All Care Home Health Provider

“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) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1.The HHA failed to ensure the comprehensive assessment included a complete physical assessment for two of seventeen sampled patients (Patient 3, Patient 12). This deficient practice resulted in Patients not receiving care according to the HHA’s procedures, which had the potential to result in complications and health status decline. (Refer G528). 2. The HHA failed to review and document all the medications and treatments the patient was currently using for six of seventeen sampled patients (Patient 2, Patient 3, Patient 6, Patient 8, Patient 12, Patient 14). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. (Refer to G536). 3. The HHA failed to ensure the comprehensive assessment for one of seventeen sampled patients (Patient 12) accurately reflected the primary care doctor responsible for the patients care. This deficient practice has the potential for delay of care by not knowing which doctor to contact in case there was a change of condition. (Refer to G538). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Comprehensive Assessment of patients to ensure home health care benefits are verified for eligibility to patients provided home health 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 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 three of seventeen sampled patients (Patient 12, Patient 14, Patient 16). 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 two of seventeen sampled patients (Patient 2, Patient 12). 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 ensure the physician reviewed and revised five of seventeen sample patients (Patient 1, Patient 2, Patient 14, Patient 15, and Patient 17) individualized plan of care. This failure had the potential to result in Patient receiving inappropriate or lacking appropriate services. (Refer to G588). 4. The HHA failed to provide written information regarding the plan of care and medication list for one of seven patients (Patient 12). 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.”

“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) failed to ensure the Condition of Participation regarding Clinical Records was met as follows: 1.The HHA failed to ensure one of seventeen sampled patients (Patient 1) clinical records included all the necessary forms. This failure resulted in an incomplete clinical record. (Refer to G1012). 2. The HHA failed to send all necessary medical information to the primary care practitioner within 5 days of discharge for two of seventeen sampled patients (Patient 15 and Patient 16). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. (Refer to G1022). 3. The HHA failed to ensure patient care records were complete and authenticated for two of seventeen sampled patients (Patient 1, Patient 2). This failure resulted in patients’ medical records being modified by people not involved in patients’ care. (Refer to G1024). The cumulative effect of these systemic practices resulted in the failure of the HHA to ensure the provision of quality health care in a safe environment.”

“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 followed for five of seventeen sampled patients (Patient 7, Patient 10, Patient 12, Patient 14, Patient 16). This failure placed patients at risk for health status decline by not providing the services as indicated in the POC. A record review of Patient 12’s Patient Profile sheet indicated a start of care date of 10/7/2024, with diagnoses including encounter for attention to colostomy (a surgically created opening of the large intestine that allows stool to exit through outside of the belly). During a concurrent observation and interview at the home visit on 11/18/2025, at 10:07 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 provided colostomy care to Patient 12. An observation of the colostomy care indicated LVN 4 did not measure Patient 12’s stoma (the opening of the intestine through the belly). LVN 4 stated she knew the size of the stoma due to the frequent visits, and that was the reason why LVN 4 was not measuring it today. Continued observation of the colostomy care indicated LVN 4 cleaned the stoma and surrounding skin with soap (from the soap dispenser in the bathroom) and water. During the colostomy care Patient 12 stated he had gained some weight, and the weight gain was making his stoma feel uncomfortable. Patient 12 stated he was working on losing weight, so his stoma doesn’t stretch. During a concurrent interview and record review on 11/18/2025, at 10:43 a.m., with LVN 4, LVN 4 reviewed Patient 12’s record titled Plan of Care, dated 10/22/2025 to 12/20/2025. The record indicated, “Colostomy care-every Tuesday and Friday”. During an interview on 11/19/2025, at 10:58 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated that nurses were supposed to provide colostomy care according to the policy, unless the doctor specified the orders. If there were no specific orders to follow, it could lead to possibly harming the patient by not giving the proper treatment. During an interview on 11/19/2025, at 12:18 p.m., the DPCS stated Patient 12 did not have a specific order for colostomy care. The expectation was for the nurses to follow the HHA’s policy on colostomy care. A record review of the HHA’s document titled, Colostomy Care, dated 11/19/2025, indicated, “Step-By-Step Colostomy Care…5. Cleanse stoma and peristomal skin gently with warm water; pat dry….Measure stoma and cut appliance opening to appropriate size…” Further review of the record did not indicate instructions for using soap to clean the stoma and surrounding skin. During a concurrent interview and record review on 11/19/2025, at 12:58 p.m., with the DPCS, the DPCS reviewed the HHA’s document titled, Colostomy Care, dated 11/19/2025. The document indicated, “Documentation must include: Stoma size, color, output characteristics…type of appliance used and wear time…”. The DPCS stated the purpose of taking the stoma size was to make sure the pouch (collection device) was the appropriate size for the patient, to prevent skin irritation. The stoma size should be getting smaller, indicating there were no complications. The DPCS stated measuring the stoma was best practices, because its for the patient safety, better health outcomes, and have to monitor the size to prevent complications. B. A record review of Patient 14’s Patient Profile sheet indicated a start of care date of 8/14/2025 with diagnoses including essential hypertension (high blood pressure). During an observation of the home visit on 11/18/2025, at 12:00 p.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 provided wound care to Patient 14’s left lower leg. An observation of Patient 14’s wound indicated an open wound. During the wound care, LVN 5 did not measure the wound. A record review of Patient 14’s document titled, Plan of Care, dated 10/13/2025 to 12/11/2025, indicated integumentary (skin) interventions included assessment of the wound. During an interview on 11/20/2025, at 10:30 a.m., with the DPCS, the DPCS stated the wound was supposed to be measured, as part of the assessment, every week. Assessment of the wound included characteristics and wound description. The DPCS stated the purpose of the wound assessment was to see if there were signs of infection, determine if the wound is improving, or if there was something that needed to be reported to the doctor. If these things were not assessed, the patient was put at risk of infection. Infection could lead to sepsis (blood infection, affecting the entire body), which could lead to harm and hospitalization. During a concurrent interview and record review on 11/20/2025, at 10:38 a.m., with the DPCS, the DPCS reviewed Patient 14’s Skilled Nurse Visit Notes, for the weeks of 10/13/2025, 10/19/2025, 10/26/2025, and 11/2/2025. The DPCS stated Patient 14’s wound had not been measured. C. A record review of Patient 16’s document titled Face Sheet indicated a start of care date of 7/26/2025, with diagnoses including essential hypertension (high blood pressure). During a concurrent interview and record review on 11/20/2025, at 11:13 a.m., with the DPCS, the DPCS reviewed Patient 16’s referral for HHA services, dated 7/26/2025. The record indicated, “Note that this member is limited English proficient and will require language assistance.” The DPCS stated the HHA did not provide language services for Patient 16. The importance of providing language services was so the HHA could get all the concerns of the patient, so the patient can have better health outcomes. The DPCS then reviewed Patient 16’s record titled, Plan of Care, dated 7/26/2025 to 9/23/2025. The DPCS stated the referral order for language services was not followed and was not included in Patient 16’s plan of care. C2. During a concurrent interview and record review on 11/20/2025, at 11:20 a.m., with the DPCS, the DPCS reviewed Patient 16’s, Plan of Care, dated 7/26/2025 to 9/23/2025. The record indicated the skilled nurse was to visit the patient two times a week, beginning on 7/29/2025, for wound care. The DPCS reviewed Patient 16’s medical records and stated there was only 1 nursing note documented on 7/31/2025. The DPCS stated there was no other notes to indicate what happened, the reason why services were not provided twice a week. The DPCS stated the visiting nurse entered a note on 11/17/2025 to indicate Patient 16 had refused services. The DPCS stated the note did not indicate when the patient refused nursing visits. A record review of the HHA’s undated document titled, Care Planning Process, indicated, “Based on the assessment and conclusions, the plan of care will include, but not limited to…Specific services and treatment to be provided…Actions to be taken to meet the patient goals…”. a. During a record review of Patient 7’s “Plan of Care” dated 10/23/2025 to 12/21/2025, indicated a start of care date of 10/23/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar levels) without complications. The plan of care indicated to notify the MD (Doctor of Medicine) if blood sugar is greater than 300mg/dl or less than 60 mg/dl. A review of Patient 7’s clinical record indicated that there is no documentation during visits regarding Patient 7’s blood sugar being checked and monitored. During an concurrent interview and record review, on 11/19/2025 at 12:25 p.m. and 1:14 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that Patient 7 did not have any documentation regarding blood sugar. DPCS stated that staff should document in their notes regarding Patient 7’s blood sugar. DPCS stated that it is important to document patient’s blood sugar so that it can be reported to the primary care physician if blood sugar is low or high. b. During a record review of Patient 10’s “Plan of Care” dated 10/25/2025 to 12/23/2025, indicated a start of care date of 10/25/2025 with a diagnosis of dementia (decline in mental ability that interferes with daily life, affecting memory, thinking, and judgment) and type 2 diabetes mellitus. The plan of care indicated to notify the MD if blood sugar is greater than 300mg/dl or less than 60 mg/dl. The plan of care further indicated that Physical Therapist (PT) treatment plan included evaluation with an effective date 0f 10/25/2025 and PT and PT Aide one time a week for one week starting 10/27/2025. A review of Patient 10’s clinical record indicated that there is no documentation regarding Patient 10’s blood sugar being checked and monitored. Further review of Patient 10’s clinical record further indicated that there was no documentation that PT had visited Patient 10. During a concurrent interview and record review, on 11/19/2025 at 1:14 p.m., with the DPCS, the DPCS stated that Patient 10 did not have any documentation regarding blood sugar. DPCS stated that it is important to document patient’s blood sugar so that it can be reported to the primary care physician if blood sugar is low or high. During an interview, on 11/19/2025 at 1:55 p.m., with the Licensed Vocational Nurse (LVN 3), LVN 3 stated that there was no documentation indicating the physician was notified and aware regarding Patient 10’s delay in PT due to family members request for Spanish speaking PT prior to 11/19/2025. During a concurrent interview and record review, on 11/19/2025 at 2:39 p.m., with the DPCS, the DPCS stated Patient 10 had a PT evaluation on 11/18/2025. DPCS stated that there was no documentation prior to 11/17/2025 regarding reason for Patient 10’s delay in PT services. DPCS stated that within 24 to 48 hours physician is to be notified if a visit has not been made. DPCS stated that the goal is to send PT right away for better health care outcome and prevent rehospitalization.”

“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 interview and record review, the Home Health Agency (HHA) failed to provide written information regarding the plan of care and medication list for two of seven patients (Patient 7 and Patient 12). This deficient practice resulted in patients and their representatives not knowing their care team or their treatment course. A record review of Patient 12’s Patient Profile sheet indicated a start of care date of 10/7/2024, with diagnoses including encounter for attention to colostomy (a surgically created opening of the large intestine that allows stool to exit through outside of the belly). During a concurrent observation and interview at the home visit on 11/18/2025, at 10:20 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 reviewed the contents of the agency folder (information required to be given to the patient). There was no plan of care (POC) and medication list in Patient 12’s home. LVN 4 stated she brought the POC and medication list to the patients home today, 11/18/2025. Patient 12 stated he had never received a copy of the POC and medication list. A record review of the HHA’s undated document titled, Care Planning Process, 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…” a. During a record review of Patient 7’s “Plan of Care” dated 10/23/2025 to 12/21/2025, indicated a start of care date of 10/23/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar levels) without complications. During a joint home visit, on 11/18/2025 at 10:35 a.m. with the Physical Therapist (PT) at Patient 7’s residence, Patient 7 was observed sitting down in by the dining table. During a concurrent observation and interview at the home visit on 11/18/2025, at 11:20 a.m., with PT, PT reviewed the contents of Patient 7’s agency folder (information required to be given to the patient). There was no plan of care (POC) and medication profile found in Patient 7’s home. During an interview, on 11/19/2025 at 12:25 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that an updated copy of the plan of care and medication profile should be in the patient’s home. DPCS stated that it is important to have a copy of the updated plan of care and medication profile in the patient’s home so that the patient and family are aware of any new orders.”

“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 patient care records were complete and authenticated for two of seventeen sampled patients (Patient 1, Patient 2). This failure resulted in patients’ medical records being modified by people not involved in patients’ care. A. During a record review of Patient 1’s Patient Profile sheet indicated a start of care date of 07/09/2025, with diagnosis including retention of urine (a condition Resulting in the inability to completely empty the bladder). During a concurrent interview and record review on 11/20/2025 at 11:45 am with DPCS Patient ’s medical record was reviewed and physicians order dated 7/18/2025 was not signed. The DPCS stated, “the MD has 30 days to sign the Plan of Care and Physician orders. It is important for the physician to see the plan of care and sign it because the physician needs to be aware and approve of the plan of care and orders.” B. During a record review of Patient 2’s Patient Profile sheet indicated a start of care date of 11/08/2024, with diagnosis including other artificial opening of urinary tract status (Refers to the presence of a surgically created opening in the urinary tract for draining urine). During a concurrent interview and record review on 11/20/2025 at 11:50 am., with DPCS Patient 2’s medical record was reviewed. The physicians order dated 9/3/2025, 9/17/2025, and 10/14/2025 were not signed. The DPCS stated, “the MD has 30 days to sign the Plan of Care and Physician orders. It is important for the physician to see the plan of care and sign it because the physician needs to be aware and approve of the plan of care and orders.” During a record review of the agency’s policy and procedure titled, “Entries in the Clinical Record” undated, the policy and procedure indicated, “Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided...” The policy and procedure further indicated, “Clinical notes shall be signed and incorporated into the patient’s health record within seven working days. The clinical note will include: A. Care that was provided B. Treatment and/or invasive procedures performed C. Patient response to treatment and/or procedures D. The date the service was provided (month, day, year) E. Signature of clinician and his/her credentials Signature authorization of clinical documentation will include the staff member’s name and credentials (as specified on professional licenses and/or certification documents). Initials will be used on forms where authentication signature space is designated on the form. All entries into the clinical record will reflect the date care was provided, including the month, day, and year...””

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure the comprehensive assessment included a complete physical assessment for two of seventeen sampled patients (Patient 3, Patient 12). This deficient practice has the potential risk to result in patients not receiving the care and services identified in the assessment and plan of care leading to complications and health status decline. A record review of Patient 12’s Patient Profile sheet indicated a start of care date of 10/7/2024, with diagnoses including encounter for attention to colostomy (a surgically created opening of the large intestine that allows stool to exit through outside of the belly). During a concurrent observation and interview at the home visit on 11/18/2025, at 10:07 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 provided colostomy care to Patient 12. An observation of the colostomy care indicated LVN 4 did not measure Patient 12’s stoma (the opening of the intestine through the belly). LVN 4 stated she knew the size of the stoma due to the frequent visits, and that was the reason why LVN 4 was not measuring it today. Continued observation of the colostomy care indicated LVN 4 cleaned the stoma and surrounding skin with soap (from the soap dispenser in the bathroom) and water. During the colostomy care Patient 12 stated he had gained some weight and the weight gain was making his stoma feel uncomfortable. Patient 12 stated he was working on losing weight so his stoma doesn’t stretch. During a concurrent interview and record review on 11/18/2025, at 10:43 a.m., with LVN 4, LVN 4 reviewed Patient 12’s record titled Plan of Care, dated 10/22/2025 to 12/20/2025. The record indicated, “Colostomy care-every Tuesday and Friday”. No other instructions for colostomy care were indicated. LVN 4 stated the plan of care was supposed to have instructions for stoma care, so everyone could follow the same treatment and nursing staff know what do to. A record review of the HHA’s document titled, Colostomy Care, dated 11/19/2025, indicated, “Step-By-Step Colostomy Care…5. Cleanse stoma and peristomal skin gently with warm water; pat dry”. Further review of the record did not indicate instructions for using soap to clean the stoma and surrounding skin. During an interview on 11/19/2025, at 10:58 a.m., with the DPCS, the DPCS stated that nurses were supposed to provide colostomy care according to the policy, unless the doctor specified the orders. If there were no specific orders to follow, it could lead to possibly harming the patient by not giving the proper treatment. During an interview on 11/19/2025, at 12:18 p.m., the DPCS stated Patient 12 did not have a specific order for colostomy care. The expectation was for the nurses to follow the HHA’s policy on colostomy care. During a concurrent interview and record review on 11/19/2025, at 12:58 p.m., with the DPCS, the DPCS reviewed the HHA’s document titled, Colostomy Care, dated 11/19/2025. The document indicated, “Documentation must include: Stoma size, color, output characteristics…type of appliance used and wear time…”. The DPCS stated the purpose of taking the stoma size was to make sure the pouch (collection device) was the appropriate size for the patient, to prevent skin irritation. The stoma size should be getting smaller, indicating there is no complications. The DPCS stated there was a conflict between what the policy indicated and what the nurses were expected to do because the HHA did not expect the nurses to measure the stoma, as indicated in the policy. The DPCS stated measuring the stoma was best practices, because its for the patient safety, better health outcomes, and have to monitor the size to prevent complications. In reference to documentation of type of appliance, the DPCS stated this was important because this specified what specific pouch was needed for the patient and to monitor the continued use of the appropriate pouch. During a concurrent interview and record review on 11/19/2025, at 1:08 p.m., with the DPCS, the DPCS reviewed Patient 12’s record titled, OASIS Nurse Recertification, dated 10/17/2025. The DPCS stated there was no stoma size, type of appliance, wear time, output characteristics documented. The purpose of monitoring output characteristics was to differentiate, to report abnormalities, unusual output, which can mean complications. The DPCS stated the purpose of the recertification assessment was a comprehensive assessment to identify the needs of the patient, to develop the plan of care. During a record review of the agency’s policy and procedure, titled “Ongoing Assessment” undated, the policy and procedure indicated, “During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for: A. Blood pressure, pulse, respirations, temperature B. Weight (once each week, if indicated by disease) C. Pain status, when applicable, including:1.Responses to pain intervention(s) 2. Progress toward pain management goals, including functional ability 3. Side effects of treatment 4. Risk factors for adverse events caused by the treatment D. Breath sounds E. Skin integrity F. Bowel sounds; elimination (urinary arid bowel) G. Appetite/diet, nutritional status H. Mental status I. Functional status J. Safety/home environment K. Patient and family/caregiver support”. A.During a record review of Patient 3’s Patient Profile sheet indicated a start of care date of 07/23/2025, with diagnoses including post laminectomy syndrome (is characterized by a persistent back or neck pain after spine surgery, sometimes accompanied by radiating pain, numbness, or weakness in the extremities). During a concurrent observation and interview on 11/18/2025 at 11:10 a.m. with Family Member 2 (FM 2), a photo was observed on FM 2’s cellular phone dated 10/28/2025 with an image of Patient 3, with a raised bump on the right side of the forehead with redness. FM 2 stated, “Patient 3 had a fall at the doctor’s office in October, based on this image it was October 28th, 2025. It was a pretty bad fall. We are lucky it happened at the doctors office and they took imaging.” During a interview and record review on 11/19/2025 at 1:55 pm with DPCS, Patient 3’s medical record was reviewed. There was no documented evidence of any falls in the communication log or documentation by the physical therapist and occupational therapist notes following 10/28/2025, dated 10/29/2025, 10/30/2025, 11/03/2025, 11/06/2025, 11/07/2025, 11/11/2025. The DPCS stated, “I don’t see any documentation Patient 3 had a fall. It is important to report falls, because it is part of the comprehensive ongoing assessment, and so we can notify the physician and monitor the progress of the patient and make sure they are okay.””

“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 the medications and treatments the patient was currently using for six of seventeen sampled patients (Patient 2, Patient 3, Patient 6, Patient 8, Patient 12, Patient 14). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. A record review of Patient 12’s Patient Profile sheet indicated a start of care date of 10/7/2024, with diagnoses including encounter for attention to colostomy (a surgically created opening of the large intestine that allows stool to exit through outside of the belly). During a concurrent observation, interview, and record review at the home visit on 11/18/2025, with Licensed Vocational Nurse 4 (LVN 4), LVN 4 reviewed the medication Patient 12 was taking using record titled, Medication Profile, dated 10/17/2025. LVN 5 stated the following medications were at home, patient reported taking, but was not listed: Atorvastatin (used to lower cholesterol (fat) levels in the blood) 10 mg (mg-milligram, unit of measurement) 1 tablet by mouth at bedtime. Triamcinolone (treats skin discomfort such as redness, itching) 0.1% (%-percent) ointment (cream). Apply and gently massage into affected are twice daily. Omega 3 (a supplement). 1000 mg capsule. 1 capsule daily. Vitamin D 3(a supplement). 50 mcg (mcg-micrograms, unit of measurement). 1 tablet daily. LVN 4 stated the medication Zofran (used to treat nausea) listed had the wrong dose documented. The medication profiled indicated Zofran 4 mg. Patient 12’s Zofran label read Zofran 8 mg 1 tablet every 8 hours as needed. During an interview on 11/18/2025, at 10:43 a.m., with LVN 4, LVN 4 stated the nurse needed to review the medications and update the medication profile every visit. The importance of reviewing medications was so the nursing staff could follow the patients treatment, to ensure the medication was effective, monitor for medication side effects, and educate the patient/family on medication use. A record review of Patient 12’s Plan of Care, dated 10/22/2025 to 12/20/2025, indicated the skilled nurse was visiting the patient twice a week for colostomy care. A record review of Patient 14’s Patient Profile sheet indicated a start of care date of 8/14/2025 with diagnoses including essential hypertension (high blood pressure). During a concurrent observation, interview, and record review at the home visit on 11/18/2025, with Licensed Vocational Nurse 5 (LVN 5), LVN 5 reviewed the medication Patient 14 was taking using record titled, Medication Profile, dated 8/14/2025. The following medications were at Patient 14’s home, Patient 14 reported taking, and were not listed on the mediation profile: Gabapentin (treats nerve pain) 200 mg, 1 capsule every day. The medication label indicated it was filled on 9/25/2025. Tamsulosin (treatment of prostate issues) 0.4 mg, 1 capsule by mouth every day. The medication label indicated it was filled on 9/25/2025. Tylenol 500 mg as needed. Patient 14 stated to LVN 5 he was taking the medication 2 to 3 times daily. LVN 5 stated Patient 14 did not tell LVN 5 Patient 14 was taking the medications listed above. During a record review of the agency’s policy and procedure, titled “Medication Profile” , undated, the policy and procedure indicated, “ Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen, including name, drug classification, date prescribed/discontinued, dose, strength, route, frequency, date and time of administration and any drug or food allergies. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. A. The review will be performed by qualified personnel and will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicative drug therapy, and noncompliance with drug therapy. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile, in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting...” b. During a record review of Patient 6’s “Plan of Care” dated 10/24/2025 to 12/22/2025, indicated a start of care date of 8/22/2025 with a primary diagnosis of an encounter for fitting and adjustment of urinary device. During a joint home visit, on 11/18/2025 at 9:30 a.m. with the Licensed Vocational Nurse (LVN 2) at Patient 6’s residence, Patient 6 was observed lying down in the couch with walker next to the couch. During a review of Patient 6’s current medication, on 11/18/2025 at 10:26 a.m. with LVN 2, the following medications were not available in Patient 6’s residence but listed in Patient 6’s medication list provided by the HHA: - Metoprolol Succinate Extended Release (used treat several cardiovascular conditions by lowering heart rate and blood pressure), 25 milligrams (mg – unit of measurement), 0.5 tablet daily - Linzess ( used to treat specific chronic constipation)145 microgram (mcg – unit of measurement), 1 capsule daily - Senna (used on a short-term basis to treat constipation) 8.6 mg tablet, 1 tablet daily - Trazodone (used to treat major depressive disorder) 50 mg tablet, 1 tablet as needed - Tolterodine Extended Release (used to treat symptoms of an overactive bladder), 4 mg capsule, 1 capsule daily - Crestor (used to lower bad cholesterol) 40 mg tablet, 1 tablet daily - Acetaminophen (used to relieve mild to moderate pain and reduce fever) 500 mg tablet, 1 tablet as needed evert 6 hours - Lidocaine Patch (used to provide temporary relief of pain by numbing the nerves in a specific area), 1 Patch as needed c. During a record review of Patient 7’s “Plan of Care” dated 10/23/2025 to 12/21/2025, indicated a start of care date of 10/23/2025 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar levels) without complications. During a joint home visit, on 11/18/2025 at 10:35 a.m. with the Physical Therapist (PT) at Patient 7’s residence, Patient 7 was observed sitting down in by the dining table. During a review of Patient 7’s current medication, on 11/18/2025 at 11:20 a.m. with PT, the following medications were not available in Patient 7’s residence but listed in Patient 7’s medication list provided by the HHA: - Vitamin D3 (supplement) mcg (1,000 units), 1 tablet daily - Carvedilol (used to treat high blood pressure). 6.25 mg tablet, 1 tablet daily During a review of Patient 7’s current medication, on 11/18/2025 at 11:20 a.m. with PT, the following medications were not available in Patient 7’s residence but listed in Patient 7’s medication list provided by the HHA: - Glipizide Extended Release (used to treat high blood sugar levels), 5 mg tablet, 1 tablet daily - Trazadone 50 mg tablet, 1 tablet daily at bedtime - Carvedilol 12.5 mg tablet, 1 tablet twice a day - Vitamin D3 125 mg (5,000 units), 1 tablet daily - Acetaminophen 500 mg tablet - Koi CBD (Cannabidiol - non-psychoactive compound found in cannabis plants that has potential medical applications like reducing anxiety and pain), 1500 mg Roll-on Gel - Koi CBD Balm 3000mg During an interview, on 11/19/2025 at 12:25 p.m., with the Director of Patient Care Services DPCS, the DPCS stated that medication reconciliation should be done every visit. DPCS stated that it is important for medication reconciliations to be done every visit to make sure patient is educated on new medications and staff check to make sure there are no discontinued medications. A. During a record review of Patient 2’s Patient Profile sheet indicated a start of care date of 11/08/2024, with diagnoses including other artificial opening of urinary tract status (Refers to the presence of a surgically created opening in the urinary tract for draining urine). During a concurrent interview and record review on 11/18/2025 at 9:50 am with Licensed Vocational Nurse 1 (LVN 1) at Patient 2’s residence, LVN 1 reviewed the medication Patient 2 was taking using record titled, Medication Profile, dated 09/03/2025-11/08/2025. LVN 1 stated the following medications were at home reflecting the dosage and frequency patient reported taking, but listed at different dosage and frequency on the Medication Profile: Lasin 20 mg tablet 1 tablet taken daily except for Monday, Wednesday, and Friday 2 tablets taken by patient, but listed as take one tablet every Monday Wednesday and Friday on the medication profile PreserVision Areds 2N/A (a supplement) 2 tablets daily, but listed as take one tab daily on medication profile Creon 24,000 units capsule takes two daily with meals, but listed as there is 36,000 units on the medication profile Sodium Bicarbonate (used for heartburn) 650mg takes three times a day, but listed as take three times weekly every Monday Wednesday and Friday on the medication profile Lokelma 10 gram powder (used to treat high potatssium levels) t packet takes three times weekly, but listed as take one packet three times daily on the medication profile Iron 325 mg (supplement) takes 1 tablet once a day, but listed as take one tablet 3 times weekly on medication profile Vitamin D 3 (supplement) 25mcg, takes once a day but listed on the medication profile as 50mcg LVN 1 stated, “medication reconciliation needs to be done by nursing staff on every visit. This was missed. It is important to do it so we can update the agency and the doctor on the patients current meds.” During an interview and record review on 11/19/2025 at 1:00 pm with DPCS, DPCS stated “medication reconciliation is supposed to be done every visit, this includes physical therapists as well nurses. They are supposed to do it on every visit. This was missed for these patients.” B. During a record review of Patient 3’s Patient Profile sheet indicated a start of care date of 07/23/2025, with diagnoses including post laminectomy syndrome (is characterized by a persistent back or neck pain after spine surgery, sometimes accompanied by radiating pain, numbness, or weakness in the extremities). During a concurrent interview and record review on 11/18/2025 at 10:55 am with Registered Nurse 1 (RN 1), at Patient 3’s residence, RN 1 reviewed the medication Patient 3 was taking using record titled, Medication Profile, dated 07/23/2025-09/18/2025. RN 1 stated the following medications were at home, patient reported taking, but was not listed: -Diclofenac sodium (an anti-inflammatory medication) 75mg, take 1 tablet by mouth twice daily as needed no indication for reason date filled 11/11/2025 -Lisinopril 10mg (a medication to lower elevated blood pressure) take 1 tablet by mouth daily date filled 7/24/2025 -Dorzolamide Hydrochloride and Timolol Maleate Ophthalmic solution (used to treat elevated pressure inside the eye) USP (united states pharmacopeia, it signifies that the product meets the stringent quality standards for identity, strength, purity, and performance) 2% /0.5% one drop in each eye daily -Brimonidine Tartrate ophthalmic solution 0.2% one drop in each eye daily. The following medications were listed on the medication profile but not available in Patient 3’s residence: -Bisoprolol fumarate (a medication to lower blood pressure) 5mg tablet take 1 tablet by mouth daily -Norco 5mg/325 mg tablet (pain medication) 1 tablet as needed every 6 hours for pain -Gabapentin 100 mg (medication for nerve pain) 2 tablets twice a day RN 1 stated, “this was missed by the physical therapist. Medication reconciliation needs to be done on every visit by physical therapists, occupational therapists and nurses. This is very important so we can keep track of all the current medications the patient has and communicate with the physician.” During an interview and record review on 11/19/2025 at 1:00 pm with DPCS, DPCS stated “medication reconciliation is supposed to be done every visit, this includes physical therapists as well nurses. They are supposed to do it on every visit. This was missed for these patients.””

“Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient’s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure the comprehensive assessment for one of seventeen sampled patients (Patient 12) accurately reflected the primary care doctor responsible for the patient’s care. This deficient practice has the potential for delay of care by not knowing which doctor to contact in case there was a change of condition. A record review of Patient 12’s Patient Profile sheet indicated a start of care date of 10/7/2024, with diagnosis including encounter for attention to colostomy (a surgically created opening of the large intestine that allows stool to exit through outside of the belly). During an interview at the home visit on 11/18/2025, at 9:50 a.m., Patient 12 stated he had a new primary care doctor since (Medical Doctor 2-MD 2) 10/18/2025 because his previous doctor (Medical Doctor 1-MD 1) had stopped taking his health insurance in September 2025. During a concurrent interview and record review on 11/19/2025, at 1:08 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 12’s record titled, OASIS Nurse Recertification, dated 10/17/2025. The record indicated MD 1 was the Physician (Doctor) Signing Plan of Care. During an interview on 11/19/2025, at 1:15 p.m., with the DPCS, the DPCS it was important to ensure the correct doctor was in the comprehensive assessment so if there were abnormal findings with the patient, the right doctor would be called so the patient can be treated right away. A record review of the HHA’s undated document titled, Ongoing Assessments, indicated, “Based on the findings of the reassessment, additional order will be generated and forwarded to the physician (doctor)…for signature(s).””

“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 t include information required in the plan of care for two of seventeen sampled patients (Patient 2, Patient 12). This failure had the potential to result in patients not receiving the identified needs and services, and decline in health status, that could affect their quality of care and well-being. B. A record review of Patient 12’s Patient Profile sheet indicated a start of care date of 10/7/2024, with diagnoses including encounter for attention to colostomy (a surgically created opening of the large intestine that allows stool to exit through outside of the belly). During a concurrent observation and interview at the home visit on 11/18/2025, at 10:07 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 provided colostomy care to Patient 12. An observation of the colostomy care indicated LVN 4 did not measure Patient 12’s stoma (the opening of the intestine through the belly). LVN 4 stated she knew the size of the stoma due to the frequent visits, and that was the reason why LVN 4 was not measuring it today. Continued observation of the colostomy care indicated LVN 4 cleaned the stoma and surrounding skin with soap (from the soap dispenser in the bathroom) and water. During the colostomy care Patient 12 stated he had gained some weight and the weight gain was making his stoma feel uncomfortable. Patient 12 stated he was working on losing weight so his stoma doesn’t stretch. During a concurrent interview and record review on 11/18/2025, at 10:43 a.m., with LVN 4, LVN 4 reviewed Patient 12’s record titled Plan of Care, dated 10/22/2025 to 12/20/2025. The record indicated, “Colostomy care-every Tuesday and Friday”. No other instructions for colostomy care were indicated. LVN 4 stated the plan of care was supposed to have instructions for stoma care, so everyone could follow the same treatment and nursing staff know what do to. During an interview on 11/19/2025, at 10:58 a.m., with the DPCS, the DPCS stated that nurses were supposed to provide colostomy care according to the policy, unless the doctor specified the orders. If there were no specific orders to follow, it could lead to possibly harming the patient by not giving the proper treatment. During a concurrent interview and record review on 11/19/2025, at 12:18 p.m., with the DPCS, the DPCS reviewed Patient 12’s record titled, Optum, dated 10/25/2024. The record indicated “Ostomy mgt. (management)/teaching”. The DPCS stated the order needed to be specific to what needed to be done. The importance of having a specific order was to provide the right treatment so nothing happens to the patient. During a concurrent interview and record review on 11/19/2025, at 12:58 p.m., with the DPCS, the DPCS reviewed the HHA’s document titled, Colostomy Care, dated 11/19/2025. The document indicated, “Documentation must include: Stoma size, color, output characteristics…type of appliance used and wear time…”. The DPCS stated the purpose of taking the stoma size was to make sure the pouch (collection device) was the appropriate size for the patient, to prevent skin irritation. The stoma size should be getting smaller, indicating there is no complications. The DPCS stated there was a conflict between what the policy indicated and what the nurses were expected to do because the HHA did not expect the nurses to measure the stoma, as indicated in the policy. The DPCS stated measuring the stoma was best practices, because its for the patient safety, better health outcomes, and have to monitor the size to prevent complications. In reference to documentation of type of appliance, the DPCS stated this was important because this specified what specific pouch was needed for the patient and to monitor the continued use of the appropriate pouch. During a concurrent interview and record review on 11/19/2025, at 1:05 p.m., with the DPCS, the DPCS reviewed Patient 12’s Skilled Nurse Visit notes for the current certification period dated 10/22/2025 to the present time. The DPCS stated the nursing notes did not indicate the stoma size, type pf appliance used, wear time, and characteristics were documented. B2: During an interview at the home visit on 11/18/2025, at 9:50 a.m., Patient 12 stated he had a new primary care doctor since (Medical Doctor 2-MD 2) 10/18/2025 because his previous doctor (Medical Doctor 1-MD 1) had stopped taking his insurance in September 2025. During a concurrent interview and record review on 11/19/2025, at 1:08 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 12’s record titled, Plan of Care, dated 10/22/2025 to 12/20/2025. The record indicated MD 1 was the attending Physician (Doctor) Plan of Care. During an interview on 11/19/2025, at 1:15 p.m., with the DPCS, the DPCS stated the importance of ensuring the right doctor was documented on the plan of care was to make sure the right doctor was notified if there were abnormal findings to report, so the patient can be treated right away. During a record review of the agency’s policy and procedure, titled “Care Planning Process” undated, 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 2’s Patient Profile sheet indicated a start of care date of 11/08/2024, with diagnoses including other artificial opening of urinary tract status (Refers to the presence of a surgically created opening in the urinary tract for draining urine). During a record review of Patient 2’s POC dated 09/03/2025 to 11/02/2025, recertified on 11/08/2025, the POC indicated, “Assess/Perform/Instruct Patient /patient caregiver :Urostomy (a surgically created opening in the abdomen that reroutes urine from the body without going through the bladder) Care effective 932025 assess genitourinary status start effective date 9/3/2025 skilled nurse continued to instruct patient/patient caregiver care of urostomy equipment and supplies start effective date 9/3/2025. There is no documented evidence in the POC of how often and how the urostomy care needs to be done, what supplies need to be used during urostomy care, or what signs and symptoms needs to be assessed for the urostomy. During an interview on 11/19/2025 at 10:45am with DPCS, the DPCS stated “the urostomy order doesn’t list what the clinician needs to do specifically, they just follow routine urostomy care, but the order and the plan of care should be very specific to the care. It should list detail of what needs to be done to the stoma site. How often care needs to be provided to the urostomy, what supplies need to be used during the care and what signs and symptoms needs to be assessed by the skilled nurse. This is important because nurses need to know what order to follow to keep the patient safe and away from harm.” During a record review of the agency’s policy and procedure, titled “Care Planning Process” undated, 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.””

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the physician reviewed and revised seven of seventeen sample patients (Patient 1, Patient 2, Patient 8, Patient 9, Patient 14, Patient 15, and Patient 17) individualized plans of care. This failure had the potential to result in Patient receiving inappropriate or lacking appropriate services. C. A record review of Patient 14’s Patient Profile sheet indicated a start of care date of 8/14/2025 with diagnoses including essential hypertension (high blood pressure). During a concurrent interview and record review with the DPCS, on 11/20/2025, at 10:20 a.m., the DPCS reviewed Patient 14’s records titled, Plan of Care, dated 8/14/2025 to 10/12/2025 and 10/13/2025 to 12/11/2025. The records did not indicate a doctor’s signature. The DPCS stated the documents were supposed to be signed by the doctor because of the rules and regulations. The signature indicated the doctor acknowledged was the primary doctor and responsible for the care of the patient. The doctor signature validated the specific treatment needed for the patient. The DPCS stated the plan of care was supposed to be signed within 30 days of admission. The risk of not signing the plan of care was the doctor not knowing what services had been provided to the patient. D. A record review of Patient 15’s record titled, Face Sheet, indicated a start of care date of 9/20/2025, with diagnoses including essential hypertension (high blood pressure). During a concurrent interview and record review with the DPCS, on 11/20/2025, at 10:52 a.m., the DPCS reviewed Patient 15’s records titled, Plan of Care, dated 9/20/2025 to 11/18/2025. The DPCS stated the plan of care had not been signed by the doctor. E. A record review of Patient 17’s record titled, Face Sheet, indicated a start of care date of 12/13/2023, with diagnoses including difficulty in walking. During a concurrent interview and record review with the DPCS, on 11/20/2025, at 12:00 p.m., the DPCS reviewed Patient 17’s records titled, Plan of Care, dated 12/13/2023 to 2/10/2024. The DPCS stated the plan of care had not been signed by the doctor. During a record review of the agency’s policy and procedure, titled “Care Planning Process” undated, the policy and procedure indicated, “All clinicians including the physician (or allowed practitioner} involved in the patient’s care, either directly or indirectly, will contribute to the plan of care. The plan of care shall be signed by a Doctor of Medicine, osteopathy, or podiatric medicine, or an allowed practitioner acting within the scope of a state license, certification or registration.” During a record review of Patient 8’s “Plan of Care” dated 10/16/2025 to 12/14/2025, indicated a start of care date of 10/16/2025 with a primary diagnosis of essential hypertension (high blood pressure). The “Plan of Care” indicated that there was no signature from the physician. During a record review of Patient 9’s “Plan of Care” dated 10/15/2025 to 12/13/2025, indicated a start of care date of 8/16/2025 with a primary diagnosis of polyneuropathies (disorders affecting multiple peripheral nerves, causing symptoms like numbness, tingling, pain, and weakness, often starting in the feet and hands). The “Plan of Care” indicated that there was no signature from the physician. During a concurrent interview and record review on 11/20/2025 at 11:45 am with DPCS, the DPCS stated that Patient 8 and Patient 9’s plan of care were not signed. DPCS stated that there is a 30 day timeframe for signing the plan of care. DPCS stated that it is important for the physician to signed the plan of care so that the physician is aware what the specific care and treatment the patients are being provided. A.During a record review of Patient 1’s Patient Profile sheet indicated a start of care date of 07/09/2025, with diagnoses including retention of urine (a condition Resulting in the inability to completely empty the bladder). During a concurrent interview and record review on 11/20/2025 at 11:43 am with DPCS Patient 1’s medical record was reviewed. The Plan of Care dated 07/09/2025 to 09/06/2025 was not signed. The DPCS stated, “the MD has 30 days to sign the Plan of Care and Physician orders. It is important for the physician to see the plan of care and sign it because the physician needs to be aware and approve of the plan of care and orders.” B. During a record review of Patient 2’s Patient Profile sheet indicated a start of care date of 11/08/2024, with diagnoses including other artificial opening of urinary tract status (Refers to the presence of a surgically created opening in the urinary tract for draining urine). During a concurrent interview and record review on 11/20/2025 at 11:50 am with DPCS Patient 2’s medical record was reviewed. The Plan of Care dated 09/03/2025 to 11/02/2025 was not signed. The DPCS stated, “the MD has 30 days to sign the Plan of Care and Physician orders. It is important for the physician to see the plan of care and sign it because the physician needs to be aware and approve of the plan of care and orders.” During a record review of the agency’s policy and procedure, titled “Care Planning Process” undated, the policy and procedure indicated, “All clinicians including the physician (or allowed practitioner} involved in the patient’s care, either directly or indirectly, will contribute to the plan of care. The plan of care shall be signed by a Doctor of Medicine, osteopathy, or podiatric medicine, or an allowed practitioner acting within the scope of a state license, certification or registration.””

“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 interview and record review, the Home Health Agency (HHA) failed to ensure one of seventeen sampled patients (Patient 1) clinical records included all the necessary forms. This failure resulted in an incomplete clinical record. A.During a record review of Patient 1’s Patient Profile sheet indicated a start of care date of 07/09/2025, with diagnoses including retention of urine (a condition Resulting in the inability to completely empty the bladder). During a concurrent interview and record review on 11/19/2025 at 11 am with LVN 3, Patient 1’s medical record communication log was reviewed. The communication log indicated, “7/22/2025 at 3:42 PM, LVN 3 indicated patients seen for Foley change, daughter called stating another nurse needs to come see patient again because Foley (urine collection device placed in the bladder) catheter was not placed right. Tried to advice patient to go to urgent care but is insisting on having another nurse come by today. LVN 3 indicated on the same day at 4:18 PM, her daughter took patient to urgent care.” LVN 3 stated, “I was the one who wrote this on 7/22/2025. RN 2 went to see Patient 1 on 7/22/2025 and changed the urinary catheter. I don’t see a note from RN 2 for that date, but the FM 5 confirmed that RN 2 was there and changed a urinary catheter on 7/22/2025. I don’t know what time RN 2 was there because there was no nursing note. I contacted the nurse, but we couldn’t get any nurses out because she wanted someone to go there within the next thirty minutes. I contacted the daughter about 40 minutes after her initial call, and FM 5 stated FM 5 had taken Patient 1 to urgent care and wasn’t willing to wait.” During a concurrent interview and record review on 11/19/2025 at 11:40 am with DPCS, DPCS stated, there is no evidence of a documented skilled nurse visit on 7/22/2025. RN 2 was the RN who visited Patient 1 on 7/22/2025, but I don’t see a nursing visit note in the medical record for that date. We have a problem with RN 2 turning in her notes, our HR reaches out to them weekly, then I follow up to make sure the notes are turned in. This was missed. It is important for nurses to turn in their notes so we can know what was done during the visit. They have five days to turn in their notes.” During a record review of the agency’s policy and procedure titled, “Entries in the Clinical Record” undated, the policy and procedure indicated, “Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided...” The policy and procedure further indicated, “Clinical notes shall be signed and incorporated into the patient’s health record within seven working days. The clinical note will include: A. Care that was provided B. Treatment and/or invasive procedures performed C. Patient response to treatment and/or procedures D. The date the service was provided (month, day, year) E. Signature of clinician and his/her credentials Signature authorization of clinical documentation will include the staff member’s name and credentials (as specified on professional licenses and/or certification documents). Initials will be used on forms where authentication signature space is designated on the form. All entries into the clinical record will reflect the date care was provided, including the month, day, and year...””

“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 Home Health Agency (HHA) failed to send all necessary medical information to the primary care practitioner within 5 days of patient’s discharge from home health services for two of seventeen sampled patients (Patient 15 and Patient 16). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. A. A record review of Patient 15’s record titled, Face Sheet, indicated a start of care date of 9/20/2025, with diagnosis including essential hypertension (high blood pressure). During a concurrent interview and record review, with the Director of Patient Care Services (DPCS), on 11/20/2025, at 10:52 a.m., the DPCS reviewed Patient 15’s record titled OASIS Discharge Physical Therapy, dated 11/13/2025. The DPCS stated the discharge summary had not been sent to the doctor. The DPCS stated the summary should have been sent within 2 days so the doctor would be aware the patient was discharged from the HHA. B. A record review of Patient 16’s document titled, Face Sheet indicated a start of care date of 7/26/2025, with diagnosis including essential hypertension (high blood pressure). During a concurrent interview and record review, with the DPC), on 11/20/2025, at 11:28 a.m., the DPCS reviewed Patient 16’s record titled OASIS Discharge Non-Visit, dated 8/6/2025. The DPCS stated the discharge summary was not sent to the doctor. The purpose of the discharge summary to be sent to the doctor, included adherence to the rules and regulations. Notifying what services were provided, if goals were met, provide the most recent medication list, were all reasons to provide the summary to the doctor. If the doctor did not receive this information, then the doctor does not know the status of the patient while in HHA services. A record review of the undated HHA’s document titled, Discharge Criteria and Process indicated, “A discharge summary will be completed for all discharged patients. A copy will be mailed to the primary physician.””