Aveanna Healthcare

“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, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that two of seven sampled patients (Patient 2 and Patient 7) received the nursing care hours written in their individualized plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals). This failure resulted in the patients’ home health needs not being consistently met, which increased the patients’ risk for rehospitalization or emergency room visit. b. b. During a review of Patient 7’s Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 11/8/2026 to 1/6/2026, the Home Health Certification and Plan of Care indicated that Patient 7 was admitted to the HHA on 9/9/2025 with a primary diagnosis of cerebral palsy (a group of permanent neurological disorders appearing in infancy or early childhood that affect body movement, muscle tone, coordination, and posture, which is caused by abnormal brain development or damage before, during, or shortly after birth), unspecified. The Plan of Care indicated the frequency for Licensed Vocational Nurse (LVN) was 32 to 40 hours a week and Registered Nurse supervisory visit was once per month. The Plan of Care indicated the patient was at risk for rehospitalization or emergency room visit related to gastronomy tube dislodgment (the partial or complete removal of a feeding tube [a flexible medical device made of silicone or polyurethane inserted into the stomach or small intestine to provide essential nutrients, fluids, and medication directly to people unable to eat or swallow safely] from the stomach, often caused by accidental pulling, decreased balloon volume, or movement), respiratory distress, feeding intolerance, and uncontrolled seizures. During a review of Patient 7’s Plan of Care for the certification period of 1/7/2026 to 3/7/2026, the Home Health Certification and Plan of Care indicated the frequency for Licensed Vocational Nurse (LVN) was 32 to 40 hours a week and Registered Nurse supervisory visit was once per month. The Plan of Care indicated the patient was at risk for rehospitalization or emergency room visit related to gastronomy tube dislodgment, respiratory distress, feeding intolerance, and uncontrolled seizures. During a telephone interview with Family Member 3 (FM 3) on 2/20/2026 at 11:40 a.m., FM 3 stated that Patient 7 started receiving nursing services from the HHA in early September 2025. FM 3 stated that Patient 7 was supposed to receive 32 to 40 hours of nursing services per week. FM 3 stated that Patient 7 had had different LVNs since he (Patient 7) was admitted to the HHA. FM 3 stated that Patient 7’s had not been getting the 32 to 40 hours the HHA agreed to provide. Per FM 3, the HHA’s management informed her there were currently no nurses available. FM 3 stated that Patient 7 had an academic support personnel, who would accompany Patient 7 to school and assist Patient 7 with his academic needs at school, and the absence of the nurse forced the academic support personnel to attend to Patient 7’s medical needs instead. FM 3 stated that Patient 7’s medical needs came before his academic needs, therefore it was very important that Patient 7 had a nurse to tend to his medical needs so that the academic support personnel could help Patient 7 achieve his academic goals. FM 3 stated the nurse was responsible for monitoring seizures, administering tube feeding and medications, assisting with transfer and toileting, and assisting with emesis (vomiting). FM 3 stated the HHA had not sent a nurse for Patient 7 since 2/12/2026. During a concurrent interview and record review with the Executive Director (ED) on 2/20/2026 at 12:30 p.m., the ED reviewed Patient 7’s Plan of Care or the certification period of 11/8/2026 to 1/6/2026 and for the certification period of 1/7/2026 to 3/7/2026. The ED also reviewed the skilled nursing flow sheet (document used by nurses to record, track, and monitor routine clinical data and patient care interventions, which was documented when the nurse has completed a shift) for Patient 7 from November 2025 to February 2026. The ED confirmed the following: For the week of 12/21/2025 to 12/27/2025, there were 3 nursing shifts recorded.For the week of 12/28/2025 to 1/3/2026, there were no nursing shifts recorded.For the week of 1/4/2026 to 1/10/2026, there were 3 nursing shifts recorded.For the week of 1/11/2026 to 1/17/2026, there were 2 nursing shifts recorded.For the week of 2/1/2026 to 2/7/2026, there were no nursing shifts recorded.For the week of 2/8/2026 to 2/14/2026, there were 1 nursing shift recorded.The ED stated that a shift was 8 hours on average, with some shifts could last up to 10 hours. The ED stated the HHA had not sent a nurse to Patient 7’s home since 2/12/2026 due to the unavailability of nursing staff. The ED stated she was aware that Patient 7 did not always receive 32 to 40 hours of nursing services as written in the Plan of Care. The ED stated that in the absence of a nurse, the family member should provide the care for the patient. Findings: a) During a review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 2’s start of care (SOC) date was 8/19/2024. During a review of Patient 2’s Plan of Care for the certification period starting from 12/12/2025 to 2/9/2026, the POC indicated Patient 2 had diagnoses that included Tetralogy of Fallot (a rare, congenital heart condition that changes the normal flow of blood through a baby’s heart), Down syndrome (a genetic condition that happens when a child is born with an extra chromosome that affects the way the child’s brain and body develop, leading to developmental delays, intellectual disability, and an increased risk for certain medical issues), and encounter for attention to gastrostomy (a surgical procedure that creates an opening into the stomach through the abdomen, allowing for the direct insertion of a feeding tube, known as a G-tube). The POC included an order for the licensed vocational nurse (LVN) level of care frequency of visits of 32-40 hours per week, and the registered nurse (RN) to conduct supervisory visit once a month. During a review of Patient 2’s Skilled Nursing Flow Sheet for the week starting from 1/4/2026 to 1/10/2026, and from 1/11/2026 to 1/17/2026, the skilled nursing flow sheet indicated the LVN only visited Patient 2 16 hours per week and not 32-40 hours per week as ordered. During a concurrent interview and interview with the Director of Patient Care Services (DPCS) on 2/20/2026 at 12:00 p.m., the DPCS reviewed Patient 2’s Skilled nursing flow sheet for the month of January 2026. The DPCS stated that Patient 2 was approved for 32-40 hours per week of LVN services, however during the week starting from 1/4/2026 to 1/10/2026 and from 1/11/2026 to 1/17/2026, Patient 2 was only visited by the LVN for 16 hours per week. The DPCS stated that care and services should follow the plan of care. The DPCS further stated that the agency is hiring more nurses to ensure adequate staffing for patients. The DPCS acknowledged the findings. During a review of the agency’s policy and procedure (P&P) titled Physician/Allowed Practitioner Orders/Plan of Care, revised 2/13/2025, the P&P indicated care and services will be provided in accordance with physician’s (or other allowed practitioner’s) orders, as required by law and regulation. A complete, individualized plan of care/treatment will be developed for all patients receiving ongoing clinical services according to applicable law and state regulations. The plan of care/treatment must include the following as applicable: frequency, duration of each treatment, service, shifts and/or visits.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. 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 therapeutics service to a patient at home) failed to conduct a complaint investigation regarding alleged physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain or mental anguish) for one of seven sampled patients (Patient 4). This failure placed Patient 4 at risk for further potential physical and psychosocial harm. During a review of Patient 4’s Face Sheet (admission record), the Face Sheet indicated Patient 4 was admitted to the HHA on 1/10/2023 with diagnoses that include chronic respiratory failure (a long term condition where there’s not enough oxygen or too much carbon dioxide in your body), tracheostomy (a surgically created opening in the neck and windpipe that provides an alternative airway for breathing), and epilepsy (a brain condition that causes recurring seizures). During a review of Patient 4’s “Home Health Certification and Plan of Care (POC)” for the certification period from 12/25/2025 to 2/22/2026, the POC indicated an order for the Licensed Vocational Nurse (LVN) to provide 60 to 80 hours of skilled nursing (SN) per week and for the Registered Nurse (RN) to visit at least once per month as needed for supervision and recertification. The POC also indicated for the SN to complete a comprehensive assessment as allowed by scope of practice every shift and as needed and to report all abnormal findings to the physician, clinical supervisor, and caregiver. During an interview on 2/18/2026 at 12:30 p.m. with the Executive Director (ED), the ED stated the agency received a call on 11/11/2025 from Family Member 1 (FM 1) who reported that she (FM 1) took Patient 4 to the general acute care hospital (GACH) on 11/10/2025 due to bruising on the legs and arms, as well as a bump on the head. Patient 4 had a computer tomography scan (CT, an imaging procedure that uses x-ray techniques to create detailed images of the body) done. The ED stated FM 1 informed the agency that she is not 100% sure that the bruising came from the agency visiting nurses. The ED also stated the GACH notified the police department who interviewed agency nurses for their own investigation. During an interview on 1/20/2026 at 11:07 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated the agency did not complete a full internal complaint investigation into Patient 4’s possible abuse. The ADM/DPCS stated not completing an investigation had the potential to result in the suspected abuse continuing. During a review of the facility’s policy and procedure (P&P) titled, “Ethics, Rights and Responsibilities: Abuse – Neglect – Exploitation Identification & Reporting,” revised 1/28/2025, the P&P indicated, “When the facility has reason to know that an internal or external report of alleged or suspected maltreatment has been made, the facility must complete an internal review within 30 calendar days and take corrective action, if necessary, to protect the health and safety of children in care. The facility must document completion of the internal review and make internal reviews accessible to the commissioner immediately upon the commissioner’s request.””

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure timely reporting of an alleged physical abuse incident (defined as the willful infliction of injury, reasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish) to the Department of Public Health, Licensing and Certification Unit within the required 24-hour timeframe for one of seven sampled patients (Patient 4). This failure resulted in a delay in initiation of the required external investigation by the Department of Public Health and had the potential to allow the alleged abuse to continue, placing Patient 4 at risk for further physical injury and psychosocial harm. During a review of Patient 4’s Face Sheet (admission record), the Face Sheet indicated Patient 4 was admitted to the HHA on 1/10/2023 with diagnoses that include chronic respiratory failure (a long term condition where there’s not enough oxygen or too much carbon dioxide in your body), tracheostomy (a surgically created opening in the neck and windpipe that provides an alternative airway for breathing), and epilepsy (a brain condition that causes recurring seizures). During a review of Patient 4’s “Home Health Certification and Plan of Care (POC)” for the certification period from 12/25/2025 to 2/22/2026, the POC indicated a physician’s order for the Licensed Vocational Nurse (LVN) to provide 60 to 80 hours of skilled nursing (SN) per week and required the Registered Nurse (RN) to visit at least once per month as needed for supervision and recertification. The POC also indicated for the SN (RN) to complete a comprehensive assessment as allowed by scope of practice every shift and as needed and to report all abnormal findings to the physician, clinical supervisor, and caregiver. During an interview on 2/18/2026 at 12:30 p.m. with the Executive Director (ED), the ED stated the agency received a call on 11/11/2025 from Family Member 1 (FM 1) who reported that she (FM 1) took Patient 4 to the general acute care hospital (GACH) on 11/10/2025 due to bruising on the legs and arms, as well as a bump on the head. Patient 4 had a computer tomography scan (CT, an imaging procedure that uses x-ray techniques to create detailed images of the body) done. The ED stated FM 1 informed the agency that she is not 100% sure that the bruising came from the agency visiting nurses. The ED also stated the GACH notified the police department who interviewed agency nurses for their own investigation. During an interview on 2/20/2026 at 11:07 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated the agency did not report the abuse allegations to the Department of Public Health. The ADM/DPCS stated they also did not make a report to the police department because the GACH already submitted one. The ADM/DPCS stated it was important to report allegations of abuse to the Department of Public Health and law enforcement to investigate if abuse or harm occurred or is continuing to occur. During a review of the facility’s policy and procedure (P&P) titled, “Ethics, Rights and Responsibilities: Abuse – Neglect – Exploitation Identification & Reporting,” revised 1/28/2025, the P&P indicated, “Any person having contact with an individual in their professional capacity is required to report suspected abuse, neglect or exploitation. All reports are made to the Location Director/Administrator of the local agency office. The Director or designee is responsible for ensuring any suspicions of abuse, neglect or exploitation are reported to the appropriate authorities or agencies.”

“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, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to maintain accurate, and current medication profiles for one of seven sampled patients (Patient 4). This failure had the potential to place Patient 4 at risk for medication errors and adverse drug reactions. During a review of Patient 4’s “Home Health Certification and Plan of Care (POC)” for the certification period from 12/25/2025 through 2/22/2026, the POC indicated Patient 4 was admitted to the HHA on 1/10/2023 with diagnoses that included-chronic respiratory failure (a long term condition where there’s not enough oxygen or too much carbon dioxide in your body), tracheostomy (a surgically created opening in the neck and windpipe that provides an alternative airway for breathing), and epilepsy (a brain condition that causes recurring seizures). During a review of Patient 4’s “Medication Profile” for the period from 12/20/2025 through 2/22/2026, the Medication Profile indicated Patient 4 was taking the following medications: - Somatropin (a medication used to treat growth failure in children) 5 milligrams (mg, a unit of measurement)/1.5 milliliters (ml, a unit of measurement), one 0.7mg/0.21ml subcutaneous injection (delivers medication into the fatty tissue layer between the skin and muscle) every night at bedtime, ordered on 1/19/2026 - Tobramycin (an antibiotic medication used to treat chronic lung infections) 40 mg/1ml, 1ml nebulized twice a day, ordered on 1/19/2026 - Ketoconazole 2% ointment (a topical antifungal used to treat skin infections), applied to groin area twice a day, ordered on 1/19/2026 - Diazepam (a medication used to treat seizures) 10 mg, one 7.5 mg tablet as needed for seizures, ordered on 10/17/2024 During a concurrent observation and record review on 2/19/2026 at 11:12 a.m. with the ADM/DPCS in the kitchen, there was one box of Skytrofa (a medication used to treat growth failure in children) 4.3 mg one subcutaneous injection to be given once a week and one box of tobramycin 80mg/ 2ml, 1ml nebulized twice a day. The ADM/DPCS stated Skytrofa was not indicated in Patient 4’s Medication Profile. The ADM/DPCS also stated the dosages for tobramycin were different compared to Patient 4’s Medication Profile. During an interview on 2/19/2026 at 11:15 a.m. with FM 1, FM 1 stated she was Patient 4’s primary caregiver. FM 1 stated Patient 4 has been taking Skytrofa for “about a month now,” and has replaced the Somatropin 5mg/1.5ml injection indicated on Patient 4’s Medication Profile. FM 1 stated Patient 4 started taking tobramycin 80mg/2ml this month and has replaced the tobramycin dosage indicated on Patient 4’s Medication Profile. FM 1 also stated Patient 4 no longer takes diazepam 10mg tablets as needed for seizures and has not been using Ketoconazole 2% ointment daily, only as needed. During an interview on 2/20/2026 at 12:32 p.m. with the ADM/DPCS, the ADM/DPCS stated medication reconciliation should be done by all nurses during every visit to ensure all medications and dosages are accurate and match their medication profile. The ADM/DPCS stated not performing a medication reconciliation at each visit could result in medications being administered incorrectly. During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile,” revised 5/20/2025, the P&P indicated, “The medication profile will be initiated at the time of admission and requires ongoing medication updates, including initiation of changes in or discontinuation of medications.””

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to integrate orders from all physicians involved in the plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for one of seven sampled patients (Patient 1). This failure had the potential to result in uncoordinated services, risking patient safety and treatment effectiveness. Findings: During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 2’s start of care (SOC) date was 9/17/2024. During a review of Patient 1’s Plan of Car (POC) for the certification period 1/102026 through 3/10/2026, the POC listed diagnoses including anoxivc brain damage, gastrostomy status, and spastic quadriplegic and cerebral palsy. The POC ordered licensed vocational nurse (LVN) services for 58-70 hours per week to provide medication instruction and administration, assess pain each shift, monitor respiratory and cardiovascular status, and administer enteral feeding consisting of Kate Farms 130 ml plus blended diet 135 ml (total 165 ml) via feeding pump at 260 ml/hr three times daily. During a joint home visit, on 2/19/2026 at 2:00 p.m., while at Patient 1’s residence with the licensed vocational nurse nurse (LVN 1), Patient 1 was observed sleeping in a baby car seat in the living room area. Patient 1 was observed to have an ongoing enteral feeding infusing at a rate of 265 ml/hour. During an interview with LVN 1, on 2/19/2026 at 2:18 p.m., LVN 1 stated Patient 1 was currently receiving enteral feeding comprising 130 ml of Kate Farms blend mixed with 135 ml blended diet, totaling 265 ml, administered at a rate of 265 ml/hour. LVN 1 stated that the order for Patient 1’s enteral feeding rate was changed from 260 ml/hr. to 265 ml/hr. by Patient 1’s physician 2-3 weeks ago. During a concurrent interview and record review, on 2/20/2026 at 12:00 p.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 1’s POC for the certification period starting from 1/10/2026 to 3/10/2026 and physician’s supplemental orders. The DPCS stated Patient 1’s medical records did not contain an order to change the enteral feeding rate from 260 ml/hr to 265 ml/hr three times a day from the patient’s physician. The DPCS stated nursing staff on the field should have coordinated with the patient’s family after every physician’s appointment visit for any new orders or changes in the current orders and should notify the office right away about these changes in order to update the patient’s records. The DPCS stated that it was important to have physicians’ most current orders in the POC to ensure the correct orders are being followed. During a record review of the HHA’s policy and procedure (P&P) titled Coordination of Care, revised 11/9/2023, the P&P indicated patient care will be coordinated with the patient, patient representative and all members of the health care team. Communication will be maintained through effective service coordination regarding changes in the patient’s needs, services, or care goals. When a situation occurs that requires action by another provider of services/care, it is the responsibility of the agency staff to contact the other provider to assure awareness of the situation. This contact should be documented in the patient’s record. The management staff will create an environment which encourages collaboration between staff and outside providers to facilitate continuity of care. It is the responsibility of location staff to identify and document the existence of other providers of care and services in order to assure appropriate coordination of care and services.”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA 1, agency that delivers skilled nursing and other therapeutic services to a patient at home) failed to ensure complete and organized documentation of all problems related to staffing and discharge planning for one of seven sampled patients (Patient 7) by failing to: 1. Ensure all staffing challenges and efforts to resolve the unavailability of private duty nurses (PDNs) were documented on Patient 7’s clinical records. 2. Ensure all discharge-related problems and attempts to ensure smooth transition of care were documented on Patient 7’s clinical records. This failure had the potential to cause a decline in Patient 7’s health due to possible confusion and inconsistent provision of care and services related to incomplete documentation on Patient 7’s clinical records. Findings: During a review of Patient 7’s medical record, titled “Patient Profile,” the “Patient Profile” indicated Patient 7’s start of care (SOC) date of 6/5/2023. During a review of Patient 7’s “Plan of Care (POC)” for the certification period 9/22/2025 – 11/20/2025, the “POC” indicated the following: 1. Patient 7 had diagnoses of epilepsy (condition characterized by recurrent, unprovoked seizures due to abnormal electrical activity in the brain) and cerebral palsy (condition marked by impaired muscle coordination and/or other disabilities due to damage to the brain before or at birth). 2. Patient 7 requires care and maintenance of gastrostomy tube (medical device inserted through abdomen into the stomach to deliver nutrition, fluids, or medication) or stoma site (small, surgical opening in the abdominal wall into the stomach). 3. Patient 7 had bowel and bladder incontinence (inability to control bowel movements and urination), developmental delay, cognitive impairment (deficits in memory, language, thinking, and judgment), was non-ambulatory (inability to walk)/wheelchair-bound, and was completely dependent on staff or caregiver for transfers. 4. Patient 7’s physician orders included: Licensed Vocational Nurse (LVN) level of care 41-57 hours per week x 1 certification and LVN in-home care 368 hours per month x 1 certification. 5. Skilled Nurse (SN) to provide PDN throughout certification period and Patient 7’s caregiver (PCG 7) to assume all responsibilities in the absence of a nurse. 6. There were no plans to discharge Patient 7 as Patient 7 “requires ongoing care.” During a review of Patient 7’s discharge amended notice (DC notice) from HHA 1, dated 9/3/2025, the DC notice indicated HHA 1 would discontinue PDN for Patient 7 effective 10/24/2025 “based on the recent event with not being able to provide adequate staffing.” The DC notice indicated the HHA 1 would assist PCG 7 in “identifying and transferring PDN services to another agency” outside of HHA 1 by the discharge date of 10/24/2025. During a review of the electronic mail of HHA 1’s Area Vice President 1 (AVP 1) to PCG 7, dated 9/3/2025, timed at 3:55 PM, AVP 1 informed PCG 7 that HHA 1 would “continue to provide nursing services” until 10/24/2025 from the HHA 1 location where Patient 7 was assigned. During a review of the electronic mail of PCG 7 to HHA 1, dated 9/3/2025, timed at 7:20 PM, PCG 7 wrote, “I have always requested consistency…but consistency does not mean refusing all new nurses or leaving shifts uncovered. What I have consistently refused to accept are unsafe practices, such as nurses who come from hours away, cancel last-minute, fall asleep on shift, or admit they haven’t read the plan of care...” During a review of the electronic mail of HHA 1’s Area Vice President 2 (AVP 2) to RP 7, dated 10/24/2025, timed at 2:36 PM, AVP 2 wrote, “In an effort to continue to collaboration and facilitate discharge, we will continue to provide staffing as we collaborate with your clinical care team. We will send updates on staffing for the next week by end of day. Please confirm once received so we can secure the available nurses.” During a telephone interview on 2/4/2025 at 11:16 AM, Licensed Vocational Nurse 1 (LVN 1) stated HHA 1 was unable to maintain consistency in scheduling “good nurses” for Patient 7. LVN 1 stated nurses would cancel last-minute, do a “no-show,” train one day and not show up again, would fall asleep during the shift, or would not be willing to work due to the long drive to Patient 7’s residence. LVN 1 stated PCG 7 was triggered to complain about HHA 1 after about 6 months of “trying to find a stable nurse” for Patient 7 and “not having adequate care” from HHA 1. LVN 1 stated PCG 7 was aware that “she had to take over when the nurses are unable to cover, but it became too much and impossible to cover.” LVN 1 stated [Patient 7] would also wake up in the middle of the night, so PCG 7 had to care for Patient 7 in the morning, evening, and night shifts. During a concurrent interview and record review on 2/6/2026 at 11:21 AM with the Executive Director (ED), Patient 7’s electronic medical records (EMRs) were reviewed. ED stated the following: 1.There was no documentation on Patient 7’s clinical records of all correspondence with the outside agencies involved in Patient 7’s care with regard to the scheduled discharge on 10/24/2025. 2. There were no notes from the HHA 1 meetings with Patient 7’s physician and case managers from outside agencies regarding Patient 7’s scheduled discharge on 10/24/2025. 3. There was no documentation on Patient 7’s clinical records of all attempts to communicate with PCG 7 regarding Patient 7’s pending discharge and care transition after the scheduled discharge on 10/24/2025 was postponed. 4. There was no documentation from 11/1/2025 -11/16/2025 on Patient 7’s clinical records regarding all efforts to staff PDNs in accordance with the Patient 7’s POC, as HHA 1 was unable to provide all the ordered SN hours for Patient 7. 5. HHA 1 utilized multiple communication platforms, including the internal text messaging system and electronic mail. ED stated the text messages and e-mail correspondence with PCG 7 regarding the interruption of care and services were not always documented on Patient 7’s EMRs. During a concurrent interview and record review on 2/6/2026 at 12:12 PM with AVP 2, Patient 7’s electronic health records were reviewed. AVP 2 stated HHA 1 did not receive the authorization from Patient 7’s health insurance for Patient 7 to continue services with HHA 1 until the morning of 10/24/2025 (date of discharge), so the electronic mail to PCG 7 to postpone Patient 7’s discharge was sent on 10/24/2025 at 2:36 PM (same date). However, AVP 2 stated there was no documentation prior to and after 10/24/2025 on Patient 7’s EMRs regarding Patient 7’s transition of care or coordination of the transfer to a different HHA (HHA 2). AVP 2 stated it was better to ensure all notes were documented on the “same place” (same electronic health record platform) to make it easier “to locate the notes.” During a review of the HHA’s policy and procedures (P&P), titled “Transfer and Discharge,” dated 5/19/2025, P&P indicated that the HHA must document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical records. During a review of the HHA’s policy and procedures (P&P), titled “Clinical Record,” dated 2/20/2025, P&P indicated the following: 1. Every patient must have a record that is established and maintained to document care and services provided. The record must contain sufficient information to identify the patient, describe their problems and needs, justify care and services, document care/services and its results, and promote continuity of care among direct care providers. 2. Records must be maintained in an organized format to promote consistency, ease of data retrieval, and usefulness of the record. 3. The record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician/s issuing orders for the plan of care and appropriate agency staff. 4. The patient record must contain appropriate notes relating to care and services, documentation of interruption in services, and identification of other individuals/organizations involved in care and services. During a review of the HHA’s policy and procedures (P&P), titled “Documentation Standards,” dated 11/20/2023, P&P indicated the following: 1. All employees and individuals under contract must be allowed to make entries in the patient’s record. 2. Any person who makes entries must complete each entry by recording the following: a) date and time of entry, b) first and last name, and c) discipline and title. 3.Care/services must be documented at the time of care/services. 4. All entries must be legible, complete, organized, current, meaningful, and succinct. 5. Each page of paper notes must include the patient’s name and/or medical/patient number, location name and number, and the date. 6. Each entry on the notes must include times. 7. For paper documentation, each note must be signed with the employee’s full name and credential. 8. Documentation must reflect, but not be limited to: a) pertinent data relating to care/services, b) ongoing status of problems identified, c) patient/caregiver education, and d) contact and coordination of care with physicians, providers, payers, caregivers, supervisors, or other healthcare team members.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an agency that delivers skilled nursing and other therapeutic services to a patient at home) failed to ensure a physician’s order for discharge was completed to one of seven sampled patients (Patient 6). This deficient practice limits the HHA’s ability to ensure a safe transition of care and poses a potential risk to the patient’s health and safety. Findings: During a review of Patient 6’s clinical record titled “Patient Profile,” the patient profile indicated Patient 6 was admitted to the HHA on 8/19/2024. During a review of Patient 6’s clinical record titled “Discharge Summary,” dated 10/20/2025, the patient’s discharge summary indicated patient’s primary diagnosis was muscular dystrophy (a disease that causes muscles to become progressively weaker and break down over time), unspecified. During a concurrent interview and review on 2/6/2026 at 11:12 AM, with the Vice-President for Clinical Operations (VPCO), reviewed Patient 6’s electronic medical record (EMR, a digital version of a patient’s paper chart, storing the medical history, diagnoses, medications, immunizations, and treatment plans within a single healthcare practice for easy access, tracking, and improved care). The VPCO stated that there was no physician’s order on record to discharge Patient 6. The VPCO stated that Patient 6’s primary doctor was informed regarding discharge, but the HHA did not obtain a physician’s order for discharge since all the existing orders were already expired. The VPCO stated that a physician’s order is needed for the patient’s start of care, resumption of care, update of care plan and discharge. The VPCO stated that she (VPCO) was under the impression that the HHA’s previous practice for a patient’s discharge did not need to have a physician’s order. The VPCO stated that physician’s order for discharge should be a standard of practice to all patients to ensure proper coordination of care between the involved healthcare team and Patient 6 should have had a physician’s order for discharge. During a review of the HHA’s P&P titled “Physician/Allowed Practitioner Orders/Plan of Care,” revised 2/13/2025, the P&P indicated that the physician (or other allowed practitioner’s) orders will be legible, complete, authenticated, and timely. Orders are required for all care and services regardless of payer source.”

“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 - a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) staff failed to review and reconcile (the process of comparing a patient’s medication order to all of the medications that the patient has been taking) all medications the patients were taking and update their medication profile for two of eight sample patients (Patient 2 and Patient 3). This deficient practice had a potential to place patients at risk for medication errors and adverse drug reactions. b.During a record review of Patient 3’s “Plan of Care” dated 10/20/2025 to 12/28/2025, indicated a start of care date of 06/27/2024 with a primary diagnosis of localized related symptomatic epilepsy with complex martial seizures not intractable with status epilepticus (describes epilepsy originating from a specific brain area, causing complex partial seizures that are manageable with medication). The plan of care indicated Licensed Vocational Nurse (LVN) level care of 32 to 40 hours per week. During a joint home visit, on 10/29/2025 at 10:30 a.m. with the LVN 1 at Patient 3’s residence, Patient 3 was observed lying in bed awake accompanied by LVN 1. During a review of Patient 3’s current medication, on 10/29/2025 at 10:40 a.m. with LVN 1, the following medication was not available in Patient 3’s residence but listed in Patient 3’s medication list provided by the HHA: • Levetiracetam 100mg/1ml (Anti Seizure medication) 700mg/7ml dose to be given as needed for seizures. During a review of Patient 3’s current medication, on 10/29/2025 at 10:45 a.m. with LVN 1, the following medication concentration listed on the medication profile did not match what was available in the patient’s residence. Patient 3’s “Medication Profile” indicated Levalbuterol HCL 0.63mg per 3ml (a prescription medication used to prevent or treat wheezing and shortness of breath in patients with reversible obstruction airway disease) inhalation as needed every 4 hours for illness and congestion, but the medication available at Patient 3’s residence was Levalbuterol 1.25 mg per 3 ml. During an interview on 10/29//2025 at 10:50 p.m. with LVN 1 at Patient 3’s residence, LVN 1 stated, “we are to do medication reconciliation on every visit and these medications were missed. The home health agency nurses should report any changes to the medications to the office and the medication profile should be updated every time there is a change in medication.” When asked when Patient 3’s medications changed, LVN 1 stated, “I am not sure. I just know Patient 3 has not had the Levetiracetam for a while.” During an interview on 10/29/2025 at 11:00 a.m. with Patient Care Giver 1 (PCG 1), and PCG 1 stated, “the Levetiracetam was discontinued for Patient 3 beginning of this year, and Levalbuterol dose was changed after Patient 3’s physician visit in May 2025.” During an interview, on 10/30/2025 at 11:31 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that medication reconciliation should be done daily. ADM/DPCS stated that it is important for medication reconciliations to be done so that staff are following the most up to date orders. During a record review of the agency policy and procedure titled, “Medication Profile”, undated, the policy and procedure indicated, “The medication profile will be initiated at the time of admission and requires ongoing medication updates, including initiation of changes in or discontinuation of medications.” a. During a record review of Patient 2’s “Plan of Care” dated 9/23/2025 to 11/21/2025, indicated a start of care date of 7/12/2016 with a primary diagnosis of chronic respiratory disease in the perinatal period (timeframe around the birth of a child). The plan of care indicated Licensed Vocational Nurse (LVN) level care of 80 to 112 hours per week. During a joint home visit, on 10/29/2025 at 3:45 p.m. with the Registered Nurse (RN 1) at Patient 2’s residence, Patient 2 was observed lying in bed watching a show in a tablet, accompanied by LVN 3. During a review of Patient 2’s current medication, on 10/29/2025 at 4:02 p.m. with LVN 3 and RN 1, the following medications were available in Patient 2’s residence but not listed in Patient 2’s medication profile provided by the HHA: • Medline Remedy Essentials Prevent Ointment (used to protect at risk skin from breakdown). • Calmoseptine Ointment (used to protect and help heal various minor skin irritations). During a review of Patient 2’s current medication, on 10/29/2025 at 4:02 p.m. with LVN 3 and RN 1, the following medication was listed in Patient 2’s medication profile that was provided by the HHA but not available at Patient 2’s residence: • Zinc Oxide (used to treat and prevent diaper rash) 40 percent - apply a liberal amount to diaper area as needed with each diaper change During a review of Patient 2’s current medication, on 10/29/2025 at 4:02 p.m. with LVN 3 and RN 1, the following medication concentration listed on the medication profile did not match what was available in the patient’s residence. Patient 2’s “Medication Profile” indicated Enalapril (used to treat high blood pressure and heart failure) 10 milligrams (mg – unit of measurement) per one milliliter (ml – unit of measurement) but the medication available at Patient 2’s residence was Enalapril 1 mg per 1 ml. During an interview, on 10/30/2025 at 11:15a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that medication reconciliation should be done daily. ADM/DPCS stated that it is important for medication reconciliations to be done so that staff are following the most up to date orders. Findings: a. During a review of Patient 2’s “Plan of Care” dated 9/23/2025 to 11/21/2025, indicated Patient 2’s start of care date of 7/12/2016 with a primary diagnosis of chronic respiratory disease in the perinatal period (timeframe around the birth of a child). The plan of care indicated Licensed Vocational Nurse (LVN) level care of 80 to 112 hours per week. During a joint home visit, on 10/29/2025 at 3:45 p.m., with the Registered Nurse (RN 1) at Patient 2’s residence, Patient 2 was observed lying in bed watching a show in a tablet, accompanied by LVN 3. During a review of Patient 2’s current medication, on 10/29/2025 at 4:02 p.m., with LVN 3 and RN 1, the following medications were available in Patient 2’s residence but not listed in Patient 2’s “Medication Profile” provided by the HHA: • Medline Remedy Essentials Prevent Ointment (used to protect at risk skin from breakdown). • Calmoseptine Ointment (used to protect and help heal various minor skin irritations). During a review of Patient 2’s current medication, on 10/29/2025 at 4:02 p.m. with LVN 3 and RN 1, the following medication was listed in Patient 2’s “Medication Profile” that was provided by the HHA but not available at Patient 2’s residence: • Zinc Oxide (used to treat and prevent diaper rash) 40 percent - apply a liberal amount to diaper area as needed with each diaper change. During a review of Patient 2’s current medication, on 10/29/2025 at 4:02 p.m. with LVN 3 and RN 1, the following medication concentration listed on the medication profile did not match what was available in the patient’s residence. Patient 2’s “Medication Profile” indicated Enalapril (used to treat high blood pressure and heart failure) 10 milligrams (mg – unit of measurement) per one milliliter (ml – unit of measurement) but the medication available at Patient 2’s residence was Enalapril 1 mg per 1 ml. During an interview, on 10/30/2025 at 11:15a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that medication reconciliation should be done daily. ADM/DPCS stated that it is important for medication reconciliations to be done so that staff are following the most up to date orders. b. During a review of Patient 3’s “Plan of Care” dated 10/20/2025 to 12/28/2025, indicated Patient 3’s start of care date of 06/27/2024 with a primary diagnosis of localized related symptomatic epilepsy with complex martial seizures not intractable with status epilepticus (describes epilepsy originating from a specific brain area, causing complex partial seizures that are manageable with medication). The plan of care indicated Licensed Vocational Nurse (LVN) level care of 32 to 40 hours per week. During a joint home visit, on 10/29/2025 at 10:30 a.m. with the LVN 1 at Patient 3’s residence, Patient 3 was observed lying in bed awake accompanied by LVN 1. During a review of Patient 3’s current medication, on 10/29/2025 at 10:40 a.m. with LVN 1, the following medication was not available in Patient 3’s residence but listed in Patient 3’s medication list provided by the HHA: • Levetiracetam 100mg/1ml (Anti Seizure medication) 700mg/7ml dose to be given as needed for seizures. During a review of Patient 3’s current medication, on 10/29/2025 at 10:45 a.m. with LVN 1, the following medication concentration listed on the medication profile did not match what was available in the patient’s residence. Patient 3’s “Medication Profile” indicated Levalbuterol HCL 0.63mg per 3ml (a prescription medication used to prevent or treat wheezing and shortness of breath in patients with reversible obstruction airway disease) inhalation as needed every 4 hours for illness and congestion, but the medication available at Patient 3’s residence was Levalbuterol 1.25 mg per 3 ml. During an interview on 10/29//2025 at 10:50 p.m. with LVN 1 at Patient 3’s residence, LVN 1 stated, “we are to do medication reconciliation on every visit and these medications were missed. The home health agency nurses should report any changes to the medications to the office and the medication profile should be updated every time there is a change in medication.” When asked when Patient 3’s medications changed, LVN 1 stated, “I am not sure. I just know Patient 3 has not had the Levetiracetam for a while.” During an interview on 10/29/2025 at 11:00 a.m. with Patient Care Giver 1 (PCG 1), and PCG 1 stated, “the Levetiracetam was discontinued for Patient 3 beginning of this year, and Levalbuterol dose was changed after Patient 3’s physician visit in May 2025.” During an interview, on 10/30/2025 at 11:31 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that medication reconciliation should be done daily. ADM/DPCS stated that it is important for medication reconciliations to be done so that staff are following the most up to date orders. During a record review of the agency policy and procedure titled, “Medication Profile”, undated, the policy and procedure indicated, “The medication profile will be initiated at the time of admission and requires ongoing medication updates, including initiation of changes in or discontinuation of medications.””