Verdugo Hills Home Care, Inc.

“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 interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Care Planning, Coordination, and Quality of Care was met as follows: 1. The HHA failed to ensure the Plan of Care (POC) was followed for one of ten sampled patients (Patient 6). This failure placed patients at risk for health status decline by not providing the services as indicated in the POC (Refer to G572). 2. The HHA failed to include information required in the plan of care for three of ten sampled patients (Patient 1, Patient 2 and Patient 7). This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. (Refer to G574). 3. The HHA failed to provide written information regarding the plan of care and medication list for four of ten patients (Patient 1, Patient 2, Patient 6, Patient 7). This deficient practice resulted in patients and their representatives not knowing their care team or their treatment course. (Refer to G612). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) compliance with Quality Assessment and Performance Improvement (QAPI, a data driven approach to improve the quality of care and services provided to patients) for the provided services to the patients as follows: 1. The Home Health Agency (HHA) failed to ensure performance improvement projects (PIP) were conducted annually. This failure had the potential to affect the quality of care provided to the home health certified patients. (Refer to G658). 2. The HHA governing body failed to provide documented evidence the QAPI program was being implemented by the agency annually. This failure has the potential to result in a substandard provision of patient care and services. (Refer to G660). The cumulative effect of this systemic practice resulted in the failure of the Home Health Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Quality Assessment and Performance Improvement for the provided services to patients certified to receive home health benefits.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [a 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 the Organization and Administration of Services as follows: 1.The HHA failed to ensure the failed to provide an appointment letter indicating that the governing body appointed the Administrator (ADM) . This deficient practice resulted in the Administrator lacking a formal appointment letter or documented proof the Administrator has the authority and responsibilities to run daily operations. (Refer to G946). 2. The Home Health agency (HHA), failed to ensure nine of nine employees were qualified to provide services (ADMIN/DPCS, DPCSD, RN 1, RN 2, RN 3, RN 4, ADMIND, OT 1, PT 1) to home health certified patients. This deficient practice had the potential to result in the provision of a substandard care and services that could affect the patient’s safety and well-being. (Refer to G952). 3. The HHA failed to provide an appointment letter indicating that the governing body and Administrator appointed the Administrator Designee (ADMD). This deficient practice resulted in the Administrator Designee lacking a formal appointment letter or documented proof the Administrator Designee has the authority and responsibilities to run daily operations when the Administrator is not available. (Refer to G954) The cumulative effect of these systemic practices resulted in the failure of the agency to deliver statutorily (written law) mandated Federal compliance for Organization and Administration of Services to ensure the highest quality of care were provided to patients certified to receive home health care and services.”

“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 ensure the Plan of Care (POC) was implemented for one of ten sampled patients (Patient 6). This failure placed patients at risk for delayed treatment and intervention that could affect the patient’s medical status and well being. During a record review of Patient 6’s “Plan of Care” (POC) dated 06/24/2026 to 08/22/2026, indicated a start of care date of 04/25/2026 with a primary diagnosis of Parkinsonism (an umbrella term for a group of brain conditions that cause movement problems, such as slowed motion, muscle stiffness, tremors, and balance issues). The POC indicated notify MD(physician) if SBP (Systolic blood pressure, the top number in the blood pressure reading) greater than 170mm/Hg (millimeters of mercury a unit of measurement), or less than 90mm/HG, diastolic blood pressure (the bottom number in the blood pressure reading) greater than 90mm of mercury and less than 55mm/Hg heart rate greater than 110 beats per minute and less than 55 beats per minute. During the record review of Patient 6’s Nurse progress notes and wound care dated 8/8/2026, indicated systolic blood pressure reading 88 mm/Hg and Diastolic blood pressure reading of 46 mm/Hg. There was no documented evidence in the clinical record the out-of-range vital signs were reported to the physician. During a concurrent record review and interview on 8/13/2026 at 11:30 a.m., of Patient 6’s 8/8/2024 nursing progress note with DPCS, DPCS stated for Patient 6’s low blood pressure needed to be reported to the physician right away. This was not done. It is important to report right away to determine if any medications need to be added or new order needed to be given to treat the patient. During a record review of the HHA policy and procedure titled, “Care Planning Process”, revised 4/2010, the policy and procedure indicated, “All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including but not limited to;…B. Changes in patients condition...””

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to provide written instructions to patients and caregivers regarding the patients’ plans of care (POC) for four of ten sampled patients (Patient 1, Patient 2, Patient 6 and Patient 7). This deficient practice had the potential for the patients and their caregivers lack of knowledge and not understand the care and services provided to the patients. c. During a record review of Patient 6’s “Plan of Care” dated 06/24/2026 to 08/22/2026, indicated a start of care date of 04/25/2026 with a primary diagnosis of Parkinsonism (an umbrella term for a group of brain conditions that cause movement problems, such as slowed motion, muscle stiffness, tremors, and balance issues). During a concurrent record review and interview on 8/12/20206 at 11:20 a.m. at Patient 6’s residence of the HHA folder, with the DPCSD, there was no Plan of Care in the patient folder. The DPCSD said, its not in the folder. This was missed. d. a. During a record review of Patient 7’s “Plan of Care” (POC) dated 06/13/2026 to 08/11/2026, indicated a start of care date of 06/13/2026 with a primary diagnosis of cellulitis of right lower limb (an infection in the skin of the right lower leg and foot). During a concurrent record review and interview on 8/12/20206 at 1:20 p.m. at Patient 7’s residence of the HHA folder, with the DPCSD, there was no Plan of Care in the patient folder. The DPCSD said, its not in the folder. This was missed. During a interview on 8/13/2026 at 11:05 a.m. with DPCS, DPCS states a copy of the POC needs to be in every patients house, this is important because the patient needs to know what care will be provided to them. During a record review of the HHA’s document titled, “Care Planning Process”, revised 4/2010, the policy and procedure indicated, “The organization shall provide the patient and caregiver with a copy of written instructions outlining: A. Visit schedule, including frequency of visits…Patient medication schedule/instructions, including medication name…” Findings: a. During a record review of Patient 1’s “Home Health Certification and Plan of Care” dated 7/29/2026 to 9/26/2026, indicated a start of care date of 10/2/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar levels). During a joint home visit, on 8/12/2026 at 8:35 a.m. with the Registered Nurse (RN 2) at Patient 1’s residence, Patient 1 was observed sitting down on the couch with caregiver present. Patient 1’s agency folder was reviewed and observed that there was no current POC found. b. During a record review of Patient 2’s “Home Health Certification and Plan of Care” dated 7/28/2026 to 9/25/2026, indicated a start of care date of 10/1/2025 with a diagnosis of open wound to abdominal wall. During a joint home visit, on 8/12/2026 at 9:55 a.m. with the Registered Nurse (RN 2) at Patient 2’s residence, Patient 2 was observed lying down on the couch with caregiver present. Patient 2’s agency folder was reviewed and observed that there was no current POC found. During an interview, on 8/13/2026 at 12:18 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that patient’s current POC have not been provide consistently in the patient’s homes. ADM/DPCS stated that it is important to provide the patients with current POC so that patients and caregivers have accurate information regarding their treatments and assessments and that everyone is on the same page. c. During a record review of Patient 6’s “Plan of Care” dated 06/24/2026 to 08/22/2026, indicated a start of care date of 04/25/2026 with a primary diagnosis of Parkinsonism (an umbrella term for a group of brain conditions that cause movement problems, such as slowed motion, muscle stiffness, tremors, and balance issues). During a concurrent record review and interview on 8/12/20206 at 11:20 a.m. at Patient 6’s residence of the HHA folder, with the DPCSD, there was no Plan of Care in the patient folder. The DPCSD said, its not in the folder. This was missed. d. a. During a record review of Patient 7’s “Plan of Care” (POC) dated 06/13/2026 to 08/11/2026, indicated a start of care date of 06/13/2026 with a primary diagnosis of cellulitis of right lower limb (an infection in the skin of the right lower leg and foot). During a concurrent record review and interview on 8/12/20206 at 1:20 p.m. at Patient 7’s residence of the HHA folder, with the DPCSD, there was no Plan of Care in the patient folder. The DPCSD said, its not in the folder. This was missed. During a interview on 8/13/2026 at 11:05 a.m. with DPCS, DPCS states a copy of the POC needs to be in every patients house, this is important because the patient needs to know what care will be provided to them. During a record review of the HHA’s document titled, “Care Planning Process”, revised 4/2010, the policy and procedure indicated, “The organization shall provide the patient and caregiver with a copy of written instructions outlining: A. Visit schedule, including frequency of visits…Patient medication schedule/instructions, including medication name…””

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure performance improvement projects (PIP) were conducted annually. This failure had the potential to affect the quality of care provided to the home health certified patients. During a concurrent interview and record review on 8/11/2026 at 2:30 pm., with Admin of QAPI (Quality Assurance and Performance Improvement: a data-driven, ongoing program mandated by Centers of Medicare/Medicaid Services CMS) folder, there was no documented evidence the PIP project was conducted annually to reflect the scope, complexity, and past performance of the HHA’s services. Admin stated, “We don’t have PIP documentation demonstrating why we choose the topic, what the outcomes were, and measurable goals. It is important to have these documentations because it will show that we have a method of implementation and that what we are doing is working. I, as well as the QAPI coordinator who is also the Administrator designee, are responsible for conducting these projects and it was not done.” The HHA’S policy and procedure titled “Sample Quality Assessment and Performance Improvement (QAPI) Plan “ revised 12/2025, the policy and procedure indicated, “The purpose of the home health copy plan is to provide a strategy for the systematic organization wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective and efficient services in accordance with its mission and current standards of practice. Through copy activities, the organization provides A mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. …to conduct performance improvement projects aimed at performance improvement and tracked performance to ensure that it is sustained….””

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on interview and record review, the HHA governing body failed to provide documented evidence the QAPI program was being implemented and maintained annually. This failure has the potential to result in the HHA not addressing priorities for improved quality of care and patient safety, and all improvement actions and performance are evaluated for effectiveness. During a review of the QAPI folder indicated the QAPI (Quality Assurance and Performance Improvement: a data-driven, ongoing program mandated by Centers of Medicare/Medicaid Services CMS) governing body minutes was not signed and dated, to indicate when meeting was done and who were in attendance. During an interview on 8/11/2026 at 2:35 p.m., with DPCS stated, the governing body minutes were not signed or dated, you can’t tell who were in attendance and what date it was done, if it doesn’t indicate on the governing body minutes. It is the governing body’s responsibility to ensure the QAPI/PIP projects are done properly. The DPCS, as part of the governing body was in charge.”

“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 maintain an updated medication profiles for three out of ten sampled patients (Patient 1, Patient 2 and Patient 7). This failure had the potential to cause medication errors and adverse side effects to medications. b. During a record review of Patient 7’s “Plan of Care” (POC) dated 06/13/2026 to 08/11/2026, indicated a start of care date of 06/13/2026 with a primary diagnosis of cellulitis of right lower limb (an infection in the skin of the right lower leg and foot). During a concurrent record review and interview on 8/12/2026 at 1 p.m. of the medications with RN 1, at Patient 7’s residence, the medication profile provided By HHA did not have the following medications listed but were available in Patient 7’s residence; 06/20/2026 Acetaminophen 500 mg (over the counter) take 1-2 tablets every 4 hours as needed for pain 07/02/2026 Gentamycin 0.1 % Ointment; Apply topically daily to wound 06/30/2026 Benadryl extra strength itch cream apply to affected area as needed 7/02/2026 Mupirocin 2% ointment; apply topically daily x 30 days to wounds 7/02/2026 Furosemide 10 mg One tab daily every morning (diuretic to excrete excess fluid from the body in order to reduce swelling) 7/30/2026 Levothyroxine 175 mg (Synthetic thyroid hormone to replace low thyroid levels) one tab daily every morning 8/10/2026 Juven 2 packets daily for wound healing 6/30/2026 Warren multi gummy vitamins 2 gummies daily RN 1 stated, “I hand wrote all the new medications on the medication list at home but this was not updated in the HHA system. We do medication reconciliation on every visit and it is important to update the system so the agency can know and track all the new medications.” During an interview on 8/13/2026 at 2:00 p.m. with DPCS, DPCS stated medication reconciliation needs to be done on every visit and updated in our system if there are ant new orders. During a record review of the HHA’s policy titled “Medication Profile”, revised 04/2010, indicated, “patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new and/or discontinued medications. ...A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are preformed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.” Findings: a. During a record review of Patient 1’s “Home Health Certification and Plan of Care” dated 7/29/2026 to 9/26/2026, indicated a start of care date of 10/2/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar levels). During a joint home visit, on 8/12/2026 at 8:35 a.m. with the Registered Nurse (RN 2) at Patient 1’s residence, Patient 1 was observed sitting down in the couch with caregiver present. During a review of Patient 1’s current medication, on 8/12/2026 at 9:10 a.m. with RN 2, the following medications were not available in Patient 1’s residence but listed in Patient 1’s medication profile provided by the HHA: - Liquid Multivitamin - Restasis 0.05 percent (eye drop used to increase the eyes’ natural ability to produce tears) - Vitamin D3 (supplement) b. During a record review of Patient 2’s “Home Health Certification and Plan of Care” dated 7/28/2026 to 9/25/2026, indicated a start of care date of 10/1/2025 with a diagnosis of open wound to abdominal wall. During a joint home visit, on 8/12/2026 at 9:55 a.m. with the Registered Nurse (RN 2) at Patient 2’s residence, Patient 2 was observed lying down in the couch with caregiver present. During a review of Patient 2’s current medication, on 8/12/2026 at 10:25 a.m. with RN 2, the following medications were not available in Patient 2’s residence but listed in Patient 2’s medication profile provided by the HHA: - Eliquis (used to treat, prevent, and lower the risk of dangerous blood clots and stroke) 5 milligrams (mg – unit of measurement) - Doxycycline Hyclate ( used to treat bacterial infections in many different parts of the body) 100 mg During an interview, on 8/13/2026 at 12:18 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that medication reconciliation is done verbally every visit and bottles are only checked during initial and recertification assessments. ADM/DPCS stated that it is important to have an accurate medication profile to make sure patients have the proper treatment and orders are carried out correctly and prevent complications. During a review of the agency’s policy and procedure (P&P) titled “Medication Profile” dated 4/2010, the P&P indicated patient receiving medications administered by the organization will have a current, accurate, medication profile in the clinical record. The P&P indicated that medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. a. During a record review of Patient 1’s “Home Health Certification and Plan of Care” dated 7/29/2026 to 9/26/2026, indicated a start of care date of 10/2/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar levels). During a joint home visit, on 8/12/2026 at 8:35 a.m., with the Registered Nurse (RN 2) at Patient 1’s residence, Patient 1 was observed sitting on the couch with caregiver present. During a review of Patient 1’s current medication, on 8/12/2026 at 9:10 a.m., with RN 2, the following medications were not available in Patient 1’s residence but listed in Patient 1’s medication profile provided by the HHA: - Liquid Multivitamin - Restasis 0.05 percent (eye drop used to increase the eyes’ natural ability to produce tears) - Vitamin D3 (supplement). b. During a record review of Patient 2’s “Home Health Certification and Plan of Care” dated 7/28/2026 to 9/25/2026, indicated a start of care date of 10/1/2025 with a diagnosis of open wound to abdominal wall. During a joint home visit, on 8/12/2026 at 9:55 a.m. with the Registered Nurse (RN 2) at Patient 2’s residence, Patient 2 was observed lying on the couch with caregiver present. During a review of Patient 2’s current medication, on 8/12/2026 at 10:25 a.m. with RN 2, the following medications were not available in Patient 2’s residence but listed in Patient 2’s medication profile provided by the HHA: - Eliquis (used to treat, prevent, and lower the risk of dangerous blood clots and stroke) 5 milligrams (mg – unit of measurement) - Doxycycline Hyclate (used to treat bacterial infections in many different parts of the body) 100 mg During an interview, on 8/13/2026 at 12:18 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that medication reconciliation is done verbally every visit and bottles are only checked during initial and recertification assessments. ADM/DPCS stated that it is important to have an accurate medication profile to make sure patients have the proper treatment and orders are carried out correctly and prevent complications. c. During a record review of Patient 7’s “Plan of Care” (POC) dated 06/13/2026 to 08/11/2026, indicated a start of care date of 06/13/2026 with a primary diagnosis of cellulitis of right lower limb (an infection in the skin of the right lower leg and foot). During a concurrent record review and interview on 8/12/2026 at 1 p.m., of the medications with RN 1, at Patient 7’s residence, the medication profile provided By HHA did not have the following medications listed but were available in Patient 7’s residence: - Acetaminophen 500 mg (over the counter) take 1-2 tablets every 4 hours as needed for pain - 6/20/2026 Gentamycin 0.1 % Ointment; Apply topically daily to wound -7/02/2026 Benadryl extra strength itch cream apply to affected area as needed- 6/30/2026 7/02/2026 Mupirocin 2% ointment; apply topically daily x 30 days to wounds 7/02/2026 Furosemide 10 mg One tab daily every morning (diuretic to excrete excess fluid from the body in order to reduce swelling) 7/30/2026 Levothyroxine 175 mg (Synthetic thyroid hormone to replace low thyroid levels) one tab daily every morning 8/10/2026 Juven 2 packets daily for wound healing 6/30/2026 Warren multi gummy vitamins 2 gummies daily RN 1 stated, “I hand wrote all the new medications on the medication list at home but this was not updated in the HHA system. We do medication reconciliation on every visit and it is important to update the system so the agency can know and track all the new medications.” During an interview on 8/13/2026 at 2:00 p.m. with DPCS, DPCS stated medication reconciliation needs to be done on every visit and updated in our system if there are ant new orders. During a record review of the HHA’s policy titled “Medication Profile”, revised 04/2010, indicated, “patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new and/or discontinued medications. ...A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are preformed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the individualized plan of care included the management of the identified medical needs of the patients and skilled nurse assessment every visit for three of ten sampled patients (Patient 1, Patient 2 and Patient 6). This failure had the potential to result in patients identified needs will not be met that could negatively impact the patient’s health status and well-being. c. During a record review of Patient 6’s “Plan of Care” dated 06/24/2026 to 08/22/2026, indicated a start of care date of 04/25/2026 with a primary diagnosis of Parkinsonism (an umbrella term for a group of brain conditions that cause movement problems, such as slowed motion, muscle stiffness, tremors, and balance issues). The POC further indicated skilled nurse frequency once a week for one week, twice a week for four weeks, once a week for four weeks +2 as needed visits for acute medical needs. During a record review of Patient 6’s communication memo/MD order dated 6/20/2026, The document indicated skilled nurse to assess weekly and as needed. During an interview on 8/13/2026 at 2:44 p.m. with DPCS, DPCS stated Its important to have an accurate Plan of care because that’s how you determine the treatment plan for patients. Patient 6’s plan of care has incorrect frequencies because there is a communication order from 6/20/2026 that indicates once a week skilled nurse visits, which is inconsistent with the plan of care frequency which stated twice a week for four weeks. During a record review of the agency’s policy and procedure, titled “Care Planning Process” revised 4/2010, the policy and procedure indicated, “ The patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan...” the policy and procedure further indicated, “Based on the assessment and conclusions, the plan of care will include, but not be limited to: A. Patient specific interventions and education B. All patient care orders from all physicians involved in the plan of care, including verbal orders C. Identified patient problems and needs, including functional limitations, activities permitted, nutritional requirements D. Reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care E. Specific services and treatments to be provided, including services furnished via telecommunication systems (if appropriate) F. Actions to be taken to meet the patient goals G. Type, including identifying the responsible discipline(s), frequency, and duration of above actions... 6. The plan of care will be based upon the physician’s (or allowed practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.” a. During a record review of Patient 1’s “Home Health Certification and Plan of Care (POC)” dated 7/29/2026 to 9/26/2026, indicated a start of care date of 10/2/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar levels). The “Home Health Certification and Plan of Care” indicated for the Skilled Nurse (SN) to change Port-A-Cath (a small medical device placed under your skin to give medicines and draw blood easily without ) line dressing and Huber needle (a special medical needle with a curved tip) weekly and as needed via sterile technique. During a review of the “Home Health Certification and Plan of Care” indicated the SN to perform and provide instructions on ostomy (a surgical operation that makes an opening on the belly) care. The “Home Health Certification and Plan of Care” failed to include instructions pertaining to the management of Port-A-Cath, and supplies to be used during ostomy care. During a joint home visit, on 8/12/2026 at 8:35 a.m., with the Registered Nurse (RN 2) at Patient 1’s residence, Patient 1 was observed sitting on the couch with caregiver present. It was observed the Port-A-Cath was on the left upper chest and ostomy to right lower abdomen observed. It was further observed the SN did not give instructions to the patient or caregiver on the management of the Port-A-Cath and ostomy care. b. During a record review of Patient 2’s “Home Health Certification and Plan of Care” dated 7/28/2026 to 9/25/2026, indicated a start of care date of 10/1/2025 with a diagnosis of open wound to abdominal wall. The “Home Health Certification and Plan of Care” indicated the SN to perform and instruct on ostomy care. The “Home Health Certification and Plan of Care” further indicated that there were no detailed instructions in the POC regarding how the ostomy care needs to be done, what supplies need to be used during care. During a joint home visit, on 8/12/2026 at 9:55 a.m. with the Registered Nurse (RN 2) at Patient 2’s residence, Patient 2 was observed lying on the couch with caregiver present. It was observed the Ostomy was on right lower abdomen. During a concurrent interview and record review on 8/13/2026 at 12:18 p.m., and 12:36 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that Patient 1 and Patient 2 did not have detailed instructions and step by step guide regarding ostomy care and port-a-cath care. ADM/DPCS stated that it is important to have detailed instructions so that staff know what they are doing and they are doing what the physician ordered and are using the correct supplies. c. During a record review of Patient 6’s “Plan of Care” dated 6/24/2026 to 8/22/2026, indicated a start of care date of 04/25/2026 with a primary diagnosis of Parkinsonism (an umbrella term for a group of brain conditions that cause movement problems, such as slowed motion, muscle stiffness, tremors, and balance issues). The POC further indicated skilled nurse frequency once a week for one week, twice a week for four weeks, once a week for four weeks +2 as needed visits for acute medical needs. During a record review of Patient 6’s MD order dated 6/20/2026, indicated for the skilled nurse to perform patient’s assessment weekly and as needed. The MD order was not identified on the POC for certification period of 6/24/2026 to 8/22/2026. During an interview on 8/13/2026 at 2:44 p.m., with DPCS, DPCS stated it’s important to have an accurate Plan of care because that’s how you determine the treatment plan for patients. Patient 6’s plan of care has incorrect frequencies because there is a communication order from 6/20/2026 that indicates once a week skilled nurse visits, which is inconsistent with the plan of care frequency which stated twice a week for four weeks. During a record review of the agency’s policy and procedure, titled “Care Planning Process” revised 4/2010, the policy and procedure indicated, the purpose of the policy and procedure is “to provide clinical direction to the clinician providing direct patient care.” The policy and procedure indicated “The patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan...” the policy and procedure further indicated, “Based on the assessment and conclusions, the plan of care will include, but not be limited to: A. Patient specific interventions and education B. All patient care orders from all physicians involved in the plan of care, including verbal orders C. Identified patient problems and needs, including functional limitations, activities permitted, nutritional requirements D. Reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care E. Specific services and treatments to be provided, including services furnished via telecommunication systems (if appropriate) F. Actions to be taken to meet the patient goals G. Type, including identifying the responsible discipline(s), frequency, and duration of above actions... 6. The plan of care will be based upon the physician’s (or allowed practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.” a. During a record review of Patient 1’s “Home Health Certification and Plan of Care (POC)” dated 7/29/2026 to 9/26/2026, indicated a start of care date of 10/2/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar levels). The “Home Health Certification and Plan of Care” indicated for the Skilled Nurse (SN) to change Port-A-Cath (a small medical device placed under your skin to give medicines and draw blood easily without repeated needle punctures) weekly and as needed via sterile technique. During a review of the “Home Health Certification and Plan of Care” indicated the SN to perform and provide instructions on ostomy (a surgical operation that makes an opening on the belly) care. The “Home Health Certification and Plan of Care” failed to include instructions pertaining to the management of Port-A-Cath, and supplies to be used during ostomy care. During a joint home visit, on 8/12/2026 at 8:35 a.m., with the Registered Nurse (RN 2) at Patient 1’s residence, Patient 1 was observed sitting on the couch with caregiver present. It was observed the Port-A-Cath was on the left upper chest with dressing intact and ileostomy (a surgical operation that creates an opening in the belly to route waste out of the small intestine when the colon cannot be used ) to right lower abdomen with dressing intact observed. RN 2 was observed changing the Port-A-Cath dressing prior to administering one liter normal saline (a sterile mixture of 0.9% sodium chloride (salt) dissolved in water). It was further observed the SN did not give instructions to the patient or caregiver on the management of the Port-A-Cath and ostomy care. b. During a record review of Patient 2’s “Home Health Certification and Plan of Care” dated 7/28/2026 to 9/25/2026, indicated a start of care date of 10/1/2025 with a diagnosis of open wound to abdominal wall. The “Home Health Certification and Plan of Care” indicated the SN to perform and instruct on ostomy care. The “Home Health Certification and Plan of Care” further indicated that there were no detailed instructions in the POC regarding how the ostomy care needs to be done, what supplies need to be used during care. During a joint home visit, on 8/12/2026 at 9:55 a.m. with the Registered Nurse (RN 2) at Patient 2’s residence, Patient 2 was observed lying on the couch with caregiver present. It was observed the urostomy (a surgical procedure that creates a new way for urine to leave the body through an opening in the abdomen called a stoma ) was on right lower abdomen. RN 2 was observed changing the urostomy dressing but no instructions on what supplies to use were found on the “Home Health Certification and Plan of Care” During a concurrent interview and record review on 8/13/2026 at 12:18 p.m., and 12:36 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that Patient 1 and Patient 2 did not have detailed instructions and step by step guide regarding ostomy care and port-a-cath care. ADM/DPCS stated that it is important to have detailed instructions so that staff know what they are doing and they are doing what the physician ordered and are using the correct supplies. c. During a record review of Patient 6’s “Plan of Care” dated 6/24/2026 to 8/22/2026, indicated a start of care date of 04/25/2026 with a primary diagnosis of Parkinsonism (an umbrella term for a group of brain conditions that cause movement problems, such as slowed motion, muscle stiffness, tremors, and balance issues). The POC further indicated skilled nurse frequency once a week for one week, twice a week for four weeks, once a week for four weeks +2 as needed visits for acute medical needs. During a record review of Patient 6’s MD order dated 6/20/2026, indicated for the skilled nurse to perform patient’s assessment weekly and as needed. The MD order was not identified on the POC for certification period of 6/24/2026 to 8/22/2026. During an interview on 8/13/2026 at 2:44 p.m., with DPCS, DPCS stated it’s important to have an accurate Plan of care because that’s how you determine the treatment plan for patients. Patient 6’s plan of care has incorrect frequencies because there is a communication order from 6/20/2026 that indicates once a week skilled nurse visits, which is inconsistent with the plan of care frequency which stated twice a week for four weeks. During a record review of the agency’s policy and procedure, titled “Care Planning Process” revised 4/2010, the policy and procedure indicated, the purpose of the policy and procedure is “to provide clinical direction to the clinician providing direct patient care.” The policy and procedure indicated “The patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan...” the policy and procedure further indicated, “Based on the assessment and conclusions, the plan of care will include, but not be limited to: A. Patient specific interventions and education B. All patient care orders from all physicians involved in the plan of care, including verbal orders C. Identified patient problems and needs, including functional limitations, activities permitted, nutritional requirements D. Reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care E. Specific services and treatments to be provided, including services furnished via telecommunication systems (if appropriate) F. Actions to be taken to meet the patient goals G. Type, including identifying the responsible discipline(s), frequency, and duration of above actions... 6. The plan of care will be based upon the physician’s (or allowed practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.””

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to provide an appointment letter indicating the governing body appointed the Administrator (ADM) to actively perform responsibilities in the daily operation of the HHA. This deficient practice has the potential to result in a substandard provision of care and services to all home health certified patients. During a record review of the Administrator’s (ADM) employee file on 8/13/2026, the ADM employee file indicated that there was no appointment letter found. During an interview, on 8/13/2026 at 2:37 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that she does not have an appointment letter as the Administrator and was not aware an appointment letter was needed. During a review of the agency’s job description titled “Job title/Position: Executive Director/Administrator” dated 4/2010, the job description indicated that the administrator is responsible for planning, coordinating, managing and directing all activities and programs of the agency.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on interview and record review the Home Health agency (HHA), failed to ensure nine of nine employees were qualified to provide services (Administrator/Director of Patient Care Services [ADM/DPCS] , Director of Patient Care Services Designee [DPCSD], Registered Nurse [RN 1], RN 2, RN 3, RN 4, Administrator Designee/Speech Pathologist [ADMD/SP 1], Occupational Therapist [OT 1], Physical Therapist [PT 1]) to home health certified patients. This deficient practice had the potential to result in the provision of a substandard care and services that could affect the patient’s safety and well-being. a.During a record review of RN 3’s employee file, indicated hire date 4/4/2025. There was no onboarding skill competency orientation, no annual performance evaluation, no job description in the employee file. b.During a record review of RN 4’s employee file, indicated hire date 1/22/2026. There was no onboarding skill competency orientation, no job description in the employee file. c.During a record review of RN 1’s employee file, indicated a hire date 5/5/2026. There was no onboarding skill competency orientation, no job description in the employee file. d.During a record review of DPCSD’s employee file, indicated a hire date 10/30/2008. There was no onboarding skill competency orientation, no annual performance evaluations, no job description in the employee file. During an interview on 8/13/2026 at 2:30 p.m. with DPCS, DPCS stated, “I am in charge of employee files. We don’t do background checks, onboarding and skills orientation, or annual performance evaluations. It is not in the files. There are no job descriptions in the employee files. This is important to do so you know if the nurses are qualified to perform their job, and know their job description.” During a record review of the HHA’s policy and procedure, titled “ Personnel Record Contents”, revised April 2010, indicated, “ General Documents A. Skills and Experience Inventory B. Signed standards of conduct C. Verified professional licensure or certification/aide registry D. CPR certification (professional personnel) Note: Online CPR certification is acceptable with in-person verification of competency E. Continuing education documentation New Hire Documents A. Evidence of pre-employment interview (Optional) B. Individual job qualifications C. Employment application D. Resume E. References (2)(0ptional) F. Diploma (copy) or educational transcripts G. Specialty practice certification certificates H. Verification of education/training I. Statement of formal training for non-professionals ( Optional) J. Orientation checklist (completed) K. Initial competency assessments L. Signed job description M. Condition of employment N. Signed and dated confidentiality statement 0. Criminal background check and national sex offender registry, if applicable and a copy of the criminal record statement (LIC 508 form) (kept in separate file) P. Driver’s license and proof of auto insurance, if applicable. Q.Completed 1-9 form which has been verified by the employer and two {2) forms of acceptable identification R. Malpractice coverage for independent contractors S. OIG exclusion list verification, if applicable Performance Evaluations/Counseling Documents A. Performance evaluation B. Performance Observation Reports (direct care only) C. Personnel counseling/disciplinary documentation D. Personnel performance plans E. EEOC/legal claims or correspondence F. Training/award certificates a. During a record review of the Administrator/Director of Patient Care Services (ADM/DPCS) employee file on 8/13/2026, the ADM/DPCS employee file indicated that there was no hire date. The ADM/DPCS employee file further indicated there was no onboarding skill competency orientation, no annual performance evaluation and no job description. b. During a record review of the Administrator Designee/Speech Pathologist (ADMD/SP 1) employee file on 8/13/2026, the ADMD/SP 1 employee file indicated a hire date of 12/27/2024. The ADMD/SP 1’s employee file further indicated there was no onboarding skill competency orientation, no annual performance evaluation and no job description. c. During a record review of the Registered Nurse (RN 2) employee file on 8/13/2026, the RN 2’s employee file indicated a hire date of 2/12/2024. The RN 2’s employee file further indicated there was no onboarding skill competency orientation, no annual performance evaluation and no job description. d. During a record review of the Occupational Therapist (OT 1) employee file on 8/13/2026, the OT 1’s employee file indicated a hire date of 11/15/2025. The OT 1’s employee file further indicated there was no onboarding skill competency orientation and no job description. e. During a record review of the Physical Therapist (PT 1) employee file on 8/13/2026, the PT 1’s employee file indicated a hire date of 12/3/2025. The PT 1’s employee file further indicated there was no onboarding skill competency orientation and no job description.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to provide an appointment letter indicating that the governing body and Administrator appointed the Administrator Designee (ADMD). This deficient practice resulted in the Administrator Designee lacking a formal appointment letter or documented proof the Administrator Designee has the authority and responsibilities to run daily operations when the Administrator is not available. During a record review of the Administrator Designee’s (ADMA) employee file on 8/13/2026, the ADMD employee file indicated that there was no appointment letter found. During an interview, on 8/13/2026 at 2:37 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated there was no appointment letter or documented evidence that the Administrator Designee was appointed for the position and was not aware an appointment letter was needed. During a review of the agency’s job description titled “Job title/Position: Executive Director/Administrator” dated 4/2010, the job description indicated essential job functions/responsibilities include appointing a similarly qualified alternate to be available at all times during operating hours in the absence of the administrator.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure one of ten sampled patients (Patient 6) clinical record included an accurate assessment of the patient’s integumentary (skin) status related to the location of the patient’s wound. This failure resulted in an inaccurate assessment of the integumentary status that could lead to provision of an inappropriate treatment and intervention. During a record review of Patient 6’s “Plan of Care” dated 06/24/2026 to 08/22/2026, indicated a start of care date of 04/25/2026 with a primary diagnosis of Parkinsonism (an umbrella term for a group of brain conditions that cause movement problems, such as slowed motion, muscle stiffness, tremors, and balance issues). During a joint home visit observation on 8/12/2026 at 10:55 a.m., with DPCSD, Patient 6 was observed lying in bed. Patient 6 was observed to have redness and skin breakdown on the right posterior arm, and low back. The DPCSD was observed providing wound care to right posterior arm, and low back. There was no skin breakdown noted on the left arm. During a concurrent record review and interview on 8/13/2026 at 11:14 a.m. of Patient 6’s 8/8/2026 nursing progress note with DPCS, the note indicated a Left posterior arm wound. The DPCS stated, the patient doesn’t have wound on the left arm its on the right arm. This was inaccurate documentation. It is important to have accurate documentation so all disciplines can see where the patients problem areas are. During a record review of the home health agency’s policy and procedure titled “Contents Of Clinical Record”, revised April 2010, the policy and procedure indicated, “A clinical record will be maintained for each patient receiving care period the clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel.””

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review the HHA failed to complete a transfer/discharge summary for one of ten sampled patients (Patient 10). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. During a record review of Patient 10’s document titled, Patient information indicated a start of care date of 5/15/2026, with diagnosis including shortness of breath, syncope (fainting), septic shock (a condition which happens after an infection becomes systemic), UTI (urinary tract infection, bladder infection), acute kidney injury, diarrhea, tachycardia (elevated heart rate above 100 beats per minute). During a record review of Patient 10’s skilled nurse discharge summary, the discharge summary of care indicated patient demonstrated improvement in bowel function, hydration status, endurance, and understanding of medication safety precautions. Lives with wife who is able to provide assistance. Declined physical therapy. During an interview on 8/13/2026 at 2:50 p.m. with DPCS stated discharge summary is supposed to contain the status of problems identified at admission and during the provision of care, the progress towards desired outcomes, medical status at discharge including continuing symptom management needs, the overall status of the patient, a summary of the care or services provided, it was not done for Patient 10. It is important to list all these things in the discharge summary, because it shows what the home health agency provided, the progress achieved, and what still needs to be done. During a record review of the HHA’s policy and procedure titled, “discharge summary”, revised April 2010, the policy and procedure indicated each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include as appropriate;…D. The status of problems identified added mission and during the provision of care E. The progress towards goals desired outcomes F. Medical status at discharge including continuing symptom management needs G. The overall status of the patient H. A summary of the care or services provided…”