Comcare Home Health, 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 Home Health Agency (HHA) failed to follow the written Plan of Care for two of 10 sampled patients (Patient 26 and Patient 27). a. Patient 26’s POC included skilled nurse services (SN) to monitor and re-evaluate the wound that included wound measurements weekly. SN failed to perform wound measurement as indicated on the POC. This has the potential to result in the inability of the HHA staff to determine if the wound was getting better or worse that could delay treatment and intervention. b. Patient 27’s care services were not provided by the HHA staff as ordered on the POC. The delay in the provision of the ordered services will result in the patient’s decline, injuries and or hospitalization. a. During a review of Patient 26’s clinical record titled Patient Profile, undated, indicated a Start of Care (SOC) date of 4/22/2025 with a primary diagnosis of Pressure ulcer of sacral region Stage 3 (a localized injury to the skin and underlying tissue, usually over a bony prominence, where there is full thickness loss and subcutaneous fat is visible but not bone, tendon, or muscle, and is caused by prolonged pressure or pressure in combination with shear and friction). During a review of Patient 26’s Plan of Care (POC), for the certification period of 4/22/2025 to 6/20/2025 indicated a frequency visit order for Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) one time a week for one week, two times a week for one week, three times a week for one week and two times a week for one week. Patient 26’s POC also indicated the skilled nurse (SN=RN or LVN) to perform skilled observation and assessment of vital signs, response/compliance with treatment, home safety, monitor for signs and symptoms (s/s) of hypoglycemia (low blood sugar)/ hyperglycemia (high blood sugar), monitor for s/s of skin infection, educate on wound care to sacrum (triangular shaped bone located at the base of the spine, connecting it to the pelvis), of cleansing with normal saline (a sterile solution of salt and water that can be used to cleanse wounds), protect surrounding skin with skin barrier, apply manuka honey (a unique type of honey produced by bee’s with potential wound healing properties due to its unique composition of methylglyoxal (compound that contributes to antibacterial effect) and antibacterial activity), cover with silicone foam (type of dressing made with soft, flexible silicone layer), secure with tape for three times a week for 2 weeks and then re-evaluate. During a review of Patient 26’s POC for the certification period of 6/21/2025 to 8/19/2025 indicated a frequency visit order for RN/LVN one time a week for one week, and three times a week for two weeks. Patient 26’s POC also indicated that the skilled nurse is to instruct the patient/patient caregiver to follow instructions regarding dosage/administration and s/s of bleeding due to use of anticoagulant medication (medication to prevent blood from clotting/ reduce risk of clotting), perform skilled observation and assessment of vital signs, response/compliance with treatment, home safety, assess and instruct on s/s of infection and monitor wound care to sacrum of cleansing with normal saline protect surrounding skin with skin barrier, apply manuka honey, cover with silicone foam, secure with tape for three times a week for 2 weeks and then re-evaluate. During an interview on 7/3/2025 at 11:06 a.m., with the Director of Patient Care Services (DPCS) stated any patients admitted to the HHA with wounds, on SOC assessment, the wounds are measured, photographed and documented on the comprehensive assessment. The DPCS stated for follow up visits, the skilled nurses are to measure the wounds every two weeks and photographs of the wounds are done every 30 days or sooner if any changes are noted in the wounds. The DPCS stated for patients referred by General Acute Care Hospital 1 (GACH1), the wounds are to be measured weekly, a requirement from GACH1. The DPCS stated the skilled nurses are to document on the visit note of page 2 the wound care that was provided, location, description of the wound and when due, the weekly measurements. The DPCS also stated for every wound a patient has; a care plan is to be formulated for each one. During a concurrent interview and record review on 7/3/2025 at 11:15 a.m., with the DPCS Patient 26’s Electronic Medical Record (EMR) for episode 1 was reviewed. Patient 26’s EMR under the section Nurses clinical Notes indicated documented skilled nurse visit notes dated 4/24/2025, 2/26/2025, 4/28/2025, 4/30/2025, 5/2/2025, 5/5/2025, 5/7/2025, 5/9/2025, 5/12/2025, 5/14/2025, 5/16/2025, 5/19/2025, 5/21/2025, 5/23/2025, 5/26/2025, 5/28/2025, and 5/30/2025. Patient 26’s skilled nurse visit notes indicated no documented evidence of the patient’s wound to the Sacrum was measured weekly by the skilled visiting nurses. The DPCS stated and confirmed that Patient 26’s skilled nurse visit notes dated 4/24/2025, 2/26/2025, 4/28/2025, 4/30/2025, 5/2/2025, 5/5/2025, 5/7/2025, 5/9/2025, 5/12/2025, 5/14/2025, 5/16/2025, 5/19/2025, 5/21/2025, 5/23/2025, 5/26/2025, 5/28/2025, and 5/30/2025 did not have documentation of the wound to the sacrum being measured weekly. The DPCS stated that the wound should have been measured weekly because every two weeks the HHA provides an updated report to the physician and GACH1 in regard to the patient’s progress or lack of progress to determine if more care services are required or if patient is ready for discharge. The DPCS stated that Patient 26’s POC was not being followed because the POC indicated the skilled nurse was to monitor and re-evaluate the wound and stated that without measurements it cannot be determined if the wound was getting better or worse. The DPCS further stated the importance of following the patient’s POC and doing weekly wound measurement determines the skilled nurses are assessing the wound and monitoring for any progress or worsening of the wound and reporting it to the physician. b. During a review of Patient 27’s clinical record titled Patient Profile, undated, indicated a Start of Care (SOC) date of 3/24/2025 with a primary diagnosis of hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone to meet the body’s needs causing fatigue, weight gain, or sensitivity to cold). During a review of Patient 27’s clinical record titled Plan of Care (POC) for the certification period of 3/24/2025 to 5/22/2025 indicated a frequency visit order for Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) one time a week for two weeks, and Home Health Aide (HHA) one time a week for one week. Patient 27’s POC also indicated the skilled nurse to perform observation and assessment of vital signs, response/compliance with treatment and home safety, educate and monitor medication compliance, monitor for signs and symptoms (s/s) of skin infection and assess/instruct patient/patient caregiver on ostomy (a surgically created opening on the body to allow waste to exit) site care and monitor for s/s hypoglycemia (low blood sugar)/hyperglycemia (high blood sugar). During a review of Patient 27’s physician order dated 3/29/2025, unsigned by the physician, the order indicated patient requested for medical social worker (MSW) evaluation to be done on 3/30/2025, PT evaluation to be done on 4/4/2025 and for HHA to help out on 4/4/2025. During a review of Patient 27’s Electronic Medical Record (EMR), the EMR indicated, under the section Communication Notes, an inter-communication note dated 3/31/2025 indicated the HHA Staffer informed Patient 27’s wife that the HHA was experiencing a delay in Speech Therapy (ST) services and would follow up with her once a response of when ST services would start for Patient 27. During a telephone interview on 7/3/2025 at 8:40 am., with Patient 27’s wife, stated that Patient 27 was referred to the HHA to receive nursing, home health aide (HHA), occupational therapy (OT), physical therapy (PT) and ST services. Patient 27’s wife stated the HHA took weeks after admission to start Patient 27 on HHA and ST services. Patient 27’s wife stated that during a phone conversation with a HHA staff member, days after the patient’s admission, she (Patient 27’s wife) was told that the HHA did not have enough staff for PT and ST. Patient 27’s wife stated that the HHA took on more patient’s than they could care for. Patient 27’s wife stated although she had private caregivers for Patient 27, at times, the patient still needed professional help from nurses with bathing and wound care right away. Patient 27’s wife also stated that because of Patient 27’s Parkinson’s disease, he needed ST as soon as possible to prevent him from declining in the progress he had made with eating by mouth. Patient 27’s wife further stated that the HHA should have informed the General Acute Care Hospital 1 (GACH1) that referred Patient 27 to them, that they were unable to provide the services requested at the moment. During a concurrent interview and record review on 7/3/2025 at 11:55 am., with Care Coordinator 1 (CC1), patient 27’s EMR was reviewed. Patient 27’s EMR indicated a physician order dated 3/29/2025, unsigned by the physician, the order indicated patient requested for medical social worker (MSW) evaluation to be done on 3/30/2025, PT evaluation to be done on 4/4/2025 and for HHA to help out on 4/4/2025. Patient 27’s EMR also indicated an inter-communication note dated 3/31/2025 indicated the HHA Staffer informed Patient 27’s wife that the HHA was experiencing a delay in Speech Therapy (ST) services and would follow up with her once a response of when ST services would start for Patient 27. CC1 stated and confirmed that the agency was experiencing a shortage with HHA staff and was having issues with the contracted Speech Therapist company which was causing a delay in providing those services. CC1 stated Patient 27’s wife was demanding, and some speech therapists were not willing to go and provide service because of that. CC1 stated when a patient referral arrives, a staffer assigns clinicians to the patient, a nurse, aide or therapist depending on the physician order for services, and those clinicians are to contact and visit the patient within 48 hours. CC1 stated if the visit is not able to be done within 48 hours because the patient is not available or stated if the agency does not have staff at the moment then a communication note is made, the patient is notified, and the physician is also notified. CC1 stated and confirmed that Patient 27’s physician’s order dated 3/29/2025 was a late notification of delay in services because the patient was to be reached out and notified within 48 hours of referral or start of care. CC1 also stated and confirmed that the inter-communication note dated 3/31/2025 was a late notification for delay or service, past the 48 hours of SOC/referral. CC1 stated she was aware that Patient 27’s wife was made aware of ST services being delayed before 3/31/2025 but stated there is no documentation to support that in the patient’s EMR. CC1 stated she was the care coordinator for Patient 27 and spoke frequently with Patient 27’s wife. During a concurrent interview and record review on 7/3/2025 at 1:45 pm., with the DPCS, Patient 27’s EMR was reviewed. The DPCS stated and confirmed Patient 27’s EMR indicated: -An authorization from GACH1, dated 3/20/2025, for Physical therapy evaluation high complex 45 minutes for 1 visit request, physical therapy in home for three visits request, speech therapy for sound product language evaluation for a one time visit request, home health aide for a one time visit request, social work visit in the home for a one time visit request, nursing assessment/evaluation for a one time visit request and a Registered Nurse home care for a one time visit request. -A physician order dated 3/29/2025, unsigned by the physician, that indicated patient requested for medical social worker (MSW) evaluation to be done on 3/30/2025, PT evaluation to be done on 4/4/2025 and for HHA to help out on 4/4/2025. -An inter-communication note dated 3/31/2025 that indicated the HHA Staffer informed Patient 27’s wife that the HHA was experiencing a delay in Speech Therapy (ST) services and would follow up with her once a response of when ST services would start for Patient 27. -A medical record titled Oasis Nurse start of care dated 3/24/2025. -A medical record titled Occupational therapy evaluation note dated 4/2/2025. -A medical record titled Physical therapy evaluation note dated 4/4/2025. -A medical record titled Note CHHA dated 4/4/2025. -A medical record titled Physical therapy discharge summary dated 5/1/2025. -A medical record titled Occupational therapy discharge summary dated 5/1/2025. -A medical record titled Speech therapy evaluation and care plan note dated 5/6/2025. -A medical record titled Oasis Discharge non visit dated 5/22/2025. -A medical record titled Speech therapy discharge summary dated 5/28/2025. The DPCS stated and confirmed that the HHA referral for home health services for Patient 27 was dated 3/20/2025 and services for HHA were not started until 4/4/2025 and services for ST were not started until 5/6/2025. The DPCS stated and confirmed that Patient 27’s EMR did not have any documented evidence of why there was a delay of care for Patient 27’s HHA and ST services. The DPCS also stated it is proper practice to document all communication or attempts in communication with the patient and/or family in the patient’s EMR to validate what did or did not happen. The DPCS further stated Patient 27’s physician orders were not followed, as the HHA did not provide Patient 27 with HHA or speech therapy services on time or within 48 hours of referral as per their policy. The DPCS stated moving forward she will inform all HHA staff that all communication with patients and/or family should be documented under a communication note. During a concurrent interview and record review on 7/3/2025 at 2 pm., with the DPCS, Patient 27’s medical record titled Plan of Care (POC) dated 3/24/2025, for the certification period of 3/24/2025 to 5/22/2025 was reviewed. The POC indicated a Skilled Nursing treatment plan with an effective date of RN/LVN frequency visits to start as of 3/24/2025, a Physical Therapy treatment plan with an effective date frequency visit to start as of 4/4/2025, an Occupational Therapy treatment plan with an effective date frequency visit to start as of 3/31/2025, and a Home Health Aide plan with an effective date of 3/31/2025. The DPCS stated and confirmed Patient 27’s POC was not followed because the physician ordered care services were delayed and not started as ordered. During a review of the HHA’s policy and procedure (P&P) titled, Care Planning Process, undated, indicated the purpose of this policy was to provide clinical direction to clinicians providing direct patient care and the care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals. The P&P further indicated the plan of care will be based upon the physicians orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. During a review of the HHA’s Policy and Procedure (P&P) titled Wound Care Policy, undated, the P&P indicated that at least every week the wound assessment and documentation will include measurement of length, width, depth and undermining or tunneling if present. During a review of the HHA’s Policy and Procedure (P&P) titled, Monitoring Patient’s Response/Reporting to Physician, undated, indicated, “Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient.” The P&P also indicated, “3. The patient’s physician will be contacted on the same day when any of the following occur: E. Changes-‘that have occurred regarding diagnoses, prognosis, or treatment (including procedures, medications, precautions, and limitations) ... 4. All conferences or attempts to communicate with the physician will be documented in the clinical record. A. Documentation of physician notification will include: 1. Date and time contacted 2. Patient name 3. Name of physician notified or his/her representative 4. Reason for notification 5. Physician’s response 6. Action taken or orders obtained 7. Professional’s signature and title”.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure all entries in the patient’s clinical record must be appropriately authenticated for two of 10 sampled patients (Patient 26 and Patient 27). This failure resulted in the lack of accountability, leading to misinformation among the home-health staff and non-continuity of care and services provided to the patients D a. During a review of Patient 26’s clinical record titled Patient Profile, undated, indicated a Start of Care (SOC) date of 4/22/2025 with a primary diagnosis of Pressure ulcer of sacral region stage 3 (a localized injury to the skin and underlying tissue, usually over a bony prominence, where there is full thickness loss and subcutaneous fat is visible but not bone, tendon, or muscle, and is caused by prolonged pressure or pressure in combination with shear and friction). During a review of Patient 26’s clinical record titled, Plan of Care (POC), for the certification period of 4/22/2025 to 6/20/2025 indicated a frequency visit order for Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) one time a week for one week, two times a week for one week, three times a week for one week and two times a week for one week. Patient 26’s POC also indicated the skilled nurse to perform skilled observation and assessment of vital signs, response/compliance with treatment, home safety, monitor for signs and symptoms (s/s) of hypoglycemia (low blood sugar)/ hyperglycemia (high blood sugar), monitor for s/s of skin infection, educate and monitor wound care, and educate and monitor on medication management. During a review of Patient 26’s POC for the certification period of 6/21/2025 to 8/19/2025 indicated a frequency visit order for RN/LVN one time a week for one week, and three times a week for two weeks. Patient 26’s POC also indicated that the skilled nurse is to instruct the patient/patient caregiver to follow instructions regarding dosage/administration and s/s of bleeding due to use of anticoagulant medication (medication to prevent blood from clotting/ reduce risk of clotting), perform skilled observation and assessment of vital signs, response/compliance with treatment, home safety, assess and instruct on s/s of infection and measures to manage it and wound care. During a review of Patient 26’s Electronic Medical Record (EMR), indicated physician orders for Patient 26 dated 4/22/2025, 5/11/2025, 6/2/2025, and 6/3/2025 with no documented evidence of a physician signature. During a review of Patient 26’s EMR, indicated the POC dated 6/3/2025 with no documented evidence of a physician signature. During a concurrent interview and record review on 7/3/2025 at 1:13 pm., with the Director of Patient Care Services (DPCS), Patient 26’s EMR was reviewed. The DPCS stated and confirmed Patient 26’s EMR had physician orders dated 4/22/2025, 5/11/2025, 6/2/2025, and 6/3/2025 and were not signed by the ordering physician. The DPCS stated all orders should be signed by the physician within 30 days, because it shows that the order was reviewed, confirmed and verified and then become active. The DPCS also stated and confirmed Patient 26’s EMR indicated a POC dated 7/1/2025 and a POC dated 6/3/2025 with no signature from the physician. The DPCS stated the ordering physician should signs all POCs within 30 days of the date because it validates the physician’s coordination in the patient’s care plan. b. During a review of Patient 27’s clinical record titled Patient Profile, undated, indicated a Start of Care (SOC) date of 3/24/2025 with a primary diagnosis of hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone to meet the body’s needs causing fatigue, weight gain, or sensitivity to cold). During a review of Patient 27’s clinical record titled Plan of Care (POC) for the certification period of 3/24/2025 to 5/22/2025 indicated a frequency visit order for Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) one time a week for two weeks, and Home Health Aide (HHA) one time a week for one week. Patient 27’s POC also indicated the skilled nurse to perform observation and assessment of vital signs, response/compliance with treatment and home safety, educate and monitor medication compliance, monitor for signs and symptoms (s/s) of skin infection and assess/instruct patient/patient caregiver on ostomy (a surgically created opening on the body to allow waste to exit) site care and monitor for s/s hypoglycemia (low blood sugar)/hyperglycemia (high blood sugar). During a review of Patient 27’s Electronic Medical Record (EMR), the EMR indicated physician orders for Patient 27 dated 3/22/2025, 3/25/2025, 3/29/2025, 4/17/2025, and 5/7/2025 with no documented evidence of a physician’s signature. During a review of Patient 27’s EMR, the EMR indicated a POC dated 3/24/2025, for the certification period of 3/24/2025 to 5/22/2025, with no documented evidence of a physician’s signature. During a concurrent interview and record review on 7/3/2025 at 1:30 pm., with the Director of Patient Care Services (DPCS), Patient 27’s EMR was reviewed. The DPCS stated and confirmed Patient 27’s EMR had physician orders dated 3/22/2025, 3/25/2025, 3/29/2025, 4/17/2025, and 5/7/2025 were not signed by the ordering physician. The DPCS stated all orders should be signed within 30 days by the ordering physician because it shows that the order was reviewed, confirmed and verified and then becomes active. The DPCS also stated and confirmed Patient 27’s EMR indicated a POC dated 3/24/2025, for the certification period of 3/24/2025 to 5/22/2025, with no signature from the physician. The DPCS stated that the ordering physician should sign all POCs within 30 days of the date completed to validate physicians’ participation and coordination in the patient’s care plan. During a review of the HHA’s policy and procedure (P&P) titled, Entries into the Clinical Record, undated, indicated that, entries into the clinical record will be made on the day care is provided to the patient. The P&P further indicated that clinical note would include the signature of the clinician and his/her credentials. During a review of the HHA’s P&P titled, Verification of Physician orders, undated, indicated, “8. A copy of the order will be kept in the patient’s clinical record... 10. Signed orders will be placed in the clinical record within 30 days of initiation of the order, unless otherwise specified by applicable state law and regulation. The unsigned copy of the order will be removed from the record.” During a review of the HHA’s P&P titled Physician Participation in Plan of care, undated, indicated, “5. The attending physician (or other authorized licensed independent practitioner) will sign the individualized plan of care/treatment within 30 days of the start of care, unless otherwise specified by applicable state law and regulation.””

“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 home health agency (HHA) failed to provide physician ordered services for one of 10 sampled patients (Patient 27). This deficient practice resulted in the delayed provision of care services ordered on the plan of care and not meeting the patient’s care goals and care needs to improve the patient’s overall health and wellbeing. a. During a review of Patient 27’s clinical record titled Patient Profile, undated, indicated a Start of Care (SOC) date of 3/24/2025 with a primary diagnosis of hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone to meet the body’s needs causing fatigue, weight gain, or sensitivity to cold). During a review of Patient 27’s clinical record titled Plan of Care (POC) for the certification period of 3/24/2025 to 5/22/2025 indicated a frequency visit order for Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) one time a week for two weeks, and Home Health Aide (HHA) one time a week for one week. Patient 27’s POC also indicated the skilled nurse to perform observation and assessment of vital signs, response/compliance with treatment and home safety, educate and monitor medication compliance, monitor for signs and symptoms (s/s) of skin infection and assess/instruct patient/patient caregiver on ostomy (a surgically created opening on the body to allow waste to exit) site care and monitor for s/s hypoglycemia (low blood sugar)/hyperglycemia (high blood sugar). During a review of Patient 27’s physician order dated 3/29/2025, unsigned by the physician, the order indicated patient requested for medical social worker (MSW) evaluation to be done on 3/30/2025, PT evaluation to be done on 4/4/2025 and for HHA to help out on 4/4/2025. During a review of Patient 27’s Electronic Medical Record (EMR), the EMR indicated, under the section Communication Notes, an inter-communication note dated 3/31/2025 indicated the HHA Staffer informed Patient 27’s wife that the HHA was experiencing a delay in Speech Therapy (ST) services and would follow up with her once a response of when ST services would start for Patient 27. During a telephone interview on 7/3/2025 at 8:40am with Patient 27’s wife, Patient 27’s wife stated that Patient 27 was referred to the HHA to receive nursing, home health aide (HHA), occupational therapy (OT), physical therapy (PT) and ST services. Patient 27’s wife stated the HHA took weeks after admission to start Patient 27 on HHA and ST services. Patient 27’s wife stated that during a phone conversation with a HHA staff member, days after the patient’s admission, she (Patient 27’s wife) was told that the HHA did not have enough staff for PT and ST. Patient 27’s wife stated that the HHA took on more patient’s than they could care for. Patient 27’s wife stated although she had private caregivers for Patient 27, at times, the patient still needed professional help from nurses with bathing and wound care right away. Patient 27’s wife also stated that because of Patient 27’s Parkinson’s disease, he needed ST as soon as possible to prevent him from declining in the progress he had made with eating by mouth. Patient 27’s wife further stated that the HHA should have informed the General Acute Care Hospital 1 (GACH1) that referred Patient 27 to them, that they were unable to provide the services requested at the moment. During a concurrent interview and record review on 7/3/2025 at 11:55am with Care Coordinator 1 (CC1), patient 27’s EMR was reviewed. Patient 27’s EMR indicated a physician order dated 3/29/2025, unsigned by the physician, the order indicated patient requested for medical social worker (MSW) evaluation to be done on 3/30/2025, PT evaluation to be done on 4/4/2025 and for HHA to help out on 4/4/2025. Patient 27’s EMR also indicated an inter-communication note dated 3/31/2025 indicated the HHA Staffer informed Patient 27’s wife that the HHA was experiencing a delay in Speech Therapy (ST) services and would follow up with her once a response of when ST services would start for Patient 27. CC1 stated and confirmed that the agency was experiencing a shortage with HHA staff and was having issues with the contracted Speech Therapist company which was causing a delay in providing those services. CC1 stated Patient 27’s wife was demanding, and some speech therapists were not willing to go and provide service because of that. CC1 stated when a patient referral arrives, a staffer assigns clinicians to the patient, a nurse, aide or therapist depending on the physician order for services, and those clinicians are to contact and visit the patient within 48 hours. CC1 stated if the visit is not able to be done within 48 hours because the patient is not available or stated if the agency does not have staff at the moment then a communication note is made, the patient is notified, and the physician is also notified. CC1 stated and confirmed that Patient 27’s physician order dated 3/29/2025 was a late notification of delay in services because the patient was to be reached out to and notified within 48 hours of referral or start of care. CC1 also stated and confirmed that the inter-communication note dated 3/31/2025 was a late notification for delay or service, past the 48 hours of SOC/referral. CC1 stated she was aware that Patient 27’s wife was made aware of ST services being delayed before 3/31/2025, but stated there is no documentation to support that in the patient’s EMR. CC1 stated she was the care coordinator for Patient 27 and spoke frequently with Patient 27’s wife. During a concurrent interview and record review on 7/3/2025 at 1:45pm with the DPCS, Patient 27’s EMR was reviewed. The DPCS stated and confirmed Patient 27’s EMR indicated: An authorization from GACH1, dated 3/20/2025, for Physical therapy evaluation high complex 45 minutes for 1 visit request, physical therapy in home for three visits request, speech therapy for sound product language evaluation for a one time visit request, home health aide for a one time visit request, social work visit in the home for a one time visit request, nursing assessment/evaluation for a one time visit request and a Registered Nurse home care for a one time visit request. A physician order dated 3/29/2025, unsigned by the physician, that indicated patient requested for medical social worker (MSW) evaluation to be done on 3/30/2025, PT evaluation to be done on 4/4/2025 and for HHA to help out on 4/4/2025. An inter-communication note dated 3/31/2025 that indicated the HHA Staffer informed Patient 27’s wife that the HHA was experiencing a delay in Speech Therapy (ST) services and would follow up with her once a response of when ST services would start for Patient 27. A medical record titled Oasis Nurse start of care dated 3/24/2025 A medical record titled Occupational therapy evaluation note dated 4/2/2025 A medical record titled Physical therapy evaluation note dated 4/4/2025 A medical record titled Note CHHA dated 4/4/2025 A medical record titled Physical therapy discharge summary dated 5/1/2025 A medical record titled Occupational therapy discharge summary dated 5/1/2025 A medical record titled Speech therapy evaluation and care plan note dated 5/6/2025 A medical record titled Oasis Discharge non visit dated 5/22/2025 A medical record titled Speech therapy discharge summary dated 5/28/2025 The DPCS stated and confirmed that the HHA referral for home health services for Patient 27 was dated 3/20/2025 and services for HHA were not started until 4/4/2025 and services for ST were not started until 5/6/2025. The DPCS stated and confirmed that Patient 27’s EMR did not have any documented evidence of why there was a delay of care for Patient 27’s HHA and ST services. The DPCS also stated it is proper practice to document all communication or attempts in communication with the patient and/or family in the patient’s EMR to validate what did or did not happen. The DPCS further stated Patient 27’s physician orders were not followed, as the HHA did not provide Patient 27 with HHA or speech therapy services on time or within 48 hours of referral as per their policy. The DPCS stated moving forward she will inform all HHA staff that all communication with patients and/or family should be documented under a communication note. During a concurrent interview and record review on 7/3/2025 at 2:00pm with the DPCS, Patient 27’s medical record titled Plan of Care (POC) dated 3/24/2025, for the certification period of 3/24/2025 to 5/22/2025 was reviewed. The POC indicated a Skilled Nursing treatment plan with an effective date of RN/LVN frequency visits to start as of 3/24/2025, a Physical Therapy treatment plan with an effective date frequency visit to start as of 4/4/2025, an Occupational Therapy treatment plan with an effective date frequency visit to start as of 3/31/2025, and a Home Health Aide plan with an effective date of 3/31/2025. The DPCS stated and confirmed Patient 27’s POC was not followed because the physician ordered care services were delayed and not started as ordered. During a review of the HHA’s policy and procedure (P&P) titled, Care Planning Process, undated, indicated the purpose of this policy was to provide clinical direction to clinicians providing direct patient care and the care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals. The P&P further indicated the plan of care will be based upon the physicians orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. During a review of the HHA’s P&P titled, Intake Process, undated, indicated, “ 5. During scheduled working hours (office hours are from 8:30 a.m. to 5:30 p.m. Monday through Friday), calls will first be received by the receptionist. Patient referral calls will be transferred to an intake specialist designated to accept referrals. E. The assigned staffer will assign personnel and schedule an assessment visit. This initial visit will be performed either within 48 hours of the referral, or within 48 hours of a patient’s return home, or on the start of care date ordered by the physician (or other authorized licensed independent practitioner). F. If service cannot be provided, intake personnel will give the caller the names of other agencies than can provide the required services. A log will be maintained on all patients who cannot be serviced.” During a review of the HHA’s P&P titled Admission Criteria and Process, undated, indicated, “Patients will be accepted for care based on the adequacy and suitability of organization personnel, resources to provide required services, and the reasonable expectation that the patient’s medical, nursing, rehabilitative, and social needs can be adequately met in the patient’s place of residence. 2. The Clinical Supervisor will assign clinical organization personnel to conduct assessments of eligibility for services within 48 hours of acceptance of referral information and/or discharge from a referring facility. A. The initial visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, or on the start of the care date ordered by the physician (or other authorized licensed independent practitioner).” The P&P also indicated, “4. In the event that the time frame for assessment cannot be met, the patient’s physician and the referral source, as well as the patient, will be notified for approval of the delay. A. Such notification and approval will be documented. 8. If approval is not obtained for the delay, the patient will be referred to another organization for services. 16. The initial written assessment will be completed within 24 hours of the original assessment/admission visit. All documentation needed to develop the plan of care will be completed and turned into the office no later than the next business day. 17. A comprehensive assessment must be completed within five (5) calendar days of the patient’s start of care.” During a review of the HHA’s P&P titled, Physician Participation in Plan of Care, undated, indicated, “ A physician will direct the care of every home health patient admitted for service. The attending physician will certify that medical, skilled, rehabilitation, and social services provided by the organization are medically necessary... The care will be provided in compliance with his/her therapeutic and diagnostic orders and accepted standards and practice.””

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Comprehensive Assessment of Patients as follows: The HHA failed to review and document all medication changes and update the medication profile with currently used medications for four of 17 sampled patients (Patient 1, Patient 2, Patient 7, and Patient 8). This deficient practice had the potential to put the patients at risk for medication errors and adverse drug reactions. (refer to G536) The HHA failed to ensure an ongoing comprehensive assessment (an assessment used to evaluate a patient’s overall health, including identifying the patient’s need for home health care) was conducted for one of 17 sampled patients (Patient 4) by failing to: Ensure the licensed nurses (in general) assessed and monitored Patient 4’s left lateral (to the side of, or away from, the middle of the body) leg wound (wound #2) and left lateral foot wound (wound #3). Ensure the licensed nurses (in general) notified Patient 4’s physician of Patient 4’s need for care orders related to Patient 4’s left lateral foot wound (wound #3). Ensure the licensed nurses obtained wound care treatment order from a physician to treat Patient 4’s lateral foot wound (wound #3). (Refer to G544). As a result, Patient 4’s did not receive care and assessment to promote healing and did not receive wound care treatment for left lateral leg wound (wound #2) and left lateral foot wound (wound #3) from 4/14/25 to 5/8/25 totaling 24 days. This failure placed Patient 4 at risk of wound complications, such as delayed healing and infection, which placed Patient 4 at risk of hospitalization and/or death. The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulation for comprehensive assessment of patients to ensure the highest quality of care were being provided to patients certified to receive home health care and services.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Care planning, coordination, and quality of care was met as follows: b. The Home Health Agency (HHA) did not follow the Plan of Care for two of seventeen sampled patients (Patient 1, Patient 2) This deficient practice could have resulted in Patient 1, Patient 2 having a change of condition, decline in health that could have led to possible hospitalization. (refer to G572) c. The home health agency (HHA) failed to provide ordered services for two of 17 sampled patients (Patient 14, and Patient 15) ordered by the physician. This failure caused Patient 14 and Patient 15 to not to receive additional assistance required to meet their care needs and improve their overall health. (refer to G580) d. The Home Health Agency (HHA) did not report promptly to the ordering physician for four of seventeen sampled patients (Patient 1, Patient 4, Patient 14, and Patient 15) a. report Patient 1’s oxygen level b. report Patient 4’s change of condition, wounds and refusal of care c. report Patient 14’s services not provided d. report Patient 15’s services not provided This deficient practice resulted in Patient 1, Patient 4, Patient 14, and Patient 15 not receiving the assessment and care needed, ultimately impacting their recuperation and overall health. (refer to G590) e. The home health agency (HHA) failed to ensure that the Plan of Care was revised and updated to reflect the current health status for three of 17 sampled patients (Patient 4, Patient 7, and Patient 8). This deficient practice had the potential to result in miscommunication among health care providers and lack of care and treatment for the patients’ health management to meet their care needs and goals. (refer to G592) The HHA failed to ensure a plan of care (a written document outlining the specific services and interventions needed to support a person’s health and well-being) was updated, followed and implemented for one of 17 patients (Patient 4) by failing to: Ensure Patient 4’s plan of care for wound care and treatment was followed and implemented for Patient 4’s ulcer (type of wound) to the left lateral (to the side of, or away from, the middle of the body) leg (Wound 2). Ensure Patient 4’s open diabetic ulcer on the left lateral foot (Wound 3) was assessed, had a physician’s order for wound treatment, and that Patient 4’s care plan was updated and implemented for the care of Patient 4’s open diabetic ulcer on the left lateral foot (Wound 3). This deficient practice resulted in Patient 4’s not being provided wound care on Patient 4’s left lateral leg wound (Wound 2) and open diabetic ulcer on the left lateral foot (Wound 3) starting from 4/14/25 to 5/8/25 totaling 24 days. Patient 4 was placed at increased risk for wound complications, such as delayed healing, infection and amputation (a surgical procedure where a part of a limb, such as a finger, toe, hand, foot, arm, or leg, is removed); increasing the risk of hospitalization and/or death. (Refer to G570) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal regulation for compliance with Care planning, coordination, and quality of care which are provided to the patients who are assessed to receive home health care services.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing care to home bound patients [patients with difficulty leaving the house]) failed to ensure the Conditions of Participations regarding Skilled professional services were met as follows: 1.The HHA failed to provide services as indicated in the Plan of Care (POC) for one of seventeen sampled patients (Patient 14). This deficient practice resulted in Patient 14 not receiving the required assistance and care needed that could have caused a declined in overall health (refer to G710). 2. The HHA failed to perform Registered Nurse (RN) supervisory visits (evaluation of the care performed by a LVN) to LVN providing patient care and services to three of 17 sampled patients, (Patient 2, Patient 4 and Patient 8) as indicated in the facility’s policy and procedures, which indicated, to have a process in place for the overseeing of all clinical care and services. This deficient practice had the potential to result in a poor-quality care and inappropriate care and services provided to the patients when the staff (in general) not being evaluated and supervised (Refer to G726). The cumulative effect of these systemic practice resulted in the failure of the HHA to deliver statutorily (written) mandated compliance with maintaining skilled professional services which can potentially affect the patients’ care and services that could lead to potential hospitalization. .”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA, agency providing care to a patient in the comfort of their home) failed to ensure the Condition of Participation for Clinical Records was met as follows: The HHA failed to ensure patients’ clinical records were completed, signed and dated by the author, and authenticated by authorized staff for 13 of 17 sampled patients (Patient 1, Patient 2, Patient 4, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16). This deficient practice resulted in incomplete clinical records and lack of accountability, leading to misinformation within the home health staff and non-continuity of care and services provided to the patients.(Refer to G1024). The cumulative effect of these systemic practice resulted in the failure of the HHA to deliver statutorily (written) mandated compliance with maintaining clinical records that reflect the patients’ past and current information which can potentially affect the patients’ care and services that could lead to potential hospitalization. .”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure an ongoing comprehensive assessment (an assessment used to evaluate a patient’s overall health, including identifying the patient’s need for home health care) was conducted for one of 17 sampled patients (Patient 4) by failing to: Ensure the licensed nurses (in general) assessed and monitored Patient 4’s left lateral leg wound (wound #2) and left lateral foot wound (wound #3). Ensure the licensed nurses (in general) notified Patient 4’s physician of Patient 4’s need for care orders related to Patient 4’s left lateral foot wound (wound #3). Ensure the licensed nurses obtained wound care treatment order from a physician to treat Patient 4’s lateral foot wound (wound #3). As a result, Patient 4 did not receive care and assessment to promote healing; and did not receive wound care treatment for left lateral leg wound (wound #2) and left lateral foot wound (wound #3) from 4/14/25 to 5/8/25 totaling 24 days. This failure placed Patient 4 at risk of wound complications, such as delayed healing and infection, which placed Patient 4 at risk of hospitalization and/or death. On 5/12/2025 at 3:20 pm., the Department called the 2nd Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s Director of Patient Care Services (DPCS), Administrator, and Administrator Designee, related to failure to ensure an ongoing comprehensive assessment (an assessment used to evaluate a patient’s overall health, including identifying the patient’s need for home health care) that reflected the patient’s current health status, was conducted for one of 17 sampled patients (Patient 4). On 5/12/2025 at 3:50 pm, the Department conducted an exit conference with the DPCS, Administrator, and Administrator Designee, with the IJ not removed. .”

“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 observation, interview, and record review the Home Health Agency (HHA) did not follow the Plan of Care for one of seventeen sampled patients (Patient 1). This deficient practice had a potential to result in Patient 1 to have a change of condition, decline in health that could have led to possible hospitalization. Findings: During a record review of Patient 1’s Patient Information sheet indicated Patient 1’s start of care was 04/03/2025, with a primary diagnosis of urinary tract infection (is when bacteria gets into your urine and travels up to your bladder). During a record review of Patient 1’s medical record form titled “Plan of Care” dated from 04/03/2025 to 06/01/2025, indicated the SN was to notify physician if: O2 saturation (oxygen saturation referring to the percentage of hemoglobin in your blood that is carrying oxygen a healthy oxygen saturation level is typically between 95% and 100% this means that a significant portion of your red blood cells are carrying oxygen, which is essential for providing oxygen to the blood tissues and organs) is less than 92% or lower. During an observation on 05/08/2025 at 11:20 a.m., a joint home visit with RN 1 at Patient 1’s residence RN 1 was observed taking patient 1’s vital signs. Patient 1’s O2 saturation was 91% while breathing room air. During an interview on 05/08/2025 at 11:45 a.m., with RN 1, RN 1 was asked if there are any reportable findings to the MD, RN 1 stated, “no all of Patient 1’s vitals are within normal limits, 91% O2 saturation is normal.” During an interview on 5/9/2025 at 1:35 p.m., with DPCS, DPCS stated, “RN one should have followed the plan of care and reported the oxygen saturation of 91% to the doctor.” During a review of the HHA’s Policy and Procedure (P&P) titled, Monitoring Patient’s Response/Reporting to Physician, undated, indicated, “Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient.” The P&P also indicated, “3. The patient’s physician will be contacted on the same day when any of the following occur: E. Changes-‘that have occurred regarding diagnoses, prognosis, or treatment (including procedures, medications, precautions, and limitations)... 4. All conferences or attempts to communicate with the physician will be documented in the clinical record. A. Documentation of physician notification will include: 1. Date and time contacted 2. Patient name 3. Name of physician notified or his/her representative 4. Reason for notification 5. Physician’s response 6. Action taken or orders obtained 7. Professional’s signature and title”.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure patients’ clinical records were completed, signed and dated by the author, and authenticated by authorized staff for 13 of 17 sampled patients (Patient 1, Patient 2, Patient 4, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16). This deficient practice resulted in incomplete clinical records and lack of accountability, leading to misinformation within the home health staff and non-continuity of care and services provided to the patients. E. A review of Patient 10’s face sheet indicated he was admitted to the Home Health Agency (HHA) on 5-2-25, with admitting diagnosis of an open wound on right knee. A review of the agency’s document entitled “plan of care summary” indicated skilled nurse visits of 3x/wk and PT visits 2x/wk. A review of the agency’s document entitled “physician’s order” with the following dates 5-1-25 and 5-2-25 were not signed by physician. On 5-9-25 at 11:50am an interview was conducted with the DPCS in the agency conference room. When asked about MD orders not being signed for all patient’s she stated it is accessible on EPIC and electronically signed. She stated it should be applied to our EMR (Netscape) but its not. DPCS stated its important to have a signed MD order so staff can be assured that’s what MD actually wanted for the patient. F. A review of patient 11’s face sheet indicated he was admitted to the Home Health Agency (HHA) on 4-26-25. With an admitting diagnosis of an abnormally high concentration of fats or lipids. A review the agency’s documentation entitled “plan of care summary” indicated PT visits 2x/week and OT visits 2x/week. A review of the agency’s document entitled “physician’s order” with the following dates 4-24-25, 4-26-25, 4-28-25, 5-2-25, and 5-8-25 (2) were not signed by physician. On 5-9-25 at 11:50am an interview was conducted with the DPCS in the agency conference room. When asked about MD orders not being signed for all patient’s she stated it is accessible on EPIC and electronically signed. She stated it should be applied to our EMR (Netscape) but its not. DPCS stated its important to have a signed MD order so staff can be assured that’s what MD actually wanted for the patient. G. A review of patient 13’s face sheet indicated she was admitted to the Home Health Agency (HHA) on 2-10-25 with an admitting diagnosis of pressure ulcer of sacral region, stage 2 and pressure-induced deep tissue damage of left heel. A review of the agency’s documentation entitled “plan of care summary” indicated PT13 visits of skilled nurse visits 3x/week, HHA visits 2x/week, PT visits 1x/week, OT visits 1x/week and MSW 1x/week. A review of the agency’s document entitled “physician’s order” with the following dates 2-10-25, 2-11-25, 2-19-25, and 3-5-25, were not signed by physician. On 5-9-25 at 11:50am an interview was conducted with the DPCS in the agency conference room. When asked about MD orders not being signed for all patient’s she stated it is accessible on EPIC and electronically signed. She stated it should be applied to our EMR (Netscape) but its not. DPCS stated its important to have a signed MD order so staff can be assured that’s what MD actually wanted for the patient. H. A review of patient 16’s face sheet indicated she was admitted to the Home Health Agency (HHA) on 1-14-25 with an admitting diagnosis of type 2 diabetes (type of diabetes mellitus with high blood sugar and insulin resistance). A review of the agency’s documentation entitled “plan of care summary” indicated PT16 had only (5) PT visits once per week. A review of the agency’s document entitled “physician’s order” with the following dates 1-11-25 and 1-18-25 were not signed by physician. On 5-9-25 at 11:50am an interview was conducted with the DPCS in the agency conference room. When asked about MD orders not being signed for all patient’s she stated it is accessible on EPIC and electronically signed. She stated it should be applied to our EMR (Netscape) but its not. DPCS stated its important to have a signed MD order so staff can be assured that’s what MD actually wanted for the patient. During and interview on 5/9/2025 at 1:10pm with the Director of Patient Care services (DPCS), the DPCS stated the ordering physician for each patient will send orders via fax or email to the HHA or provide verbal orders as well. The DPCS stated all orders are to transcribed into the patient’s Electronic Medical Record (EMR). The DPCS also stated the orders that are faxed or emailed to the HHA are to be uploaded to the patient’s EMR for verification and validation of order and signature. b. A review of Patient 7’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 3/17/2025 with a primary diagnosis of Hemiplegia following cerebral infarct affecting right dominant side (condition of being paralyzed or complete loss of strength on one side of the body due to deficiency of blood flow to the brain causing brain tissue death) and a secondary diagnosis of bed confinement status. During a review of Patient 7’s medical record titled, Plan of Care (POC), for the certification period of 3/17/2025 to 5/15/2025 indicated, a frequency order for Physical Therapist (PT)/ Physical Therapist Assistant (PTA) one time a week for I week starting 4/23/2025, one time a week for one week starting 4/27/2025, one time a week for one week starting 4/30/2025, two times a week for 1 week starting 5/4/2025, and one time a week for one week starting 5/11/2025. Patient 7’s POC also indicated an order for skilled observation and assessment of vital signs, response/compliance with treatment, home safety, assess musculoskeletal status, instruct on disease process and sign/symptoms, treatment/management, instruct on patient/caregiver on emergency measures and when to call PT/ medical doctor/911 for any significant changes/findings. During a review of Patient 7’s Electronic Medical Record (EMR), the EMR indicated physician orders for Patient 7 dated 3/16/2025, 3/25/2025, 4/10/2025, 4/17/2025, 4/22/2025, 4/23/2025, 5/2/2025, and 5/7/2025 with no documented evidence of a physician signature. During a review of Patient 7’s EMR, the EMR indicated POC’s dated 3/17/2025, and 4/22/2025 with no physician signature. During a concurrent interview and record review on 5/9/2025 at 1:51pm with the Director of Patient Care Services (DPCS), Patient 7’s EMR was reviewed. The DPCS stated and confirmed Patient 7’s EMR had physician orders dated 3/16/2025, 3/25/2025, 4/10/2025, 4/17/2025, 4/22/2025, 4/23/2025, 5/2/2025, and 5/7/2025 and were not signed by the ordering physician. The DPCS stated all orders should be signed because it shows that the order was done, approved and validated. The DPCS also stated and confirmed Patient 7’s EMR indicated POC’s dated 3/17/2025 and 4/22/2025 with no signature from the ordering physician. The DPCS stated the ordering physician is to sign all POCs to validate the patient’s care plan. c. A review of Patient 8’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 1/29/2025 with a primary diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing causing damage to the tiny blood vessels in the kidneys) and other diagnosis of gangrene (condition where tissue dies due to loss of blood supply), and encounter for change or removal of surgical wound dressing. During a review of Patient 8’s medical record titled, Plan of Care (POC), for the certification period of 3/30/2025 to 5/28/2025 indicated, a recertification frequency order for Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) for one time a day for seven days starting 4/8/2025 with an estimate of services to be required for 9 weeks. Patient 8’s POC also indicated order for skilled nurse (SN) to educate the patient about the signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), pain management, medication management/compliance, and assess/perform/ instruct the patient/caregiver on wound care to left foot to paint left forefoot with betadine solution (topical antiseptic used to kill bacteria, fungi, viruses) and cover with dry dressing fluffs and kerlix, and ace wrap daily. During a review of Patient 8’s Electronic Medical Record (EMR), the EMR indicated physician orders for Patient 8 dated 3/27/2025, 3/28/2025 and 4/8/2025 with no documented evidence of a physician signature. During a concurrent interview and record review on 5/9/2025 at 2:15pm with the DPCS, Patient 8’s EMR was reviewed. The DPCS stated and confirmed Patient 8’s EMR had physician orders dated 3/27/2025, 3/28/2025 and 4/8/2025 that were not signed by the ordering physician. The DPCS stated all orders should be signed because it shows validation of orders and that they will be done. d. A review of Patient 9’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 3/27/2025 with a primary diagnosis of Type 2 diabetes mellitus with foot ulcer (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Patient 9’s medical record titled, Plan of Care (POC), for the certification period of 3/27/2025 to 5/25/2025 indicated, a frequency order for Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) for one time a week for 1 week starting 3/26/2025, three times a week for one week starting 3/31/2025, three times a week for one week starting 4/7/2025, and one time a week for one week starting 4/11/2025. During a review of Patient 9’s Electronic Medical Record (EMR), the EMR indicated a physician order for Patient 9 dated 4/12/2025 with no documented evidence of a physician signature. During a review of Patient 9’s EMR, the EMR indicated a POC dated 3/27/2025, for the certification period of 3/27/2025 to 5/25/2025, with no documented evidence of a physician signature. During a concurrent interview and record review on 5/9/2025 at 3:25pm with the DPCS, Patient 9’s EMR was reviewed. The DPCS stated and confirmed Patient 9’s EMR had a discharge physician order dated 4/12/2025 and was not signed by the ordering physician. The DPCS stated and confirmed it has been 26 days since Patient 9 was discharged from the HHA. The DPCS also stated and confirmed Patient 9’s EMR indicated a POC for the certification period of 3/27/2025 to 5/25/2025 with no signature from the ordering physician. The DPCS stated and confirmed that was the last formulated POC for Patient 9 before being discharged on 4/12/2025. k. A review of Patient 14’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 1/3/2025 with a primary diagnosis of unspecified physical fracture of lower end of right tibia (section of the shin bone that forms the inner part of the ankle joint) and secondary diagnosis of encounter for other specified surgical aftercare. During a review of Patient 14’s medical record titled, Plan of Care (POC), for the certification period of 1/3/2025 to 3/3/2025 indicated, a frequency order for Physical Therapist (PT)/ Physical Therapist Assistant (PTA) evaluation one time a week for one week starting 1/27/2025, PT/PTA one time a week for one week starting 1/29/2025, PT/PTA one time a week for one week starting 2/2/2025, Occupational Therapy (OT)/ Certified Occupational Therapy Assistant (COTA) one time a week for two weeks starting 1/10/2025, OT/COTA one time a week for one week starting 1/29/2025, and Home Health Aide (HHA) one time a week for one week starting 1/20/2025. During a review of Patient 14’s Electronic Medical Record (EMR), the EMR indicated physician orders for Patient 14 dated 12/27/2024, 1/3/2025, and 1/29/2025 with no documented evidence of a physician signature. During a review of Patient 14’s EMR, the EMR indicated a POC dated 1/3/2025, for the certification period of 1/3/2025 to 3/3/2025 with no physician signature. During a review of Patient 14’s medical record titled Audit log for the dates o 5/7/2025 to 5/9/2025 it indicated the Case Coordination note dated 1/24/2025 was created and documented on 5/8/2025 by Case Coordinator 1 (CC1). During a concurrent interview and record review on 5/9/2025 at 12:35pm with the Administrator Designee (ADMD), Patient 14’s EMR was reviewed. Patient 14’s medical record titled Audit log for the dates of 5/7/2025 to 5/9/2025 indicated Patient 14’s care coordination note dated 1/24/2025 was created and documented on 5/8/2025 by CC1. The ADMD stated and confirmed that the care coordination note dated 1/24/2025 was created and documented by CC1 on 5/8/2025. During a concurrent interview and record review on 5/9/2025 at 2:21pm with Care Coordinator 1 (CC1), Patient 14’s EMR was reviewed. Patient 14’s EMR indicated a care coordination note dated 1/24/2025 by CC1. CC1 stated she did document the care coordination note dated 1/24/2025. CC1 stated and confirmed she did not document the care coordination note on 1/24/2025 as the document indicated and confirmed she had created and documented the note on 5/8/2025. The CC1 further stated she was asked on 5/8/2025 by DPCS to assist in verifying why Patient 14’s EMR indicated a delay of care with the Physical Therapist (PT), the home health aide (HHA) and speech therapy evaluation. CC1 stated she called and spoke with the physical therapist, the home health aide and the contracted speech therapy company that were assigned to the patient to gather information as to why there was a delay of care. CC1 stated and confirmed there was no documented evidence in Patient 14’s EMR of the physical therapist, the HHA or speech therapist documenting the reason of delay of care for their services. CC1 also stated the care coordinator for Patient 14, during the time of services with the HHA, does not work for HHA anymore. CC1 stated her documentation was not accurate as she did not document in real time and date and instead backdated the note. CC1 stated the importance of documenting in real time and date is to gather current and accurate information with all parties involved and stated she was not able to get the facts from the patient or family member because she investigated after Patient 14’s discharge date of 2/4/2025. During a concurrent interview and record review on 5/9/2025 at 3pm with the DPCS, Patient 14’s EMR was reviewed. The DPCS stated and confirmed Patient 14s EMR had physician orders dated 12/27/2024, 1/3/2025, and 1/29/2025 that were not signed by the ordering physician. The DPCS stated and confirmed it has been 94 days since Patient 14 was discharged from the HHA. The DPCS also stated and confirmed Patient 14’s EMR indicated a POC for the certification period of 1/3/2025 to 3/3/2025 with no signature from the ordering physician. The DPCS stated and confirmed that it was the last formulated POC for Patient 14 before being discharged on 2/4/2025. During a concurrent interview and record review on 5/9/2025 at 3:05pm with the DPCS, Patient 14’s EMR was reviewed. The DPCS stated and confirmed Patient 14s EMR indicated a care coordination note dated 1/24/2025. During review of Patient 14’s medical record titled audit log from dates of 5/7/2025 to 5/9/2025, the DPCS stated and confirmed that Patient 14’s care coordination note dated 1/24/2025 was created and documented on 5/8/2025 by CC1. The DPCS stated it was not correct documentation practice for the CC1 to backdate the care coordination note. The DPCS stated the care coordinator, at the time of the occurrence, the physical therapist and the speech therapist should have documented in real time, their own note as to why there was a delay of care. The DPCS stated that authentication of documentation is important because it validates what happened, when it happened and assist in coordination of care. During a review of the HHA’s Policy and Procedure (P&P) titled, Verification of Physician orders, undated, indicated, “8. A copy of the order will be kept in the patient’s clinical record... 10. Signed orders will be placed in the clinical record within 30 days of initiation of the order, unless otherwise specified by applicable state law and regulation. The unsigned copy of the order will be removed from the record.” During a review of the HHA’s P&P titled Physician Participation in Plan of care, undated, indicated, “5. The attending physician (or other authorized licensed independent practitioner) will sign the individualized plan of care/treatment within 30 days of the start of care, unless otherwise specified by applicable state law and regulation.” A review of Patient 4’s Patient Profile indicated that Patient 4, an 82-year-old male, was admitted to HHA on 2/8/2025, with home health recertification on 4/9/2025- 6/7/2025, with diagnosis of Type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar and using it in the body), diabetic polyneuropathy (a nerve damage condition that arises as a complication of diabetes), foot ulcer (an open sore on the foot that fails to heal and can involve skin, tissue, and potentially deeper structures like bones), and chronic foot ulcer (a persistent, open sore on the foot that fails to heal within a reasonable timeframe, often due to underlying conditions like diabetes, poor circulation, or peripheral neuropathy). A review of Patient 4’s medical record Skilled Nurse Supervisory Visit, dated 4/21/2025, indicated that DPCS performed a supervisory visit. The medical record indicated that there was a manual clock in at 5:00pm and a manual clock out at 5:30pm by Director of Patient Care Services. During an interview on 5/9/2025 at 3:30 pm, Care Coordinator 3 (CC3) stated she created and filled out the Skilled Nursing Supervisory Visit, dated 4/21/2025 in Patient 4’s medical record. CC3 entered the information into Patient 4’s medical record on 5/8/2024 (17 days after the entry reported). CC4 stated that she was verbally told by the DPCS what to enter under the DPCS name. During an interview on 5/9/2025 at 3:35pm, Director of Patient Care Services (DPCS) stated that she did not enter the information contained in Patient 4’s medical record titled, Skilled Nursing Supervisory Visit,” dated 4/21/2025. DPCS stated that she called CC3 on 5/8/2025 and told her what to enter into the medical record under the DPCS name. DPCS stated a skilled supervisory visit requires a Registered Nurse to perform and that CC3 was not a registered nurse. A review of the facility’s undated policy titled, “Entries into the Clinical Record,” indicated that, “entries into the clinical record will be made on the day care is provided to the patient.” The policy further indicated that clinical note will include the signature of the clinician and his/her credentials.” Findings: a. During a review of Patient 1’s Patient Information sheet indicated Patient 1’s start of care was 04/03/2025, with a primary diagnosis of urinary tract infection. During a review of Patient 2’s Electronic Medical Record (EMR, is the systematized collection of electronically stored patient and population health information in a digital format), the EMR indicated the plan of care, dated 4/03/2025 to 6/01/2025 there was no documented evidence of a physician signature. During a concurrent interview and record review on 5/9/2025 at 1:34 p.m., with the DPCS, Patient 1’s EMR was reviewed. The DPCS stated and confirmed Patient 2’s EMR had no evidence of physician signature on the plan of care. DPCS stated it is important to have the plan of care signed by the physician so the nurses can accurately follow a plan of care which has been validated by the physician. b. During a review of Patient 2’s Patient Information sheet indicated Patient 2’s start of care date was 10/15/2024, with a primary diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy. During a review of Patient 2’s Electronic Medical Record (EMR), the EMR indicated the physician orders for Patient 2 dated 2/18/2025, 3/03/2025, 3/17/2025, 3/30/2025 and 4/28/2025 with no documented evidence of a physician signature. During a review of Patient 2’s EMR, the EMR indicated the plan of care, dated 4/13/2025 to 6/11/2025 there was no documented evidence of a physician signature. During a concurrent interview and record review on 5/9/2025 at 1:27 p.m., with the DPCS, Patient 2’s EMR was reviewed. The DPCS stated and confirmed Patient 2’s EMR had physician orders dated 2/18/2025, 3/03/2025, 3/17/2025, 3/30/2025 and 4/28/2025 that were not signed by the Medical Director 1 (MD1). The DPCS stated and confirmed there was no physician signature on Patient 2’s plan of care. The DPCS stated all plan of care documents and physician orders should be signed because it would showed validation of orders and that they would be done.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to review and document all medication changes and update the medication profile with currently used medications for four of 17 sampled patients (Patient 1, Patient 2, Patient 7, and Patient 8). This deficient practice had the potential to put the patients at risk for medication errors and adverse drug reactions. A. During a record review of Patient 1’s Patient Information sheet indicated Patient 1’s start of care was 04/03/2025, with a primary diagnosis of urinary tract infection (an infection in any part of the urinary system including the kidneys the bladder and the urethra). During a concurrent observation, interview and record review on 5/8/2025, at 11:24 a.m., at the home visit on Registered Nurse 1 (RN 1), reviewed Patient 1’s medications using the patients record titled, “Patient Medication Profile”, dated 5/7/2025. The following medication was present in Patient 1’s residence but not listed on the Patient Medication Profile: The label for medication Budesonide Inhaler suspension(a corticosteroid medication used to reduce inflammation in the body used to treat asthma) 0.5mg/2ml suspension for nebulizer (a medical device that converts liquid medication into a fine mist that can be inhaled through the lungs) indicated to take 2ml(ml-milliliters, unit of measurement) via nebulizer 2 times a day. RN 1 stated, “ I haven’t seen this medication before. I have only seen Patient 1 a few times. The nurse that does the regular visits is supposed to check all the medications the Patient is talking and update it in our system. This medication is not on our medication profile.” During an interview on 5/8/2025 at 11:30 am with Patient 1’s Caregiver, he stated “Patient 1 has been using this medication for at least 2-3 weeks now.” B. During a review a record review of Patient 2’s Patient Information sheet indicated Patient 2’s start of care date was 10/15/2024, with a primary diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy (a condition where nerves are damaged due to prolonged high blood sugar levels). During a concurrent observation, interview and record review at the home visit on 5/8/2025, at 12:31 p.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Patient 2’s “Patient Medication Profile”, dated 5/7/2025. The following medication had the wrong frequency listed: Calcium acetate (a medication used to treat too much phosphate in the blood prescribed to patients with end stage kidney disease who are on dialysis) on the medication profile indicated 667mg, one tablet by mouth three times a day. The medication label dispensed by pharmacy indicated calcium acetate 667 mg, take 3 tab by mouth three times a day. LVN 1 stated, “this wasn’t updated in our system, our medication profile indicated only 1 tab by mouth 3 times a day but the actual prescribed dose from the pharmacy is 3 tabs by mouth three times a day. I am not the regular nurse for this patient but the nurse that visits this patient on the regular bases should have caught this and updated it in our system.” During a concurrent observation, interview and record review at the home visit on 5/8/2025, at 12:33 PM, with LVN 1, the following medications were present at Patient 2’s residence which were not listed on the Patient Medication Profile, dated 5/7/2025 : lovastatin 40 milligram tab (a medication used to treat high cholesterol levels in the blood) take one tablet by mouth every evening, zinc 50 milligram over the counter (a chemical element used to benefit people with low levels of zinc), iron 65 milligrams over the counter (a supplement used to treat low iron levels in the blood) and B12 5000 micrograms over the counter (a vitamin supplement to treat low vitamin B levels in the blood). LVN 1 stated, “these medications should have all been listed on our medication profile. The ongoing regular nurse should have went through the medications and updated our system to indicate all the medications including the vitamins.” During an interview on 5/9/2025 at 1: 20 with DPCS, DPCS stated, “ the skilled visiting nurses are supposed to be looking at the patients medications during every visit and updated the medical record if there are any changes in the medication to reflect patients medication profile accurately.” a. A review of Patient 7’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 3/17/2025 with a primary diagnosis of Hemiplegia following cerebral infarct affecting right dominant side (condition of being paralyzed or complete loss of strength on one side of the body due to deficiency of blood flow to the brain causing brain tissue death) and a secondary diagnosis of bed confinement status. During a review of Patient 7’s medical record titled, Plan of Care (POC), for the certification period of 3/17/2025 to 5/15/2025 indicated, a frequency order for Physical Therapist (PT)/ Physical Therapist Assistant (PTA) one time a week for I week starting 4/23/2025, one time a week for one week starting 4/27/2025, one time a week for one week starting 4/30/2025, two times a week for 1 week starting 5/4/2025, and one time a week for one week starting 5/11/2025. Patient 7’s POC also indicated an order for skilled observation and assessment of vital signs, response/compliance with treatment, home safety, assess musculoskeletal status, instruct on disease process and sign/symptoms, treatment/management, instruct on patient/caregiver on emergency measures and when to call PT/ medical doctor/911 for any significant changes/findings. During a review of Patient 7’s medication profile dated 4/22/2025 it indicated medications of: Pacerone (medication used to treat life threatening heart rhythm problems) 200 milligrams (mg- unit of measurement) 1 tablet daily orally Norvasc (medication used to treat high blood pressure and chest pain) 10mg 1 tablet daily orally Colace (medication used to make bowel movements softer and easier to pass) 250mg 1 tablet daily orally Crestor (medication used to lower the risk of a heart complications) 20mg 1 tablet daily orally Sensipar (medication used to lower the amount of calcium in the blood) 80mg 1 tablet daily Lasix (medication used to treat fluid retention and swelling in the body) 80mg 1 tablet daily During a joint home visit on 5/8/2025 at 10:57am, at Patient 7’s resident with Physical Therapist 1 (PT1) Patient 7 was observed lying on a hospital bed with the head of the bed elevated, awake, alert and oriented to self, date, time and location. Patient 7 was observed able to communicate her needs. During a joint home visit on 5/8/2025 at 11:13am, at Patient 7’s residence with PT1, Patient 7’s medications were reviewed. Upon review of Patient 7’s medication bottles, it was noted a medication bottle for Levothyroxine (medication used to treat underactive thyroid gland) and a medication bottle for Tylenol (medication used to treat minor aches and pains and reduces fever). During a review of Patient 7’s medication profile dated 4/22/2025 it did not indicate an order for Patient 7’s medication bottle Levothyroxine and Tylenol. Patient 7’s daughter stated Patient 7 takes Tylenol for her pain every so often. Patient 7’s daughter also stated the day prior a staff member for the HHA came over to Patient 7’s home to review the medications. When reviewing Patient 7’s medication list in her HHA booklet, the medications on that list did not reflect the medications on Patient 7’s POC and medication profile the HHA had. During an interview on 5/9/2025 at 1:18pm with the Director of Patient Care Services (DPCS), the DPCS stated the Skilled Nurse (SN) is to do a review of the patient’s medication at every visit. The DPCS stated the SN is to have the medication list with them and compare it with the patient’s home medication bottles. The DPCS also stated the SN is to ask the patient or family if there are any new medication order since the last home visit, and if there is, the SN is to update the medication list in the patient’s booklet at home, update the medication profile in the Electronic Medical Record (EMR), update the POC and notify the HHA of the changes. The DPCS further stated the importance of the SN to do medication reconciliation at every home visit is to prevent medication errors and provide education to the patient/family about the right medication, the right route to be give, the right dose to take, the side effects, contraindications and what the medication is for. During a concurrent interview and record review on 5/9/2025 at 1:53pm with the DPCS, Patient 7’s EMR was reviewed. The DPCS stated and confirmed that Patient 7’s POC and medication profile did not include a medication order for Tylenol or Levothyroxine. The DPCS was made aware that Patient 7’s medication list in her HHA booklet at home was updated to reflect the current medications the patient is taking, but the POC and medication profile were not updated. The DPCS stated Patient 7’s POC and medication profile in the EMR were to have been updated, as well, by the PT1 and notify the patient’s case manager about the changes. b. A review of Patient 8’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 1/29/2025 with a primary diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing causing damage to the tiny blood vessels in the kidneys) and other diagnosis of gangrene (condition where tissue dies due to loss of blood supply), and encounter for change or removal of surgical wound dressing. During a review of Patient 8’s medical record titled, Plan of Care (POC), for the certification period of 3/30/2025 to 5/28/2025 indicated, a recertification frequency order for Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) for one time a day for seven days starting 4/8/2025 with an estimate of services to be required for 9 weeks. Patient 8’s POC also indicated order for skilled nurse (SN) to educate the patient about the signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), pain management, medication management/compliance, and assess/perform/ instruct the patient/caregiver on wound care to left foot to paint left forefoot with betadine solution (topical antiseptic used to kill bacteria, fungi, viruses) and cover with dry dressing fluffs and kerlix, and ace wrap daily. During a review of Patient 8’s medication profile undated, it indicated medications of: Metoprolol tartrate (medication to treat high blood pressure, chest pain or heart failure) 100 milligrams (mg- unit of measurement) take two tablets orally two times daily Clonidine (medication to treat high blood pressure) 0.2mg/24 hour weekly transdermal (skin) patch place 1 patch one time weekly Minoxidil (medication to treat high blood pressure) 2.5mg take 1 tablet orally two times daily Xarelto (a blood thinner medication to treat and prevent blood clots) 2.5mg take 1 tablet orally two times daily Furosemide (a water pill, medication to treat fluid retention and swelling in the body) 80mg take 1 tablet orally one time daily Amlodipine (medication to treat high blood pressure and chest pain) 10mg take 1 tablet orally one time daily Lisinopril (medication to treat high blood pressure, heart failure and reduce the risk of death after a heart attack) 20mg take 1 tablet orally one time daily Trazadone (medication to treat depression) 50mg take 1 tablet orally one time daily Lipitor (medication to treat high cholesterol [when you have too much of a fatty substance in your blood]) 40mg take 1 tablet orally one time daily Aspirin (medication to treat pain, fever, headache, inflammation and prevent blood clots) 81mg delayed release (action that postpones the release of the medication until a specific time after administration) take 1 tablet orally one time daily Clonidine (medication to treat high blood pressure) 0.2mg take 1 tablet orally as needed daily if systolic blood pressure (the highest blood pressure reading during a heartbeat) is more than 160 or diastolic blood pressure (the pressure in the arteries when the heart is at rest between beats) more than 100 Velphoro (medication that helps prevent low levels of calcium in the blood) 500mg chewable tablet take 2 tablets orally three times daily During a joint home visit on 5/8/2025 at 12:10pm with Licensed Vocational Nurse 2 (LVN2), at Patient 8’s residence, Patient 8 was observed sitting up on his bed awake, alert, oriented to self, time, place and location and able to communicate his needs. During a concurrent interview and record review on 5/8/2025 at 12:40pm with LVN2 at Patient 8’s residence, Patient 8’s medications were reviewed. During a review of Patient 8’s medication bottles with Patient 8’s medication profile it was noted that the medication profile did not include patient 8’s current medication bottle of hydrocodone (strong class of pain medication) 5/325 mg take 1 tablet orally every 6 hours as needed for pain. LVN2 stated and confirmed Patient 8’s medication profile did not include an order for the medication hydrocodone. During the medication review it was also indicated that Patient 8’s medication bottle for Minoxidil had an order for 10 mg take 1 tablet orally twice a day, and the medication profile indicated and order for Minoxidil 2.5 mg take 1 tablet orally two times daily. Patient 8 stated and confirmed that the order on the medication bottle for Minoxidil is the correct order of how he takes his medication. LVN2 stated and confirmed Patient 8’s order for the medication bottle for Minoxidil did not match the order for Minoxidil in the medication profile. LVN2 was observed updating Patient 8’s medication order for Minoxidil on his medication profile in his HHA booklet, then took a picture of the update list. LVN2 stated she took the picture of the updated medication profile to send it to the HHA so Patient 8’s medication profile on the EMR and the POC can be updated. LVN2 stated if there is a change that needs to be done to the patient’s medication list or POC she can access the EMR and make the changes or she can send the picture of the changes though text messaging, to the case manager and they can make the changes. LVN2 stated she has been doing home visits with Patient 8 daily from Monday through Friday as ordered for wound care. During a concurrent interview and record review on 5/9/2025 at 2:09pm with the DPCS, Patient 8’s EMR was reviewed. The DPCS stated and confirmed that Patient 8’s medication profile did not include an order for the medication Hydrocodone 5/325 mg take 1 tablet orally every 6 hours as needed for pain. The DPCPS was made aware that Patient 8’s medication bottle for Minoxidil had a different order, of 10mg 1 tablet twice a day, than what was on the medication profile, of 2.5mg 1 tablet orally twice daily, and Patient 8 confirmed the medication order on the bottle was the most current order he was taking his medication. The DPCS stated and confirmed Patient 8’s medication profile and the POC indicated an order for Minoxidil that read 2.5 mg take 1 tablet orally twice daily. The DPCS stated she was informed by LVN2 yesterday about updating Patient 8’s medication profile to reflect his current medications, and stated the HHA would be updating the patient’s medication list and the POC in the EMR. The DPCS also stated if LVN2 was visiting the patient daily, Monday through Friday, for wound care, then the medications should have been reviewed daily and any changes should have been promptly made to the medication list and POC. During a review of the HHA’s Policy and Procedure (P&P) titled, Medication profile, undated, indicated, “medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.” The P&P also indicated “4. During subsequent home visits, the emdicationprofile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver,a s well as other clinicians, understand the medication regimen.””

“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 home health agency (HHA) failed to provide ordered services for two of 17 sampled patients (Patient 14, and Patient 15) ordered by the physician. This deficient practice caused Patient 14 and Patient 15 not to receive additional assistance required to meet their care needs and improve their overall health. A review of patient 13’s face sheet indicated she was admitted to the Home Health Agency (HHA) on 2-10-25 with an admitting diagnosis of pressure ulcer of sacral region, stage 2 and pressure-induced deep tissue damage of left heel. A review of the agency’s documentation entitled “plan of care summary” indicated PT13 had home visits ordered of skilled nurse visits 3x/week, HHA visits 2x/week, PT visits 1x/week, OT visits 1x/week and MSW 1x/week. Only skilled nurse visits 3x/week were made, the other disciplines were not done and documented on because agency staff stated PT13 requested no other visits due to pain. On 5-8-25 at 4:40pm a phone interview was conducted with PT 13’s daughter and indicated the family was waiting for all services ordered by MD between 2-10-25 to 2-19-25, she stated only the nurse came and all other disciplines did not show up. When asked if her mother requested to hold all other services to the agency, she stated not to her knowledge. She stated we were waiting for these other services that never came. A review of the agency’s documentation entitled “skilled nurse visit note” dated 2-12-25, 2-14-25, 2-17-25, and 2-19-25 did not indicate any pain for PT13 on each visit by LVN3. Another assessment of PT13 on 2-19-25 by RN2 did not indicate any pain. On 5-9-25 at 1:00pm an interview was conducted with the DPCS in the agency conference room. She stated that only nurse visits were done during the time she was here. She stated PT, OT, HHA, and MSW visits were not being made because the PT13 requested to hold these services due to pain. I told her that a recent interview with PT13’s daughter indicated the family was actually waiting for these services that were ordered by MD and not made. We also checked EMR to see if notes were in the system and no notes could be located. We also reviewed the nurse visit notes dated 2/12/25, 2/14/25, 2/17/25, and 2/19/25 and the nurse indicated no pain experienced by PT13 on all visits made. DPCS was able to confirm these findings. A review of the agency’s policy entitled “Care Planning Process” undated indicated the purpose of this policy was to provide clinical direction to clinicians providing direct patient care. The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals. The plan of care will be based upon the physicians orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. a. A review of Patient 14’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 1/3/2025 with a primary diagnosis of unspecified physical fracture of lower end of right tibia (section of the shin bone that forms the inner part of the ankle joint) and secondary diagnosis of encounter for other specified surgical aftercare. During a review of Patient 14’s medical record titled, Plan of Care (POC), for the certification period of 1/3/2025 to 3/3/2025 indicated, a frequency order for Physical Therapist (PT)/ Physical Therapist Assistant (PTA) evaluation one time a week for one week starting 1/27/2025, PT/PTA one time a week for one week starting 1/29/2025, PT/PTA one time a week for one week starting 2/2/2025, Occupational Therapy (OT)/ Certified Occupational Therapy Assistant (COTA) one time a week for two weeks starting 1/10/2025, OT/COTA one time a week for one week starting 1/29/2025, and Home Health Aide (HHA) one time a week for one week starting 1/20/2025. During a review of Patient 14’s EMR, the EMR indicated a medical record titled Care Coordinator Note dated 1/24/2025. During a review of Patient 14’s medical record titled Audit log for the dates of 5/7/2025 to 5/9/2025 it indicated the Care Coordination note dated 1/24/2025 was created and documented on 5/8/2025 by Care Coordinator 1 (CC1). During an interview on 5/8/2025 at 1:49pm with Patient 14’s son, Patient 14’s son stated Patient 14 was referred to the HHA by Acute Care Hospital 1 for therapy services due to weakness to her right and left legs. Patient 14’s son stated Patient 14 had an initial assessment in December 2024 with a male staff member from the HHA, was given the HHA booklet and informed a staff from the HHA would be contacting him to set up visit appointments for Patient 14. Patient 14’s son stated a month passed by and he had not been contacted to set up visit appointments and he also attempted calling the HHA agency, but the call would not go through until on one occasion where he was answered and complained to the HHA that Patient 14’s physical therapy and home health aide services had not started. Patient 14’s son stated that after that phone call he had with the HHA the Occupational Therapist (OT) started doing home visits with the patient and about a week later the physical therapist (PT) came. Patient 14’s son stated Patient 14 did not have any home visits from a speech therapist or a home health aide. Patient14’s son stated Patient 14 had about 6 to 8 sessions of therapy between the OT and PT with the HHA. Patient 14’s son stated once Patient 14 completed PT/OT sessions with the HHA Acute Care Hospital 1 did not order anymore or any other services to be done with the HHA and instead gave an order for Patient 14 to continue physical therapy as an outpatient. Patient 14’s son stated he should not have had to initiate the HHA to start services that were already ordered for Patient 14. Patient 14’s son stated Patient 14 was discharged from the HHA in February of 2025. Patient 14’s son also stated stated Patient 14 should not have been waiting for so long to start services she needed to prevent her legs from getting weaker. During a concurrent interview and record review on 5/9/2025 at 12:35pm with the Administrator Designee (ADMD), Patient 14’s EMR was reviewed. Patient 14’s medical record titled Audit log for the dates of 5/7/2025 to 5/9/2025 indicated Patient 14’s care coordination note dated 1/24/2025 was created and documented on 5/8/2025 by CC1. The ADMD stated and confirmed that the care coordination note dated 1/24/2025 was created and documented by CC1 on 5/8/2025. During a concurrent interview and record review on 5/9/2025 at 3:05pm with the DPCS, Patient 14’s EMR was reviewed. The DPCS stated and confirmed Patient 14s EMR indicated a care coordination note dated 1/24/2025. During review of Patient 14’s medical record titled audit log from dates of 5/7/2025 to 5/9/2025, the DPCS stated and confirmed that Patient 14’s care coordination note dated 1/24/2025 was created and documented on 5/8/2025 by CC1. The DPCS stated it was not correct documentation practice for the CC1 to backdate the care coordination note. The DPCS stated the care coordinator, at the time of the occurrence, the physical therapist and the speech therapist should have documented in real time, their own note as to why there was a delay of care. The DPCS stated that authentication of documentation is important because it validates what happened, when it happened and assists in coordination of care. During a concurrent interview and record review on 5/9/2025 at 3:1opm with the DPCS, Patient 14’s EMR was reviewed. The DPCS stated and confirmed Patient 14’s EMR indicated: An authorization from Acute Care Hospital, dated 12/24/2024, for Physical therapy evaluation for 1 visit request, physical therapy in home for three visits request, Occupational therapy evaluation one time visit request, occupational therapy in the home for a one time visit request, speech therapy evaluation for a one time visit request, and home health aide for a one time visit request A medical record titled Inter-office Communication Note dated 12/27/2024 with documentation that indicated the HHA staffer communicated with Patient 14’s son on 12/27/2024 and was okay to be seen for home health services. A medical record titled Oasis Physical Therapy start of care/ recertification of care dated 1/3/2025 A medical record titled Occupational therapy evaluation note dated 1/10/2025 A medical record titled Occupational therapy follow up note dated 1/17/2025 A medical record titled Physical therapy evaluation note dated 1/27/2025 A medical record titled Occupational therapy discharge note dated 1/29/2025 A medical record titled Physical therapy assistant follow up notes dated 1/30/2025 and 2/4/2025 A referral order dated 1/31/2025 from the Acute Care Hospital 1 stating “Patient’s family reports they have not received assistance, order placed in December 2024. This is second request for Home health care aide to provide assistance with bathing, please. Thank you.” The DPCS stated and confirmed that the HHA received the referral for home health services for Patient 14 on 12/25/2024 and services were not started until 1/3/2025. The DPCS stated and confirmed that Patient 14’s EMR did not have any documented evidence of why there was a delay of care for Patient 14. The DPCS stated and verified Patient 14 had orders for HHA and Speech therapy services and the HHA did not provide Patient 14 with those services.The DPCS stated and confirmed Patient 14’s EMR did not have documentation of communication with the ordering physician about the physical home health aide and speech therapy services not provided to the patient. The DPCS also stated it is proper practice to document all communication or attempts in communication with the patient and/or family in the patient’s EMR to validate what did or did not happen. The DPCS further stated Patient14’s physician orders were not followed, as the HHA did not provide Patient 14 with HHA or speech therapy services and the ordering physician was not notified of the matter. The DPCS stated what the patient’s care team, the DPCS or care coordinator, should have done was ask for a report from Patient 14’s existing clinician to see if patient still required HHA or ST services and offer them within the time frame of the care the HHA was delivering to Patient 14. During a concurrent interview and record review on 5/9/2025 at 3:20pm with the DPCS, Patient 14’s medical record titled Plan of Care (POC) for the certification period of 1/3/2025 to 3/3/2025 was reviewed. The POC indicated a Physical Therapy treatment plan with an effective date of 1/3/2025, an Occupational Therapy treatment plan with an effective date of 1/3/2025, a Speech therapy treatment plan with an effective date of 1/3/2025 and a Home Health Aide plan with an effective date of 1/3/2025. The DPCS stated and confirmed Patient 14’s POC was not followed. The DPCS stated Patient 14’s POC was not followed because Patient 14 did not receive Speech therapy and Home health aide services from the HHA as ordered and indicated in the POC. During a review of the HHA’s Policy and Procedure (P&P) titled, Monitoring Patient’s Response/Reporting to Physician, undated, indicated, “Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient.” The P&P also indicated, “3. The patient’s physician will be contacted on the same day when any of the following occur: E. Changes-‘that have occurred regarding diagnoses, prognosis, or treatment (including procedures, medications, precautions, and limitations)... 4. All conferences or attempts to communicate with the physician will be documented in the clinical record. A. Documentation of physician notification will include: 1. Date and time contacted 2. Patient name 3. Name of physician notified or his/her representative 4. Reason for notification 5. Physician’s response 6. Action taken or orders obtained 7. Professional’s signature and title”. During a review of the HHA’s P&P titled, Intake Process, undated, indicated, “ 5. During scheduled working hours (office hours are from 8:30 a.m. to 5:30 p.m. Monday through Friday), calls will first be received by the receptionist. Patient referral calls will be transferred to an intake specialist designated to accept referrals. E. The assigned stafer will assign personnel and schedule an assessment visit. This initial visit will be performed either within 48 hours of the referral, or within 48 hours of a patient’s return home, or on the start of care date ordered by the physician (or other authorized licensed independent practitioner). F. If service cannot be provided, intake personnel will give the caller the names of other agencies than can provide the required services. A log will be maintained on all patients who cannot be serviced.” During a review of the HHA’s P&P titled Admission Criteria and Process, undated, indicated, “Patients will be accepted for care based on the adequacy and suitability of organization personnel, resources to provide required services, and the reasonable expectation that the patient’s medical, nursing, rehabilitative, and social needs can be adequately met in the patient’s place of residence. 2. The Clinical Supervisor will assign clinical organization personnel to conduct assessments of eligibility for services within 48 hours of acceptance of referral information and/or discharge from a referring facility. A. The initial visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, or on the start of the care date ordered by the physician (or other authorized licensed independent practitioner).” The P&P also indicated, “4. In the event that the time frame for assessment cannot be met, the patient’s physician and the referral source, as well as the patient, will be notified for approval of the delay. A. Such notification and approval will be documented. 8. If approval is not obtained for the delay, the patient will be referred to another organization for services. 16. The initial written assessment will be completed within 24 hours of the original assessment/admission visit. All documentation needed to develop the plan of care will be completed and turned into the office no later than the next business day. 17. A comprehensive assessment must be completed within five (5) calendar days of the patient’s start of care.” During a review of the HHA’s P&P titled, Physician Participation in Plan of Care, undated, indicated, “ A physician will direct the care of every home health patient admitted for service. The attending physician will certify that medical, skilled, rehabilitation, and social services provided by the organization are medically necessary... The care will be provided in compliance with his/her therapeutic and diagnostic orders and accepted standards and practice.””

“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 observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure a plan of care (a written document outlining the specific services and interventions needed to support a person’s health and well-being) was updated, followed and implemented for one of 17 patients (Patient 4) by failing to: 1.Ensure Patient 4’s plan of care for wound care and treatment was followed and implemented for Patient 4’s ulcer (type of wound) to the left lateral (to the side of, or away from, the middle of the body) leg (Wound 2). 2. Ensure Patient 4’s open diabetic ulcer on the left lateral foot (Wound 3) was assessed, had a physician’s order for wound treatment, and that Patient 4’s care plan was updated and implemented for the care of Patient 4’s open diabetic ulcer on the left lateral foot (Wound 3). This deficient practice resulted in Patient 4’s not being provided wound care on Patient 4’s left lateral leg wound (Wound 2) and open diabetic ulcer on the left lateral foot (Wound 3) starting from 4/14/25 to 5/8/25 totaling 24 days. Patient 4 was placed at increased risk for wound complications, such as delayed healing, infection and amputation (a surgical procedure where a part of a limb, such as a finger, toe, hand, foot, arm, or leg, is removed); increasing the risk of hospitalization and/or death. On 5/9/2025 at 5:10 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s Director of Nursing Services (DPCS), Administrator, and Administrator designee, related to failure of the agency to ensure a plan of care was updated, follow, and implemented for the recertification period of one of 17 sampled patients (Patient 4). On 5/12/2025 at 3:50 p.m., the Department conducted an exit conference with the DPCS, Administrator, and Administrator Designee with the IJ situation not removed. Findings: During a review of Patient 4’s Information Sheet, the Information Sheet indicated that Patient 4 Start of Care (SOC- the first date a patient is eligible for home health services and the first date of a billable visit) date was 2/8/2025, with home health recertification (the physician or allowed practitioner must certify [attest] that the home health services are or were needed because the patient is or was confined to the home) date of 4/9/2025 to 6/7/2025, with diagnosis of Type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar and using it in the body), diabetic polyneuropathy (a nerve damage condition that arises as a complication of diabetes), foot ulcer (an open sore [wound] on the foot that fails to heal and can involve skin, tissue, and potentially deeper structures like bones), and chronic foot ulcer (a persistent, open sore on the foot that fails to heal, often due to conditions like diabetes). During a record review of Patient 4’s recertification assessment dated 4/7/2025, the recertification assessment indicated that Patient 4 had three wounds (Wound 1; Wound 2; Wound 3). Wound 1 was described as an open diabetic ulcer (a wound, especially on the feet, that develops in people with diabetes due to factors like poor blood circulation, nerve damage, and high blood sugar levels) on the great right toe (largest and innermost toe on the foot) measuring 1.5 centimeter (cm-unit of measure) by 1.0 cm with a depth of 0.5 cm. Wound 2 was described as an ulcer (a break on the skin) on the left lateral leg measuring 3.0 cm by 3.0 cm with a depth of 0.3 cm. Wound 3 was described as an open diabetic ulcer on the left lateral foot measuring 3.0 cm by 2.0 cm with a depth of 0.2 cm. The appearance of Wound 3 was described as red with necrotic bed tissue (dead tissue, usually black in color, which impedes wound healing) and without odor. During a record review of Patient 4’s Physicians Orders dated 4/7/2025, the physician orders indicated the following: Change the right toe (Wound 1) dressings only ; cleanse with normal saline (a mixture of water and salt use to rinse wounds), apply Santyl (medication used to treat wounds), Aguacel ag (a type of wound dressing) and roll gauze. Do not change bilateral (both) leg wraps (a long piece of fabric, like a bandage or a blanket, that’s wrapped around the leg), vascular surgeon (a doctor who specializes in treating problems with blood vessels) will change them. Continue to care for the right toe (Wound 1). During a record review of Patient 4’s Physicians Orders dated 4/14/2025, the physician orders indicated the following: Cleanse left lateral leg wound (Wound 2) with normal saline, pat dry. Apply dry dressing twice weekly. Continue with wound care of right toe (Wound 1). During a record review of Patient 4’s Plan of Care for the recertification period of 4/9/2025 to 6/7/2025, the Plan of Care indicated to start Patient 4’s updated wound care with an effective date of 4/14/25. Cleanse left lateral leg wound (Wound 2) with normal saline. Pat dry. Apply dry dressing. Twice a week. The record further indicated to continue wound care of right toe (Wound 1) as previously ordered.” During a record review of Patient 4’s skilled nursing visit notes dated 4/16/2025, 4/21/2025, 4/24/2025, 4/29/2025 and 5/2/2025, there was no record of assessment or treatment for Wound 2 or Wound 3. During a concurrent observation and interview on 5/8/2025 at 10:30 am, Patient 4’s open diabetic ulcer on the left lateral foot (Wound 3) was observed during the home visit to be necrotic (black tissue- a sign of dying tissue) with purulent drainage (a sign of infection and is caused by the accumulation of white blood cells, bacteria, and other debris in the affected area) and odor, with a measurement of approximately 3.5 cm by 3.5 cm. The depth of Patient 4’s open diabetic ulcer on the left lateral foot (Wound 3) was not measurable due to the black tissue covering the wound bed. Licensed Vocational Nurse 4 (LVN 4) stated that Patient 4’s left lateral foot wound (Wound 3) had a foul odor (a smell that is very unpleasant, often described as strong, disgusting, or offensive). LVN 4 stated that the foul odor from Patient 4’s left lateral foot wound needed to be reported to the physician because she (LVN 4) was concerned about infection. During a concurrent interview and record review of Patient 4’s Physicians Orders and Plan of Care on 5/9/2025 at 2:43 pm, the Director of Patient Care Services (DPCS) stated that there was no order for treatment or care of Patient 4’s left lateral foot wound (Wound 3). DPCS stated that the HHA did not obtain an order to care for Patient 4’s open diabetic ulcer on the left lateral foot (Wound 3). DPCS further stated that there was no record of Patient 4’s open diabetic ulcer on the left lateral foot (Wound 3) in Patient 4’s plan of care. During a concurrent interview and record review of Patient 4’s Physician’s Orders, Plan of Care, Skilled nursing visits on 5/9/2025 at 2:43 pm, the DPCS stated there was no record of an assessment or treatment being conducted for Patient 4’s ulcer to the left lateral leg (Wound 2) or open diabetic ulcer on the left lateral foot (Wound 3) after the physicians change of orders on 4/14/2025 to 5/8/25 (totaling 24 days). DPCS stated that the lack of physicians’ orders for treatment and care for Patient 4’s open diabetic ulcer on the left lateral foot (Wound 3), as well as the lack of treatment to Patient 4’s ulcer to the left lateral leg (Wound 2) put Patient 4 at risk for infection, serious illness, hospitalization and possible amputation of the left foot. A review of the facility’s undated policy and procedures titled, “Ongoing Assessments,” indicated that, “during each home visit, the clinician will re-evaluate the patient according to the problems during the initial visit and subsequent visits.” The policy further indicated that, “based on each reassessment, the plan of care will be reviewed and revised by the clinician.” A review of the facility’s undated policy and procedures titled, “Care Planning Process,” indicated that the purpose of the care planning process/care plan was, “provide clinical direction to clinicians providing direct care.” A review of the facility’s undated policy and procedures titled “Wound Care,” indicated to document wound care, appearance, and description of drainage during each visit in the clinical note.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation, interview and record review the Home Health Agency (HHA) did not report promptly to the ordering physician for four of seventeen sampled patients (Patient 1, Patient 4, Patient 14, and Patient 15), the following, a. report Patient 1’s oxygen level b. report Patient 4’s change of condition, wounds and refusal of care c. report Patient 14’s services not provided d. report Patient 15’s services not provided This deficient practice resulted in Patient 1, Patient 4, Patient 14, and Patient 15 not receiving the assessment and care needed, ultimately impacting their recuperation and overall health. Findings: A review of Patient 14’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 1/3/2025 with a primary diagnosis of unspecified physical fracture of lower end of right tibia (section of the shin bone that forms the inner part of the ankle joint) and secondary diagnosis of encounter for other specified surgical aftercare. During a review of Patient 14’s medical record titled, Plan of Care (POC), for the certification period of 1/3/2025 to 3/3/2025 indicated, a frequency order for Physical Therapist (PT)/ Physical Therapist Assistant (PTA) evaluation one time a week for one week starting 1/27/2025, PT/PTA one time a week for one week starting 1/29/2025, PT/PTA one time a week for one week starting 2/2/2025, Occupational Therapy (OT)/ Certified Occupational Therapy Assistant (COTA) one time a week for two weeks starting 1/10/2025, OT/COTA one time a week for one week starting 1/29/2025, and Home Health Aide (HHA) one time a week for one week starting 1/20/2025. During a review of Patient 14’s EMR, the EMR indicated a medical record titled Care Coordinator Note dated 1/24/2025. During a review of Patient 14’s medical record titled Audit log for the dates of 5/7/2025 to 5/9/2025 it indicated the Care Coordination note dated 1/24/2025 was created and documented on 5/8/2025 by Care Coordinator 1 (CC1). During an interview on 5/8/2025 at 1:49 pm with Patient 14’s son, Patient 14’s son stated Patient 14 was referred to the HHA by Acute Care Hospital 1 for therapy services due to weakness to her right and left legs. Patient 14’s son stated Patient 14 had an initial assessment in December 2024 with a male staff member from the HHA, was given the HHA booklet and informed a staff from the HHA would be contacting him to set up visit appointments for Patient 14. Patient 14’s son stated a month passed by and he had not been contacted to set up visit appointments and he also attempted calling the HHA agency, but the call would not go through until on one occasion where he was answered and complained to the HHA that Patient 14’s physical therapy and home health aide services had not started. Patient 14’s son stated that after that phone call he had with the HHA the Occupational Therapist (OT) started doing home visits with the patient and about a week later the physical therapist (PT) came. Patient 14’s son stated Patient 14 did not have any home visits from a speech therapist or a home health aide. Patient14’s son stated Patient 14 had about 6 to 8 sessions of therapy between the OT and PT with the HHA. Patient 14’s son stated once Patient 14 completed PT/OT sessions with the HHA Acute Care Hospital 1 did not order anymore or any other services to be done with the HHA and instead gave an order for Patient 14 to continue physical therapy as an outpatient. Patient 14’s son stated he should not have had to initiate the HHA to start services that were already ordered for Patient 14. Patient 14’s son stated Patient 14 was discharged from the HHA in February of 2025. Patient 14’s son also stated stated Patient 14 should not have been waiting for so long to start services she needed to prevent her legs from getting weaker. During a concurrent interview and record review on 5/9/2025 at 12:35 pm with the Administrator Designee (ADMD), Patient 14’s EMR was reviewed. Patient 14’s medical record titled Audit log for the dates of 5/7/2025 to 5/9/2025 indicated Patient 14’s care coordination note dated 1/24/2025 was created and documented on 5/8/2025 by CC1. The ADMD stated and confirmed that the care coordination note dated 1/24/2025 was created and documented by CC1 on 5/8/2025. During a concurrent interview and record review on 5/9/2025 at 3:05 pm with the DPCS, Patient 14’s EMR was reviewed. The DPCS stated and confirmed Patient 14s EMR indicated a care coordination note dated 1/24/2025. During review of Patient 14’s medical record titled audit log from dates of 5/7/2025 to 5/9/2025, the DPCS stated and confirmed that Patient 14’s care coordination note dated 1/24/2025 was created and documented on 5/8/2025 by CC1. The DPCS stated it was not correct documentation practice for the CC1 to backdate the care coordination note. The DPCS stated the care coordinator, at the time of the occurrence, the physical therapist and the speech therapist should have documented in real time, their own note as to why there was a delay of care. The DPCS stated that authentication of documentation is important because it validates what happened, when it happened and assists in coordination of care. During a concurrent interview and record review on 5/9/2025 at 3:10 pm with the DPCS, Patient 14’s EMR was reviewed. The DPCS stated and confirmed Patient 14’s EMR indicated: An authorization from Acute Care Hospital, dated 12/24/2024, for Physical therapy evaluation for 1 visit request, physical therapy in home for three visits request, Occupational therapy evaluation one time visit request, occupational therapy in the home for a one time visit request, speech therapy evaluation for a one time visit request, and home health aide for a one time visit request A medical record titled Inter-office Communication Note dated 12/27/2024 with documentation that indicated the HHA staffer communicated with Patient 14’s son on 12/27/2024 and was okay to be seen for home health services. A medical record titled Oasis Physical Therapy start of care/ recertification of care dated 1/3/2025 A medical record titled Occupational therapy evaluation note dated 1/10/2025 A medical record titled Occupational therapy follow up note dated 1/17/2025 A medical record titled Physical therapy evaluation note dated 1/27/2025 A medical record titled Occupational therapy discharge note dated 1/29/2025 A medical record titled Physical therapy assistant follow up notes dated 1/30/2025 and 2/4/2025 A referral order dated 1/31/2025 from the Acute Care Hospital 1 stating “Patient’s family reports they have not received assistance, order placed in December 2024. This is second request for Home health care aide to provide assistance with bathing, please. Thank you.” The DPCS stated and confirmed that the HHA received the referral for home health services for Patient 14 on 12/25/2024 and services were not started until 1/3/2025. The DPCS stated and confirmed that Patient 14’s EMR did not have any documented evidence of why there was a delay of care for Patient 14. The DPCS stated and verified Patient 14 had orders for HHA and Speech therapy services and the HHA did not provide Patient 14 with those services. The DPCS stated and confirmed Patient 14’s EMR did not have documentation of communication with the ordering physician about the physical home health aide and speech therapy services not provided to the patient. The DPCS also stated it is proper practice to document all communication or attempts in communication with the patient and/or family in the patient’s EMR to validate what did or did not happen. The DPCS further stated Patient14’s physician orders were not followed, as the HHA did not provide Patient 14 with HHA or speech therapy services and the ordering physician was not notified of the matter. The DPCS stated what the patient’s care team, the DPCS or care coordinator, should have done was ask for a report from Patient 14’s existing clinician to see if patient still required HHA or ST services and offer them within the time frame of the care the HHA was delivering to Patient 14. During a concurrent interview and record review on 5/9/2025 at 3:20 pm with the DPCS, Patient 14’s medical record titled Plan of Care (POC) for the certification period of 1/3/2025 to 3/3/2025 was reviewed. The POC indicated a Physical Therapy treatment plan with an effective date of 1/3/2025, an Occupational Therapy treatment plan with an effective date of 1/3/2025, a Speech therapy treatment plan with an effective date of 1/3/2025 and a Home Health Aide plan with an effective date of 1/3/2025. The DPCS stated and confirmed Patient 14’s POC was not followed. The DPCS stated Patient 14’s POC was not followed because Patient 14 did not receive Speech therapy and Home health aide services from the HHA as ordered and indicated in the POC. During a review of the HHA’s Policy and Procedure (P&P) titled, Monitoring Patient’s Response/Reporting to Physician, undated, indicated, “Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient.” The P&P also indicated, “3. The patient’s physician will be contacted on the same day when any of the following occur: E. Changes-‘that have occurred regarding diagnoses, prognosis, or treatment (including procedures, medications, precautions, and limitations)... 4. All conferences or attempts to communicate with the physician will be documented in the clinical record. A. Documentation of physician notification will include: 1. Date and time contacted 2. Patient name 3. Name of physician notified or his/her representative 4. Reason for notification 5. Physician’s response 6. Action taken or orders obtained 7. Professional’s signature and title”.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to ensure that the Plan of Care was revised and updated to reflect the current health status for two of 17 sampled patients (Patient 7 and Patient 8). This deficient practice had the potential to result in miscommunication among health care providers and lack of care and treatment for the patients’ health management to meet their care needs and goals. During an interview on 5/9/2025 at 1:57pm with the Director of Patient Care Services (DPCS), the DPCS stated the patient’s Plan of Care (POC) is updated every 60 days, and as needed when the patient has a change in condition, change in care or services or change in medication. The DPCS stated the skilled nurses (SN), Physical Therapist (PT), Speech Therapist (ST), Occupational Therapist (OT) or the patient’s case manager can access the patient’s EMR and update the POC. b. A review of Patient 7’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 3/17/2025 with a primary diagnosis of Hemiplegia following cerebral infarct affecting right dominant side (condition of being paralyzed or complete loss of strength on one side of the body due to deficiency of blood flow to the brain causing brain tissue death) and a secondary diagnosis of bed confinement status. During a review of Patient 7’s medical record titled, Plan of Care (POC), for the certification period of 3/17/2025 to 5/15/2025 indicated, a frequency order for Physical Therapist (PT)/ Physical Therapist Assistant (PTA) one time a week for I week starting 4/23/2025, one time a week for one week starting 4/27/2025, one time a week for one week starting 4/30/2025, two times a week for 1 week starting 5/4/2025, and one time a week for one week starting 5/11/2025. Patient 7’s POC also indicated an order for skilled observation and assessment of vital signs, response/compliance with treatment, home safety, assess musculoskeletal status, instruct on disease process and sign/symptoms, treatment/management, instruct on patient/caregiver on emergency measures and when to call PT/ medical doctor/911 for any significant changes/findings. During a review of Patient 7’s medication profile dated 4/22/2025 it indicated medications of: Pacerone (medication used to treat life threatening heart rhythm problems) 200 milligrams (mg- unit of measurement) 1 tablet daily orally Norvasc (medication used to treat high blood pressure and chest pain) 10mg 1 tablet daily orally Colace (medication used to make bowel movements softer and easier to pass) 250mg 1 tablet daily orally Crestor (medication used to lower the risk of a heart complications) 20mg 1 tablet daily orally Sensipar (medication used to lower the amount of calcium in the blood) 80mg 1 tablet daily Lasix (medication used to treat fluid retention and swelling in the body) 80mg 1 tablet daily During a joint home visit on 5/8/2025 at 10:57am, at Patient 7’s resident with Physical Therapist 1 (PT1), Patient 7 was observed lying on a hospital bed with the head of the bed elevated, awake, alert and oriented to self, date, time and location. Patient 7 was observed able to communicate her needs. During a joint home visit on 5/8/2025 at 11:13am, at Patient 7’s residence with PT1, Patient 7’s medications were reviewed. Upon review of Patient 7’s medication bottles, it was noted a medication bottle for Levothyroxine (medication used to treat underactive thyroid gland) and a medication bottle for Tylenol (medication used to treat minor aches and pains and reduces fever). During a review of Patient 7’s medication profile dated 4/22/2025 it did not indicate an order for Patient 7’s medication bottle Levothyroxine and Tylenol. Patient 7’s daughter stated Patient 7 takes Tylenol for her pain every so often. Patient 7’s daughter also stated the day prior a staff member for the HHA came over to Patient 7’s home to review the medications. When reviewing Patient 7’s medication list in her HHA booklet, the medications on that list did not reflect the medications on Patient 7’s POC and medication profile the HHA had. During a concurrent interview and record review on 5/9/2025 at 1:53pm with the DPCS, Patient 7’s EMR was reviewed. The DPCS stated and confirmed that Patient 7’s POC and medication profile did not include a medication order for Tylenol or Levothyroxine. The DPCS was made aware that Patient 7’s medication list in her HHA booklet at home was updated to reflect the current medications the patient is taking, but the POC and medication profile were not updated. The DPCS stated Patient 7’s POC and medication profile in the EMR were to have been updated, as well, by the PT1 and/or case manager. c. A review of Patient 8’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 1/29/2025 with a primary diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing causing damage to the tiny blood vessels in the kidneys) and other diagnosis of gangrene (condition where tissue dies due to loss of blood supply), and encounter for change or removal of surgical wound dressing. During a review of Patient 8’s medical record titled, Plan of Care (POC), for the certification period of 3/30/2025 to 5/28/2025 indicated, a recertification frequency order for Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) for one time a day for seven days starting 4/8/2025 with an estimate of services to be required for 9 weeks. Patient 8’s POC also indicated order for skilled nurse (SN) to educate the patient about the signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), pain management, medication management/compliance, and assess/perform/ instruct the patient/caregiver on wound care to left foot to paint left forefoot with betadine solution (topical antiseptic used to kill bacteria, fungi, viruses) and cover with dry dressing fluffs and kerlix, and ace wrap daily. During a review of Patient 8’s medication profile undated, it indicated medications of: Metoprolol tartrate (medication to treat high blood pressure, chest pain or heart failure) 100 milligrams (mg- unit of measurement) take two tablets orally two times daily Clonidine (medication to treat high blood pressure) 0.2mg/24 hour weekly transdermal (skin) patch place 1 patch one time weekly Minoxidil (medication to treat high blood pressure) 2.5mg take 1 tablet orally two times daily Xarelto (a blood thinner medication to treat and prevent blood clots) 2.5mg take 1 tablet orally two times daily Furosemide (a water pill, medication to treat fluid retention and swelling in the body) 80mg take 1 tablet orally one time daily Amlodipine (medication to treat high blood pressure and chest pain) 10mg take 1 tablet orally one time daily Lisinopril (medication to treat high blood pressure, heart failure and reduce the risk of death after a heart attack) 20mg take 1 tablet orally one time daily Trazadone (medication to treat depression) 50mg take 1 tablet orally one time daily Lipitor (medication to treat high cholesterol [when you have too much of a fatty substance in your blood]) 40mg take 1 tablet orally one time daily Aspirin (medication to treat pain, fever, headache, inflammation and prevent blood clots) 81mg delayed release (action that postpones the release of the medication until a specific time after administration) take 1 tablet orally one time daily Clonidine (medication to treat high blood pressure) 0.2mg take 1 tablet orally as needed daily if systolic blood pressure (the highest blood pressure reading during a heartbeat) is more than 160 or diastolic blood pressure (the pressure in the arteries when the heart is at rest between beats) more than 100 Velphoro (medication that helps prevent low levels of calcium in the blood) 500mg chewable tablet take 2 tablets orally three times daily During a joint home visit on 5/8/2025 at 12:10pm with Licensed Vocational Nurse 2 (LVN2), at Patient 8’s residence, Patient 8 was observed sitting up on his bed awake, alert, oriented to self, time, place and location and able to communicate his needs. During a concurrent interview and record review on 5/8/2025 at 12:40pm with LVN2 at Patient 8’s residence, Patient 8’s medications were reviewed. During a review of Patient 8’s medication bottles with Patient 8’s medication profile it was noted that the medication profile did not include patient 8’s current medication bottle of hydrocodone (strong class of pain medication) 5/325 mg take 1 tablet orally every 6 hours as needed for pain. LVN2 stated and confirmed Patient 8’s medication profile did not include an order for the medication hydrocodone. During the medication review it was also indicated that Patient 8’s medication bottle for Minoxidil had an order for 10 mg take 1 tablet orally twice a day, and the medication profile indicated and order for Minoxidil 2.5 mg take 1 tablet orally two times daily. Patient 8 stated and confirmed that the order on the medication bottle for Minoxidil is the correct order of how he takes his medication. LVN2 stated and confirmed Patient 8’s order for the medication bottle for Minoxidil did not match the order for Minoxidil in the medication profile. LVN2 was observed updating Patient 8’s medication order for Minoxidil on his medication profile in his HHA booklet, then took a picture of the update list. LVN2 stated she took the picture of the updated medication profile to send it to the HHA so Patient 8’s medication profile on the EMR and the POC can be updated. LVN2 stated if there is a change that needs to be done to the patient’s medication list or POC she can access the EMR and make the changes or she can send the picture of the changes though text messaging, to the case manager and they can make the changes. LVN2 stated she has been doing home visits with Patient 8 daily from Monday through Friday as ordered for wound care. During a concurrent interview and record review on 5/9/2025 at 2:09pm with the DPCS, Patient 8’s EMR was reviewed. The DPCS stated and confirmed that Patient 8’s medication profile did not include an order for the medication Hydrocodone 5/325 mg take 1 tablet orally every 6 hours as needed for pain. The DPCPS was made aware that Patient 8’s medication bottle for Minoxidil had a different order, of 10mg 1 tablet twice a day, than what was on the medication profile, of 2.5mg 1 tablet orally twice daily, and Patient 8 confirmed the medication order on the bottle was the most current order he was taking his medication. The DPCS stated and confirmed Patient 8’s medication profile and the POC indicated an order for Minoxidil that read 2.5 mg take 1 tablet orally twice daily. The DPCS stated she was informed by LVN2 yesterday about updating Patient 8’s medication profile to reflect his current medications, and stated the HHA would be updating the patient’s medication list and the POC in the EMR. The DPCS also stated if LVN2 was visiting the patient daily, Monday through Friday, for wound care, then the medications should have been reviewed daily and any changes should have been promptly made to the medication list and POC. During a review of the HHA’s Policy and Procedure (P&P) titled, Care Planning Process, undated, indicated “3. Based on the assessment and conclusions, the plan of care will include, but not be limited to: L. All medications”. The P&P also indicated, “8. The plan of care will be revised no less than every sixty (60) days or as frequently as deemed necessary by the clinician, based on the ongoing assessments of the patient. Revision dates will be noted on the plan of care.” .”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure one of 17 sampled patients (Patient 2) received education and training according to the plan of care. This deficient practice resulted in patients not receiving all their ordered treatments which placed them at risk for injury and hospitalizations. Findings: During a review of Patient 2’s Patient Information sheet indicated Patient 2’s start of care date was 10/15/2024, with a primary diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy. During a review of Patient 2’s medical record form titled “Plan of Care” dated from 04/13/2025 to 06/11/2025, indicated the Skilled Nurse (SN, in general) was to assess and instruct the importance of medication compliance, high risk medication use, side effects, contraindications, possible drug to drug interaction and special consideration. During an interview on 05/08/2025 at 12:40 p.m., in Patient 2’s residence, Patient 2 stated, “I don’t know what the medication lovastatin was for. My nurse never educated me on any of my medications. I thought the nurses that come from this agency are just here to do wound care on my leg they have never talked to me about any of my medications.” During an interview on 5/09/2025 at 1:25 p.m. with DPCS she stated, “all skilled nurses are supposed to go over all the medications with the patients and educate them on the indication for the medication the dose, the frequency, the route, and about potential side effects and interactions.” During a review of the HHA’s Policy and Procedure (P&P) titled, “Patient Education Process”, undated, P & P indicated, “ 1. The clinician will assess, plan, implement, and evaluate the following on each patient and family/caregiver, as appropriate 6. Unless otherwise ordered by the physician ( or other authorized licensed independent practitioner}, the patient and family/caregiver will receive verbal and, as appropriate, written instructions that are in plain language that does not use medical abbreviations on: A. The patient’s disease process and prognosis, B. The medical regimen C. Medication management and administration D. Food and drug interactions…””

“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 Home Health Agency (HHA) failed to provide care and services as indicated in the Plan of Care (POC) for two of seventeen sampled patients (Patient 14 and Patient 15). This deficient practice resulted in Patient 14 and Patient 15 not receiving the required care and services needed to meet the care goals need of patients that could have caused a declined in overall health. Findings: During a review of Patient #15’s Patient Profile indicated that Patient 14 was admitted to home health services on 2/5/2025 with diagnosis of gastrointestinal hemorrhage ( bleeding that occurs anywhere within the digestive system [a series of organs and glands that work together to break down food, absorb nutrients, and eliminate waste products]), colostomy ( an opening (stoma) in the large intestine (colon), a surgical procedure is done that creates one), and malaise (a general feeling of bad health or lack of energy). During a review of Patient 15’s Plan of Care dated 2/5/2025 indicated that Patient 15’s treatment plan would include a nursing visit once a week starting 2/9/2025. During a review of Patient 15’s Communication Notes dated 2/7/2025 at 12:25pm indicated that Patient 15 was refusing home health care services. During a review of Patient 15’s Communication Notes dated 2/14/2025 indicated that Patient 15 requested to continue home health services. The note indicated continue with nursing services. During a review of Patient 15’s skilled nursing notes after the continuation of care restarted on 2/15/2025 indicated a skilled nursing visit was performed on 3/1/2025 (14 days after continuing care). During an interview and record review of Patient 15’s skilled nursing notes on 5/9/2025 at 12:50 p.m., with the Director of Patient Care Services stated that the HHA continued care on 2/14/2025 but that a nurse did not see the patient until 3/1/2025. The DPCS stated that the plan of care indicated that the patient was to be seen once a week for teaching on colostomy care as it was a new colostomy for the patient. DPCS stated she did not know why there was a delay in care. The DPCS stated that the purpose of the skilled nursing visits for Patient 15 was to teach the Patient and Patient representatives how to care for a new colostomy and that by not having the proper instructions for care it put Patient 15 at risk for problems with the colostomy. During an interview on 5/9/2025 at 11:25 am, Patient 15’s representative (REP 15) stated that it took the agency two weeks to send a nurse to see Patient 15. REP 15 stated that Patient 15 had a new colostomy and that the purpose of the HHA nurse was to make sure that they were properly caring for the new colostomy. REP 15 stated it was frustrating not having the nurses come timely to help support her or Patient 15 during this time. a. A review of Patient 14’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 1/3/2025 with a primary diagnosis of unspecified physical fracture of lower end of right tibia (section of the shin bone that forms the inner part of the ankle joint) and secondary diagnosis of encounter for other specified surgical aftercare. During a review of Patient 14’s medical record titled, Plan of Care (POC), for the certification period of 1/3/2025 to 3/3/2025 indicated, a frequency order for Physical Therapist (PT)/ Physical Therapist Assistant (PTA) evaluation one time a week for one week starting 1/27/2025, PT/PTA one time a week for one week starting 1/29/2025, PT/PTA one time a week for one week starting 2/2/2025, Occupational Therapy (OT)/ Certified Occupational Therapy Assistant (COTA) one time a week for two weeks starting 1/10/2025, OT/COTA one time a week for one week starting 1/29/2025, and Home Health Aide (HHA) one time a week for one week starting 1/20/2025. During a review of Patient 14’s EMR, the EMR indicated a medical record titled Care Coordinator Note dated 1/24/2025. During a review of Patient 14’s medical record titled Audit log for the dates of 5/7/2025 to 5/9/2025 it indicated the Care Coordination note dated 1/24/2025 was created and documented on 5/8/2025 by Care Coordinator 1 (CC1). During an interview on 5/8/2025 at 1:49pm with Patient 14’s son, Patient 14’s son stated Patient 14 was referred to the HHA by Acute Care Hospital 1 for therapy services due to weakness to her right and left legs. Patient 14’s son stated Patient 14 had an initial assessment in December 2024 with a male staff member from the HHA, was given the HHA booklet and informed a staff from the HHA would be contacting him to set up visit appointments for Patient 14. Patient 14’s son stated a month passed by and he had not been contacted to set up visit appointments and he also attempted calling the HHA agency, but the call would not go through until on one occasion where he was answered and complained to the HHA that Patient 14’s physical therapy and home health aide services had not started. Patient 14’s son stated that after that phone call he had with the HHA the Occupational Therapist (OT) started doing home visits with the patient and about a week later the physical therapist (PT) came. Patient 14’s son stated Patient 14 did not have any home visits from a speech therapist or a home health aide. Patient14’s son stated Patient 14 had about 6 to 8 sessions of therapy between the OT and PT with the HHA. Patient 14’s son stated once Patient 14 completed PT/OT sessions with the HHA Acute Care Hospital 1 did not order anymore or any other services to be done with the HHA and instead gave an order for Patient 14 to continue physical therapy as an outpatient. Patient 14’s son stated he should not have had to initiate the HHA to start services that were already ordered for Patient 14. Patient 14’s son stated Patient 14 was discharged from the HHA in February of 2025. Patient 14’s son also stated stated Patient 14 should not have been waiting for so long to start services she needed to prevent her legs from getting weaker. During a concurrent interview and record review on 5/9/2025 at 12:35pm with the Administrator Designee (ADMD), Patient 14’s EMR was reviewed. Patient 14’s medical record titled Audit log for the dates of 5/7/2025 to 5/9/2025 indicated Patient 14’s care coordination note dated 1/24/2025 was created and documented on 5/8/2025 by CC1. The ADMD stated and confirmed that the care coordination note dated 1/24/2025 was created and documented by CC1 on 5/8/2025. During a concurrent interview and record review on 5/9/2025 at 3:05pm with the DPCS, Patient 14’s EMR was reviewed. The DPCS stated and confirmed Patient 14s EMR indicated a care coordination note dated 1/24/2025. During review of Patient 14’s medical record titled audit log from dates of 5/7/2025 to 5/9/2025, the DPCS stated and confirmed that Patient 14’s care coordination note dated 1/24/2025 was created and documented on 5/8/2025 by CC1. The DPCS stated it was not correct documentation practice for the CC1 to backdate the care coordination note. The DPCS stated the care coordinator, at the time of the occurrence, the physical therapist and the speech therapist should have documented in real time, their own note as to why there was a delay of care. The DPCS stated that authentication of documentation is important because it validates what happened, when it happened and assists in coordination of care. During a concurrent interview and record review on 5/9/2025 at 3:10pm with the DPCS, Patient 14’s EMR was reviewed. The DPCS stated and confirmed Patient 14’s EMR indicated: An authorization from Acute Care Hospital, dated 12/24/2024, for Physical therapy evaluation for 1 visit request, physical therapy in home for three visits request, Occupational therapy evaluation one time visit request, occupational therapy in the home for a one time visit request, speech therapy evaluation for a one time visit request, and home health aide for a one time visit request A medical record titled Inter-office Communication Note dated 12/27/2024 with documentation that indicated the HHA staffer communicated with Patient 14’s son on 12/27/2024 and was okay to be seen for home health services. A medical record titled Oasis Physical Therapy start of care/ recertification of care dated 1/3/2025 A medical record titled Occupational therapy evaluation note dated 1/10/2025 A medical record titled Occupational therapy follow up note dated 1/17/2025 A medical record titled Physical therapy evaluation note dated 1/27/2025 A medical record titled Occupational therapy discharge note dated 1/29/2025 A medical record titled Physical therapy assistant follow up notes dated 1/30/2025 and 2/4/2025 A referral order dated 1/31/2025 from the Acute Care Hospital 1 stating “Patient’s family reports they have not received assistance, order placed in December 2024. This is second request for Home health care aide to provide assistance with bathing, please. Thank you.” The DPCS stated and confirmed that the HHA received the referral for home health services for Patient 14 on 12/25/2024 and services were not started until 1/3/2025. The DPCS stated and confirmed that Patient 14’s EMR did not have any documented evidence of why there was a delay of care for Patient 14. The DPCS stated and verified Patient 14 had orders for HHA and Speech therapy services and the HHA did not provide Patient 14 with those services.The DPCS stated and confirmed Patient 14’s EMR did not have documentation of communication with the ordering physician about the physical home health aide and speech therapy services not provided to the patient. The DPCS also stated it is proper practice to document all communication or attempts in communication with the patient and/or family in the patient’s EMR to validate what did or did not happen. The DPCS further stated Patient14’s physician orders were not followed, as the HHA did not provide Patient 14 with HHA or speech therapy services and the ordering physician was not notified of the matter. The DPCS stated what the patient’s care team, the DPCS or care coordinator, should have done was ask for a report from Patient 14’s existing clinician to see if patient still required HHA or ST services and offer them within the time frame of the care the HHA was delivering to Patient 14. During a concurrent interview and record review on 5/9/2025 at 3:20pm with the DPCS, Patient 14’s medical record titled Plan of Care (POC) for the certification period of 1/3/2025 to 3/3/2025 was reviewed. The POC indicated a Physical Therapy treatment plan with an effective date of 1/3/2025, an Occupational Therapy treatment plan with an effective date of 1/3/2025, a Speech therapy treatment plan with an effective date of 1/3/2025 and a Home Health Aide plan with an effective date of 1/3/2025. The DPCS stated and confirmed Patient 14’s POC was not followed. The DPCS stated Patient 14’s POC was not followed because Patient 14 did not receive Speech therapy and Home health aide services from the HHA as ordered and indicated in the POC. During a review of the HHA’s Policy and Procedure (P&P) titled, Monitoring Patient’s response/reporting to physician, undated, indicated, “3. The patient’s physician will be contacted on the same day when any of the following occur: E. Changes that have occurred regarding diagnoses, prognosis, or treatment (including procedures, medications, precautions, and limitations) F. When there is any problem implementing the plan of care”. During a review of the HHA’s P&P titled Care Coordination, undated, indicated, “5. All organization personnel involved in patient care, including those providing contracted services, will have access to the plan of care and all other relevant patient information to ensure coordination and continuity of care. All personnel will be knowledgeable regarding patient needs, goals of care and services. During a review of the HHA’s P&P titled, Physician Participation in Plan of Care, undated, indicated, “ A physician will direct the care of every home health patient admitted for service. The attending physician will certify that medical, skilled, rehabilitation, and social services provided by the organization are medically necessary... The care will be provided in compliance with his/her therapeutic and diagnostic orders and accepted standards and practice.””

“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 Home Health Agency (HHA) failed to perform Registered Nurse (RN) supervisory visits (evaluation of the care performed by a Licensed Vocational Nurse [LVN]) to LVN providing patient care and services to three of 17 sampled patients, (Patient 2, Patient 4 and Patient 8) as indicated in the facility’s policy and procedures, which indicated, to have a process in place for the overseeing of all clinical care and services. This deficient practice had the potential to result in a poor-quality care and inappropriate care and services provided to the patients when the staff (in general) not being evaluated and supervised A review of Patient 4’s Patient Profile indicated that Patient 4, an 82-year-old male, was admitted to HHA on 2/8/2025, with home health recertification on 4/9/2025- 6/7/2025, with diagnosis of Type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar and using it in the body), diabetic polyneuropathy (a nerve damage condition that arises as a complication of diabetes), foot ulcer (an open sore on the foot that fails to heal and can involve skin, tissue, and potentially deeper structures like bones), and chronic foot ulcer (a persistent, open sore on the foot that fails to heal within a reasonable timeframe, often due to underlying conditions like diabetes, poor circulation, or peripheral neuropathy). A record review of Patient 4’s recertification assessment dated 4/7/2025, indicated Patient 4 had three wounds. Wound 1 was described as an open diabetic ulcer on the great right toe measuring 1.5 cm x 1.0 cm with a depth of 0.5 cm. Wound 2 was described as an ulcer on the left lateral leg measuring 3.0 cm x 3.0 cm with a depth of 0.3 cm. Wound 3 was described as an open diabetic ulcer on the left lateral foot measuring 3.0 cm x 2.0 cm with a depth of 0.2 cm. The appearance of Wound 3 is described as red with necrotic bed tissue and without odor. During a record review of Patient 4’s clinical record, skilled nursing visit notes dated 4/16/2025, 4/21/2025, 4/24/2025, 4/29/2025 and 5/2/2025, there was no record of assessment or of the treatment for wound #2 or wound #3. During an interview and record review of Patient 4’s clinical record on 5/9/2025 at 2:43 pm, DPCS stated there was a physician’s order to treat Patient 4’s left lateral leg wound (wound #2), however there was no order for treatment of Patient 4’s left lateral foot wound (wound #3). DPCS stated that HHA did not obtain an order for wound #3 and that it was the responsibility of the HHA to obtain an order to treat wound #3. During an interview and record review of Patient 4’s clinical record on 5/9/2025 at 2:43 pm, DPCS stated there was no record of the nurse performing any assessment or treatment of wound #2 or wound #3 after the HHA assumed care of the wounds with the physicians change of orders on 4/14/2025 (25 days after the change in care plan). DPCS stated this put Patient 4 at risk for infection, serious illness, hospitalization and possible amputation of the left foot. During a concurrent interview and record review of Patient 4’s clinical record on 5/9/2025 at 3:15pm, DPCS stated that the HHA is required to perform supervisory visits of all licensed vocational nurses. DPCS stated that the purpose of the supervisory visits was to ensure the proper care of the patients. DPCS stated that when performing an LVN supervisory visit, there should be a review of the record, including orders, treatments, assessments, and to identify any issues in the medical record of the patient. DPCS stated an observation of the nurse performing care should be done to ensure competency of the nurse. During a concurrent interview and record review of Patient 4’s clinical record Skilled Nursing Supervisory Visit, dated 4/21/2025 on 5/9/2025 at 3:15pm, DPCS stated she spoke with LVN 4 on the phone and did not go to Patient 4’s home, while performing the supervisory visit. DPCS stated that she did not identify the issues of missing assessments and wound treatment during reviews of the clinical record she performed for accuracy and completion. DPCS did not observe the wounds because she did not observe the patient or the care the patient was receiving in person. A review of the facility’s undated policy titled, “Responsibilities/Supervision of the Clinical Services,” indicated that the purpose of the policy was to ensure a process is in place for the overseeing of all clinical care and services. The policy further indicated that, “the LVN will be supervised by a registered nurse as directed by the State Practice Act.” Findings: 1. During a review of Patient 2’s Patient Information sheet indicated Patient 2’s start of care date was 10/15/2024, with a primary diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy. During a concurrent interview and record review on 5/9/2025 at 1:30 p.m., of Patient 2’s clinical record with the DPCS, there was no documented evidence of an RN Supervisory Visit from Patient 2’s start of care. The DPCS stated, “I don’t see any RN Supervisory Visits done for Patient 2 in the clinical record. We usually do supervisory visits at a minimum of every 60 days per California Nursing Act, but we try to do at least every 30 days. During a concurrent interview and record review of Patient 2’s clinical record on 5/9/2025 at 3:15 p.m., the DPCS stated that the HHA is required to perform supervisory visits of all licensed vocational nurses. The DPCS stated that the purpose of the supervisory visits was to ensure the proper care of the patients. The DPCS stated that when performing an LVN supervisory visit, there should be a review of the record, including orders, treatments, assessments, and to identify any issues in the medical record of the patient. The DPCS stated an observation of the nurse performing care should be done to ensure competency of the nurse. a. A review of Patient 8’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 1/29/2025 with a primary diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing causing damage to the tiny blood vessels in the kidneys) and other diagnosis of gangrene (condition where tissue dies due to loss of blood supply), and encounter for change or removal of surgical wound dressing. During a review of Patient 8’s medical record titled, Plan of Care (POC), for the certification period of 3/30/2025 to 5/28/2025 indicated, a recertification frequency order for Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) for one time a day for seven days starting 4/8/2025 with an estimate of services to be required for 9 weeks. Patient 8’s POC also indicated order for skilled nurse (SN) to educate the patient about the signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), pain management, medication management/compliance, and assess/perform/ instruct the patient/caregiver on wound care to left foot to paint left forefoot with betadine solution (topical antiseptic used to kill bacteria, fungi, viruses) and cover with dry dressing fluffs and kerlix, and ace wrap daily. During a review of Patient 8’s Electronic Medical Record (EMR), the EMR indicated medical records titled Skilled Nurse Visit Note for the dates of 3/31/2025, 4/1/2025, 4/2/2025, 4/4/2025, 4/8/2025, 4/10/2025, 4/11/2025, 4/14/2025, 4/15/2025, 4/16/2025, 4/18/2025, 4/21/2025, 4/22/2025, 4/23/2205, 4/25/2025, 4/28/2025, 4/30/2025, 5/1/2025, 5/2/2025, 5/5/2025, 5/7/2025, and 5/8/2025 with Licensed Vocational Nurse 2 (LVN2) as the author. During a concurrent interview and record review on 5/9/2025 at 2:12pm with the Director of Patient Care Services (DPCS), Patient 8’s EMR was reviewed. Patient 8’s EMR indicated documented visits by LVN2 dated 3/31/2025, 4/1/2025, 4/2/2025, 4/4/2025, 4/8/2025, 4/10/2025, 4/11/2025, 4/14/2025, 4/15/2025, 4/16/2025, 4/18/2025, 4/21/2025, 4/22/2025, 4/23/2205, 4/25/2025, 4/28/2025, 4/30/2025, 5/1/2025, 5/2/2025, 5/5/2025, 5/7/2025, and 5/8/2025. Patient 8’s EMR also indicated there was no documented evidence of a Registered Nurse (RN) documentation for a supervisory visit. The DPCS stated and confirmed Patient 8’s EMR did not include documentation that a supervisory visit for the Licensed Vocational Nurse (LVN) was completed by an RN. The DPCS stated Patient 8’s recertification visit dated 3/26/2025 was completed by an RN but did not count as a supervisory visit as an LVN was not present during the visit to assess their performance and care provided to Patient 8. The DPCS further stated the HHA follows the guidelines from the state practice act for licensed supervisory visits to be done every 62 days. Findings: 1. During a review of Patient 2’s Patient Information sheet indicated Patient 2’s start of care date was 10/15/2024, with a primary diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy. During a concurrent interview and record review on 5/9/2025 at 1:30 p.m., of Patient 2’s clinical record with the DPCS, there was no documented evidence of an RN Supervisory Visit from Patient 2’s start of care. The DPCS stated, “I don’t see any RN Supervisory Visits done for Patient 2 in the clinical record. We usually do supervisory visits at a minimum of every 60 days per California Nursing Act, but we try to do at least every 30 days. During a concurrent interview and record review of Patient 2’s clinical record on 5/9/2025 at 3:15 p.m., the DPCS stated that the HHA is required to perform supervisory visits of all licensed vocational nurses. The DPCS stated that the purpose of the supervisory visits was to ensure the proper care of the patients. The DPCS stated that when performing an LVN supervisory visit, there should be a review of the record, including orders, treatments, assessments, and to identify any issues in the medical record of the patient. The DPCS stated an observation of the nurse performing care should be done to ensure competency of the nurse. 2. During a review of Patient 4’s Patient Profile indicated that Patient 4, an 82-year-old male, was admitted to HHA on 2/8/2025, with home health recertification on 4/9/2025- 6/7/2025, with diagnosis of type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar and using it in the body), diabetic polyneuropathy (a nerve damage condition that arises as a complication of diabetes), foot ulcer (an open sore on the foot that fails to heal and can involve skin, tissue, and potentially deeper structures like bones), and chronic foot ulcer (a persistent, open sore on the foot that fails to heal within a reasonable timeframe, often due to underlying conditions like diabetes, poor circulation, or peripheral neuropathy). During a review of Patient 4’s recertification assessment dated 4/7/2025, indicated Patient 4 had three wounds. Wound 1 was described as an open diabetic ulcer on the great right toe measuring 1.5 cm x 1.0 cm with a depth of 0.5 cm. Wound 2 was described as an ulcer on the left lateral leg measuring 3.0 cm x 3.0 cm with a depth of 0.3 cm. Wound 3 was described as an open diabetic ulcer on the left lateral foot measuring 3.0 cm x 2.0 cm with a depth of 0.2 cm. The appearance of Wound 3 is described as red with necrotic bed tissue and without odor. During a review of Patient 4’s clinical record, skilled nursing visit notes dated 4/16/2025, 4/21/2025, 4/24/2025, 4/29/2025 and 5/2/2025, there was no record of assessment or of the treatment for wound #2 or wound #3. During an interview and record review of Patient 4’s clinical record on 5/9/2025 at 2:43 p.m., with the DPCS, the DPCS stated there was a physician’s order to treat Patient 4’s left lateral leg wound (wound #2), however there was no order for treatment of Patient 4’s left lateral foot wound (wound #3). DPCS stated that HHA did not obtain an order for wound #3 and that it was the responsibility of the HHA to obtain an order to treat wound #3. During an interview and record review of Patient 4’s clinical record on 5/9/2025 at 2:43 p.m., with the DPCS, the DPCS stated there was no record of the nurse performing any assessment or treatment of wound #2 or wound #3 after the HHA assumed care of the wounds with the physicians change of orders on 4/14/2025 (25 days after the change in care plan). The DPCS stated this put Patient 4 at risk for infection, serious illness, hospitalization and possible amputation of the left foot. During a concurrent interview and review of Patient 4’s clinical record on 5/9/2025 at 3:15 p.m., the DPCS, the DPCS stated that the HHA was required to perform supervisory visits of all licensed vocational nurses. DPCS stated that the purpose of the supervisory visits was to ensure the proper care of the patients. The DPCS stated that when performing an LVN supervisory visit, there should be a review of the record, including orders, treatments, assessments, and to identify any issues in the medical record of the patient. DPCS stated an observation of the nurse performing care should be done to ensure competency of the nurse. During a concurrent interview and record review of Patient 4’s clinical record Skilled Nursing Supervisory Visit, dated 4/21/2025 on 5/9/2025 at 3:15 pm, DPCS stated she spoke with LVN 4 on the phone and did not go to Patient 4’s home, while performing the supervisory visit. DPCS stated that she did not identify the issues of missing assessments and wound treatment during reviews of the clinical record she performed for accuracy and completion. DPCS did not observe the wounds because she did not observe the patient or the care the patient was receiving in person. A review of the facility’s undated policy titled, “Responsibilities/Supervision of the Clinical Services,” indicated that the purpose of the policy was to ensure a process is in place for the overseeing of all clinical care and services. The policy further indicated that, “the LVN will be supervised by a registered nurse as directed by the State Practice Act.” a. 3. A review of Patient 8’s medical record titled, Patient Profile, undated, indicated a Start of Care (SOC) date of 1/29/2025 with a primary diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing causing damage to the tiny blood vessels in the kidneys) and other diagnosis of gangrene (condition where tissue dies due to loss of blood supply), and encounter for change or removal of surgical wound dressing. During a review of Patient 8’s medical record titled, Plan of Care (POC), for the certification period of 3/30/2025 to 5/28/2025 indicated, a recertification frequency order for Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) for one time a day for seven days starting 4/8/2025 with an estimate of services to be required for 9 weeks. Patient 8’s POC also indicated order for skilled nurse (SN) to educate the patient about the signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), pain management, medication management/compliance, and assess/perform/ instruct the patient/caregiver on wound care to left foot to paint left forefoot with betadine solution (topical antiseptic used to kill bacteria, fungi, viruses) and cover with dry dressing fluffs and kerlix, and ace wrap daily. During a review of Patient 8’s Electronic Medical Record (EMR), the EMR indicated medical records titled Skilled Nurse Visit Note for the dates of 3/31/2025, 4/1/2025, 4/2/2025, 4/4/2025, 4/8/2025, 4/10/2025, 4/11/2025, 4/14/2025, 4/15/2025, 4/16/2025, 4/18/2025, 4/21/2025, 4/22/2025, 4/23/2205, 4/25/2025, 4/28/2025, 4/30/2025, 5/1/2025, 5/2/2025, 5/5/2025, 5/7/2025, and 5/8/2025 with Licensed Vocational Nurse 2 (LVN2) as the author. During a concurrent interview and record review on 5/9/2025 at 2:12 p.m., with the Director of Patient Care Services (DPCS), Patient 8’s EMR was reviewed. Patient 8’s EMR indicated documented visits by LVN2 dated 3/31/2025, 4/1/2025, 4/2/2025, 4/4/2025, 4/8/2025, 4/10/2025, 4/11/2025, 4/14/2025, 4/15/2025, 4/16/2025, 4/18/2025, 4/21/2025, 4/22/2025, 4/23/2205, 4/25/2025, 4/28/2025, 4/30/2025, 5/1/2025, 5/2/2025, 5/5/2025, 5/7/2025, and 5/8/2025. Patient 8’s EMR also indicated there was no documented evidence of a Registered Nurse (RN) documentation for a supervisory visit. The DPCS stated and confirmed Patient 8’s EMR did not include documentation that a supervisory visit for the Licensed Vocational Nurse (LVN) was completed by an RN. The DPCS stated Patient 8’s recertification visit dated 3/26/2025 was completed by an RN but did not count as a supervisory visit as an LVN was not present during the visit to assess their performance and care provided to Patient 8. The DPCS further stated the HHA follows the guidelines from the state practice act for licensed supervisory visits to be done every 62 days.”