Home Health Care Management Inc.

“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 one of seven sampled patients (Patient 3) had a complete and accurate individualized Plan of Care (POC, a personalized, doctor approved roadmap outlining the specific medical services, goals, and treatments a patient receives at home) developed to meet their individual medical needs within seven working days. This failure could lead to inadequate care coordination between the healthcare team, resulting in the potential for negative clinical outcomes and specific needs not being identified in a timely manner. Findings: Patient 3’s clinical record was reviewed. Patient 3 was admitted for home health services on 1/6/26, for diagnoses that included other sequela of cerebral infarction (long term lasting complications, or physical or mental limitations that remain following a stroke), diabetes ( too much sugar in the blood), weakness, hypercholesterolemia (high cholesterol levels in the blood), syncope and collapse (fainting or passing out), hypokalemia (low potassium levels in the blood), and falls. During a review, of Patient 3’s clinical record, a document titled, “Home Health Care Certification and Plan of Care,” dated 3/7/26 through 5/5/26, indicated this POC was completed and signed by the Registered Nurse (RN) on 3/24/26, 19 days after the assessment was completed on 3/5/26. During an interview, on 3/24/25 at 2:55 pm, the Intermittent Program Manager (IPM) confirmed, that this POC was late for Patient 3 per their agency’s policy, and they had missed the seven-day requirement. IPM stated, “I confirm the POC recert was late, we missed this because we send our POCs to coding, and this was the delay. It was stuck there and we did not check the status of this POC. I confirm the POC was late being developed.” During an interview, on 3/24/25 at 4:10 pm, the Program Manager (PM) confirmed, that the POC was late being developed for Patient 3. The PM confirmed the POC was needed to provide care in the home for an accurate, up to date, orders, treatments and medications to follow while providing care in the home. PM stated, “I confirm seven days is the regulation and our policy for all POCs even though it is not specifically listed in the POC policy. The administrator also confirmed this POC is late for Patient 3.””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, and interview, the facility failed to ensure that they followed the standard of care when expired patient care supplies were found in the medical supplies at one of two reviewed sites (Redding office). This failure resulted in the potential for staff to utilize expired supplies when providing in home care to patients; resulting in potential negative health outcomes for patients. The facility policy titled, “Medical Supply Requests,” dated 4/30/18, indicted, that supply chain manger responsibility: supply chain manager on a weekly basis is to confirm that all supplies in the supply room have not expired. Expired supplies are to be removed from the supply room. During an observation, and concurrent interview, on 3/25/26 at 8:55 am, with the RBOM (Office Manager -- Redding Branch) the contents of the medical supply closet were reviewed. Two foley catheters (sterile tube inserted into the bladder) were noted to be expired; one dated 1/1/21, and one dated 7/1/20. One box labeled, “Areza calcium alginate dressing” (a type of wound dressing) contained two individually sealed dressings, both labeled “EXP 2023-05.” The RBOM verified, that that these medical supplies were expired. RBOM stated that staff who provide nursing services bring supplies from the Chico Branch Office. RBOM confirmed that she is the staff member responsible for managing the supply closet.”

“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 review and reconcile (process of creating an up to date, accurate medication list) of all medications and supplements in the home for two out of three sampled patients (Patient 3, and Patient 4) during the follow-up home visits to include in the clinical record, provide an updated copy to the patient, and for the physician to review for safety. This failure had the potential to cause unrecognized medication interactions, medication errors, and cause negative clinical outcomes. Findings: During a review of the agency’s policy and procedure (P&P) titled “Medication Reconciliation,” dated 1/1/25, the P&P indicated, “To ensure accurate and complete medication information is consistently communicated across transitions of care, reducing medication errors, and improving patient safety. It shall be the policy of the agency that all medications and treatments will be reconciled according to this policy and procedure. Compile a complete medication list including prescription medications, over the counter (OTC) drugs, and herbal supplements. Verify drug name, dose, frequency, route and indication. Assess patient adherence and understanding. Ongoing medication reconciliation will be performed at each visit, as appropriate.” During a review of Patient 3’s clinical record, Patient 3 was admitted for home health services on 1/6/26 for diagnoses that included other sequela of cerebral infarction (long term lasting complications, or physical or mental limitations that remain following a stroke), diabetes ( too much sugar in the blood), weakness, hypercholesterolemia (high cholesterol levels in the blood) syncope and collapse (fainting or passing out), hypokalemia (low potassium levels in the blood), and falls. During an observation on 3/25/26 at 10:02 am, a medication fluticasone nasal spray 50 micrograms (mcg, a unit of measurement) was sitting at the bedside dresser beside Resident 3 with no label or instructions for use. During an interview on 3/25/26 at 10:05 am, Patient 3 stated, “Oh, I did not know what that is or what that is for? I don’t remember how it got there. Yes, the staff here gives me all my medicines, they handle all of that.” During a concurrent observation and interview in Patient 3’s bedroom at 10:15 am, Registered Nurse (RN) A confirmed there was a bottle of nasal spray fluticasone nasal 50 mcg with no patient name or instructions for use by the bedside. RN A stated, “I don’t know why the staff left the nasal spray in here, I will have to ask them about it. It is on her medication list I have.” During a concurrent interview and record review on 3/25/26 at 10:30 am, RN A confirmed the medication fluticasone nasal 50 mcg/inhalation spray was ordered for Patient 3 as follows; administer 1 spray in each nostril once a day. During an interview on 3/25/26 at 10:45 am, the family member K of Patient 3 stated, “Yes, I know what that medication is for. [Patient 3] gets a tickle in her throat and that spray helps it. The staff here gives it to her.” During an interview on 3/25/26 at 11:20 am, with the Resident Care Coordinator (RCC) and the Medication Tech (MT) at a local assisted living facility confirmed the medication fluticasone nasal 50 mcg/inhalation spray was not listed on their medication list ordered for Patient 3. RCC stated, “We are happy to add it, but we need a doctor’s order.” During an interview on 3/25/26 at 11:25 am. MT stated, “We check the communication notes in case we miss the home health nurse, but we have not seen a new order or any new instructions listed on our in house forms we have for home health agencies for Patient 3.” During an interview on 3/25/26 at 11:30 am, RN A confirmed she had not checked the medication list at any visits to Patient 3 comparing her medication list with the medication list in the assisted living facility. RN A stated, “I was never taught to, but I will check at every visit from now on to make sure they are the same, I will get a order faxed today to add the medication for Patient 3 to administer as ordered.” During an interview on 3/25/26 at 11:55 am, the Program Manager confirmed medication reconciliation should be completed at every visit for Patient 3, and in every setting including assisted living facilities. A review of Patient 4’s “Home Health Certification and Plan of Care,” dated 3/5/26, indicated, Patient 4 was admitted to home health services (nursing care provided to a patient in their home) on 9/9/25 with the diagnoses of lumbar spinal stenosis without neurogenic claudication (an area in the spine [bones that run down the back] became narrow and caused pain and weakness when walking), diastolic congestive heart failure (stiffening of the left side of the heart muscle that caused blood to back up into the lungs and body because the heart could not pump blood properly) and insomnia (inability to sleep). During an observation on 2/25/26 at 10:10 am, RN B asked Family Member (FM) I if Patient 4’s medications have changed. FM I stated, “I started [Patient 4], the first week of the month on some herbals for edema.” (herbals are considered over the counter supplements and edema was when the body retains fluid causing the feet and legs to become swollen). During an interview on 2/25/26 at 11:05 am, RN B confirmed not performing a medication reconciliation during the home visit and indicated that the herbal medication should have been reviewed with FM I. A review of Patient 4’s “Medication Profile,” dated 9/9/25 through 3/18/26 indicated, on 9/9/25, the Physician prescribed Norco (an opioid pain medication) 7.5/325 milligrams (mg), take one tablet by mouth four times a day (this order indicated the medication was scheduled, to be taken four times a day, and not as needed for pain). A review of Patient 4’s “Medication Profile,” dated 9/9/25 through 3/18/26 indicated, on 9/9/25, the Physician prescribed trazodone (an antidepressant medication that was used to treated insomnia) 150 mg, take two tablets by mouth every day. During a concurrent observation and interview on 2/25/26 at 11:27 am, Patient 4’s Family Member (FM) I produced Patient 4’s medications. FM I confirmed, telling RN B that FM I had started giving Patient 4 an over-the-counter herbal medication. FM I provided a bottle labeled Lymph MD (an over-the-counter supplement that removed extra fluid in the body and decreased edema) to review. The label indicated that it should be taken with a meal and eight ounces of water, or as directed by a healthcare professional. The label indicated, individuals with a known medical condition should talk with their Physician before taking this medication. FM I provided Patient 4’s trazodone pill bottle and the label indicated that Patient 4 was prescribed trazodone 150 mg, one tablet by mouth to be taken once a day. FM I confirmed the medication label indicated the dose decrease occurred on 8/26/25 (prior to admission to the home health agency). FM I provided Patient 4’s Norco pill bottle and the medication label indicated the Norco dose had increased from 7.5/325 mg to 10/325 mg and was allowed to take one tablet every six hours as needed for pain. FM I was asked if the home health nurses reviewed the medications and pill bottles at every visit and FM I stated, “they ask if something is new and I tell them if the meds change.” During a concurrent interview and record review on 3/25/26 at 1:50 pm with RN Program Manager (PM), Resident 4’s “Medication Profile,” dated 9/9/25 through 3/18/26 and the photos of medication labels taken during the home visit observation was reviewed. PM indicated, medication reconciliation should happen at the start of care (the very first home visit), all the medications are entered into the electronic medical record and the computer system reviews the medications for interactions (ensuring the medication can be taken together without causing unwanted side effects). The nurses should review the pill bottles at every visit to ensure the medication profile is up-to-date and complete. PM stated, if the medication is different than what’s ordered, or there are any changes, the Physician is notified.” PM reviewed the medication label photos against the “Medication Profile,” and confirmed, RN B did not perform a medication reconciliation during the home visit and the “Medication Profile” was inaccurate.”

“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 include all treatments, pertinent diagnoses with interventions and goals as relevant to the plan of care for four out of seven sampled patients (Patient 1, 3, 4, and Patient 6). This failure had the potential for unidentified problems, risk for hospitalization and negative clinical outcomes. Findings: 1a. A review of the facility’s policies and procedures (P&P) titled, “Plan of Treatment/Plan of Care”, dated 1/1/25, indicated, the plan of care would be established for each patient whose care required medical orders. The P&P indicated, the patient’s diagnosis and treatment goals would be included in the plan of care. A review of Patient 4’s “Home Health Certification and Plan of Care,” dated 1/12/26, indicated Patient 1 was admitted to home health services 1/12/26, with the diagnosis of unilateral (one sided) primary osteoarthritis, left hip (common wear and tear of the joints) and systolic congestive heart failure (CHF, the left side of the heart was weak and unable to pump blood adequately). A review of the “Summary of Care,” dated 1/6/26, indicated Patient 1 was being discharged from the hospital after having a left hip replacement surgery. During a concurrent interview and record review on 3/25/26 at 2:55 pm, with RN Program Manager (PM), Patient 1’s “Home Health Certification and Plan of Care,” dated 1/12/26 was reviewed. PM confirmed, the plan of care did not include a diagnosis for Patient 1’s left hip surgery or CHF and stated, “it should be there.” 1b. A review of the facility’s P&P titled, “Plan of Treatment/Plan of Care”, dated 1/1/25, indicated, all patient medication would be listed on the plan of care. A review of the facility’s P&P titled, “Medication Reconciliation,” dated 1/1/25, indicated all medication would be verified to include the drug name, dose, frequency (how often medication was taken), and the indication (reason for use). During a concurrent interview and record review on 3/25/26 at 2:55 pm, with RN Program Manager (PM), Patient 1’s “Home Health Certification and Plan of Care,” dated 1/12/26 was reviewed. PM confirmed, the plan of care indicated that the Physician prescribed Norco (pain medication) 325 milligrams (mg)/10 mg, take one tablet by mouth and Ambien (used to help patients sleep) 5 mg, take 1 tablet by mouth. PM confirmed, the medication order entered in the plan of care for Norco and Ambien did not include the dose, frequency, or indication for use, and stated, “it should have.” 4a. A review of Patient 4’s “Home Health Certification and Plan of Care,” dated 3/5/26, indicated, Patient 4 was admitted to home health services on 9/9/25 with the diagnoses of diastolic CHF (stiffening of the heart muscle that caused blood to back up into the lungs and body because the heart could not pump blood adequately) and hypertension (high blood pressure). During an interview on 3/25/26 at 11:05 am, Registered Nurse (RN) B confirmed that Patient 4 had diagnoses of CHF and HTN and they were not included in the plan of care. A review of the untitled document, dated 2/26/26, indicated Patient 4 had diagnosis of right lateral ankle pressure ulcer (wound to the outer right ankle that was caused by pressure). During a concurrent interview and record review on 3/25/26 at 2:15 pm, with PM, Patient 4’s “Home Health Certification and Plan of Care,” dated 3/5/26, was reviewed. PM confirmed, there was no diagnosis of CHF or HTN and stated, “there should be.” PM confirmed that Patient 4 had a wound to the right outer ankle and confirmed there was no wound diagnosis included in the plan of care. 4b. During a concurrent interview and record review on 3/25/26 at 2:55 pm, with RN Program Manager (PM), Patient 1’s “Home Health Certification and Plan of Care,” dated 3/5/26 was reviewed. PM confirmed the plan of care indicated that the Physician prescribed Trazodone (an antidepressant, used to treat a sad mood or insomnia) 150 mg, take one tablet two times a day. PM confirmed, the indication for use was not on the plan of care. PM confirmed the plan of care indicated Patient 4 had a Foley catheter (a tube that was inserted into the bladder that drained urine into a bag) that required flushes (sterile water that was inserted through the Foley catheter and washed out the bladder. Flushing the Foley catheter also removed blockages that clogged the tube). PM confirmed that the plan of care did not include an order or instructions for the Foley catheter flush, that included what type of flush was to be used, the amount, or the frequency. Findings: During a review of the agency’s policy and procedure (P&P) titled, “Plan of Treatment/Plan of Care,” dated 1/1/25, the P&P indicated, “The plan of treatment or plan of care shall include, but not be limited to the following pertinent information: Diagnosis, types of services, statement of treatment goals, medications and treatment, functional limitations, mental status/psychosocial status, activities permitted, nutritional requirements, rehabilitation potential and prognosis, any safety measures to protect against injury to the patient, proposed frequency and duration of services, discharge and referral plan, instructions to patient and family, and food or drug allergies. During a review of Patient 3’s clinical record, Patient 3 was admitted for home health services on 1/6/26 for diagnoses that included other sequela of cerebral infarction (long term lasting complications, or physical or mental limitations that remain following a stroke), diabetes ( too much sugar in the blood), weakness, hypercholesterolemia (high cholesterol levels in the blood) syncope and collapse (fainting or passing out), hypokalemia (low potassium levels in the blood), and falls. During a review of Patient 3’s clinical record, a document titled, “Home Health Care Certification and Plan of Care,” dated 3/7/26 through 5/5/26, indicated this POC did not include any orders, interventions or goals for the diagnoses of history of hospitalizations for a fall with injury, education needed for the assisted living facility staff for prevention of falls, history of hypokalemia, or memory loss from a CVA. During an interview on 3/25/26 at 11:50 am, the Intermittent Program Manager (IPM) confirmed the POC for Patient 3 was not specific and did not include safety interventions for wearing the life alert necklace related to multiple falls and current injury. IPM stated, “I confirm the POC is not thorough and needed more interventions for education to the assisted living facility. I confirm that all the diagnoses were not listed in the POC and medication management was not listed to teach the staff or family.” During an interview on 3/25/26 at 4:20 pm, the Program Manager (PM) confirmed the POC did not have all the needed orders and interventions for Patient 3 for home health visits. PM stated, “I confirm the POC for Patient 3 needs to be more specific and I confirm medication management should be on all POCs for safety to educate in the homes.” During a review of Patient 6’s clinical record, Patient 6 was admitted for home health services on 2/9/26 for diagnoses that included constipation (problem passing stool or having a bowel movement fewer than three times a week), hypertensive heart disease with heart failure (weakened heart from high blood pressure causing the heart not to adequately pump enough blood to meet the body’s needs which can lead up to fluid in the lungs and other parts of the body), asthma (long term lung condition that inflames and narrows the airways, causing difficulty breathing), epilepsy (a brain disorder causing reoccurring seizures, an abnormal burst of electrical activity), unspecified intellectual disabilities (significant limitations in both intellectual functioning such as learning, reasoning, and problem solving and daily life skills), and blindness in one eye (limited vision, no vision in one eye). During a review of Patient 6’s clinical record, a document titled, “Home Health Care Certification and Plan of Care,” dated 2/9/26 through 4/9/26, indicated this POC did not include any orders, interventions or goals for the diagnoses of seizures, heart failure, high blood pressure, unspecified intellectual disabilities or blindness of one eye. During an interview on 3/26/26 at 10:55 am, the PM confirmed the POC was not patient specific and did not list all interventions needed for pertinent diagnoses of Patient 6 for home safety. During an interview on 3/26/26 at 2:40 pm, the IPM confirmed all POC’s need to be more patient specific, more interventions were needed for identified needs for all patients in the home health setting. IPM stated, “We will add medication management and all other pertinent diagnoses interventions moving forward to all POCs and be more detailed.””

“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 observations, interviews, and record reviews, the facility did not obtain a Physician’s order for one out of seven sampled patients (Patient 4) before administering wound care. This failure had the potential to cause a delay in physician being able to coordinate care which could lead to negative clinical outcomes. Findings: A review, of the facility’s undated policy and procedure titled, “Physician/Allowed Practitioner Orders Management,” indicated, that a Physician’s order was required prior to providing any care to patients. Patient 4’ s clinical record was reviewed. Patient 4 was admitted to home health services on 9/9/25, with the diagnosis of benign prostatic hyperplasia with lower urinary tract symptoms (a non-cancerous condition that caused the prostate gland to become larger than normal and made urination difficult). During a concurrent interview, and observation, on 3/25/26 at 10:10 am, Patient 4 was observed sitting in a wheelchair with both feet resting on top of a small footstool (a small piece of furniture that a person used to rest their feet on). Patient 4’s right outer ankle was observed to be covered with a wound dressing (bandage). The top of the right ankle was observed to have a small scab (hard, dry, or crusty layer) and was not covered with a wound dressing. Registered Nurse (RN) B provided wound care to the right outer ankle and stated, “I don’t dress [apply wound dressing] top wound, I think Family Member I does it.” FM I stated, “generally you guys do it, usually you clean and add a band aide. I’d like it open to air.” RN B was observed cleansing the top of Patient 4’s right ankle, and applied a wound care dressing over the scab. During an interview, on 3/25/26 at 11:05 am, RN B was asked if there was a Physician’s order for the wound care that was performed to the top of Patient 4’s right ankle. RN B stated, “there is no order for the top wound, only the right ankle. I’ve always left it open to air.” RN B confirmed providing wound care to the right top ankle without a Physician’s order. During a concurrent interview, and record review, on 3/25/26 at 1:50 pm, with RN Program Manager (PM), Patient 4’s “Patient Care Order,” dated 3/11/26 was reviewed. PM confirmed that the “Patient Care Order,” indicated wound care would be provided to the outer right ankle. PM confirmed the wound care that RN B provided to Patient 4’s right top ankle was performed without a Physician’s order. A review, of Patient 4’s “Skilled Nursing Visit Note,” dated 3/25/26, indicated, Patient 4 had a healed abrasion (an injury that caused the top layer of skin to be torn or rubbed off), located on the top of the right foot ankle area, RN B cleansed the healed wound, and applied a wound dressing.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure care coordination was completed for one of seven sampled patients (Patient 3) when: 1. A medication was not administered by the staff at the assisted living facility ordered by the physician on Patient 3’s home health medication profile and Plan of Care. 2. Safety interventions including a life alert necklace not worn by Patient 3 were not communicated to the assisting living facility after a fall with injury. 3. An ordered lab was late due to Patient 3 not fasting before labs were scheduled to be drawn by the home health agency. This failure resulted in a medication error, late labs obtained, and the potential for unidentified problems, risk for hospitalization and negative clinical outcomes. 1. During a review of the agency’s policy and procedure (P&P) titled “Medication Reconciliation,” dated 1/1/25, the P&P indicated, to ensure accurate and complete medication information is consistently communicated across transitions of care, reducing medication errors, and improving patient safety. It shall be the policy of the agency that all medications and treatments will be reconciled according to this policy and procedure. Compile a complete medication list including prescription medications, over the counter (OTC) drugs, and herbal supplements. Verify drug name, dose, frequency, route and indication. Assess patient adherence and understanding. Ongoing medication reconciliation will be performed at each visit, as appropriate. Patient 3’s clinical record was reviewed. Patient 3 was admitted for home health services on 1/6/26, for diagnoses that included other sequela of cerebral infarction (long term lasting complications, or physical or mental limitations that remain following a stroke), diabetes ( too much sugar in the blood), weakness, hypercholesterolemia (high cholesterol levels in the blood), syncope and collapse (fainting or passing out), hypokalemia (low potassium levels in the blood), and falls. During a concurrent observation, and interview, in Patient 3’s bedroom at 10:15 am, Registered Nurse (RN) A confirmed there was a bottle of nasal spray fluticasone nasal 50 mcg with no patient name or instructions for use by the bedside. RN A stated, “I don’t know why the staff left the nasal spray in here, I will have to ask them about it. It is on her medication list I have.” During a concurrent interview, and record review, on 3/25/26 at 10:30 am, RN A confirmed the medication fluticasone nasal 50 mcg/inhalation spray was ordered for Patient 3 as follows; administer 1 spray in each nostril once a day. During an interview, on 3/25/26 at 11:20 am, with the Resident Care Coordinator (RCC), and the Medication Tech, at a local assisted living facility confirmed the medication fluticasone nasal 50 mcg/inhalation spray was not listed on their medication list ordered for Patient 3. RCC stated, “We are happy to add it, but we need a doctor’s order.” During an interview, on 3/25/26 at 11:25 am. MT stated, “We check the communication notes in case we miss the home health nurse, but we have not seen a new order or any new instructions listed on our in house forms we have for home health agencies for Patient 3.” During an interview, on 3/25/26 at 11:30 am, RN A confirmed she had not checked the medication list at any visits to Patient 3 comparing to her medication list with the medication list in the assisted living facility. RN A stated, “I was never taught to, but I will check at every visit from now on to make sure they are the same, I will get a order faxed today to add the medication for Patient 3 to administer as ordered.” 2. During a review, of the agency’s policy and procedure (P&P) titled, “Plan of Treatment/Plan of Care,” dated 1/1/25, the P&P indicated, the plan of treatment or plan of care (POC, a personalized, doctor approved roadmap outlining the specific medical services, goals, and treatments a patient receives at home) shall include, but not be limited to the following pertinent information: Diagnosis, types of services, statement of treatment goals, medications and treatment, functional limitations, mental status/psychosocial status, activities permitted, nutritional requirements, rehabilitation potential and prognosis, any safety measures to protect against injury to the patient, proposed frequency and duration of services, discharge and referral plan, instructions to patient and family, and food or drug allergies. During a concurrent observation, and interview, on 3/25/26 at 10:05 am, Patient 3 was not wearing the life alert necklace, and it was observed on a bedside dresser for Patient 3. Patient 3 stated, “Oh, I forget to wear it sometimes, my memory is not good. I get tired of wearing it, but I know I need to.” During a concurrent interview, and record review, on 3/25/26 at 10:30 am, Registered Nurse (RN) A confirmed Patient 3 had five staples to the left side of the top of her head from a recent fall at the facility beside her bed, was on a medication that is a blood thinner, and is a high risk for falls. RN A stated, “I confirm Patient 3 should be reminded and encouraged by the facility staff and all home health staff to wear the life alert necklace due to the high fall risk, history of syncope (fainting spells), falls with a current injury. The doctor just discontinued one of her blood pressure medications.” During a concurrent record review, and interview, with the Medication Tech (MT), and Resident Care Coordinator (RCC), at 11:35 am, the MT and RCC both confirmed the current care plan dated 12/2025 at the facility was not up to date and indicated Patient 3 walks with a cane instead of a walker. RCC stated, “The Wellness Director (Licensed Nurse) updates the care plans every six months and as needed. We both agree Patient 3 needs frequent checks every two hours, and we need to remind her to wear her life alert necklace.” MT stated, “I did not notice she was not wearing it this morning when I gave her medications.” During an interview, on 3/25/26 at 11:40 am, RN A confirmed new fall prevention interventions needed to be discussed and implemented for Patient 3 for safety with the assisted living facility and care coordination needed to be discussed with the Wellness Director (nurse) at the facility to provide more education to the staff. During an interview, on 3/25/26 at 11:50 am, the Intermittent Program Manager (IPM) confirmed more fall prevention interventions were needed to be added to the POC, education provided to the assisted living facility, and reminders provided for the life alert necklace for safety. IPM stated, “They told me they check on patients every 8 hours, they never said every two hours or more often as needed. I did not know they have a care plan at the facility.” 3. During a concurrent record review, and interview, on 3/24/26 at 1:50 pm, the IPM confirmed Patient 3’s labs were ordered 3/13/26 and obtained 6 days later on 3/19/26. IPM stated, “The labs were late due to Patient 3 not fasting the morning we scheduled to obtain them. I did not know the facility can get the labs drawn.” IPM confirmed no staff was updated about labs needed for Patient 3 to hold her breakfast until the labs were drawn per order. During an interview, on 3/25/26 at 11:28 am, the RCC conformed all labs ordered can be obtained at the facility if a physician order is obtained to give to the laboratory that comes in every Friday morning. RCC stated, “It is no problem, the nurse can fill out our form we use for communication called the Outside Agency Documentation form and just fax over or bring in the physician order we need. The agency nurse can also update us when they come in for a visit.” During an interview, on 3/25/26 at 11:50 am, the IPM confirmed the care coordination was not adequate for Patient 3. IPM stated, “I confirm we need did not know about a specific form the assisted living facility uses for communication, I did not know they can help us with labs needed, and I did not know the staff checks on Patient 3 more than every eight hours. I am still learning, but this is good to know, and we will use the form, call as needed and provide more education to the staff for safety.” During an interview, on 3/25/26 at 3:30 pm, the PM confirmed the care coordination for Patient 3 was needed at the assisted living facility. PM stated, “We don’t have a policy, but I will tell the Administrator (Admin) we need one. I confirm we need to communicate and educate the staff at all assisted living facilities.” During an interview, on 3/26/26 at 9:25 am, the Admin confirmed the care coordination for Patient 3 is needed and for all patients in an assisted living facility. Admin stated, “I confirm this coordination is needed for patient safety, and this is a learning experience for all of us. We will provide more education specifically to this setting.””

“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 interview, and record review, the agency failed to ensure the plan of care (a personalized, doctor approved roadmap outlining the specific medical services, goals, and treatments a patient receives at home) was followed for three of seven sampled patients (Patient 3, 4, and Patient 5) when: 1. Patient 3 did not receive Physical Therapy (PT, health care professional that uses various techniques to help pain, mobility, balance and function to restore overall wellness) as ordered by the physician. 2. Patient 4 did not receive skilled nursing (SN, services performed by or under the supervision of a licensed nurse and includes assessment of patient condition, monitoring for signs of infection, and addressing patient concerns) and PT as ordered by the physician. 3. Patient 5 did not receive SN, and PT as ordered by the physician. This failure had the potential to cause a delay in needed services, which could lead to negative clinical outcomes. 3. A review of Patient 4’s “Home Health Certification and Plan of Care,” dated 1/28/26 indicated Patient 5 was admitted to home health care services on 1/28/26 with diagnoses that included acute respiratory failure (difficulty breathing,) heart failure, pneumonia, and muscle weakness. His physician’s order, dated 1/26/26 indicated; “Skilled nursing to asses and evaluate 1wk 8 wk (visit once a week for 8 weeks total) beginning 1/30/26 – ending 3/21/26” A second physician’s order, dated 1/26/26 indicated; “Physical therapy to asses and evaluate 1/28/26 through 2/1/26.” A third physician’s order, dated 2/1/26, indicated “Physical therapy 1wk 2 wk (visit once a week for 2 weeks) 2/5/26 – 2/14/26 During a concurrent interview and record review, on 3/27/26 at 2pm with Administrator (Admin) and RN Intermittant Program Manager (IPM,) the documentation of Patient 5’s visits was reviewed. IPM confirmed that the record indicated Patient 5 did not receive a skilled nursing visit during the week of 3/1/26 – 3/7/26 and that a weekly visit by skilled nursing staff should have been conducted on that week. IPM was unable to find documentation that this was at the patient’s request. IPM was unable to find documentation that the physician had been notified of this missed visit. Admin confirmed that the record indicated Patient 5 did not receive a visit from the physical therapist the week of 2/8/26 – 2/14/26 and that a weekly visit from a physical therapist should have been conducted on that week. A clinical note, dated 2/12/26, from the physical therapist indicated that this was a missed visit, but did not indicated the physician had been notified. Admin stated that the staff thought the system would automatically send a notification, which it does not. IPM confirmed that one skilled nursing visit and 1 physical therapy visit did not occur for Patient 5, that no attempt to reschedule had been documented, and the physician had not been notified. During a review of Patient 3’s clinical record, Patient 3 was admitted for home health services on 1/6/26 for diagnoses that included other sequela of cerebral infarction (long term lasting complications, or physical or mental limitations that remain following a stroke), diabetes ( too much sugar in the blood), weakness, hypercholesterolemia (high cholesterol levels in the blood) syncope and collapse (fainting or passing out), hypokalemia (low potassium levels in the blood), and falls. During a review of Patient 3’s clinical record, a document titled, “Home Health Care Certification and Plan of Care,” dated 1/6/26 through 3/6/26, indicated this POC had PT ordered two times weekly through 3/6/26 for weakness and falls. During a concurrent record review and interview on 3/24/26 at 2:00 pm with the Intermittent Program Manager (IPM), Patient 3’s clinical record indicated a PT visit was missed on 1/28/26 and the physician was not updated. IPM confirmed the physician was not updated for this missed visit and stated, “ I confirm the doctor was not updated and there were no attempts documented to reschedule.” During a review of Patient 3’s clinical record, a document titled, “Physical Therapy Visit Note,” dated 1/28/26 indicated the physician was not updated for this missed visit and there were no attempts to reschedule this visit. During an interview on 3/26/26 at 10:30 am, the Program Manager confirmed it is the agency’s policy to update the physician for all missed visits for PT and SN. PM stated, “I confirm the doctor was not updated for Patient 3’s missed visit for PT.” A review of the facility’s policy and procedure (P&P) titled, “Missed Visits,” dated 12/15/24, indicated, “Clinical staff will document Missed Patient Visits and notify the ordering medical provider [Physician]. A missed visit occurs when a scheduled home health visit is not completed as ordered.” The P&P indicated when a home visit could not be made on the scheduled day, clinical staff would reschedule the home visit for a different day in the week. A review of Patient 4’s “Home Health Certification and Plan of Care,” dated 3/5/26, indicated, Patient 4 was admitted to home health services (nursing care provided to a patient in their home) on 9/9/25 with the diagnoses of lumbar spinal stenosis without neurogenic claudication (an area in the spine [bones that run down the back] became narrow and caused pain and weakness when walking) and diastolic congestive heart failure (stiffening of the left side of the heart muscle that caused blood to back up into the lungs and body because the heart could not pump blood properly). During a concurrent interview and record review on 3/25/26 at 2:25 pm, with RN Program Manager (PM), Patient 4’s missed visit notes dated 3/9/26, 3/12/26, and 3/18/26 were reviewed. PM confirmed, the missed visit note dated 3/9/26, indicated the Licensed Vocational Nurse (LVN) missed the home health care visit that included a wound care dressing change, did not attempt to reschedule, and did not notify the Physician. PM confirmed, Patient 4’s missed visit notes dated 3/12/26 and 3/18/26 indicated the PT missed the home heath care visit, did not attempt to reschedule, and did not notify the Physician.”