Amberkare Home Health, Inc.

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included the process for collaboration with the regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency’s 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not include a process for collaboration with the regional and tribal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. On 4/23/26 at 1615 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This failure created the potential risk of not being to facilitate patients evacuation and transportation at an emergency event. Findings: Review of the agency’s 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not include policies and procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. On 4/23/26 at 1618 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included procedures to inform State and local officials of any on-duty staff or patients that they are unable to contact. This failure created the potential risk of not providing continuity of necessary care and services to the patients during emergency events. Review of the agency’s 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not include procedures to inform State and local officials of any on-duty staff or patients that they are unable to contact. On 4/23/26 at 1620 hours, an interview and concurrent facility document review was conducted with the DPCS. She was informed and acknowledged the above finding.”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness P&P included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. This failure created the potential risk of not protecting the patient’s confidential information during an emergency event. Findings: Review of the agency’s 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not address system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. On 4/23/26 at 1623 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency’s 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. On 4/23/26 at 1625 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included a communication plan that showed the contact information for tribal and regional emergency preparedness staff. This failure created the potential risk of not getting possible immediate resources for necessary care and services to the patients during emergency events. Findings: Review of the agency’s 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not include a communication plan that showed the contact information for tribal and regional emergency preparedness staff. On 4/23/26 at 1627 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included method for sharing information and medical documentation for patients under the agency’s care, as necessary, with other health providers to maintain the continuity of care. This failure created the potential risk of not maintaining continuity of care and services to the patients during emergency events. Findings: Review of the agency’s 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not address method for sharing information and medical documentation for the patients under the agency’s care, as necessary, with other health providers to maintain the continuity of care. On 4/23/26 at 1627 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness communication plan included a means of providing information about the agency’s occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This failure created the risk of not providing the necessary care and services to the patients during emergency events. Findings: Review of the agency’s 2026 emergency preparedness program documents was conducted on 4/23/26. However, the emergency preparedness communication plan did not include a means of providing information about the agency’s occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. On 4/23/26 at 1629 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences to the receiving facility to ensure the safe and effective transition of care for one of eight sampled patients (Patient 2). This failure had a potential risk of not providing continuity of necessary care and services to the patient. Review of the agency’s P&P titled Transfer Summary revised 4/2019 showed the completed transfer summaries will be given to a clinical records clerk, who will send a copy to the receiving organization, along with a copy of the clinical records, within two business days of a planned transfer or within two days of becoming an unplanned transfer and will file the original in the clinical record. Review of Patient 2’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 11/7/25. The patient was certified for home health services during the certification periods from 11/7/25 to 1/5/26 and 1/6/26 to 3/6/26. The patient was discharged on 2/24/26. Review of Patient 2’s Comprehensive Transfer Without Discharge dated 2/24/26, showed the patient was taken to the general acute care hospital due to the NP’s recommendations for acute medical decline characterized by worsening hypoxemia, productive cough with suspected aspiration pneumonia, significant dehydration with metabolic acidosis, persistent hyponatremia increasing seizure and delirium risk, acute altered mental status beyond her usual dementia baseline, tachycardia on EKG consistent with systemic illness, and severe malnutrition. The Comprehensive Transfer Without Discharge showed the plan of care was provided to the physician and to another facility. However, the facility name to which the plan of care was provided was not the same as the hospital name to where the patient was transferred. On 4/23/26 at 1614 hours, an interview and document review was conducted with the DPCS and Intake Coordinator. The DPCS was asked where Patient 2 was transferred. The DPCS stated Patient 2 was sent to the hospital. The DPCS was asked if a copy of a transfer summary was sent to the hospital. The DPCS stated the Intake Coordinator usually sent the copy. The Intake Coordinator was informed and verified she sent to another facility but not to the hospital where the patient was transferred. On 4/23/26 at 1640 hours, the DPCS and Administrator were informed and acknowledged the findings.”

“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 agency failed to ensure the SN and the CHHA missed visits were rescheduled for two of eight sampled patients (Patients 2 and 7). This failure had a potential risk to provide necessary care and services to the patients. Review of the agency’s P&P titled Missed Visits showed if a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 1. Review of Patient 2’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 11/7/25. The patient was certified for home health services during the certification periods from 11/7/25 to 1/5/26 and 1/6/26 to 3/6/26. The patient was discharged on 3/6/26. Review of the POC dated 1/7/26, showed SN visits 2W2 (two times a week for two weeks), and 1W7; and CHHA visits 2W9. Review of Patient 2’s calendar visits showed the following documentation of the missed visits: -On 1/13 and 2/3/26, the physician was informed of the CHHA missed visit and reason. However, there was no documentation of a rescheduled CHHA visit. On 4/23/26 at 0936 hours, an interview and clinical record review was conducted with the DPCS. The DPCS verified the findings. 2. Review of Patient 7’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification period from 2/27/26 to 4/27/26. Review of the POC dated 2/27/26, for the certification period from 2/27/26 to 4/27/26, showed SN visits 1W1, 3W, 2W7, and 1W1; and CHHA visits 0W1, 2W8, and 1W1. Review of Patient 7’s calendar visits showed the following documentation of the missed visits: -On 3/30/26, the physician was informed of the missed visit and reason. However, there was no documentation of the reschedule of CHHA visit. On 4/23/26 at 1022 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the missed visit should have been rescheduled.”

“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 record review and interview, the agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for one of eight sampled patients (Patient 3). This failure had the potential for not providing the necessary care and services timely to this patient. Findings: The agency’s P&P titled Initial and Comprehensive Assessment revised 4/2019 showed an initial patient assessment will be performed and documented in the patient’s clinical record by a registered nurse, physical therapist, or speech therapist on all patients referred. The initial assessment visit must be performed either within 48 hours of the referral, on the start of care date ordered by the physician (or other authorized licensed independent practitioner), or at the patient/family request with the approval of the physician (or other authorized licensed independent practitioner). A comprehensive patient assessment will be completed within five (5) calendar days of the patient’s start of care. Review of Patient 3’s clinical record was initiated on 4/17/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. The clinical record showed the referral date was 1/9/26, and the patient’s Comprehensive Start of Care was 1/14/26. However, further review of the clinical record showed no documented evidence of the reason why the SOC was 1/14/26, instead of the 48 hours of the referral date of 1/9/26. On 4/23/26 at 1318 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the finding.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient’s immediate needs, but no later than five calendar days after the SOC date for one of eight sampled patients (Patient 3). This failure created the risk of not identifying and addressing the care needs timely for this patient. Findings: Review of Patient 3’s clinical record was initiated on 4/17/26. The clinical record showed SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. The Comprehensive Start of Care Assessment dated 1/14/26, showed the patient’s primary diagnosis was other specified chronic obstructive pulmonary disease. The narrative notes showed the patient had asthma. Further review of the Comprehensive Start of Care Assessment included the section for respiratory. The assessment showed the patient was assessed to have dyspnea with ADL care. Breath sound was assessed to have wheezing on the anterior and posterior lung fields. However, there was no documented evidence the oxygen saturation level was assessed as the section was left blank. In addition, the section for home oxygen risk assessment and compliance checklist showed the sections for the flow rate setting and prescribe setting. However, those sections were left blank. On 4/23/256 at 1318 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the medication profiles were reviewed and updated to reflect the current medications and include specific indications and parameters for its use for two of eight sampled patients (Patients 3 and 4). These failures had the potential for the patients not to receive the appropriate care and necessary services and negatively affect the patients’ well-being. Findings: 2. Review of Patient 4’s clinical record was initiated on 4/20/26. The clinical record showed SOC was 2/20/26. The patient was certified for home health services during the certification periods from 2/20/26 to 4/20/26. The Medication Profile revised date 3/20/26 included fluticasone propionate/salmeterol aerosol inhaler, to inhale 1 puff by mouth three times a day. On 4/20/26 at 1333 hours, a home visit observation, interview and concurrent document review with RN 3 and medical technician for Patient 4 residing in an Assisted Living Facility. During the medication profile review, a medication, fluticasone propionate/salmeterol aerosol inhaler was not available. The medical technician was asked and informed the Patient 4 no longer used the medication. RN 3 was asked if it should have been followed up and updated in the medication profile. RN 3 acknowledged the medication profile should have been updated. 3. Review of Patient 7’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Wound Care Consult dated 2/24/26 showed for wound #1 located at sacrum, sacral region, wound #2 located at right buttock, wound #3 located at left hip and #4 located at left lateral lower leg sacral region, all with wound treatment order to cleanse with normal saline, pat dry, apply medihoney and calcium alginate then cover with border foam dressing, SN to follow up two times per week and wound care specialist one time per week. However, Patient 7’s Medication Profile was not updated not include calcium alginate. On 4/23/26 at 0932 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the findings. On 4/23/26 at 1640 hours, an interview was conducted with the DPCS and Administrator. Both were informed and acknowledged the findings. Review of the hospice’s P&P titled Medication Profile revised 4/2019 showed patients receiving the medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and or discontinued medications. 1. Review of Patient 3’s clinical record was initiated on 4/17/26. The clinical record showed SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. The Medication Profile revised date 2/18/26 showed the patient was on bisacodyl (laxative) 10 mg unwrap and insert one suppository rectally every other day as needed for constipation, ibuprofen (NSAID) 600 mg one tablet PO Q6H PRN for pain NTE 4 doses per 24H, Acetaminophen (NSAID) 325 mg one tablet POQ6H for severe pain, milk of magnesia (laxatives) 400 mg per 5 ml oral suspension take two tablespoon (30 ml) Q8H PRN for constipation and Fleet enema (laxative) 19 gm- 7gm/118ml insert one dose rectally every 24H PRN for constipation. A joint home visit with LVN 2 was conducted on 4/23/26 at 1300 hours, to the Assisted Living facility where Patient 3 resided. Review of the patients medication with the LVN 2 and the facilities medical technician was conducted. However, the above list of medications were discontinued on 3/16/26. On 4/17/26 at 1347 hours an interview and clinical record was conducted with the facility medical technician. The medical technician was asked as to the availability of the above medications. The medical technician checked the facility’s medication orders and replied, those medications were discontinued on 3/16/26. On 4/17/26 at 1402 hours, the an interview and concurrent clinical record review was conducted with the LVN 2. LVN 2 was asked as to the frequency of medication check. LVN 2 replied every visit. LVN 2 was informed and acknowledged the findings. On 4/23/26 at 1318 hours, the findings were shared with the Administrator/DPCS. The Administrator/DPCS acknowledged the findings.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessment was updated within the last five days of every 60 days for one of eight sampled patients (Patients 6). This failure had the potential for not addressing the care needs for this patient. Findings: Review of Patient 6’s clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26. The Comprehensive Recertification dated 3/9/26, showed the patient’s vital signs were checked. However, there was no documented evidence the patient’s oxygen saturation level was checked as part of the comprehensive assessment. On 4/23/26 at 1411 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the POCs included specific information related to medications, DME and blood sugar instructions for five of eight sampled patients (Patients 1, 3, 6, 7, and 8). This failure created the risk of not addressing the care needs for these patients. Findings: The agency P&P titled Care Planning Process revised 4/2019 showed the plan of care will include but not limited to all patient care orders from all physicians involved in the plan of care, specific services and treatments to be provided, equipment and supplies and all medications. 1. Review of Patient 1’s closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25 and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. Review of Wound Pros Progress Notes dated 10/2/25 showed the treatment orders for the patients’ stage 3 pressure injury to the center midline sacrococcyx. The treatment included cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte to the wound bed followed by collagen (clinician’s supply) and oil emulsion gauze. Apply foam dressing three times weekly and PRN for soiled or loose dressing and as needed for soilage /saturation. Use bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. The dressing frequency showed one time a week by the Wound Pros clinician and two times a week by the nurse and PRN. Review of the POC, for the certification period from 10/6/25 to 12/4/25, cited SN visits 2W2 (two times a week for two weeks), 1W7 (one time a week for seven weeks) to perform comprehensive observation and assessment and all the body systems. SN to assess and observe for signs and symptoms of wound infection/complication on sacral region, presence of pus, increase pain, swelling, redness, increase in wound size and fever. However, the POC did not include specific instructions to address the medications or treatment for the patients’ stage 3 pressure injury to the sacrum. On 4/23/26 at 1427 hours an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 4/17/26. The clinical record showed the SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. The POC for the certification periods from 3/15/26 to 5/13/26 on the section of DME showed cane and incontinence supplies. The medication included oxygen at 2 liters via nasal cannula as needed for SOB. On 4/17/26 at 1300 hours, an joint visit was conducted with the LVN 2 to the patients home. The patient was observed to have an oxygen via nasal cannula connected to the oxygen concentrator. However, there was no documented evidence of the oxygen concentrator was listed in the POC on the section of DME. On 4/23/256 at 1318 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the finding. 3. Review of Patient 8’s clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26. The patients principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. The POC for the certification period from 1/31/26 to 3/31/26 cited 0W1, 2W1, 1W8. The POC included SN to perform proper blood sugar checking/recording. Review of the SN visit notes dated 2/2, 2/5, 2/10, 2/20, 2/26, 3/4, 3/12 and 3/25/26 showed the SN had performed the patients blood sugar check as ordered in the POC. However, the POC failed to include specific instructions as to who will check/ monitor the patients’ blood sugar level during non - SN visit days. On 4/23/256 at 1411hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 4. Review of Patient 6’s clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26. The POC for the certification periods from 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26 cited SN 1W9. The POC included SN to instruct medication and pain management. The POC showed the list of the following pain medications. -Excedrin Extra Strength (analgesic, NSAID, CNS stimulant) APAP 250 mg/ASA 250 mg/caffeine 65 mg) two tablets PRN for pain, -Meloxicam (NSAID) 7.5 mg one tablet PO PRN for arthritis pain, -hydrocodone bitartrate (narcotic) 5 mg /acetaminophen 325 mg oral tablet one tablet PO TID PRN for pain. However, the POC failed to include specific instructions as to the level of pain when to give the PRN medications. On 4/23/26 at 1417 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if they needed to include the level of pain for the PRN pain medications. The Administrator/DPCS replied, there should be a pain level. The Administrator/DPCS was informed and acknowledged the findings. Review of Patient 7’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Wound Care Consult dated 2/24/26 showed for wound #1 located at sacrum, sacral region, wound #2 located at right buttock, wound #3 located at left hip and #4 located at left lateral lower leg sacral region, all with wound treatment order to cleanse with normal saline, pat dry, apply medihoney and calcium alginate then cover with border foam dressing, SN to follow up two times per week and wound care specialist one time per week. The wound care consult with further following recommendations: -Turn patient every two hours, keep the skin clean and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain the current level of activity, mobility, and range of motion, use positioning devices to prevent prolonged pressure bony prominences, keep the head of the bed as low as possible to reduce risk of shearing, and keep sheets dry and wrinkle free. Please remove all products with fragrance, including body washes and lotions. -To order diaper wipes without fragrance; ideally, the patient should use chemical-free, fragrance-free disposable washcloths -Aggressive offloading, recommend: Every 2 hours turning; -Frequent diaper checks and changes; -No sitting beyond 2 hours -Dietary recommendations for wound healing Review of the POC dated 2/27/26 for the certification period from 2/27/26 to 4/27/26 showed SN frequency of visits of 1wk1 (one time a week) , 3wk1 ( three time a week for one week), 2wk7 ( two times a week for seven weeks) and 1wk1 (one time a week) to continue to monitor and record vital signs, and perform skilled nursing assessment, observation and evaluation of all body systems with emphasis on integumentary, cardiovascular, gastrointestinal, endocrine and genitourinary systems. SN to assess and observe for signs and symptoms of wound infection/complication on pressure ulcer of sacral region, stage 4, presence of pus, increased pain, swelling, redness, increase in wound size and fever, to inform SN/physician immediately if observed, However, the POC did not show individualized plan of care for the all wound sites that included wound care interventions and the additional wound care consult recommendations. On 4/23/26 at 1107 hours, an interview and record review was conducted with the DPCS. The DPCS was asked to show individualized plan of care documentation on all the wound sites, treatment and recommendations as instructed by the wound care consult. The DPCS acknowledged specific individualized plan of care should have been done as instructed by the wound care consult. On 4/23/26 at 1701 hours, an interview was conducted with the Administrator and DPCS. The Administrator and DPCS acknowledged the findings. The agency’s P&P titled Care Planning Process revised 4/2019 showed the plan of care will include but not limited to all patient care orders from all physicians involved in the plan of care, specific services and treatments to be provided, equipment and supplies and all medications. 1. Review of Patient 1’s closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25 and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. Review of the Wound Pros Progress Notes dated 10/2/25, showed the treatment orders for the patient’s Stage 3 pressure injury to the center midline sacrococcyx. The treatment was to cleanse the wound with cleanser and pat dry with gauze, apply Tetracyte to the wound bed followed by collagen (clinician’s supply) and oil emulsion gauze, apply foam dressing three times weekly and PRN for soiled or loose dressing and as needed for soilage /saturation, and use a bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. The dressing frequency showed one time a week by the Wound Pros clinician and two times a week by the nurse and PRN. Review of the POC, for the certification period from 10/6/25 to 12/4/25, cited SN visits 2W2 and 1W7 to perform comprehensive observation and assessment and all the body systems. The POC also cited SN to assess and observe for signs and symptoms of wound infection/complication on sacral region, presence of pus, increase pain, swelling, redness, increase in wound size, and fever. However, the POC did not include specific instructions to address the medications or treatment for the patient’s Stage 3 pressure injury to the sacrum. On 4/23/26 at 1427 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 4/17/26. The clinical record showed the SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. The POC, for the certification periods from 3/15/26 to 5/13/26, showed cane and incontinence supplies. The medication included oxygen at 2 liters via nasal cannula as needed for SOB. On 4/17/26 at 1300 hours, an joint visit was conducted with LVN 2 to the patient’s home. The patient was observed to have an oxygen via nasal cannula connected to the oxygen concentrator. However, there was no documented evidence of the oxygen concentrator listed in the POC on the section of DME. On 4/23/256 at 1318 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the finding. 3. Review of Patient 8’s clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26. The patients principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. The POC for the certification period from 1/31/26 to 3/31/26 cited 0W1, 2W1, 1W8. The POC included SN to perform proper blood sugar checking/recording. Review of the SN visit notes dated 2/2, 2/5, 2/10, 2/20, 2/26, 3/4, 3/12 and 3/25/26 showed the SN had performed the patients blood sugar check as ordered in the POC. However, the POC failed to include specific instructions as to who will check/ monitor the patients’ blood sugar level during non - SN visit days. On 4/23/256 at 1411hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 4. Review of Patient 6’s clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26. The POC for the certification periods from 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26 cited SN 1W9. The POC included SN to instruct medication and pain management. The POC showed the list of the following pain medications. -Excedrin Extra Strength (analgesic, NSAID, CNS stimulant) APAP 250 mg/ASA 250 mg/caffeine 65 mg) two tablets PRN for pain, -Meloxicam (NSAID) 7.5 mg one tablet PO PRN for arthritis pain, -hydrocodone bitartrate (narcotic) 5 mg /acetaminophen 325 mg oral tablet one tablet PO TID PRN for pain. However, the POC failed to include specific instructions as to the level of pain when to give the PRN medications. On 4/23/26 at 1417 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if they needed to include the level of pain for the PRN pain medications. The Administrator/DPCS replied, there should be a pain level. The Administrator/DPCS was informed and acknowledged the findings. 5. Review of Patient 7’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Wound Care Consult dated 2/24/26 showed for wound #1 located at sacrum, sacral region, wound #2 located at right buttock, wound #3 located at left hip and #4 located at left lateral lower leg sacral region, all with wound treatment order to cleanse with normal saline, pat dry, apply medihoney and calcium alginate then cover with border foam dressing, SN to follow up two times per week and wound care specialist one time per week. The wound care consult with further following recommendations: -Turn patient every two hours, keep the skin clean and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain the current level of activity, mobility, and range of motion, use positioning devices to prevent prolonged pressure bony prominences, keep the head of the bed as low as possible to reduce risk of shearing, and keep sheets dry and wrinkle free. Please remove all products with fragrance, including body washes and lotions. -To order diaper wipes without fragrance; ideally, the patient should use chemical-free, fragrance-free disposable washcloths -Aggressive offloading, recommend: Every 2 hours turning; -Frequent diaper checks and changes; -No sitting beyond 2 hours -Dietary recommendations for wound healing Review of the POC dated 2/27/26 for the certification period from 2/27/26 to 4/27/26 showed SN frequency of visits of 1wk1 (one time a week) , 3wk1 ( three time a week for one week), 2wk7 ( two times a week for seven weeks) and 1wk1 (one time a week) to continue to monitor and record vital signs, and perform skilled nursing assessment, observation and evaluation of all body systems with emphasis on integumentary, cardiovascular, gastrointestinal, endocrine and genitourinary systems. SN to assess and observe for signs and symptoms of wound infection/complication on pressure ulcer of sacral region, stage 4, presence of pus, increased pain, swelling, redness, increase in wound size and fever, to inform SN/physician immediately if observed, However, the POC did not show individualized plan of care for the all wound sites that included wound care interventions and the additional wound care consult recommendations. On 4/23/26 at 1107 hours, an interview and record review was conducted with the DPCS. The DPCS was asked to show individualized plan of care documentation on all the wound sites, treatment and recommendations as instructed by the wound care consult. The DPCS acknowledged specific individualized plan of care should have been done as instructed by the wound care consult. On 4/23/26 at 1701 hours, an interview was conducted with the Administrator and DPCS. The Administrator and DPCS acknowledged the findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the treatment was provided only as ordered by the physician for three of eight sampled patients (Patients 1, 7, and 8). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: XX. Review of Patient 7’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Wound Care Consult dated 2/24/26 showed for wound #1 located at sacrum, sacral region, wound #2 located at right buttock, wound #3 located at left hip and wound #4 located at left lateral lower leg sacral region, all with wound care consult treatment order to cleanse with normal saline, pat dry, apply medihoney and calcium alginate then cover with border foam dressing, SN to follow up two times per week and wound care specialist one time per week. The wound care consult showed the following further recommendations: -Turn patient every two hours, keep the skin clean and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain the current level of activity, mobility, and range of motion, use positioning devices to prevent prolonged pressure bony prominences, keep the head of the bed as low as possible to reduce risk of shearing, and keep sheets dry and wrinkle free. Please remove all products with fragrance, including body washes and lotions. -To order diaper wipes without fragrance; ideally, the patient should use chemical-free, fragrance-free disposable washcloths -Aggressive offloading, recommend: Every 2 hours turning; -Frequent diaper checks and changes; -No sitting beyond 2 hours -Dietary recommendations for wound healing Review of Patient 7’s SOC dated 2/27/26 showed RN 1 performed wound assessments and treatment for sacral, left hip, right buttocks, right lateral foot, left leg site #1, left leg site #2, right leg, right medial knee, and right lateral knee. RN 1 cleansed all wounds with NS, applied Manuka honey and covered with non woven sponge gauze 4x4. However, RN 1’s wound treatment to all wound sites did not include application of calcium alginate, use of bordered foam dressing and recommendations as ordered from the wound care consult. On 4/23/26 at 1107 hours, an interview and record review was conducted with the DPCS. The DPCS was asked if the wound care consult treatment and recommendations dated 2/24/26 should have been followed by RN 1 during her SOC dated 2/27/26. The DPCS verified the RN should have followed the wound care consult treatment orders and recommendations. On 4/23/26 at 1640 hours, an interview was conducted with the Intake Coordinator, Administrator and DPCS. The Administrator and DPCS acknowledged the findings. 1. Review of Patient 1’s closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25 and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. Review of the Comprehensive Recertification dated 10/5/25, showed the RN 1 performed comprehensive assessment. The assessment showed RN 1 had performed wound assessment and treatment to the patients’ stage 3 pressure injury to the sacrum. The treatment showed cleansed with wound care spray, pat dry, applied with Medihoney and wet to dry dressing, wrapped with foam dressing daily and as needed if soiled. In addition, review of the Comprehensive Discharge dated 12/4/24, showed the RN 2 had performed comprehensive assessment. The assessment showed RN 2 had performed wound assessment and treatment to the patients stage 3 pressure injury to the sacrum. The treatment showed cleansed with wound care spray, pat dry, applied with Medihoney and wet to dry dressing, wrapped with foam dressing daily and as needed if soiled. However, review of the closed clinical record failed to show documented evidenced of the physicians’ order of the treatment provided for the patients’ stage 3 pressure injury to the sacrum. On 4/23/25 at 1427 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if there was order for the above treatment. The Administrator/DPCS reviewed the closed clinical record and replied no. The Administrator/DPCS was also asked if they can provide treatment without a physicians’ order. The Administrator/DPCS replied, no. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 8’s clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26. The patients principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. The POC for the certification period from 4/1/26 to 5/30/26 cited SN 1W1, 2W1 and 1W7. Review of the clinical record showed the SN had visited the patient on Weeks 1 (4/1/26 to 4/3/26) and Week 2 (4/12/26 to 4/18/26) as ordered in the POC. However, there was no documented evidenced of the SN visit was conducted on Week 3 (4/12/26 to 4/18/26) as ordered in the POC. On 4/23/256 at 1411 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if there was a visit conducted on Week 3. The Administrator /DPCS reviewed the clinical record and replied, there was a visit on 4/16/26 but there was no notes submitted. The Administrator/DPCS was also asked as to the timeline of clinical notes submission. The Administrator/DPCS replied within 24 hours from the visit date. The Administrator/DPCS as informed and acknowledged the findings.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review, the agency failed to revise and update the POC for one of eight sampled patients (Patient 1). This failure created the risk for not providing the necessary care and services to this patient. Findings: Review of Patient 1’s closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25, and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. Review of the wound care company’s progress notes dated 10/2/25, showed the treatment orders for the patients’ Stage 3 pressure injury to the center midline sacrococcyx. The treatment was to cleanse the wound with cleanser, pat dry with a gauze, apply Tetracyte to the wound bed followed by collagen (clinician’s supply) and oil emulsion gauze, apply a foam dressing three times weekly and PRN for soiled or loose dressing and as needed for soilage /saturation, and use bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. The dressing frequency showed one time a week by the wound care company’s clinician and two times a week by the nurse and PRN. Review of the POC, for the certification period from 10/6/25 to 12/4/25, cited SN visits 2W2 and 1W7 to perform comprehensive observation and assessment and all the body systems. However, the POC was not revised to address the changes of the SN visit frequency for wound care. On 4/23/25 at 1427 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.”

“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 interview and record review, the agency failed to ensure the wound care, PT, and OT services were coordinated for five of eight sampled patients (Patients 1, 3, 6, 7, and 8). This failure created the risk of not providing the necessary care and services to these patients. Findings: The agency’s P&P titled Care Coordination revised 4/2019 showed to ensure coordination of services for each patients. Each patient will be assigned a Case Manager upon admission by the Clinical Director or Clinical Supervisor. Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group, will be appropriate to the needs and abilities of the patient, and will be relevant to the care provided. Written evidence of care coordination will be recorded during the case conference and repeated in skilled nursing visit reports in the patient’s clinical records. 1. Review of Patient 1’s closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25 and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. The POC for the certification periods from 10/5/25 and 10/6/25 to 12/4/25 cited SN 2W2 (two times a week for two weeks) 1W7 (one time a week for seven weeks) for skilled nursing assessment, observation and evaluation of all body system. Review of the closed clinical record from Week 3 (10/19/25 to 10/25/25) to Week 8 (11/23/25 to 11/29/25) showed the SN visit frequency was one time a week. Review of Wound Pros Progress Notes dated 10/14, 10/23, 10/30, 11/6, 11/13, 11/20, 11/25 and 12/2/25 showed the treatment orders for the patients’ stage 3 pressure injury to the center midline sacrococcyx. The treatment included cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte to the wound bed followed by collagen (clinician’s supply) and oil emulsion gauze. Apply foam dressing three times weekly and PRN for soiled or loose dressing and as needed for soilage /saturation. Use bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. The dressing frequency showed one time a week by the Wound Pros clinician and two times a week by the nurse and PRN. However, there was no documented evidence of the changes in the visit frequency to two times a week was coordinated as ordered by the Wound Care NP. On 4/23/25 at 1427 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS replied, no. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 4/17/26. The clinical record showed SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. a. The Comprehensive Recertification dated 3/14/26 on the section of referrals showed a check mark for PT. However, there was no documented evidence of the RN had coordinated the referral for PT as identified on the comprehensive recertification assessment. b. Review of the Physical Therapy Clinical Notes dated 1/30/26 on the narrative showed patient was discharge from skilled therapy services. However, there was no documented evidence of the physician was notified of the PT discharge as the section for care coordination for MD was left blank. On 4/23/256 at 1318 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the findings. 3. Review of Patient 8’s clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26. The Comprehensive Recertification dated 1/30/26 on the section of referrals showed a check mark for PT and OT. However, there was no documented evidence of the RN had coordinated the referral for PT and OT as identified on the comprehensive recertification assessment. On 4/23/256 at 1411hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 4. Review of Patient 6’s clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26. The Comprehensive Recertification dated 3/9/26 on the section of referrals showed a check mark for PT. However, there was no documented evidence of the RN had coordinated the referral for PT as identified on the comprehensive recertification assessment. On 4/23/26 at 1417 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. XX. Review of Patient 7’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Wound Care Consult dated 2/24/26 showed for wound #1 located at sacrum, sacral region, wound #2 located at right buttock, wound #3 located at left hip and #4 located at left lateral lower leg sacral region, all with wound treatment order to cleanse with normal saline, pat dry, apply medihoney and calcium alginate then cover with border foam dressing, SN to follow up two times per week and wound care specialist one time per week. The wound care consult with further following recommendations: -Turn patient every two hours, keep the skin clean and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain the current level of activity, mobility, and range of motion, use positioning devices to prevent prolonged pressure bony prominences, keep the head of the bed as low as possible to reduce risk of shearing, and keep sheets dry and wrinkle free. Please remove all products with fragrance, including body washes and lotions. -To order diaper wipes without fragrance; ideally, the patient should use chemical-free, fragrance-free disposable washcloths -Aggressive offloading, recommend: Every 2 hours turning, -Frequent diaper checks and changes, -No sitting beyond 2 hours, -Dietary recommendations for wound healing. Review of the POC dated 2/27/26 for the certification period from 2/27/26 to 4/27/26 showed SN frequency of visits of 1wk1 (one time a week) , 3wk1 ( three time a week for one week), 2wk7 ( two times a week for seven weeks) and 1wk1 (one time a week) to continue to monitor and record vital signs, and perform skilled nursing assessment, observation and evaluation of all body systems with emphasis on integumentary, cardiovascular, gastrointestinal, endocrine and genitourinary systems. SN to assess and observe for signs and symptoms of wound infection/complication on pressure ulcer of sacral region, stage 4, presence of pus, increased pain, swelling, redness, increase in wound size and fever, to inform SN/physician immediately if observed, However, the POC did not show documented evidence of the wound care consult treatment orders, recommendations and visit frequency were included. Review of Patient 7’s miscellaneous notes dated 3/20/26 NP’s notes showed remove as per communication with NP regarding report that catheter was removed due to no urine output, minor bleeding during removal, with NP recommendation to follow up urinalysis result, are there any signs and symptoms of infection?. However, there was no documentation for clarifications on following up with with NP regarding her recommendation and as to FC removal as change of condition or to discontinue. On 4/23/26 at 1107 hours, an interview and record review was conducted with the DPCS. The DPCS was informed and verified the above findings. On 4/23/26 at 1640 hours, an interview was conducted with the Administrator and DPCS. The Administrator and DPCS acknowledged the findings.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide a written instruction outlining the visit schedule for one of eight sampled patients (Patient 3). This failure had the potential for not providing the necessary information to this patient. Findings: Review of Patient 3’s clinical record was initiated on 4/17/26. The clinical record showed SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. The POC, for the certification period from 3/15/26 to 5/13/26, cited SN visits 2W2 and 1W7 for assessment, observation, and evaluation of all body systems. A joint home visit with LVN 2 was conducted on 4/17/26 at 1300 hours, to Patient 3’s home. Review of the patient’s home folder was conducted with LVN 2. The home folder showed the visit schedule showing SN for the month of January 2026. However, there was no documented evidence of the updated written instructions outlining the SN visit schedules after January 2026. On 4/17/26 at 1402 hours, an interview and concurrent document review was conducted with LVN 2. LVN 2 was asked if a visit schedule was available in the home folder. LVN 2 stated no. On 4/23/256 at 1318 hours, the finding was shared with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide care and services as per the written plan of care for two of eight sampled patients (Patients 1 and 7). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 1’s closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25 and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. The POC, for the certification period from 10/6/25 to 12/4/25 included a diagnosis of hypertensive heart disease. The POC cited SN visits 1W9 for SN to perform skilled nursing assessment, observation and evaluation of all the body systems. SN to weight patient once a week and report to MD if weight gain greater than 5 lbs. in one week, swelling and plus 3 edema or greater. Review of the SN notes dated 10/8, 10/11, 10/14, 10/17, 10/24, 10/31, 11/6, 11/12, 11/21, 11/24 and 12/1/25 showed the SN had performed the body system assessment. However, there was no documented evidence the SN had performed genitourinary assessment as the section was left blank. In addition, there was no documented evidence of the SN had weight the patient weekly as the section was left blank. On 4/23/25 at 1427 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 7’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Patient 7’s Face to Face Encounter dated 2/14/26 showed medical necessary services for Skilled Nursing, Wound Care, Home Health Aide, Cardiac, Care, Diabetic Care and for other services needed as foley catheter care and change. Review of SOC dated 2/27/26 showed RN performed Urinary Catheter Assessment. The Urinary Catheter Assessment showed Patient 7 was with French 16 indwelling catheter inflated with 10 ml balloon. Review of SN notes showed the following: -dated 3/26/26, 4/2/26 with no genitourinary assessment On 4/23/26 at 1107 hours, an interview and record review was conducted with the DPCS. The DPCS was informed and verified the above findings. On 4/23/26 at 1640 hours, an interview was conducted with the Intake Coordinator, Administrator and DPCS. All acknowledged the findings.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the instructions or teachings on wound care as advised by wound care consults were provided to patients/caregiver for one of eight sampled patients (Patient 7). This failure posed a potential for the caregiver not knowing how to care for this patient. Review of Patient 7’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification period from 2/27/26 to 4/27/26. Review of Patient 7’s Wound Care Consult dated 2/24, 3/3, 3/10, 3/17, 3/24, 3/31, and 4/7/26, showed the following: -Additional Recommendations: Turn patient every two hours, keep the skin clean and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain the current level of activity, mobility, and range of motion, use of positioning devices to prevent prolonged pressure bony prominences, keep the head of the bed as low as possible to reduce risk of shearing, and keep sheets dry and wrinkle free. To remove all products with fragrance, including body washes and lotions. Family and patients were instructed to order diaper wipes without fragrance; ideally, the patient should use chemical-free, fragrance-free disposable washcloths -Aggressive offloading and recommend: every 2 hours turning, frequent diaper checks and changes, no sitting beyond 2 hours, and refer to the PCP recommendations for dietary recommendations for wound healing. However. the SN visit notes dated 3/5, 3/7, 3/12, 3/19, 3/24, 3/26, 3/28, 4/2, 4/4, and 4/9/26, did not show the patient/caregiver were provided education regarding the wound care consult’s recommendations. On 4/23/26 at 1112 hours, an interview and document review was conducted with the DPCS. The DPCS was asked if she could show any documentation from the SN visits regarding education was provided to the patient/family/caregiver on the additional recommendations advised by wound care consult. The DPCS verified all recommendations should have been included as teaching or reminders to the patient/family/caregiver.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s skilled professionals prepared accurate clinical notes for four of eight sampled patients (Patients 1, 3, 7, and 8). This failure created the increased risk of substandard healthcare outcomes to these patients. Findings: 4. Review of Patient 7’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Patient 7’s Face to Face Encounter dated 2/14/26 showed medical necessary services for Skilled Nursing, Wound Care, Home Health Aide, Cardiac, Care, Diabetic Care and for other services needed as foley catheter care and change. Review of SOC dated 2/27/26 showed RN performed Urinary Catheter Assessment. The Urinary Catheter Assessment showed Patient 7 was with French 16 indwelling catheter inflated with 10 ml balloon. Review of SN notes showed the following: -dated 2/28, 3/5/26 genitourinary assessment showed Patient 7 was with 16 French catheter, incontinent with yellow urine output. However, there was no documentation of when the foley catheter was last changed. -dated 3/10/26 genitourinary assessment showed Patient 7 was with foley catheter, with no odor, clear, yellow urine output. However, there was no documentation on French size and date last changed. On 4/23/26 at 1107 hours, an interview and record review was conducted with the DPCS. The DPCS was informed and verified the above findings. On 4/23/26 at 1640 hours, an interview was conducted with the Intake Coordinator, Administrator and DPCS. The Administrator and DPCS acknowledged the findings. 1. Review of Patient 1’s closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25 and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. Review of the POC, for the certification period from 10/6/25 to 12/4/25, cited SN visits 2W2, 1W7 (two times a week for two weeks) to perform comprehensive observation and assessment and all the body systems. SN to assess and observe for signs and symptoms of wound infection/complication on Sacral region, presence of pus, increase pain, swelling, redness, increase in wound size and fever. a. Review of the Wound Pros Progress Report dated10/14/25 showed the following measurement: Length = 1, Width = 1, and Depth = 0.3. Review of the SN visit Notes dated 10/14/25 showed the SN had performed wound assessment to the patients stage 3 pressure injury to the sacrum. The measurement in centimeters showed the following: Length = 2 , Width = 2, and Depth = 0.3. However, the length and width was inconsistent. *Review of the Wound Pros Progress Report dated11/6/25 showed the following measurement: Length = 0.6, Width = 0.4, and Depth = 0.3. Review of the SN visit Notes dated 11/6/25 showed the SN had performed wound assessment to the patients stage 3 pressure injury to the sacrum. The measurement in centimeters showed the following: Length = 2 , Width = 2, and Depth = 0.3. However, the length and width was inconsistent. b. Review of the SN visit Notes dated 10/8, 10/11, 10/14, 10/17,10/24, 10/31, 11/5, 11/12, 11/21, 11/24 and 12/1/25 showed the SN had performed wound assessment to the patients’ stage 3 pressure injury to the sacrum. The section for comment showed a check marked on other “see tx order”. However, there was no documented evidence as to what the treatment order was. On 4/23/26 at 1427 hours an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked as to what the treatment order was. The Administrator/DPCS reviewed the clinical record and replied, it was from Wound Pros, it was not documented on the SN visit notes. The Administrator/DPCS was also asked if the wound measurement were accurate in relation to the wound pros assessment. The Administrator/DPCS replied no, it was inconsistent. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 4/17/26. The clinical record showed SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. a. Review of the Comprehensive Recertification dated 3/14/26 on the section of respiratory showed the patient was assessed to have dyspnea with ADL’s. Breath sound was assessed to have wheezing on the anterior and posterior lung fields. However, there was no documented evidenced of oxygen saturation was assessed as the section was left blank. In addition, on the section of home oxygen risk assessment and compliance checklist showed a section for the documentation of the flow rate setting and prescribe setting. However, those sections were left blank. On 4/23/256 at 1318 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the findings. b. The POC for the certification period from 1/14/26 to 3/14/26 cited SN 1w1, 2W1 and 1W7 to monitor and record vital signs, perform nursing assessment, observation and evaluation of all body systems. Review of the SN visit notes dated 1/20, 1/23, 1/29, 2/5, 2/13, 2/17, 2/23 and 3/4/26 showed the SN had performed vital signs and body system assessment. The vital signs included the oxygen saturation. However, on the section for the continuous, intermittent and PRN use of oxygen was left blank. Review of the SN visit notes dated 1/20, 2/5/26 showed the SN had performed vital signs and body system assessment. The vital signs included the oxygen saturation. On the section of respiratory showed the patients breath sound was assessed to have wheeze and with SOB on exertion, oxygen saturation was checked. However, on the section for the continuous, intermittent and PRN use of oxygen was left blank. Further review of the SN visit notes dated 1/23, 1/29,2/13, 2/17, 2/23 and 3/4/26 showed the patient was assessed to have clear breath sounds, with SOB on exertion. However, on the section for the continuous, intermittent and PRN use of oxygen was left blank. On 4/23/256 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the findings. 3. Review of Patient 8’s clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26. The patients principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. The POC for the certification period from 4/1/26 to 5/30/26 cited SN 1W1, 2W1, 1 W2. The POC included SN to perform proper blood sugar checking/recording. Review of the SN visit notes dated 4/2, 4/6, 4/11/26 showed documented evidenced of the patients’ blood sugar level. However, the section where to indicate a check mark if it was done by SN and or done by patient/PCG was left blank. On 4/23/26 at 1411 hours, an interview and concurrent clinical record review was conducted with the Administrator/ DPCS. The Administrator/DPCS was informed and acknowledged the findings.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the HHA’s RN provided supervision to the LVN to ensure quality of care and services were provided for two of eight sampled patients (Patients 1 and 6). This failure had the potential for substandard health outcomes to these patients. Findings: The agency’s P&P titled Supervisory Visits (LVN) undated showed all LVNs must be supervised by a Registered Nurse (RN) in accordance with CMS regulations to ensure safe and effective patient care. The procedure includes RN responsibilities to review LVN documentation, provide clinical oversight and adherence to the plan of care. The RN must still perform supervisory visit every 30 days. 1. Review of Patient 1’s closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25, and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. The POC, for the certification period from 10/6/25 to 12/4/25, cited SN visits 2W2 and 1W7. Review of the clinical record for Patient 1 showed the LVN did not provide services in accordance with the POC for this patient. Cross reference to G710, example #1. Review of the Supervisory Visit dated 11/6/25, showed the Administrator/DPCS had conducted a supervisory visit for LVN 2. However, the Administrator/DPCS failed to identify LVN 2 did not provide services in accordance with the POC. On 4/23/25 at 1427 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 6’s clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26. The POC, for the certification periods from 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26, showed the supervisory visit was conducted for LVN 5 on 2/4, 2/24, and 4/7/26. However, there was no documented evidence the RN had conducted a supervisory visit for LVN 5 for the month of March as per the agency’s P&P. On 4/23/25 at 1417 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency’s RN provided the onsite supervision for the CHHA no less frequently than every 14 days to ensure quality of care and services provided for one of eight sampled patients (Patient 1). This failure had the potential for substandard health outcomes to this patient. Findings: The agency’s P&P titled Supervisory Visits undated showed to ensure quality of care and compliance with supervision requirements for Certified Home Health Aides (CHHAs). All CHHA s must be supervised by a Registered Nurse (RN) in accordance with CMS regulations to ensure safe and effective patient care. RN must performed supervisory visits at least every14 days ( while aide services are provided). Review of Patient 1’s closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25, and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. The POC, for the certification period from 10/6/25 to 12/4/25, cited CHHA/CNA visits 2W9. The CHHA notes showed the CHHA visits were conducted during Week 1 (10/6/25 to 10/11/25), Week 3 (10/19/25 to 10/25/25) and Week 7 (11/16/25 to 11/22725). However, review of the Supervisory Visit showed the Administrator/DPCS performed the supervisory visit on 11/6/25, during Week 5 for CHHA 1. There was no documented evidence the RN completed a supervisory visit to conduct the assessment of CHHA services provided no less frequently than every 14 days during the above time period. On 4/23/25 at 1427 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked about the frequency for the CHHA supervisory visit. The Administrator/DPCS replied every 14 days. The Administrator/DPCS was informed and acknowledged the findings.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on interview and document review, the agency’s Administrator failed to be responsible for the day-to-day operations related to the following: -The written agreements with Contractors 1, 2, 3, 4, 5, and 6 did not include the roles, rights and responsibilities. -The PT/OT evaluation was not conducted timely for five of eight sampled patients (Patients 2, 4, 5, 6, and 8) as per the agency’s P&P. -The SN visit notes were not submitted/completed timely for one of eight sampled patients (Patient 8) as per the agency’s P&P. -The personnel P&Ps were not followed. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: Review of the HHA’s Administrator Job Description Summary revised 4/2019 showed Administrator is responsible for planning, coordinating, managing, and directing all activities and programs of the HHA. The essential job functions/ responsibilities included the following: -planning, and directing operations to ensure the provision of adequate and appropriate care and services. -recruiting, employing and retaining qualified personnel to maintain appropriate staffing levels. -ensuring ongoing oversight of the agency’s quality management system. -evaluating services and programs. -ensuring personnel development including orientation, in service education and continuing education. -ensuring that appropriate service policies are developed and implemented. -directing personnel in performance of their duties including admission, discharge and provision of service to patients. Review of agency’s P&P titled Start of Care Referral (undated) showed scope that applies to Intake/Referral Coordinators, Registered Nurses, Clinical Supervisors and Therapy Staff as Physical Therapy/ Occupational Therapy/ Speech Therapy. SOC (Start of care must be initiated within 48 hours of referral. Review of agency’s P&P titled Physical Therapy Evaluation (undated) showed scheduling of evaluation included PT (Physical Therapy) evaluation must be completed within 48 hours of referral or as ordered by the physician or based on patient needs, coordinate visit with patient/caregiver. Review of the agency’s P&P titled Initial and Comprehensive Assessment revised 4/2019 showed an initial patient assessment will be performed and documented in the patient’s clinical record by a registered nurse, physical therapist, or speech therapist on all patients referred. The initial assessment visit must be performed either with 48 hours of the referral, within 48 hours of the patient’s return home, on the start of care date ordered by the physician (or other authorized license independent practitioner), or at the patient/family request with the approval of the physician( or other authorized licensed independent practitioner). 1.Review of Patient 2’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 11/7/25. The patient was certified for home health service during the certification periods from 11/7/25 to 1/5/26 and 1/6/26 to 3/6/26. Patient 2 was discharged on 3/6/26. Review of Patient 2’s POC dated 1/14/26 showed Skilled Nursing Frequency Visit and duration of 2wk2 (two times a week for two weeks), 1wk7 ( one time a week for seven weeks), CHHA Certified Home Health Aide Visit Frequency and duration was 2wk9 (two times a week for nine weeks), Physical Therapy evaluation and treatment. Review of Patient 2’s Recertification Order dated 1/5/26 showed Patient 2 was for Physical Therapy evaluation and treatment. Review of Patient 2’s Physical Therapy Evaluation and Plan of Care dated 11/11/25 showed PT 3 assessed for functional status as bed mobility, gait, ADL ( activities of daily living), stretch and range of motion, posture, endurance, palpitation, sitting balance, standing balance plan of care, frequency an duration of treatment. However, PT 3’s date of visit was more than 48 hours from the SOC and showed no documentation explaining the reason PT evaluation was not conducted within 48 hours of referral. On 4/23/26 at 0945H hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the above findings. 2. Review of Patient 4’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/20/26 The patient was certified for home health service during the certification periods from 2/20/26 to 3/21/26 and 3/22/26- 4/20/26. Review of Patient 4’s POC dated 2/27/26 showed Patient 4 was for Physical Therapy evaluation and treatment. Review of Patient 4’s SOC dated 2/20/26 showed Patient 4 was for Physical Therapy Evaluation and Treatment. Review of Patient 4’s Physical Therapy Evaluation and POC showed PT 1 conducted assessments for functional status, balance, range of motion exercises, strength, frequency and treatment. However, PT 1’s date of visit was more than 48 hours from the SOC and showed no documentation explaining the reason PT evaluation was not conducted within 48 hours of referral. On 4/23/26 at 1054 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the above findings. 3. Review of Patient 5’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 3/28/26. The patient was certified for home health services during the certification periods from 3/28/26 to 5/26/26. Review of Patient 5’s POC dated 3/29/26 showed physician’s orders for discipline and treatments that included Skilled Nursing visit and Physical Therapy evaluation and treatment. Review of Patient 5’s SOC dated 3/28/26 showed a physician admission orders for Physical Therapy evaluation and treatment. Review of Patient 5’s Physical Therapy evaluation and POC dated 3/31/26 showed Patient 5 was visited by PT 1. PT 1 assessed Patient 5’s functional status as bed mobility, gait,range of motion, sitting balance, standing balance, frequency and treatment. However, PT 1’s date of visit was more than 48 hours from the SOC and showed no documentation explaining the reason PT evaluation was not conducted within 48 hours of referral. On 4/23/26 at 1132 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the above findings. The agency P&P titled Appointment of Executive Director/Administrator revised 4/2019 showed the Executive Director/Administrator will be responsible for the day - to-day operations of the organization. Title 22 Section 74719 (Services Arranged by Agreement), showed the following: (b) The agreement shall include at least the following: (1) The nature and scope of the services to be provided; (2) The rights and responsibilities of the agency or individual providing services and of the contracting agency in the coordination, supervision, and evaluation of the care or services provided; (3) The role, if any, of the agency and the contracted individual or agency in: (A) The patient admission process, (B) Patient assessment, (C) The development, review, and revision of the plan of treatment or plan of care, (D) Patient care conferences, (E) The scheduling of visits or hours, (F) Discharge planning; (4) The submission to the agency of documentation of services provided; (5) The responsibility of the contracted individual or agency to adhere to applicable agency policies, including personnel qualifications; (6) The procedures for determining charges and reimbursement; and (7) The term of the agreement and the conditions for its renewal or termination. (c) Agreements shall be reviewed and revised as necessary. 1a. Review of the written agreements between the agency and Contractor 1 was initiated on 4/23/26. The written agreement showed for wound care services. However, the written agreements with Contractor 1 did not include the rights and responsibilities of the program and the contracted providers in the coordination, supervision and evaluation of care and services provided. In addition, the written agreement failed to include the role of the agency and contractor in patient admission process, patient assessment, development, review and revision of the POT or POC, patient care conferences and discharge planning. Moreover, the written agreement failed to include the responsibility of the contractor to applicable agency policies, procedures for determining charges and reimbursement and term of agreement and conditions for its renewal. Furthermore, the written agreement failed to include the agreements shall be reviewed and revised as necessary. b. Review of the written agreements between the agency and Contractor 2 was initiated on 4/23/26. The written agreement showed for PT,OT and ST services. However, the written agreements with Contractor 2 did not include the rights and responsibilities of the program and the contracted providers in the coordination, supervision and evaluation of care and services provided. c. Review of the written agreements between the agency and Contractor 3 was initiated on 4/23/26. The written agreement showed for DME services. However, the written agreements with Contractor 3 did not include the rights and responsibilities of the program and the contracted providers in the coordination, supervision and evaluation of care and services provided. In addition, the written agreement failed to include the agreements shall be reviewed and revised as necessary. Further review of the written agreement showed the written agreement was signed on 4/7/23. However, the service agreement was entered on 12/30/25 which was inconsistent. d. Review of the written agreements between the agency and Contractor 4 was initiated on 4/23/26. The written agreement showed for DME services. The written agreement was effective on 1/8/26. However, on the section of term, showed the agreement shall be effective as of October 18, 2022 which inconsistent. In addition, the written agreements with Contractor 4 did not include the rights and responsibilities of the program and the contracted providers in the coordination, supervision and evaluation of care and services provided. Moreover, the written agreement failed to include the responsibility of the contractor for the procedures for determining charges and reimbursement and term of agreement and conditions for its renewal. Further, the written agreement failed to include the agreements shall be reviewed and revised as necessary. e. Review of the written agreements between the agency and Contractor 5 was initiated on 4/23/26. The written agreement showed for PT, OT and ST services. However, the written agreements with Contractor 5 did not include the rights and responsibilities of the program and the contracted providers in the coordination and supervision of care and services provided. In addition, the written agreement failed to include the role of the agency and contractor in patient admission process, patient assessment and discharge planning. On 4/23/26 at 1000 hours, an interview and concurrent document review was conducted with the President. The President was informed and acknowledged the findings. 2. The agency P&P titled Submission of SN/HHA/PT Notes and Documentation undated showed all Skilled Nursing (SN), Home Health Aide (HHA), and Physical Therapy (PT) staff must complete and submit clinical documentation in a timely, accurate, and compliant manner in accordance with Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) and agency standards. All visit notes must be completed on the same day of service whenever possible. Documentation must be submitted no later than 24 hours after the visit. Review of Patient 8’s clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26. The patients principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. a. The POC for the certification period from 4/1/26 to 5/30/26 showed an order for PT evaluation and treatment. Review of the Physical Therapy Clinical Notes showed the PT had a visit on 4/9/26 which was more than 48 hours as ordered in the POC. b. The POC for the certification period from 4/1/26 to 5/30/26 cited SN 1W1, 2W1 and 1W7. Review of the clinical record showed the SN had visited the patient on Weeks 1 (4/1/26 to 4/3/26) and Week 2 (4/12/26 to 4/18/26) as ordered in the POC. However, there was no documented evidenced of the SN visit was conducted on Week 3 (4/12/26 to 4/18/26) as ordered in the POC. On 4/23/256 at 1411 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked as to the timeline for the PT to performed the evaluation. The Administrator/DPCS replied within 48 hours from the physicians order. The Administrator/ DPCS was also asked if there was a missed visit on Week 3. The Administrator/DPCS reviewed the clinical record and replied, there was a visit on 4/16 but the notes were not submitted. The Administrator/DPCS was informed and acknowledged the findings. 3. Review of Patient 6’s clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26. The POC for the certification period from 1/9/26 to 3/9/26 showed an order for PT evaluation. Review of the clinical record showed the PT 2 performed the evaluation on 1/27/26 which was more than 48 hours from the POC. Further review of the POC for the certification period from 1/9/26 to 3/9/26 showed an order for OT evaluation. Review of the clinical record showed the OT 1 performed the initial evaluation on 2/6/26 which was more than 48 hours from the POC. On 4/23/256 at 1448 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. Review of the HHA’s Administrator Job Description Summary revised 4/2019 showed the Administrator is responsible for planning, coordinating, managing, and directing all activities and programs of the HHA. The essential job functions/ responsibilities included the following: -planning, and directing operations to ensure the provision of adequate and appropriate care and services. -recruiting, employing and retaining qualified personnel to maintain appropriate staffing levels. -ensuring ongoing oversight of the agency’s quality management system. -evaluating services and programs. -ensuring personnel development including orientation, in service education and continuing education. -ensuring that appropriate service policies are developed and implemented. -directing personnel in performance of their duties including admission, discharge and provision of service to patients. 1.Title 22 Section 74719 (Services Arranged by Agreement), showed the following: (b) The agreement shall include at least the following: (1) The nature and scope of the services to be provided; (2) The rights and responsibilities of the agency or individual providing services and of the contracting agency in the coordination, supervision, and evaluation of the care or services provided; (3) The role, if any, of the agency and the contracted individual or agency in: (A) The patient admission process, (B) Patient assessment, (C) The development, review, and revision of the plan of treatment or plan of care, (D) Patient care conferences, (E) The scheduling of visits or hours, (F) Discharge planning; (4) The submission to the agency of documentation of services provided; (5) The responsibility of the contracted individual or agency to adhere to applicable agency policies, including personnel qualifications; (6) The procedures for determining charges and reimbursement; and (7) The term of the agreement and the conditions for its renewal or termination. (c) Agreements shall be reviewed and revised as necessary. a. Review of the written agreements between the agency and Contractor 1 was initiated on 4/23/26. The written agreement was for wound care services. However, the written agreement with Contractor 1 did not include the rights and responsibilities of the agency and contracted provider in the coordination, supervision and evaluation of care and services provided. In addition, the written agreement failed to include the role of the agency and contractor in the patient admission process, patient assessment, development, review and revision of the POT or POC, patient care conferences, and discharge planning. The written agreement failed to include the responsibility of the contractor to applicable agency policies, procedures for determining charges and reimbursement and term of agreement and conditions for its renewal. Furthermore, the written agreement failed to include the agreements shall be reviewed and revised as necessary. b. Review of the written agreements between the agency and Contractor 2 was initiated on 4/23/26. The written agreement was for PT,OT and ST services. However, the written agreement with Contractor 2 did not include the rights and responsibilities of the agency and contracted provider in the coordination, supervision and evaluation of care and services provided. c. Review of the written agreement between the agency and Contractor 3 was initiated on 4/23/26. The written agreement was for DME services. However, the written agreement with Contractor 3 did not include the rights and responsibilities of the program and the contracted providers in the coordination, supervision and evaluation of care and services provided. In addition, the written agreement failed to include the agreements shall be reviewed and revised as necessary. Further review of the written agreement showed the written agreement was signed on 4/7/23. However, the service agreement was entered on 12/30/25 which was inconsistent. d. Review of the written agreement between the agency and Contractor 4 was initiated on 4/23/26. The written agreement was for DME services. The written agreement was effective on 1/8/26. However, the section for term showed the agreement shall be effective as of October 18, 2022, which inconsistent. In addition, the written agreement with Contractor 4 did not include the rights and responsibilities of the program and the contracted providers in the coordination, supervision and evaluation of care and services provided. The written agreement did not include the responsibility of the contractor for the procedures for determining charges and reimbursement and term of agreement and conditions for its renewal. The written agreement failed to include the agreements shall be reviewed and revised as necessary. e. Review of the written agreements between the agency and Contractor 5 was initiated on 4/23/26. The written agreement was for PT, OT and ST services. However, the written agreements with Contractor 5 did not include the rights and responsibilities of the program and the contracted providers in the coordination and supervision of care and services provided. In addition, the written agreement failed to include the role of the agency and contractor in patient admission process, patient assessment and discharge planning. On 4/23/26 at 1000 hours, an interview and concurrent document review was conducted with the President. The President was informed and acknowledged the findings. 2. The agency’s P&P titled Submission of SN/HHA/PT Notes and Documentation undated showed all Skilled Nursing (SN), Home Health Aide (HHA), and Physical Therapy (PT) staff must complete and submit clinical documentation in a timely, accurate, and compliant manner in accordance with Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) and agency standards. All visit notes must be completed on the same day of service whenever possible. Documentation must be submitted no later than 24 hours after the visit. Review of Patient 8’s clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26, and 4/1/26 to 5/30/26. The patient’s principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. The POC, for the certification period from 4/1/26 to 5/30/26, cited SN 1W1, 2W1, and 1W7. Review of the clinical record showed the SN had visited the patient during Week 1 (4/1/26 to 4/3/26) and Week 2 (4/12/26 to 4/18/26) as ordered in the POC. However, there was no documented evidenced of the SN visit was conducted during Week 3 (4/12/26 to 4/18/26). On 4/23/26 at 1411 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/ DPCS was asked if there was a missed SN visit during Week 3. The Administrator/DPCS reviewed the clinical record and stated there was a visit on 4/16 but the notes was not submitted. The Administrator/DPCS was informed and acknowledged the findings. 3. Review of the agency’s P&P titled Start of Care Referral (undated) showed scope that applies to Intake/Referral Coordinators, Registered Nurses, Clinical Supervisors and Therapy Staff as Physical Therapy/Occupational Therapy/ Speech Therapy. Start of care must be initiated within 48 hours of referral. Review of the agency’s P&P titled Physical Therapy Evaluation (undated) showed scheduling of evaluation included PT (Physical Therapy) evaluation must be completed within 48 hours of referral or as ordered by the physician or based on patient needs, coordinate visit with the patient/caregiver. Review of the agency’s P&P titled Initial and Comprehensive Assessment revised 4/2019 showed an initial patient assessment will be performed and documented in the patient’s clinical record by a registered nurse, physical therapist, or speech therapist on all patients referred. The initial assessment visit must be performed either with 48 hours of the referral, within 48 hours of the patient’s return home, on the start of care date ordered by the physician (or other authorized license independent practitioner), or at the patient/family request with the approval of the physician( or other authorized licensed independent practitioner). a.Review of Patient 2’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 11/7/25. The patient was certified for home health service during the certification periods from 11/7/25 to 1/5/26 and 1/6/26 to 3/6/26. Patient 2 was discharged on 3/6/26. Review of Patient 2’s POC dated 1/14/26 showed SN visits 2W2 and 1wk7, CHHA visit 2W9, and PT evaluation and treatment. Review of Patient 2’s Recertification Order dated 1/5/26, showed Patient 2 was to receive PT evaluation and treatment. Review of Patient 2’s Physical Therapy Evaluation and Plan of Care dated 11/11/25, showed PT 3 assessed for functional status as bed mobility, gait, ADL, stretch and range of motion, posture, endurance, palpitation, sitting balance, standing balance plan of care, frequency an duration of treatment. However, PT 3’s date of visit was more than 48 hours from the SOC. There was no documentation explaining the reason PT evaluation was not conducted within 48 hours of the order date. On 4/23/26 at 0945 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the above findings. b. Review of Patient 4’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/20/26 The patient was certified for home health service during the certification periods from 2/20/26 to 3/21/26 and 3/22/26- 4/20/26. Review of Patient 4’s POC dated 2/27/26 showed Patient 4 was to receive PT evaluation and treatment. Review of Patient 4’s SOC dated 2/20/26 showed Patient 4 was to receive PT evaluation and treatment. Review of Patient 4’s Physical Therapy Evaluation and POC showed PT 1 conducted the assessments for functional status, balance, range of motion exercises, strength, frequency and treatment. However, PT 1’s date of visit was more than 48 hours from the SOC and there was no documentation explaining the reason PT evaluation was not conducted within 48 hours of the order date. On 4/23/26 at 1054 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the above findings. c. Review of Patient 5’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 3/28/26. The patient was certified for home health services during the certification periods from 3/28/26 to 5/26/26. Review of Patient 5’s POC dated 3/29/26, showed the physician’s orders for discipline and treatments that included Skilled Nursing visit and Physical Therapy evaluation and treatment. Review of Patient 5’s SOC dated 3/28/26, showed the physician admission orders for Physical Therapy evaluation and treatment. Review of Patient 5’s Physical Therapy evaluation and POC dated 3/31/26, showed Patient 5 was visited by PT 1. PT 1 assessed Patient 5’s functional status as bed mobility, gait, range of motion, sitting balance, standing balance, frequency and treatment. However, PT 1’s date of visit was more than 48 hours from the SOC and there was no documentation explaining the reason PT evaluation was not conducted within 48 hours of the order date. On 4/23/26 at 1132 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the above findings. d. Review of Patient 8’s clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26, and 4/1/26 to 5/30/26. The patient’s principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. The POC, for the certification period from 4/1/26 to 5/30/26, showed an order for PT evaluation and treatment. Review of the Physical Therapy Clinical Notes showed the PT had a visit on 4/9/26, more than 48 hours from when it was ordered. On 4/23/26 at 1411 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked regarding the timeline for the PT to perform the evaluation. The Administrator/DPCS replied within 48 hours of the physicians order. e. Review of Patient 6’s clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26. The POC, for the certification period from 1/9/26 to 3/9/26, showed an order for PT evaluation. Review of the clinical record showed PT 2 performed the evaluation on 1/27/26, which was more than 48 hours from when it was ordered. Further review of the POC, for the certification period from 1/9/26 to 3/9/26, showed an order for OT evaluation. Review of the clinical record showed OT 1 performed the initial evaluation on 2/6/26, which was more than 48 hours from when it was ordered. On 4/23/26 at 1448 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 4. Review of the agency’s P&P titled Selection/Hiring of Personnel revised 4/2019 showed the candidates are screened to ensure that the candidate meets the job requirements, competencies and qualifications. Valid license, certification or registration are required by law to practice a profession, the organization verifies these credentials with the primary source on hire and upon expiration. Review of the agency’s P&P titled Physical Examination Policy and Procedure (undated) showed all employees and contracted personnel providing patient care must be physically capable of performing assigned duties and must complete a physical examination prior to hire and as required thereafter. The P&P included the pre-employment requirement as follows: -Physical examination must be completed prior to patient contact -Conducted by licensed practitioner Review of the agency’s P&P titled Performance Evaluation Policy (undated) showed agency ensures that all employees and contracted personnel receive ongoing performance evaluations to assess competency, clinical quality, compliance with agency standards, and adherence to patient care requirements. The procedures included the following: -Frequency: initial evaluation at completion of orientation/probationary period (typically 90 days), annually performance evaluation thereafter, additional evaluations as needed. Review of the agency’s P&P titled Contracted Personnel (On Hiring) undated, showed the agency ensures that all contracted personnel meet the same standards as employed staff regarding qualifications, competency, health screening, and compliance with regulatory requirements. The procedure included the following: -Precontract requirements as valid professional license/certification verification, background check, verification of education, and experience and professional references -Health requirements as physical examination clearance, TB screening compliance, immunization records. -Orientation as contracted personnel must complete orientation including agencies policies and procedures, infection control, emergency preparedness, patient rights and documentation standards. -Competency Validation as skills validation based on discipline and specialty competencies -Documentation as personnel file maintained for each contractor includes all credentials, health records, and evaluations. Review of the personnel files for the agency’s employees was conducted with the Intake Coordinator on 4/22/26, and showed the following: 1. RN 3’s personnel file did not show any documentation of the pre-employment physical examinations. 2. LVN 3’s personnel file did no show documentation of the 90 days performance evaluation. 3. PT 1’s personnel file showed PT 1 was the contracted staff. However, PT 1 ‘s personnel file did not contain the current valid professional license, hiring orientation, performance evaluations, and skill competencies. The Intake Coordinator verified the above findings. On 4/22/26 at 1330 hours, an interview and concurrent document review were conducted with the Administrator and Intake Coordinator. The Administrator and the Intake Coordinator were informed and acknowledged the above findings”

“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 agency failed to send a completed Transfer Summary to the receiving hospital within two business days for one of eight sampled patient (Patient 7). This failure had a potential risk of not providing continuity of care and services to the patient. Review of the agency’s P&P titled Transfer Summary revised 4/2019 showed within 48 hours of transfer, the transferring clinician will complete a transfer summary that includes, as appropriate: A. The reason for transfer B. The physical and psychosocial status at the tie of transfer, including specific medical, psychosocial or other problems requiring interventions or follow up. C. Continuing symptom management needs D. Medication Profile E. A summary of care provided and the progress toward achieving goals F. Any instructions and referrals provided to the patient G. The existence of any Advance Directive known to the organization H. Date of face to face encounter, if during initial certification I. The date of transfer, which is the date of last visit made. 2. Completed summaries will be given to the clinical records clerk who will send a copy to the receiving organization, along with a copy of the clinical record, within two business days of a planned transfer or within two days of becoming aware of unplanned transfer and will file the original in the clinical record. 3. A copy of the transfer summary will be sent to the physician within 48 hours of transfer. Review of Patient 7’s clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification period from 2/27/26 to 4/27/26. Review of Patient 7’s Comprehensive Transfer Without Discharge dated 4/10/26, showed in the agency’s electronic system as 13 days overdue. The Comprehensive Transfer Without Discharged record showed the patient tracking information, administrative information, health condition, medications, special treatment, procedures and programs, participation in assessment and goal setting were completed by the DPCS. However, the details of emergent care or hospitalization or transfer to the SNF/Nursing Home if known was not completed. On 4/23/26 at 1016 hours, an interview and a document review was conducted with the DPCS and Intake Coordinator. The DPCS verified it was 13 days overdue and acknowledged the electronic record showed no details of emergent care or hospitalization or transfer to SNF/Nursing Home if known. The Intake Coordinator was asked if a transfer summary copy was sent to the hospital. The Intake Coordinator verified none was sent because it was only few days ago that it was learned that patient was transferred to the hospital.”