record review of Patient 3’s document titled, Reason for Assessment-Start of Care, dated 5/9/2026, did not indicate the signature of the nurse who completed the assessment. 4. During a record review of Patient 4’s document titled, Patient Profile, indicated a start of care on 10/7/2025 with diagnoses including encounter for change or removal of surgical wound dressing. During a concurrent interview and record review on 5/15/2026, at 11:21 a.m., with the DON, the DON reviewed Patient 4’s SN visit notes dated 4/6/2025, 4/8/2026, 4/10/2026, 4/15/2026, 4/17/2026, 4/20/2026, 4/22/2026, 4/27/2026, 4/29/2026, 5/1/2026, 5/4/2026, 5/6/2026, and 5/8/2026. The DON stated notes were not signed by the visiting nurse. 5. During a record review of Patient 5’s document titled, Patient Profile, indicated a start of care on 7/29/2025, with diagnoses including cellulitis of abdominal wall (infection of the skin). During a record review of Patient 5’s OASIS Tracker, dated 4/1/2025-5/14/2026 indicated the Recertification (follow-up) assessment, for the episode start date of 3/26/2026 was signed by Registered Nurse 4 (RN 4) on 5/13/2026. 6. During a record review of Patient 10’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 4/25/2026 with a primary diagnosis of hemiplegia (complete paralysis) and hemiparesis (partial weakness/loss of strength) following cerebral infarction (blocked blood supply to brain) affecting right dominant side. During a record review of Patient 10’s medical record form titled “Reason for Assessment: Transferred to an inpatient facility – patient not discharged from the agency” undated, with a transfer date of 5/4/2026, indicated it was incomplete. The form did not indicate who the author was. Lastly, the form did not indicate it had a signature. During a concurrent interview and record review on 5/18/2026 at 10:45 a.m. with the Director of Nurses (DON) of Patient 10’s medical record, the DON stated that she (DON) does not know who completed the form because it did not indicate the authors name or signature. The DON stated that Patient 10’s transfer OASIS was incomplete. The DON stated that it was important to complete the transfer assessment to be able to compare it when the patient returns for services. The DON stated that a signature was important, “if it is not signed, we don’t know who did it. A signature confirms what they did”. During a record review of the HHA’s document titled, Contents of Clinical Record, dated 11/2017, indicated, “the following information will be available in the clinical record for patients receiving skilled care…Signed and dated progress notes for each discipline rendering service. Clinical notes shall be signed and incorporated into the patient’s health record at least every seven working days.””

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to patients’ personal residence) failed to ensure three of thirteen sampled patients (Patient 9, Patient 10 and Patient 11) initial assessments conducted by the registered nurses were completed within 48 hours or start of care. This failure placed the patients’ needs will not be identified and the individualized plans of care (POC) will not be developed and implemented causing the delay to render the provision of the care needs to these certified patients. 1. During a record review of Patient 9’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 3/29/2026 with a primary diagnosis of essential (primary) hypertension (high blood pressure). During a record review of Patient 9’s medical record form titled “Reason for Assessment: Start of Care (SOC)” dated 4/02/2026, indicated the assessment form was incomplete. Patient 9’s SOC assessment was missing pain assessment, emergency preparation planning, patient/caregiver education, disciplines and their frequency, and the durable medical supply section was left blank. Lastly, the form indicated Registered Nurse 3 (RN3) electronically signed the form on 4/2/2026. During a concurrent interview and record review on 5/15/2026 at 11:07 a.m. with Registered Nurse 3 (RN3) of Patient 9’s medical record, RN3 stated that she (RN3) could not state why Patient 9’s initial assessment had “a lot of fields missing”. RN3 stated that she (RN3) should have been thorough when assessing Patient 9’s pain to be able to ensure the HHA was providing proper treatment. RN3 stated she (RN3) emailed Patient 9’s ordered disciplines and their frequency to the HHA, and she (RN3) did not know why that information was not on her (Patient 9) initial assessment. RN3 stated emergency planning was required to ensure the patient was able to know what to do in case of an emergency because she (Patient 9) lives on her own. 2. During a record review of Patient 10’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 4/25/2026 with a primary diagnosis of hemiplegia (complete paralysis) and hemiparesis (partial weakness/loss of strength) following cerebral infarction (blocked blood supply to brain) affecting right dominant side. During a record review of Patient 10’s medical record form titled “Reason for Assessment: Start of Care (SOC)” dated 4/28/2026, indicated the assessment form was incomplete. Patient 10’s SOC assessment was missing emergency preparedness, emergency contact information, neuro/emotional/behavior status, psychosocial, living arrangements/supportive assistance, fall risk assessment, musculoskeletal, mental status, bowel and elimination status, nutritional status, abdomen, genitalia, pain assessment, vital signs (blood pressure, pulse, respirations), cardiopulmonary, advance directive, endocrine/hematology, integumentary status, home environment safety, risk factors/hospital admission/emergency room, strength/limitations, patient/caregiver education, summary checklist: care plan, medication status, and care coordination, and DME/medical supplies. Lastly, the form indicated Registered Nurse 3 (RN3) electronically signed the form on 4/28/2026. During a concurrent interview and record review on 5/18/2026 at 10:45 a.m. with the Director of Nurses (DON) of Patient 10’s medical record, the DON stated that Patient 10’s initial assessment was completed by Registered Nurse 3 on 4/28/2026. The DON stated that her (DON) job included assuring that patient’s initial assessment was complete. The DON confirmed Patient 10’s initial assessment was incomplete. The DON stated that the pain assessment was required to know the patients pain tolerance/level. The DON stated that if a patient is in pain, “how can they get better”. The DON stated that this was poor documentation and that she (DON) did not have time to check it. The DON stated that she (DON) completes patients plans of care after reviewing the initial nursing assessment, history and physical, and speaking with the admitting nurse. 3. During a record review of Patient 11’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 3/26/2026 with a primary diagnosis of type 2 diabetes Mellitus with hyperglycemia (high blood sugar). During a record review of Patient 11’s medical record form titled “Reason for Assessment: Start of Care (SOC)” dated 3/30/2026, indicated the assessment form was incomplete. Patient 11’s SOC assessment was missing emergency preparedness, emergency contact information, psychosocial, pain assessment, advance directive, and strength/limitations. Lastly, the form indicated Registered Nurse 3 (RN3) electronically signed the form on 3/30/2026. During a concurrent interview and record review on 5/18/2026 at 11:25 a.m., with the Director of Nurses (DON) of Patient 11’s medical record, the DON stated that Patient 11’s initial assessment was completed by Registered Nurse 3 on 3/30/2026. The DON stated that Patient 11’s initial nursing assessment was not complete. The DON stated Patient 11’s initial nursing assessment was missing a pain assessment, there was no height or weight documented, and there was no emergency prepardness planning. During a record review of the HHAs form titled “Admission Criteria and Process” revised 11/2017, indicated “Once a patient is admitted to services, the organization is responsible for providing care and services within ... applicable law and regulations”. The form also indicated “The initial assessment visit must be performed either within 48 hours of the referral...”. During a record review of the HHAs form titled “Emergency Management Plan” revised 11/2017, indicated “The organization educates patients and their families on emergency preparedness at the time of admission...”. During a record review of the HHAs form titled “Initial and Comprehensive Assessment” undated, indicated “An initial patient assessment will be performed and documented in the patients clinical record by a registered nurse... within 48 hours of the referral...”.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patients personal residence) failed to review and document all the medications and treatments the patient was currently using for four of thirteen sampled patients (Patient 2, Patient 3, Patient 8 and Patient 9). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. During an interview on 5/13/2026 at 12:45 p.m. with License Vocational Nurse 1 (LVN1), LVN1 stated that he (LVN1) reconciles patients’ medications during the first home visit and after every doctor’s appointment. LVN1 stated that medication reconciliation is done to ensure the patient is taking the medications prescribed. 1. During a record review of Patient 2’s document titled, Patient Profile, indicated a start of care date on 3/5/2026, with diagnoses including Type 2 diabetes (too much sugar in the blood). During a concurrent observation, interview, and record review during the home visit on 5/13/2026, at 11:02 a.m., with the Director of Nurses (DON), the DON reviewed the medication Patient 2 was taking using record titled, Patient Medication Profile, dated 5/4/2026-7/2/2026. The DON stated the medication Isosorbide mononitrate (treats heart related chest pain) 20 mg (mg-milligram, unit of measurement) had the incorrect dose written in the medication profile. The medication label indicated for Patient 2 to take half a tablet by mouth daily. The medication profile indicated to take 1 tablet my mouth daily. The DON verified with Patient 2’s primary caregiver (CG 1) that Patient 2 was taking half a tablet. During an interview on 5/14/2026, at 10:45 a.m., with the DON, the DON stated the correct dosage was important because the medication needed to match what the doctor ordered. If the patient takes the wrong dosage or amount, medication cannot be effective. The medication can be under or over effective. The DON stated the medication profile should have been updated to reflect the correct amount during the recertification visit. 2. During a record review of Patient 3’s document titled, Patient Profile, indicated a start of care on 5/4/2026, with diagnoses including essential hypertension. During a concurrent observation, interview, and record review at the home visit on 5/13/2026, at 12:35 a.m., with DON, the DON reviewed the medication Patient 3 was taking using record titled, Patient Medication Profile, dated 5/4/2026-7/2/2026. Patient 3 stated was taking the following medications: Lantus (insulin-helps control high blood sugar levels) 20 units (units-unit of measurement) every day. Humalog (insulin) sliding scale (amount that is given, based on the blood sugar level) take 7-8 units in the evening for a blood sugar level of over 200. Mupirocin 2% (an ointment to treat skin infections) Cadexomer iodine topical 0.9% gel (treats wounds/openings of the skin). The DON stated the medications forementioned were not in Patient 3’s Patient Medication Profile. 3. During a record review of Patient 8’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 4/16/2026 with a primary diagnosis of essential (primary) hypertension (high blood pressure). During a record review of Patient 8’s medical record form titled “Patient Medication Profile” undated, indicated Patient 8 was prescribed Amlodipine (medication to treat high blood pressure). The Patient Medication Profile did not indicate Patient 8 was prescribed Super B complex (supplement). Patient 8’s medication profile indicated the patient has no known allergies. During a concurrent observation, interview, and record review on 5/13/2026 at 2 p.m., with Licensed Vocational Nurse 1 (LVN1) at Patient 8’s residence, LVN1 did not reconcile Patient 8’s medication with the patient’s HHA medication profile during the home visit. During the review revealed Amlodipine was not found in Patient 8’s medications. Patient 8 stated that her cardiologist told her about three weeks ago, not to take Amlodipine any longer. Patient 8 stated that the Super B complex was prescribed to her about two weeks ago by her primary physician. Patient 8 also stated that she had an allergy to Iodine. LVN1 stated that he was not aware of Patient 8’s allergy to Iodine. LVN1 stated that he reconciled Patient 8’s medications on 5/1/2026. LVN1 stated that on 5/9/2026 he asked Patient 8 if she had any new medications to report. Patient 8 told LVN1, No. LVN1 further stated, he did not have any reason to reconcile Patient 8’s medications at that time. During an interview on 5/13/2026 at 2:50 p.m., with LVN1 stated, medications are reconciled to ensure the patients have the prescribed medication and are taking them as indicated. 4. During a record review of Patient 9’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 3/29/2026 with a primary diagnosis of essential (primary) hypertension (high blood pressure). During an observation on 5/13/2026 at 12:20 p.m., of Licensed Vocational Nurse 1 (LVN1) at Patient 9’s residence, LVN1 did not reconciled Patient 9’s medication with Patient 9’s HHA medication profile during the home visit. During an interview on 5/13/2026 at 12:45 p.m., with LVN1 stated that he needed to reconcile Patient 9’s medications to ensure accuracy of the prescribed medications. LVN1 stated that Patient 9 might have her blood pressure out of range which places Patient 9 at risk of a stroke (blocked blood to the brain) or a heart attack. During a record review of the HHAs form titled “Medication Profile” revised on 11/2017, indicated “Medication profiles will be updated for each change to reflect current medications, new and/or discontinued medications.””

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered 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 Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure written information regarding the patient’s medication regime was present for one of thirteen sampled patients (Patient 8). This deficient practice resulted in the patient’s missing information regarding the treatment plan the HHA was providing. During a record review of Patient 8’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 4/16/2026 with a primary diagnosis of essential (primary) hypertension (high blood pressure). During a record review of Patient 8’s medical record form titled “Patient Medication Profile” undated, indicated Patient 8 was prescribed Amlodipine (medication to treat high blood pressure). The Patient Medication Profile did not indicate Patient 8 was prescribed Super B complex (supplement). Lastly, Patient 8’s medication profile indicated Patient 8 has no known allergies. During a concurrent observation, interview, and record review on 5/13/2026 at 2 p.m., with Licensed Vocational Nurse 1 (LVN1) at Patient 8’s residence, Patient 8 was asked to provide her the HHA patient home folder. A review of Patient 8’s HHA home folder did not indicate it had Patient 8’s HHA medication profile. LVN1 stated that he (LVN1) carries Patient 8’smedication profile in his (LVN1) folder and reviews it before the home visits. LVN1 was not noted reconciliating Patient 8’s medication with Patient 8’s HHA medication profile. Patient 8 provided her (Patient 8) medications. Amlodipine was not found in Patient 8’s medications. Patient 8 stated that her (Patient 8) cardiologist told her (Patient 8), about three weeks ago, not to take Amlodipine any longer. Patient 8 then stated that the Super B complex was prescribed to her (Patient 8) about two weeks ago by her primary physician. Patient 8 also stated that she (Patient 8) had an allergy to Iodine. LVN1 stated that he (LVN1) was not aware of Patient 8’s allergy to Iodine. During a record review of the HHAs form titled “Patient Bill of Rights” revised 11/2017, indicated “Each patient will be an active, informed participant in his/her plan of care.” During a record review of the HHAs form titled “Care Planning Process” revised 11/20217, indicated “The organization shall provide the patient and caregiver with a copy of written instructions outlining: visit schedule... frequency of visits by personnel... medication schedule /instructions... treatments to be administered...and any other pertinent instruction related to the patients care and treatments...” Based on observation, interview, and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure written information regarding the patient’s medication regime was present for one of thirteen sampled patients (Patient 8). This deficient practice resulted in the patient’s missing information regarding the treatment plan the HHA was providing.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interviews and record review the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure nine of thirteen sampled patients (Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13) clinical records included completed plans of care, clinical notes, updated OASIS information, completed comprehensive assessments , and other pertinent medical information for these certified home health care patients. This failure resulted in an incomplete clinical record. During an interview on 5/14/2026, at 9:54 a.m., with the Director of Nurses (DON), the DON stated the initial comprehensive assessment (OASIS) was supposed to be completed within 48 hours of the start of care because the assessment was used to develop the POC. The POC was for the nurses to know what needed to be done with the patients care. During an interview on 5/14/2026 at 10:02 a.m., with the DON, the DON stated the plan of care was supposed to be completed within 5 days of the start of care. The DON stated the agency was behind in completing the POC’s. The DON stated the POC for Patients 2, 3, 8, and 9 were completed on 5/13/26. 1. During a record review of Patient 2’s document titled, Patient Profile, indicated a start of care date on 3/5/2026, with diagnoses including Type 2 diabetes (too much sugar in the blood). On 5/12/2026, there was no POC in the medical record for Patient 2. The Administrator (ADM), the ADM stated the plan of care (POC) for Patient 2, was not completed yet. 2. During a record review of Patient 3’s document titled, Patient Profile, indicated a start of care on 5/4/2026, with diagnoses including essential hypertension. On 5/12/2026, there was no POC in the medical record for Patient 3. The Administrator (ADM) stated the plans of care (POC) for Patient 3 was not completed yet. During a record review of Patient 3’s document titled, OASIS Tracker, dated 4/1/2025-5/14/2026, indicated the document was completed (locked) on 5/9/2026. 3. During a record review of Patient 4’s document titled, Patient Profile, indicated a start of care on 10/7/2025 with diagnoses including encounter for change or removal of surgical wound dressing. During a record review of Patient 4’s document titled, OASIS Tracker, dated 4/1/2025-5/14/2026, indicated the document was completed (locked) by the office staff (OS). During an interview on 5/18/2026, at 9:55 a.m., with Registered Nurse 1 (RN 1) stated she was behind in her documentation and did not remember when she had completed the initial comprehensive assessment (OASIS) for Patient 4. 4. During a record review of Patient 8’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 4/16/2026 with a primary diagnosis of essential (primary) hypertension (high blood pressure). On 5/12/2026 at 1 p.m., the Administrator (ADM) stated the plan of care (POC) for Patient 8 was not completed yet. During a record review of Patient 8’s medical record form titled “Reason for Assessment: Start of Care (SOC)” dated 4/20/2026, indicate Registered Nurse 1 (RN1) electronically signed the form on 4/20/2026. During a record review of Patient 8’s medical record form titled “OASIS Tracker” dated 4/1/2025-5/14/2026, indicated Patient 8’s medical record form titled Reason for Assessment: Start of Care, was being tracked. Patient 8’s OASIS Tracker also indicated it was completed (locked) by a consultant (MC) on 4/20/2026. Patient 8’s OASIS Tracker also indicated RN1 last updated Patient 8’s medical record form titled Reason for Assessment: Start of Care, on 5/13/2026. Patient 8’s OASIS Tracker indicated it was exported on 5/13/2026. 5. During a record review of Patient 9’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 3/29/2026 with a primary diagnosis of essential (primary) hypertension (high blood pressure). During a concurrent interview and record review on 5/15/2026 at 11:07 a.m. with Registered Nurse 3 (RN3) of Patient 9’s medical record form titled “Reason for Assessment: Start of Care (SOC)” dated 4/02/2026, indicated the assessment form was incomplete. Patient 9’s SOC assessment was missing pain assessment, emergency preparation planning, patient/caregiver education, disciplines and their frequency, and the durable medical supply section was left blank. Lastly, the form indicated Registered Nurse 3 (RN3) electronically signed the form on 4/2/2026. RN3 stated that she (RN3) could not state why Patient 9’s initial assessment had “a lot of fields missing” During a record review of Patient 9’s medical record form titled “Reason for Assessment: Start of Care” dated 4/02/2026, indicated it was electronically signed by Registered Nurse 3 (RN3) on 4/2/2026. During a record review of Patient 9’s medical record form titled “OASIS Tracker” dated 4/1/2025-5/14/2026, indicated Patient 9’s medical record form titled Reason for Assessment: Start of Care, was being tracked. Patient 9’s OASIS Tracker also indicated it was completed (locked) by a consultant (MC) on 4/2/2026. Patient 9’s OASIS Tracker also indicated RN3 last updated Patient 9’s medical record form titled Reason for Assessment: Start of Care, on 5/13/2026. Patient 9’s OASIS Tracker indicated it was exported on 5/13/2026. 6. During a record review of Patient 10’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 4/25/2026 with a primary diagnosis of hemiplegia (complete paralysis) and hemiparesis (partial weakness/loss of strength) following cerebral infarction (blocked blood supply to brain) affecting right dominant side. During a concurrent interview and record review on 5/18/2026 at 10:45 a.m. with the Director of Nurses (DON) of Patient 10’s medical record, the DON stated that Patient 10’s initial assessment was completed by Registered Nurse 3 on 4/28/2026. The DON stated that her (DON) job included assuring that patient’s initial assessment was complete. The DON confirmed Patient 10’s initial assessment was incomplete. The DON stated that the pain assessment was required to know the patients pain tolerance/level. The DON stated that if a patient is in pain, “how can they get better”. The DON stated that this was poor documentation and that she (DON) did not have time to check it. During a record review of Patient 10’s medical record form titled “OASIS Tracker” dated 3/3/2026-5/14/2026, indicated Patient 10’s medical record form titled Reason for Assessment: Start of Care, was being tracked. Patient 10’s OASIS Tracker also indicated it was completed (locked) by the Director of Nurses (DON) on 4/28/2026. Patient 10’s OASIS Tracker also indicated RN3 last updated Patient 10’s medical record form titled Reason for Assessment: Start of Care, on 5/13/2026. Patient 10’s OASIS Tracker indicated it was exported on 5/13/2026. 7. During a record review of Patient 11’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 3/26/2026 with a primary diagnosis of type 2 diabetes Mellitus with hyperglycemia (high blood sugar). During a record review of Patient 11’s medical record form titled “Reason for Assessment: Start of Care (SOC)” dated 3/30/2026, indicated Registered Nurse 3 (RN3) electronically signed the form on 3/30/2026. During a record review of Patient 11’s medical record form titled “OASIS Tracker” dated 3/3/2026-5/14/2026, indicated Patient 11’s medical record form titled Reason for Assessment: Start of Care, was being tracked. Patient 11’s OASIS Tracker also indicated it was completed (locked) by a consultant (MC) on 3/30/2026. Patient 11’s OASIS Tracker also indicated RN3 last updated Patient 11’s medical record form titled Reason for Assessment: Start of Care, on 5/13/2026. Patient 11’s OASIS Tracker did not indicate it was exported. 8. During a record review of Patient 12’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 5/5/2025 with a primary diagnosis of essential (primary) hypertension (high blood pressure). During a record review of Patient 12’s medical record form titled “Reason for Assessment: Start of Care (SOC)” dated 5/10/2025, indicated Registered Nurse 1 (RN1) electronically signed the form on 5/10/2025. During a record review of Patient 12’s medical record form titled “OASIS Tracker” dated 5/5/2025-7/3/2025, indicated Patient 12’s medical record form titled Reason for Assessment: Start of Care, was being tracked. Patient 12’s OASIS Tracker also indicated it was completed (locked) by a consultant (MC) on 5/10/2025. Patient 12’s OASIS Tracker also indicated RN1 last updated Patient 12’s medical record form titled Reason for Assessment: Start of Care, on 5/13/2026. Patient 12’s OASIS Tracker indicated it was exported on 7/7/2025. 9. During a record review of Patient 13’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 2/9/2025 with a primary diagnosis of sepsis (blood infection) unspecified organism. During a record review of Patient 13’s medical record form titled “Reason for Assessment: Recertification (follow-up) assessment” dated 6/10/2025, indicate Registered Nurse 1 (RN1) electronically signed the form on 6/10/2025. During a record review of Patient 13’s medical record form titled “OASIS Tracker” dated 2/9/2025-8/7/2025, indicated one of Patient 13’s medical record form titled Reason for Assessment: Recertification (follow-up) assessment with an episode start date of 6/9/2025, was being tracked. Patient 13’s OASIS Tracker also indicated it was completed (locked) by a consultant (MC) on 6/10/2025. Patient 13’s OASIS Tracker also indicated RN1 last updated Patient 13’s medical record form titled Reason for Assessment: Recertification (follow-up) assessment with an episode start date of 6/9/2025, on 5/13/2026. Patient 13’s OASIS Tracker indicated it was exported on 10/30/2025. During a record review of the HHA’s document titled, Contents of Clinical Record, dated 11/2017, indicated, “the following information will be available in the clinical record for patients receiving skilled care…All assessments from the most recent home health admission, clinical notes, plans of care and physicians orders.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patients personal residence) failed to send all necessary medical information to the primary care practitioner within 5 days of discharge for four of thirteen sampled patients (Patient 6, Patient 7, Patient 12 and Patient 13). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. During an interview on 5/15/2026, at 10:39 a.m., with the Director of Nurses (DON), the DON stated the discharge summary provided the summary of care that was given to the patients and to indicate the patients met the care goals. The DON stated that the discharge summary was supposed to be provided to the doctor within 3 to 5 days of the discharge date. The importance of providing the discharge summary was so the doctor is aware the patient was under the care of the HHA, services received, and the patient is now in the care of the primary care doctor. 1. During a record review of Patient 6’s document titled, Patient Profile, indicated a start of care date on 12/20/2024, with diagnoses including surgical aftercare. The record also indicated Patient 6 was discharged on 2/10/2025. During a concurrent interview and record review on 5/15/2026, at 10:39 a.m., with the DON, the DON reviewed Patient 6’s medical record and stated there was no discharge summary. 2. During a record review of Patient 7’s document titled, Patient Profile, indicated a start of care date on 1/19/2025, with diagnoses including disorders of the brain. The record also indicated Patient 7 was discharged on 3/3/2025. During a concurrent interview and record review on 5/15/2026, at 11:02 a.m., with the DON, the DON reviewed Patient 7’s medical record and stated there was no discharge summary. 3. During a record review of Patient 12’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 5/5/2025 with a primary diagnosis of essential (primary) hypertension (high blood pressure). During a concurrent interview and record review on 5/15/2026, at 11:07 a.m., with the DON, the DON reviewed Patient 12’s medical record and stated there was no discharge summary. 4. During a record review of Patient 13’s medical record form titled “Patient Profile by Episode” undated, indicated a start of care date of 2/9/2025 with a primary diagnosis of sepsis (blood infection) unspecified organism. During a concurrent interview and record review on 5/15/2026, at 11:07 a.m., with the DON, the DON reviewed Patient 13’s medical record and stated there was no discharge summary. During a record review of the HHA’s document titled, Discharge Summary, dated 11/2017, indicated, “Each patient discharged from a service and/or from the organization will have a written discharge summary completed and filed in the clinical record…Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged…The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service…A copy of the discharge summary will be provided to the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five (5) business days of the patient’s discharge.””