Bright Horizons Home Health Services, Inc.

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan address the patient population, including but not limited to the type of services the HHA has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. This failure posed the potential risk for not providing the necessary care and services to the patients during the emergency disaster events. Review of the agency’s emergency preparedness program was conducted on 8/19/25, and showed the the emergency preparedness plan did not address the patient population, including but not limited to the type of services that the HHA has ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. On 8/20/25 at 1027 hours, an interview and concurrent document review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: Based on record review and interview, the hospice failed to develop the emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least every two years. This failure created the potential risk of not providing the necessary care and services to the patients during the emergency events. Findings: Review of the agency’s emergency preparedness program was conducted on 8/19/25, and showed the communication plan was not developed that complied with Federal, State, and local laws and was reviewed and updated at least every two years. On 8/20/25 at 1027 hours, an interview and concurrent document review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop the emergency communication plan to include the name and contact information of the staff, entities provided services under agreement, patients physicians and volunteers. This failure created the risk of not able to contact or request for assistance in the emergency events. Findings: Review of the agency’s emergency preparedness program was conducted on 8/19/25, and showed the communication plan did not include the name and contact information of the staff, entities provided services under agreement, patients physicians and volunteers. On 8/20/25 at 1027 hours, an interview and concurrent document review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop the emergency communication plan to include the name and contact information for the Federal, State, regional, and local emergency preparedness staff and other sources of assistance. This failure created the risk of not able to contact or request for assistance in the emergency events. Findings: Review of the agency’s emergency preparedness program documents was conducted on 8/19/25, and showed the communication plan did not include the contact information for the Federal, State, regional, and local emergency preparedness staff and other sources of assistance. On 8/20/25 at 1027 hours, an interview and concurrent document review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop the emergency communication plan to include the primary and alternate means for communicating with the HHA’s staff and the the Federal, State, regional, and local emergency management agencies. This failure created the risk of not able to contact or request for assistance in the emergency events. Findings: Review of the agency’s emergency preparedness program documents was conducted on 8/19/25, and showed the communication plan did not include the primary and alternate means for communicating with the HHA’s staff and the the Federal, State, regional, and local emergency management agencies. On 8/20/25 at 1027 hours, an interview and concurrent document review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial training in emergency preparedness plan was provided to all of the staff including the contracted staff and volunteers, consistent with their expected role and demonstrate knowledge of emergency procedures. This failure created the risk of the staff not knowing what to do in case of the emergency. Findings: Review of the agency’s emergency preparedness training and testing program was conducted on 8/19/25, and showed no documented evidence the initial training in the emergency preparedness P&P was provided to the contracted staff and volunteers, consistent with their expected role. In addition, there was no documented evidenced of the demonstration of staff knowledge of emergency procedure. On 8/20/25 at 1027 hours, an interview and concurrent document review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to conduct and participate in a full-scale exercise that is community-based, facility based functional exercises that may include a mock disaster drill and analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. This failure created the risk of the staff not knowing what to do in case of the emergency. Findings: Review of the agency’s emergency preparedness training and testing program was conducted on 8/19/25, and showed no documented evidence the agency participated in a full - scale exercise that is community based, facility based functional exercises that may include mock disaster drills. In addition, there was no documented evidenced the HHA analyzed the response and maintain documentation of all drills, tabletop exercises, and emergency events. On 8/20/25 at 1027 hours, an interview and concurrent document review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the OASIS data was transmitted within 30 days of completing the OASIS data sets. This failure had the potential for not reporting and coordinating the patient care assessment timely for the patients receiving care and services at the agency. Findings: Review of the OASIS Final Validation Reports for May 2025 was initiated on 8/19/25. The agency’s OASIS Agency Final Validation Report from May 2025 showed one OASIS data set was submitted more than 30 days from the assessment completion date. On 8/20/25 at 0854 hours, an interview and concurrent agency document review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the above finding.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to accurately code the OASIS for one of eight sampled patients (Patient 4). This failure had the potential to negatively affect the care provided to Patient 4 due to inaccurate data. Findings: Review of Patient 4’s clinical record was initiated on 8/14/25. The clinical record showed the SOC was 6/26/25. The patient was certified for home health services during the certification period from 6/26/25 to 8/24/25. Review of the Plan of Care (undated) showed Patient 4 had a diagnosis of Type 2 Diabetes Mellitus. Review of the Medication Profile dated 6/26/25, showed to administer metformin HCL (antidiabetic medication) 500 mg tablet orally. Review of the OASIS- SOC dated 6/26/25, showed Section “N0415JI - J. Hypoglycemic (including insulin) is taking” was coded as no. However, Patient 4 was taking metformin, a hypoglycemic drug. On 8/20/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the finding.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure a written individualized plan of care was developed and care and services were provided as per the POC and P&P for five of eight sampled patients (Patients 1, 3, 4, 6, and 7). This failure had the potential risk for not addressing and providing the appropriate care needs for these patients. Findings: #. Review of Patient 1’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/29/25. The patient was certified for home health services during the certification period from 7/29/25 to 9/26/25. a. The OASIS E1 Start of Care Assessment dated 7/29/25, showed the SN frequency of visits cited 2W2 (two visits every week for 2 weeks) and 1W6 (one visit every week for six weeks). However, review of the clinical record failed to show documented evidenced of the SN visits on Week 2 (from 8/3/25 to 8/9/25) as cited on the OASIS E1 Start of Care Assessment dated 7/29/25. b. The OASIS E1 Start of Care Assessment dated 7/29/25 showed the RN 1 had performed an assessment. The assessment included the following: - on the section of Homebound Status showed a check mark on: Leaving home requires a considerable and taxing effort as indicated. The comment includes recent fall, high fall risk, unsteady gait. However, review of the POC failed to show documented evidenced of a care plan was created to address the patients recent fall and unsteady gait. - on the section of Swallowing/Nutritional Status included an interventions. The RN 1 documented a check mark on DM Type 2, insulin/oral agent controlled, glucometer use/monitor in home and the FBS range results. However, there was no care plan developed to address the patients DM Type 2. On 8/20/25 at 1106 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO reviewed the clinical record and acknowledged the findings. #. Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. a. The POC for the certification period from 5/29/25 to 7/27/25, showed the patients principal diagnosis was Cerebral Infarction, unspecified. The POC includes on the section for Orders for Disciplines and Treatment cited SN visit 1W9. The POC also included the list of medications. The medication list included Eliquis (anticoagulant) 5 mg oral, one tablet BID. However, review of the POC failed to show documented evidenced of a care plan was developed for patient/PCG education related to the principal diagnosis of Cerebral Infarction, unspecified and the use of Eliquis 5 mg oral, one tablet BID. b. Review of the OASIS E1 Start of Care Assessment dated 7/29/25 showed the RN 1 had performed an assessment. The patient was assessed to have problems with neurological, musculoskeletal, cardiovascular system. However, review of the POC failed to show documented evidenced of the care plans were developed to address the patients neurological, musculoskeletal and cardiovascular problems. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Review of the agency’s P&P titled Plan of Care (undated) showed the agency will ensure that all patients accepted to care/services have an individualized written plan of care that is developed in consultation with the patient, physician or allowed practitioner, and agency staff. The individualized plan of care will identify patient-specific measurable outcomes and goals. #. Review of Patient 4’s clinical record was initiated on 8/14/25. The clinical record showed the SOC was 6/26/25. The patient was certified for home health services during the certification period from 6/26/25 to 8/24/25. a. The POC, for the certification period from 6/26/25 to 8/24/25, cited SN visits 1 visit per week for 6 weeks starting on week 1. The Communication Note dated 7/5/25, showed the SN was unable to contact the patient. The SN Visit Notes showed the patient did not have a visit during the weeks of 6/29/25 to 7/5/25, 7/6/25 to 7/12/25, 7/13/25 to 7/19/25, and 7/27/25 to 8/2/25. However, there was no documented evidence an attempt to reschedule the missed visit was made for the remaining days of the week nor was the MD notified of the missed visits. b. The OASIS SOC Assessment dated 6/26/25, showed RN 6 had performed an assessment. The assessment included the following: -on the section of Musculoskeletal showed the patient had bilateral foot pain. However, review of the POC failed to show documented evidence of a care plan was created to address the patient’s pain. -on the sections of Blood Sugar and Medication showed the patient requested a new glucometer and was taking metformin. However, review of the POC failed to show documented evidence the care plan included a goal and measurable outcome of diabetic management. On 8/20/25 at 1455 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. #. Review of Patient 8’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 8/1/25. The patient was certified for home health services during the certification period from 8/1/25 to 9/29/25. The OASIS SOC Assessment dated 8/1/25, showed RN 4 had performed an assessment. The assessment included the following: -on section of Respiratory showed diminished breath sounds, labored breathing and included interventions for deep breathing exercises and monitoring for oxygen saturation. However, review of the POC failed to show documented evidence the care plan included a goal and measurable outcome for respiratory problems. -on section of Blood Sugar showed the patient reported a result of fasting blood glucose level of 115 mg/dl, DM Type 2, and interventions included diabetic teaching, exercise, medication management, and skin check. However, review of the POC failed to show documented evidence the care plan included a goal and measurable outcome for diabetes. On 8/20/25 at 1109 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. #. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. a. The POC, for the certification period from 5/29/25 to 7/27/25, cited SN visits 2 visits per week for a total of 8 weeks. The Communication Notes dated 6/13/25, 6/24/25, 6/27/25, 7/425, and 7/7/25 showed the SN missed the home visits. The SN Visit Notes showed the patient did not have a visit during the weeks of 6/22/25 to 6/28/25 and 6/26/25 to 7/4/25 instead of two visits. In addition, during the week of 6/8/25 to 6/14/25, SN visited the patient once instead of two visits within the week. However, there was no documented evidence an attempt to reschedule the missed visit was made for the remaining days of the week nor was the MD notified of the missed visits. b. The OASIS SOC Assessment dated 5/29/25 showed RN 8 had performed an assessment. The assessment included the following: -on the section of Diagnosis and Symptom Control showed primary diagnosis as DM Type 2 with foot ulcer. -on the section of Skin Conditions showed the patient had three diabetic ulcers and interventions for wound treatments. However, review of the POC failed to show documented evidence the care plan included a goal and measurable outcome for the diabetic ulcers. On 8/20/25 at 1338 hours, an interview and concurrent closed clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. Findings: The agency P&P titled Missed Visits revised 4/2020 showed missed visits will be communicated to the clinical supervisor and the patient’s physician. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. x. Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. The SOC OASIS for the certification period from 8/3/25 to 10/1/25, cited the SN visits 2W3. Review of the Missed Visit Form dated 8/6/25 showed the visit was missed. However, there was no documented evidence the MD was notified of the missed visit. In addition, there was no documented evidence an attempt to re-schedule the visit was made for the remaining days of the week as per the agency’s P&P. On 8/20/25 at 1021 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS confirmed the patient was not contacted for the rest of the week and the physician was not notified for the missed visit. x. Review of Patient 7’s closed clinical record review showed the SOC was 5/1/25. The closed clinical record showed the patient received home health services during the certification periods from 5/1/25 to 6/29/25. a.The Home Health Certification and Plan of Care dated 5/1/25 for certification period 5/1/25 to 6/29/25 showed RN visits two times a week for ten weeks. *However, RN 5 had only seen the patient on SOC, 5/1/25. There was no documented evidence the MD was notified of the missed visits, and neither had RN 5 attempted to reschedule the visits. b. The Physician Order dated 5/10/25 showed an OT order for two times a week for four weeks. *However, there was no documented evidence the MD was notified for the missed on visit for the week 5/11/25 to 5/17/25, and neither had the OT 1 attempted to reschedule the visit. c.The Physician Order dated 5/12/25 showed a PT order for two times a week for four weeks. The PT had seen the patient for evaluation on 5/12/25. *However, no succeeding visits were completed. There was no documented evidence the MD was notified of the missed visits, and neither had the PT 1 attempted to reschedule the visits.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to utilize the quality indicator data in the design of its program. This failure had the potential risk of not improving care and services provided to the patients. Findings: Review of the agency’s QAPI Program (undated) showed data collection is a uniform and systematic process that ensures that only relevant, useful, and necessary data is collected. It includes measuring functions, processes, and outcomes that affect the dimension of care, patient, and family involvement in care and customer quality and satisfaction. In addition, the agency will measure the following functions: - right, responsibilities and ethics - assessment of patients using the OASIS data findings - continuum of care - care, treatment, and service - education - leadership - management of information - management of human resources - management of the care environment - surveillance, prevention, and control of infection - improving organizational performance - major variances in allocated budgets - evaluating the incentive provided by the agency On 8/20/25 at 1045 hours, an interview was conducted with the Administrator/CEO. The Administrator/CEO stated the agency did not have a targeted QAPI plan for the years 2023, 2024, and 2025. The Administrator/CEO stated she was responsible for collecting and gathering data for the QAPI program. The Administrator/CEO stated she did not have documented evidence of data collection for a targeted QAPI plan or tools used to collect the data.”

“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 hospice failed to document the reasons for conducting or selecting the PIP for the years of 2023 and 2024; and consistently measure the progress achieved on these projects. This failure had the potential risk of not identifying the opportunity for improvement for care and services provided to the agency’s patients. Findings: Review of the agency’s P&P titled Quality Assessment Performance Improvement Plan (undated) showed the agency will develop, implement, evaluate, and maintain an effective, ongoing, agency-wide, data driven QAPI program. The agency’s governing body/owner must ensure that the program reflects the complexity of it’s organization and services; involves all agency 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 readmissions; and takes actions that address the agency’s performance across the spectrum of care, including the prevention and reduction of medical errors. The agency must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. The agency measures, analyzes, and tracts quality indicators, including adverse patient events, and other aspects of performance that enable the agency to assess processes of care, services, and operations. The QAPI Committee must review and update or revise the plan of implementation at least once within a calendar year, or more often if needed. On 8/20/25 at 1045 hours, an interview was conducted with the Administrator/CEO. The Administrator/CEO stated the QAPI Committee included herself, the DPCS, Intake Case Manager/Office Manager, and clinicians involved in the patients’ care. The Administrator/CEO stated the purpose of the QAPI program was to ensure the agency can discuss the issues that arise within the agency that could be improved. The Administrator/CEO stated she was responsible for collecting data. The Administrator/CEO stated the timeframe for the QAPI meeting was annually. The Administrator/CEO stated currently the agency did not have a QAPI plan because she did not know she had to do one. The Administrator/CEO stated she did not have any documented evidence to show QAPI meetings were conducted, a targeted plan was developed and implemented, and data was collected from 2023 to 2024. The Administrator/CEO was informed and acknowledged the findings.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to provide at least one of services directly by the agency’s staff. This failure had the potential to result in the agency’s inability to provide care to patients who need specific services. Findings: Review of the list of patients from April to August 2025 showed the following: - For April 2025, the agency admitted one patient. - For May 2025, the agency had no admission. - For June 2025, the agency admitted four patients. - For July 2025, the agency admitted three patients. - For August 2025, the agency admitted seven patients. On 8/14/25 at 0925 hours, an interview was conducted with the Administrator/CEO. The Administrator/CEO stated the agency used RNs, LVNs, PTs, OTs, STs, and CHHAs from the registry (staffing agency). The Administrator/CEO stated there was a portal online from the registry, where the agency could post the patient’s case. Then, the clinicians such as the RNs, LVNs, PTs, OTs, STs, and CHHAs would accept the patient’s case and those clinicians would do the home visits and provide the services that the patient needs. The Administrator/CEO stated the agency would provide online access to the clinician to access the patient’s electronic health record. On 8/15/25 at 0815 hours, a follow-up interview was conducted with the Administrator/CEO. The Administrator/CEO stated the agency’s employees were herself, the DPCS, and Intake Case Manager/Office Manager. The Administrator/CEO stated the agency started admitting the patients in April 2025. The Administrator/CEO stated when the agency started admitting the patients in April 2025, they already used the registry staff to provide the services for the patients. The Administrator/CEO stated the DPCS would occasionally see the patient once or twice a month or during emergency situations, but she was available via cellphone. The Administrator/CEO stated the agency did not have job postings for RNs, LVNs, or CHHAs currently. The Administrator/CEO verified the agency had not exhausted efforts on staffing to post job postings due to financial constraints.”

“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 agency failed to ensure the clinical records were completed and authenticated for six of eight sampled patients (Patients 1, 3, 4, 6, 7, and 8). This failure had the potential risk for substandard care provided to these patients as their clinical information was not complete. Findings: Findings: x. Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. a.Review of the SOC OASIS dated 8/3/25, showed the RN 4 had performed a comprehensive assessment. The RN 4 had electronically signed the SOC OASIS. However, there was no date when the RN 4 had electronically signed the SOC OASIS. On 8/20/25 at 1021 hours, an interview and concurrent record review was conducted with the DPCS. The DPCS confirmed and acknowledged the above finding. x. Review of Patient 7’s closed clinical record review showed the SOC was 5/1/25. The closed clinical record showed the patient received home health services during the certification periods from 5/1/25 to 6/29/25. a.Review of the Physician Order dated 5/10/25, showed the OT 1 had evaluated the patient. *However, in the section order read back and verified with MD, the clinician has no signature. b.Review of the Physician Order dated 5/12/25, showed the PT 1 had evaluated the patient. *However, in the section order read back and verified with MD, the clinician has no signature. On 8/20/25 at 1119 hours, an interview and concurrent record review was conducted with the DPCS. The DPCS stated the HHA has no coordination of care. The DPCS confirmed the findings. #. Review of Patient 4’s clinical record was initiated on 8/14/25. The clinical record showed the SOC was 6/26/25. The patient was certified for home health services during the certification period from 6/26/25 to 8/24/25. a. The OASIS SOC Assessment dated 6/26/25, showed RN 6 conducted the initial comprehensive assessment. However, there was no documented evidence a date was included in her electronic signature of when the assessment was completed as per the agency’s P&P. b. The POC, for the certification period from 6/26/25 to 8/24/25, showed the section for the Nurse’s Signature and Date of Verbal SOC Where Applicable. However, the section was left blank. c. The SN Visit Notes showed LVN 3 conducted home visits on 7/26, 8/3, and 8/11/25. However, there was no documented evidence to show LVN 3’s professional title and date the visit notes were completed as per the agency’s P&P. On 8/20/25 at 1450 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. #. Review of Patient 8’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 8/1/25. The patient was certified for home health services during the certification period from 8/1/25 to 9/29/25. a. The OASIS SOC Assessment dated 8/1/25, showed RN 4 conducted the initial comprehensive assessment. However, there was no documented evidence a date was included in her electronic signature of when the assessment was completed as per the agency’s P&P. b. The POC, for the certification period from 8/1/25 to 9/29/25, showed the section for the Nurse’s Signature and Date of Verbal SOC Where Applicable. However, the section was left blank. On 8/20/25 at 1050 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. #. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. The OASIS SOC Assessment dated 5/29/25, showed RN 8 conducted the initial comprehensive assessment. However, there was no documented evidence a date was included in her electronic signature of when the assessment was completed as per the agency’s P&P. On 8/20/25 at 1337 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the finding. Review of the agency’s P&P titled Submission of Clinical Records dated April 2020 showed the agency shall ensure that all medical records are complete, accurate and timely. Documentation must reflect the care and services provided, comply with federal and state regulations, and support the integrity of patients health information. The procedure includes the documentation standards. The standards included all entries must be accurate, complete and legible. Documentation shall include date, time, discipline and signatures/credential of the staff member. The procedure also includes timely completion. Clinical documentation must be completed within 24 hours of service delivery. #. Review of Patient 1’s clinical record was initiated on 8/13/25. The patient was certified for home health services during the certification periods from 7/29/25 to 9/26/25. a. Review of the SN 1 visit note dated 8/16/25, showed the SN 1 had visited the patient. The assessment showed the SN 1 documented the patients weight, respiration and the temperature. However, review of the visit note failed to show documented evidenced of the SN 1 had completed the assessment within 24 hours from the visit date as per P&P. Further review of the SN 1 visit note dated 8/16/25, showed the SN 1 had electronically signed the visit. However, the body system assessment was left blank. b. Review of the POC for the certification period from 7/29/25 to 9/26/25, showed the section for the Nurse’s signature and Date of Verbal SOC Where Applicable. However, the section was left blank. On 8/20/25 at 1106 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was asked as to the timeline the SN needed to complete the visit notes. The Administrator/CEO reviewed the clinical record and replied the visit note should have been completed within 48 hours from the visit date. The Administrator/CEO was also asked as to who received the verbal order for the POC. The Administrator/CEO replied, the nurse but it was not signed. The Administrator/CEO was informed and acknowledged the findings.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the patient and PCG were advised of the availability of the toll-free state hotline established by the State and that the purpose of the hotline to receive complaints for three of eight sampled patients (Patients 2, 3, and 8). This failure had the potential risk of violating the patient’s rights to be informed of the availability of the state hotline information to these patients. Findings: #. Review of Patient 8’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 8/1/25. The patient was certified for home health services during the certification period from 8/1/25 to 9/29/25. A joint home visit with PTA 1 was conducted on 8/15/25 at 1105 hours, to Patient 8’s home. The patient was asked if she was aware of the state hotline toll-free telephone number and replied no. Review of the patient’s admission folder provided by the HHA included the admission packet. The admission packet showed the Patient Consent for Care and Treatment. The Patient Consent for Care and Treatment included a section for Grievance/Policy/Procedure where the state home health care hotline number was listed. However, the state hotline number was for LA County instead of Orange County. On 8/15/25 at 1200 hours, an interview and concurrent agency document review was conducted with PTA 1. PTA 1 verified and acknowledged the state toll-free telephone number was incorrect in the patient’s admission packet the agency provided. On 8/20/25 at 1106 hours, the Intake Case Manager/Office Manager was informed of the finding. #. Review of Patient 2’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/9/25. The patient was certified for home health services during the certification period from 7/9/25 to 9/6/25. The patient was discharged from the agency on 8/14/25. The POC, for the certification period from 7/9/25 to 9/6/25, cited SN visits 1W1, PT visits starting week 1 and OT visits starting week 1. A joint home visit with RN 2 was conducted on 8/14/25 at 1147 hours, to Patient 2’s home. Review of the patient’s home folder provided by the HHA included the admission packet. The admission packet showed the Patient Consent for Care and Treatment. The Patient Consent for Care and Treatment included a section for Grievance/Policy/Procedure where the state home health care hotline number was listed. However, the state hotline number was for LA county instead of Orange County. On 8/20/25 at 1324 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the finding. Findings: 1. Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. On 8/14/25 at 0847 hours, a joint home visit was conducted with the DPCS to Patient 3’s home. Review of the patient’s home folder provided by the HHA included the admission packet. The admission packet showed the Patient Consent for Care and Treatment. The Patient Consent for Care and Treatment included a section for Grievance/Policy/Procedure where the state home health care hotline number was listed. However, the state hotline number was for LA county instead of Orange County. Patient 3 stated the printed state hotline number on the admission packet will be called for complaints. The DPCS confirmed and acknowledged the finding.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment visits were conducted within 48 hours of the referral or within 48 hours of the patient’s return home for three of eight sampled patients (Patients 1, 5, and 6). This failure had the potential for not providing the necessary care and services timely to these patients. Findings: #. Review of Patient 1’s clinical record was initiated on 8/13/25. The SOC was 7/29/25. The patient was certified for home health services during the certification period from 7/29/25 to 9/26/25. Review of the patient’s referral information showed a faxed referral from the physicians office dated 7/25/25. Review of the clinical record showed the OASIS E 1-Start Of Care Assessment was performed on 7/29/25. However, the SOC assessment was performed more than 48 hours from the referral date. In addition, there was no documented evidenced of the reason why the OASIS E 1-Start Of Care Assessment was performed more than 48 hours from the referral date. On 8/20/25 at 1106 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO reviewed the clinical record and acknowledged the finding. #. Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. Review of the patient’s referral information showed a faxed referral from the hospital dated 5/21/25. The referral also showed a discharge from hospital dated 5/23/25. Review of the clinical record showed the OASIS E 1-Start Of Care Assessment was performed on 5/29/25. However, the SOC was performed more than 48 hours from the referral date. In addition, there was no documented evidenced of the reason why the OASIS E 1-Start Of Care Assessment was performed more than 48 hours from the referral date. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Review of the agency’s P&P titled Initial and Comprehensive Patient Assessment (undated) showed the agency will ensure that all patients referred for care/services will receive an initial assessment. The initial assessment will be conducted within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician’s ordered start-of-care date. #. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. Review of the patient’s referral information showed a documentation of a faxed referral from the hospital dated 5/22/25. However, further review of the clinical record showed no documented evidence of the reason why the SOC was 5/29/25, instead of the 48 hours after the referral date of 5/22/25. On 8/20/25 at 1325 hours, an interview and concurrent closed clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager stated there was no communication note in the patient’s records as to why the patient’s SOC was more than 48 hours from the referral date. The Intake Case Manager/Office Manager was informed and acknowledged the above finding.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessments were completed no later than five calendar days after the SOC, consistent with the patients’ immediate needs for seven of eight sampled patients (Patients 1, 2, 3, 4, 5, 6, and 8). This failure had the potential risk of not identifying and addressing the care needs timely for these patients. Findings: x.Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. a.Review of the OASIS SOC dated 8/3/25, showed no documented evidence the following were assessed: -Date last seen by MD -Psychosocial assessment -TUG test -Medication review drug reactions -Emergency disaster/disaster code -Spiritual/cultural needs -Safety hazards -Sanitation hazards -Last BM -Understanding of the instruction regarding pain medication and non-pharmacological pain reducing methods. b.Review of the OASIS SOC dated 8/3/25 cited the PT visit for 1W1 for evaluation. However, PT evaluation was done on 8/18/25. On 8/20/25 at 1021 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated the PT should be evaluating the patient within five days from SOC. There was no communication why the PT evaluation was not done within five days from SOC. The DPCS acknowledged and confirmed the findings. #. Review of Patient 1’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/29/25. The patient was certified for home health services during the certification period from 7/29/25 to 9/26/25. The Physicians referral dated 7/25/25 showed an order for nursing nursing visit and Physical Therapy three times a week for eight weeks. The Diagnosis was Left humerus fracture s/p Fall. The OASIS E1 Start of Care Assessment dated 7/29/25, showed the RN 1 had performed the initial comprehensive assessment. The assessment included pain. However, the section for the location of pain was left blank. In addition, the section for the current medications was left blank. Moreover, on the section for the frequency showed SN visits. However, there was no documented evidenced of the PT visit frequency was included as per referral order. Furthermore, the RN 1 did not complete the initial comprehensive assessment timely as the RN did not complete the patients pain assessment, current medications and the PT visits as per referral order. On 8/20/25 at 1106 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO reviewed the clinical record and acknowledged the findings. #. Review of Patient 2’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/9/25. The patient was certified for home health services during the certification periods from 7/9/25 to 9/6/25. The patient was discharged from the agency on 8/14/25. Review of the POC, for the certification period from 7/9/25 to 9/6/25 cited SN visits, PT and OT evaluation. a. Review of the clinical record showed the OT performed the initial comprehensive assessment dated 7/21/25. However, the OT performed the assessment more than five calendar days from the start of care. b. Review of the OASIS E1 Start of Care Assessment dated 7/9/25, showed the RN 3 had performed the initial comprehensive assessment. The assessment included the following sections: -the Immunization/Screening, -psychosocial, -homebound status and -ER visits and Re-hospitalization Risks and Interventions. However, the RN 3 failed to complete the comprehensive assessment within five days from the start of care as the above sections were left blank. On 8/20/25 at 1336 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. #. Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. Review of the OASIS E1 Start of Care Assessment dated 5/29/25, showed the RN 7 had performed the initial comprehensive assessment. The assessment included pain. However, the section for the location/description of pain was left blank. In addition, the section for the current medications was left blank. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Review of the agency’s P&P titled Initial and Comprehensive Patient Assessment (undated) showed the HHA will provide each patient with a patient-specific comprehensive assessment that accurately reflects the patient’s current health. The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than five calendar days after the start of care. #. Review of Patient 4’s clinical record was initiated on 8/14/25. The clinical record showed the SOC was 6/26/25. The patient was certified for home health services during the certification period from 6/26/25 to 8/24/25. Review of the OASIS SOC Assessment dated 6/26/25, failed to show documented evidence of the cardiovascular status. In addition, review of the SN Visit Note dated 8/3/25, showed under the narrative notes the patient had an implanted port-a catheter on his left upper extremities. However, the implanted port-a-catheter was not reflected in the OASIS SOC assessment. On 8/20/25 at 1423 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. #. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. Review of the OASIS SOC Assessment dated 5/29/25, failed to show documented evidence of the immunization screening, mouth condition, nasal condition, neurological, psychosocial, and blood sugar assessment. On 8/20/25 at 1337 hours, an interview and concurrent closed clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. #. Review of Patient 8’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 8/1/25. The patient was certified for home health services during the certification period from 8/1/25 to 9/29/25. Review of the OASIS SOC Assessment dated 8/1/25, failed to show documented evidence of the height, weight, past medical history with issued and diagnosis, medications, medication review drug reactions, and mental status. On 8/20/25 at 1035 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the review of the medications included the patient’s current medications to identify any potential adverse effects and drug reactions for one of eight sampled patients (Patients 2). This failure had the potential risk for not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for this patient. Findings: #. Review of Patient 2’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/9/25. The patient was certified for home health services during the certification period from 7/9/25 to 9/6/25. The patient was discharged from the agency on 8/14/25. The Medication Profile for the certification period from 7/9/25 to 9/6/25, showed the patient’s medications included acetaminophen (analgesic) 160 mg in 5 ml oral solution Q8H PRN, ipratropium bromide (respiratory inhalation) 0.5 mg/ albuterol sulfate 3 mg in 3 ml Q6H PRN, Keppra (anticonvulsant) 100 mg in 1 ml oral solution Q12H, mupirocin (topical antibiotic) 2% topical ointment Q12H, propranolol HCL (beta blockers) 10 mg oral tablet Q12H, Refresh tears (ophthalmic) 0.5% one drop both eyes PRN and Vitamin D2 (supplement) 50,000 IU oral once per week. A joint home visit with LVN 1 was conducted on 8/14/25 at 1147 hours, to Patient 2’s home. The PCG reported patients Vitamin D2 dosage was changed from 50,000 IU once per week to D3 (supplement) 20,000 IU (50 mcg) one tablet once a day. In addition, the patient /PCG reported he was taking the tablet form of Keppra instead of liquid solution as written on the medication profile. However, the medication was not updated to show the changes in the dosage and preparations of the above medications. On 8/20/25 at 1324 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Findings: Review of the agency’s P&P titled Medication Profile revised 4/2020 showed the patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Review of the agency’s P&P titled Initial and Comprehensive Patient Assessment (undated) showed the Home Health Agency (HHA) will provide each patient with a specific comprehensive assessment that accurately reflects the patient’s current health. x. Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. On 8/14/25 at 0847 hours, a joint home visit was conducted with the DPCS to Patient 3’s home. Review of the patient’s medications with DPCS, the patient stated she was not taking the Keflex (antibiotic) 500 mg every 4 hours prescribed; however, the medical update and patient information does not contain information regarding patient’s medications. The DPCS confirmed and acknowledged the finding.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated within the last 5 days of every 60 days for one of eight sampled patients (Patient 5). This failure created the increased risk of not addressing the care needs for this patient. Findings: Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The POC, for the certification period from 5/29/25 to 7/27/25, cited SN visit 1W9. Further review of the clinical record showed no documented evidence of the comprehensive assessment completed within the last five day of the certification period. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was asked if they needed to complete the recertification OASIS assessment. The Administrator/CEO replied yes, it should have been completed from the last two days prior to the new certification period. The Administrator was also asked if the patient was still admitted. The Administrator replied yes. The Administrator stated the patient was still admitted but unable to see the visit notes for the month of August in the system. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure the update comprehensive assessment was completed within 48 hours of the patient’s return to home from the hospital for one of eight sampled patients (Patients 5). This failure created the risk of not providing the necessary care and services timely to meet the care needs for this patient. Findings: Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. a. Review of the clinical record showed the patient was discharged from the hospital on 6/18/25. Review of the clinical record showed the OASIS E1 Resumption of Care was completed on 6/23/25, more than 48 hours of the patient’s return to home. b. Review of the Communication Notes dated 6/25/25, showed the patient was admitted to the hospital. Further review of the clinical record showed a faxed documentation from the hospital dated 6/27/25. The documents showed an order for the resumption of care. However, review of the clinical record failed to show documented evidence of a resumption of care assessment performed within 48 hours of the patient’s return to home. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the discharge assessment was completed for two of eight sampled patients (Patients 2 and 6). This failure had the potential for not addressing the care needs for these patients. Findings: #. Review of Patient 2’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/9/25. The patient was certified for home health services during the certification periods from 7/9/25 to 9/6/25. The patient was discharged from the agency on 8/14/25. The POC, for the certification period from 7/9/25 to 9/6/25, cited SN visits 1W1, PT visits starting week 1 and OT visits starting week 1. A joint home visit with RN 2 was conducted on 8/14/25 at 1147 hours, to Patient 2’s home. The visit was for the RN 2 to discharge the patient. Review of the OASIS E 1 Discharge Assessment dated 8/11/25 showed the RN 2 had performed the comprehensive assessment. The assessment included a section for TUG test. However, the section was left blank. On 8/20/25 at 1336 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Review of the agency’s P&P titled Patient Transfer/Discharge (undated) showed the agency will forward the necessary medical information pertaining to the patient’s current course of illness and treatment, post discharge goals of care, and treatment preferences to the receiving facility or healthcare practitioner to ensure the safe and effective transition of care. The HHA will comply with any request made by the receiving facility or healthcare practitioner for additional clinical information that may be necessary for treatment of the patient. #. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. Review of the Communication Note dated 7/8/25, showed the Administrator called the patient and the patient stated he no longer needed home health services. However, further review of the clinical records did not show documented evidence the patient was discharged on 7/9/25 or a Discharge OASIS or discharge assessment was completed. On 8/20/25 at 1412 hours, an interview and concurrent closed clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager stated a Discharge OASIS should be completed within 24 hours of the patient’s discharge. The Intake Case Manager/Office Manager was informed and acknowledged the finding.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the POC included the required components for seven of eight sampled patients (Patients 1, 2, 4, 5, 6, 7, and 8). This failure had the potential risk of not addressing the care needs for these patients. Findings: #. Review of Patient 1’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/29/25. The patient was certified for home health services during the certification period from 7/29/25 to 9/26/25. The POC, for the certification period from 7/29/25 to 9/26/25, showed the patients’, the providers and physicians name and address. The POC also showed the following sections were left blank. -Principal diagnosis -Surgical procedure -Other pertinent diagnoses -DME and supplies -Safety measures -Nutritional Requirement -Allergies -Functional Limitations -Activities Permitted -Mental status In addition, the section for Orders for Discipline and Treatments (specify Amount/Frequency/Duration) showed the patients nutritional status was assessed. The section for the Goals/Rehabilitation Potential/Discharge Plans had an entry related to neurological status and the psychosocial needs. Further, review of the POC showed the document was on “draft”. However, there was no documented evidenced of the components of the POC was completed after the RN performed the Start of Care Assessment on 7/29/25. On 8/20/25 at 1106 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO reviewed the clinical record and acknowledged the findings. #. Review of Patient 2’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/9/25. The patient was certified for home health services during the certification periods from 7/9/25 to 9/6/25. The patient was discharged on 8/14/25. The POC, for the certification period from 7/9/25 to 9/6/25, showed the following sections were left blank. -Surgical procedure -Other pertinent diagnoses -DME and supplies -Nutritional Requirement -Functional Limitations In addition, the section for Orders for Discipline and Treatments (specify Amount/Frequency/Duration) showed the disciplines needed. The disciplines were SN, PT and OT. However, the frequency and duration for the PT and OT was left blank. Further review of the POC failed to include the orders for disciplines and treatments. On 8/20/25 at 1336 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. #. Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The POC for the certification period from 5/29/25 to 7/27/25 cited SN visit 1W9 (one time a week for nine weeks). The POC included a section for nutritional requirement. However, the nutritional requirement was left blank. In addition, on the section of the section for Orders for Discipline and Treatments (specify Amount/Frequency/Duration) showed the disciplines needed. However, the treatments per disciplines were left blank. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Findings: x. Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. On 8/14/25 at 0847 hours, a joint home visit was conducted with the DPCS to Patient 3’s home. The DPCS provided wound care to the left below the knee amputation of Patient 3. When asked about the medications, Patient 3 showed a regular insulin, Lantus and Keflex (antibiotics) 500 mg four times a day. *However, the POC, for the certification period 8/3/25 to 10/1/25 was blank. There were no documented diagnosis, medications, functional limitations, order for discipline and treatments, goal/rehabilitation. On 8/20/21 at 1021 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS confirmed there was no plan of care for Patient 3. x.Review of Patient 7’s closed clinical record review showed the SOC was 5/1/25. The closed clinical record showed the patient received home health services during the certification periods from 5/1/25 to 6/29/25. The Medication Profile for Patient 7 dated 5/1/25 showed the following medications: -Hydrocodone Bitartrate 5 mg/Acetaminophen 325 mg (pain reliever), one tablet every six hours as needed. -Leucovorin Calcium (medication used to reduce the harmful side effects of certain chemotherapy drugs) 5 mg one tablet, every Saturday and Sunday. -Ondansetron (medication used to prevent nausea and vomiting) 8 mg, one tablet every six hours. -Pantoprazole Sodium (medication used to treat excess stomach acid) 40 mg, one tablet daily. -Posaconazole (medication used to treat and prevent severe fungal infections) 100 mg, three tablets daily. -Rena-vite (vitamin supplement for people with kidney disease), one tablet one tablet daily. -Sevelamer (medication used in patients with chronic kidney disease) 800 mg, one tablet three times a day. -Sulfamethoxazole 800 mg/Trimethroprim (combination antibiotic used to treat a wide variety of bacterial infections) 160 mg, one tablet three times a day. -Tacrolimus (medication used to treat other autoimmune diseases) 0.5 mg, two capsules two times a day. -Ursodiol (medication used to treat liver diseases) 300 mg, one tablet two times a day. -Valacyclovir (medication used to treat and suppress viral infections) 500 mg, one tablet two times a day. However, there were no specific indications, instructions and no possible side effects indicated for these medications. On 8/20/25 at 1119 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated there was no coordination between the nurse and the physician. The DPCS confirmed the finding. Review of the agency’s P&P titled Plan of Care (undated) showed the agency will develop a written plan of care for each patient accepted to care/services. The plan of care will be developed in consultation with the patient, physician or allowed practitioner, and agency staff. The initial plan of care includes, but is not limited to: - SOC date - Certification period - Patient’s demographics - Principle diagnoses and other pertinent diagnoses - Medications dose/frequency/route - Allergies - Orders for therapy services, including specific procedures and modalities to be used - Orders for all disciplines include amount, frequency, and duration of visits to be made - Equipment and supply needs - Caregiver needs - Functional limitations - Diet and nutritional requirements - Safety measures to protect against injury - Patient-specific interventions and education, measurable outcomes, and goals identified by the HHA and the patient - Problems/needs - Interventions - Expected patient outcomes/goals - Treatments/orders - Mental/psychosocial/cognitive status - Rehabilitation potential - Activities permitted - Prognosis - Patient and caregiver education and training to facilitate timely discharge - Information related to any Advance Directives #. Review of Patient 8’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 8/1/25. The patient was certified for home health services during the certification period from 8/1/25 to 9/29/25. The POC, for the certification period from 8/1/25 to 9/29/25, showed the sections for medications dose/frequency/route, nutritional requirement, and mental status were left blank. In addition, the POC showed the document was on “draft”. However, there was no documented evidence of the components of the POC was completed after the RN performed the Start of Care Assessment on 8/1/25. On 8/20/25 at 1011 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. #. Review of Patient 4’s clinical record was initiated on 8/14/25. The clinical record showed the SOC was 6/26/25. The patient was certified for home health services during the certification period from 6/26/25 to 8/24/25. The POC, for the certification period from 6/26/25 to 8/24/25, showed the section for nutritional requirements was left blank. In addition, cited SN visits once every week for 6 weeks and 1 visit as needed every week starting week 1 and PT visits once every week for 6 weeks and 1 visit as needed every week starting week 2. However, there were no specific indication for the use of PRN visits. On 8/20/25 at 1440 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. #. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. The OASIS SOC Assessment dated 5/29/25, showed the patient had a left foot lateral fifth toe, left foot lateral fifth head toe, and left foot diabetic ulcer and a left fourth toe amputation surgical wound. The POC, for the certification period from 6/26/25 to 8/24/25, showed in the section of orders for discipline and treatments showed a wound care treatment to left foot ulcer. However, the POC did not include specific instructions/interventions for wound care for the left foot lateral fifth toe and left foot lateral fifth head toe diabetic ulcer and left fourth toe amputation surgical wound. In addition, the POC showed in sections of DME and supplies, nutritional requirements, and prognosis were left blank. On 8/20/25 at 1409 hours, an interview and concurrent closed clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure the patients received care and services as per the written POCs for two of eight sampled patients (Patients 3 and 8). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: #. Review of Patient 8’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 8/1/25. The patient was certified for home health services during the certification period from 8/1/25 to 9/29/25. The POC for the certification period 8/1/25 to 9/29/25 showed an order for disciplines to monitor the oxygen saturation. Review of the PT Visit Notes dated 8/6 and 8/11/25 failed to show documented evidence the patient’s oxygen saturation was monitored. On 8/20/25 at 1055 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the finding. #. Review of Patient 1’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/29/25. The patient was certified for home health services during the certification period from 7/29/25 to 9/26/25. The POC for the certification period from 7/29/25 to 9/26/25 showed an order for nutrition: Patient was assessed to at moderate nutritional risk. Plan to monitor and reevaluate nutritional status regularly. Review of the Clinical record dated 8/13/25, showed the SN 2 had performed and assessment. However, there was no documented evidenced of the SN 2 had evaluated the patients nutrition status as ordered in the POC. On 8/20/25 at 1106 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO reviewed the clinical record and acknowledged the findings.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the verbal orders were authenticated timely for four of eight sampled patients (Patients 4, 5, 6, and 7). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: #. Review of Patient 7’s closed clinical record review showed the SOC was 5/1/25. The closed clinical record showed the patient received home health services during the certification periods from 5/1/25 to 6/29/25. The physician failed to electronically signed and date the following verbal orders after 30 days as per P&P: -Home Health Certification of Care and Plan of Care dated 5/1/25. -Physician Order dated 5/10/25 clarification of order for skilled Occupational Therapy. -Physician Order dated 5/1/25 for PT. -Discharge Physician Order and Summary of Care dated 6/19/25. On 8/20/25 at 1119 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS confirmed there was a lack of communication and coordination between the HHA and the physician. The DPCS acknowledged the above findings. #. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. The POC for the certification period from 5/29/25 to 7/27/25, showed RN 8 had electronically signed and dated the verbal SOC on 6/6/25. The POC also included the physician’s name and contact number. However, the physician failed to electronically sign and date the verbal SOC orders within 30 days as per the agency’s P&P. On 8/20/25 at 1332 hours, an interview and concurrent closed clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. #. Review of Patient 4’s clinical record was initiated on 8/14/25. The clinical record showed the SOC was 6/26/25. The patient was certified for home health services during the certification period from 6/26/25 to 8/24/25. a. The POC for the certification period from 6/26/25 to 8/24/25, showed the physician’s name, address, and contact number. However, the physician failed to electronically sign and date the verbal SOC orders within 30 days as per the agency’s P&P. b. The PT Initial Evaluation dated 7/15/25, showed a verbal order from the physician was received on the PT POC for request of 1W1 and 2W3 for PT skilled services to improve the patient’s transfer, gait, balance, endurance, safety, and function. However, the physician failed to electronically sign and date the verbal SOC orders within 30 days as per the agency’s P&P. On 8/20/25 at 1435 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. The agency P&P titled Physicians Order revised April 2020 showed the procedure included Order Authentication. All verbal/telephone orders must be signed and dated by the ordering provider within 30 days (or as required by state law or accreditation). #. Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The POC for the certification period from 5/29/25 to 7/27/25 showed the nurse had electronically signed and date the verbal SOC on 5/31/25. The POC also include the physicians name and address. However, the physician failed to electronically signed and date the verbal SOC orders after 30 days as per P&P. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure a written individualized plan of care and services were reviewed and revised for one of eight sampled patients (Patient 5). This failure created the risk of not providing appropriate, consistent, and quality care to this patient. Findings: Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The POC for the certification period from 5/29/25 to 7/27/25 cited SN visit 1W9. However, review of the clinical record failed to show a plan of care was reviewed and revised after the first certification was completed. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was asked if they needed to develope a plan of care. The Administrator/CEO replied yes but none was documented. The patient was still admitted and they had conducted the visits but there was problem on the system, and unable to view the visit notes for the month of August. The Administrator/CEO was informed and acknowledged the findings.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the physician was notified promptly related to the changes of conditions for one of eight sampled patients (Patient 4). This failure had the potential risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: Review of the agency’s P&P titled Plan of Care (undated) showed the agency will ensure that the physician(s) or allowed practitioner is promptly notified to any changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered. Review of Patient 4’s clinical record was initiated on 8/14/25. The clinical record showed the SOC was 6/26/25. The patient was certified for home health services during the certification period from 6/26/25 to 8/24/25. The OASIS SOC Assessment dated 6/26/25, showed the patient had chronic, continuous, and sharp bilateral foot pain. In addition, the assessment showed the patient was taking gabapentin (a drug that treats peripheral neuropathy) once daily, and the medication was not effective and the patient was not satisfied with the effects of the medication due to continuous pain. The SN Visit Note dated 7/26/25, showed the patient verbalized that his left fingers were hard for him to close compared to his right fingers. However, there was no documented evidence the physician was notified about the patient’s continuous bilateral foot pain, the ineffectiveness of gabapentin, and the patient’s left fingers were hard to close. On 8/20/25 at 1450 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged findings.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure effective communication with the patient’s physician for five of eight sampled patients (Patients 1, 3, 4, 5, and 6). This failure had the potential of not providing necessary care and services to these patients. Findings: 1.Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. Review of the Communication Note dated 7/8/25, showed the nurse called the patient due to a missed visit. The patient stated he no longer needed home health services. Review of the Discharged Patients List showed the patient was discharged on 7/8/25. However, there was no documented evidence the nurse notified the physician that the patient no longer needed home health services. On 8/20/25 at 1412 hours, an interview and concurrent closed clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the finding. 2. Review of Patient 4’s clinical record was initiated on 8/14/25. The clinical record showed the SOC was 6/26/25. The patient was certified for home health services during the certification period from 6/26/25 to 8/24/25. a. The POC, for the certification period from 6/26/25 to 8/24/25, showed cited CHHA 2 visits every week for 6 weeks starting week 2. Further review of the clinical record failed to show documented evidence the patient was provided with CHHA visits as per the POC. On 8/15/25 at 1451 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO stated the patient was not receiving CHHA services because the patient’s insurance did not approve the CHHA services. Further review of the clinical record failed to show documented evidence the physician was notified that CHHA services were not approved by the patient’s insurance. The Administrator verified the above finding. b. The POC, for the certification period from 6/26/25 to 8/24/25, cited SN visits once every week for 6 weeks starting on week 1 and PT visits once every week for 6 weeks starting on week 2. Review of the SN Visit Notes showed RN 6 completed the OASIS SOC Assessment on 6/26/25 and the next SN visit was on 7/26/25. Review of the PT Initial Evaluation was completed on 7/15/25. Further review of the clinical record failed to show documented evidence the SN and PT conducted a home visit during the weeks of 6/29/25 to 7/5/25 and 7/6/25 to 7/12/25, as per the patient’s POC. On 8/20/25 at 1504 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager stated the agency did not get an authorization for the SN and PT visits until 7/9/25. The authorization information was not coordinated properly and made a mistake on the patient’s SOC and that was the reason why there were no SN and PT visits during the weeks of 6/29/25 to 7/5/25 and 7/6/25 to 7/12/25. However, further review of the clinical record failed to show documented evidence the physician was notified of the delay in obtaining an authorization for the SN and PT until 7/9/25. The Intake Case Manager/Office Manager was informed and acknowledged findings. 3. Review of Patient 1’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/29/25. The patient was certified for home health services during the certification period from 7/29/25 to 9/26/25. The OASIS E1 Start of Care Assessment dated 7/29/25, showed SN visits 2W2 and 1W6. However, review of the clinical record failed to show documented evidence the RN had communicated to the physician regarding the plan of care to include the SN visit frequency as identified on the OASIS E1 Start of Care Assessment dated 7/29/25. On 8/20/25 at 1106 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO reviewed the clinical record and acknowledged the finding. 4. Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. a. The POC for the certification period from 5/29/25 to 7/27/25, cited SN visit 1W9. However, review of the clinical record failed to show an order for recertification was coordinated with the physician. b. Review of LVN 3’s visit notes dated 7/12/25, showed documentation of pain medication, Tylenol (analgesic) 500 mg two tablets PRN. In addition, the narrative section showed the patient had an order of meclizine (antivertigo) 12.5 mg PRN. Further review of LVN 3’s visit notes dated 7/19 and 7/26/25, showed documentation of pain medication, Tylenol (analgesic) 500 mg two tablets PRN. However, review of the clinical record failed to show LVN 3 had coordinated with the physicians related to the pain and antivertigo medication as the section for care coordination was left blank. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was asked if the patient had an order for Tylenol 500 mg. The Administrator/CEO replied, no order. The Administrator/CEO was also asked if the medications were coordinated with the physician. The Administrator/CEO replied, no coordination with the MD. 5. Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. The GACH’s referral to home health dated 7/27/25, showed to provide PT. Review of the OASIS dated 8/3/25, for the certification period from 8/3/25 to 10/1/25, showed a recommendation for PT evaluation of 1W1. However, review of the clinical record failed to show documented evidence the physician was notified of the recommendation for PT evaluation. On 8/20/25 at 1021 hours, an interview and clinical record review was conducted with the DPCS. The DPCS reviewed the clinical record and acknowledged the finding.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the ST services was integrated for one of eight sampled patients (Patient 2). This failure had the potential risk of not providing quality of care and services to this patient. Findings: 3.Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. Review of the SOC OASIS dated 8/3/25 cited the PT visit for 1W1 for evaluation. However, review of the clinical record failed to show documented evidence of a PT evaluation within five days of SOC. The PT evaluation was done on 8/18/25. On 8/20/25 at 1021 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated the PT should be evaluating the patient within five days from SOC. There was no communication why the PT evaluation was not done within five days from SOC. The DPCS acknowledged and confirmed the findings. The agency’s P&P titled Care Coordination revised April 2020, showed care coordination will include but not limited to integrate orders from all physicians involved in the plan of care. Integration of services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. 1. Review of Patient 2’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/9/25. The patient was certified for home health services during the certification periods from 7/9/25 to 9/6/25. The patient was discharged from the agency on 8/14/25. Review of the referral from the hospital dated 7/7/25, showed the list of disciplines needed were RN, ST and OT. Review of the POC, for the certification period from 7/9/25 to 9/6/25 cited SN visits, PT and OT evaluation. However, the POC failed to integrate ST services as ordered on the hospitals’ referral form dated 7/7/25. On 8/20/25 at 1336 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the finding. 2. Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. Review of PT Initial Evaluation Notes dated 7/14/25, on the section of Additional disciplines included OT. On the section of coordination of care showed OT. Further review of the PT Progress Notes dated 7/21 and 7/23/25, on the section of Additional disciplines included OT. On the section of coordination of care showed OT. However, review of the clinical record failed to show documented evidenced of an OT evaluation was conducted as coordinated by the physical therapist. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was asked if the OT evaluation was performed. The Administrator/CEO replied, no it was missed. The Administrator/CEO was also asked if they coordinated with the OT. The informed and acknowledged the finding.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the services were integrated in the POC for two of eight sampled patients (Patients 4 and 5). This failure had the potential risk of not providing quality of care and services to these patients. Findings: Findings: x. Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. The GACH’s referral to home health dated 7/27/25, showed to provide PT. Review of the OASIS dated 8/3/25 for the certification period from 8/3/25 to 10/1/25 showed a recommended PT evaluation of 1W1. However, the review of the clinical record failed to show documented evidence of the physician’s order for PT evaluation. On 8/20/25 at 1021 hours, an interview and clinical record review was conducted with the DPCS. The DPCS stated there was no physician’s order for the PT evaluation. The DPCS reviewed the clinical record and acknowledged the finding. #. Review of Patient 1’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/29/25. The patient was certified for home health services during the certification period from 7/29/25 to 9/26/25. The OASIS E1 Start of Care Assessment dated 7/29/25, showed the SN frequency of visits cited 2W2 (two visits every week for 2 weeks) and 1W6 (one visit every week for six weeks). However, review of the clinical record failed to show documented evidenced of the RN had communicated to the physicians the plan of care to include the SN visit frequency as identified on the OASIS E1 Start of Care Assessment dated 7/29/25. In addition, review of the clinical record showed a missed visit on 8/1/25. However, review of the clinical record failed to show documented evidenced of an attempt to re-schedule the visit for the week. Moreover, there was no documented evidenced of the physician was notified of the missed visit. Further review of the clinical record showed the SN had visited the patient on Week 3 (from 8/10 to 8/16/25), two times dated 8/13 and 8/16/25 instead of one time as written on the OASIS E1 Start of Care Assessment dated 7/29/25. However, there was no documented evidenced as to the reason why the SN had performed two visits instead of one visit as identified on the OASIS E1 Start of Care Assessment dated 7/29/25. On 8/20/25 at 1106 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO reviewed the clinical record and acknowledged the findings. #. Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. a. The POC for the certification period from 5/29/25 to 7/27/25 cited SN visit 1W9 (one time a week for nine weeks). However, review of the clinical record failed to show an order for recertification was coordinated with the physician. b. Review of the LVN 3 visit notes dated 7/12/25 on the section of Pain Regimen showed a documentation of pain medication. The medication was Tylenol (analgesic) 500 mg two tablets PRN. In addition on the section of Narrative, showed patient had an order of meclizine (antivertigo) 12.5 mg PRN. Further review of the LVN 3 visit notes dated 7/19 and 7/26/25 showed on the section of Pain Regimen showed a documentation of pain medication. The medication was Tylenol (analgesic) 500 mg two tablets PRN. However, review of the clinical record failed to show the LVN 3 had coordinated with the physicians related to the pain and antivertigo medication as the section for care coordination was left blank. c. Moreover review of the Review of the LVN 3 visit notes dated 7/12/25 on the section of Narrative, showed the PCG requested for an ST visit. However, review of the clinical record failed to show documented evidenced of the LVN 3 had coordinated the ST visit as the section for care coordination was left blank. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was asked if the patient had an order for Tylenol 500 mg. The Administrator/CEO replied, no order. The Administrator/CEO was also asked if the medications were coordinated with the physician. The Administrator/CEO replied, no coordination with MD. The Administrator/CEO was further asked if the request for ST visit was coordinated with the physician. The Administrator/CEO replied, no, have to request for an MD order for the insurance authorization. The Administrator/CEO was informed and acknowledged the findings. Review of the agency’s P&P titled Care Coordination revised April 2020 showed each patient will be assigned a Case Manager upon admission by the Clinical Director or Clinical Supervisor. It will be the responsibility of the Case Manager to facilitate communication about changes in the patient status among assigned personnel. Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group, will appropriate to the needs and abilities of the patient, and will be relevant to the care provided. The clinicians will be responsible for facilitating communications about changes in the patient’s status among the assigned personnel. Written evidence of care coordination will be recorded during the case conference and repeated skilled nursing visit reports in the patient’s clinical records. #. Review of Patient 4’s clinical record was initiated on 8/14/25. The clinical record showed the SOC was 6/26/25. The patient was certified for home health services during the certification period from 6/26/25 to 8/24/25. a. The POC, for the certification period from 6/26/25 to 8/24/25, showed cited SN visits once every week for 6 weeks starting on week 1 and PT visits once every week for 6 weeks starting on week 2. Review of the SN Visit Notes showed RN 6 completed an OASIS SOC Assessment on 6/26/25, and the next SN visit was on 7/26/25. Review of the PT Initial Evaluation was completed on 7/15/25. Further review of the clinical records failed to show documented evidence the SN and PT conducted a home visit during the weeks of 6/29/25 to 7/5/25 and 7/6/25 to 7/12/25 as per the patient’s POC. On 8/20/25 at 1504 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager stated the agency did not get an authorization for the SN and PT visits until 7/9/25. The authorization information was not coordinated properly and made a mistake on the patient SOC and that is the reason why there were no SN and PT visits during the weeks of 6/29/25 to 7/5/25 and 7/6/25 to 7/12/25. The Intake Case Manager/Office Manager was informed and acknowledged findings. b. The OASIS SOC Assessment dated 6/26/25, showed the patient requested a new glucometer. The POC, for the certification period from 6/26/25 to 8/24/25, showed the patient was instructed to contact their primary care physician to request for a diabetic glucometer. However, further review of the clinical records failed to show documented evidence the patient received a new glucometer. On 8/20/25 at 1423 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager stated she was responsible in following up concerns about the patient’s needs such as the patient’s request for the glucometer. The Intake Case Manager/Office Manager stated clinicians should write a note in the communications section or send a text message so other team members will be notified of the patient or caregiver’s concerns. The Intake Case Manager/Office Manager was informed and acknowledged the finding.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide the written instructions outlining the disciplines (SN and PT) visit schedules for three of eight sampled patients (Patients 1, 3, and 8). This failure had the potential risk for not providing the necessary information to these patients. Findings: #. Review of Patient 8’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 8/1/25. The patient was certified for home health services during the certification period from 8/1/25 to 9/29/25. The POC, for the certification period from 8/1/25 to 9/29/25, cited PT visits 2w5 and 1w1. A joint home visit with PTA 1 was conducted on 8/15/25 at 1105 hours, to Patient 8’s home. Review of the agency’s admission packet was conducted with PTA 1. The agency’s admission packet did not include a written calendar form. PTA 1 stated she would schedule a home visit with the patient prior to leaving during her home visit and confirm again via telephone the day before her next home visit. On 8/15/25 at 1200 hours, an interview and concurrent agency document review was conducted with PTA 1. PTA 1 verified and acknowledged there was no written calendar visit form in the patient’s admission packet the agency provided. On 8/20/25 at 1106 hours, the Intake Case Manager/Office Manager was informed of the finding. #. Review of Patient 2’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/9/25. The patient was certified for home health services during the certification period from 7/9/25 to 9/6/25. The patient was discharged from the agency on 8/14/25. The POC, for the certification period from 7/9/25 to 9/6/25, cited SN visits 1W1, PT visits starting week 1 and OT visits starting week 1. A joint home visit with RN 2 was conducted on 8/14/25 at 1147 hours, to Patient 2’s home. The patient/PCG was asked for the written instructions outlining the SN/PT visit schedule. The patient/PCG replied, no, they call prior to the visit. “. Review of the patient’s home folder provided by the HHA showed the visit calendar. The visit calendar showed an SOC visit was conducted on 7/9/25. However, there was no other visits documented on the visit calendar. On 8/20/25 at 1324 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the finding. Findings: x. Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. The OASIS SOC dated 8/3/25 for the certification period from 8/3/25 to 10/1/25 cited SN visits 2W3. A joint home visit with the DPCS was conducted on 8/14/25 at 0847 hours to Patient 3’s home. The patient stated SN was only seen once and did not provide a visit schedule. Review of the patient’s admission packet provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedule. The DPCS acknowledged and confirmed the finding.”

“Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This Element is not met as evidenced by: Based on observation, interview, and clinical record review, the agency failed to provide the written instructions outlining any treatments to be administered by the HHA personnel and personnel acting on behalf of the HHA for two of eight sampled patients (Patients 3 and 8). This failure had the potential risk of not providing the necessary information to these patients. Findings: #. Review of Patient 8’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 8/1/25. The patient was certified for home health services during the certification period from 8/1/25 to 9/29/25. The POC, for the certification period from 8/1/25 to 9/29/25, cited PT visits 2w5 and 1w1. The POC also included for care to check the patient’s blood pressure, medication management, diabetes teaching, diet, exercise, skin check, deep breathing exercises, and monitoring for oxygen saturation level. A joint home visit with PTA 1 was conducted on 8/15/25 at 1105 hours, to Patient 8’s home. The patient stated the nurse did not provide her with written instructions outlining any treatments to be administered by the HHA personnel and personnel acting on behalf of the HHA. The patient stated the nurse verbally informed her of her plan of care regarding PT visiting her for exercise two times a week. On 8/15/25 at 1200 hours, an interview and concurrent agency document review was conducted with PTA 1. PTA 1 verified and acknowledged there was no written instructions outlining the patient’s plan of care in the folder that the agency provided during the patient’s admission. On 8/20/25 at 1106 hours, the Intake Case Manager/Office Manager was informed of the finding. x. Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. Review of the SOC OASIS dated 8/3/25, for the certification period from 8/3/25 to 10/1/25, cited SN visits 2W3. SN’s narrative showed patient have a surgical incision to left below knee with staples. SN performed wet to dry dressing. Patient and family was educated on signs and symptoms of infection to surgical incision and when to report to MD. A joint home visit with the DPCS was conducted on 8/14/25 at 0847 hours to Patient 3’s home. The patient stated there were no written instruction outlining any treatments to be administered by the HHA personnel and/or patient or caregiver. Review of the patient’s home folder provided by HHA showed no documented evidence of the written instruction outlining any treatments to be administered by the HHA personnel and/or patient or caregiver. The DPCS confirmed and acknowledged the finding.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the clinical managers’ contact information were provided to three of eight sampled patients (Patients 2, 3, and 8). This failure had the potential risk of substandard care provided to these patients as the contact information were not available. Findings: #. Review of Patient 8’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 8/1/25. The patient was certified for home health services during the certification period from 8/1/25 to 9/29/25. The POC, for the certification period from 8/1/25 to 9/29/25, cited PT visits 2w5 (two visits per week for five weeks) and 1w1. A joint home visit with PTA 1 was conducted on 8/15/25 at 1105 hours, to Patient 8’s home. Review of the agency’s admission packet was conducted with PTA 1. The agency’s admission packet showed “Clinical Manager” and the agency’s business contact number. However, review of the patient’s admission packet provided by the agency showed no documented evidence of the specific name and contact information of the HHA’s clinical manager. On 8/15/25 at 1200 hours, an interview and concurrent agency document review was conducted with PTA 1 and Patient 8. PTA 1 and Patient 8 were informed and verified the clinical manager’s name and contact information was not written in the admission packet the HHA provided the patient. Patient 8 stated if she needed to contact someone from the HHA, she would contact the Administrator. On 8/20/25 at 1106 hours, the Intake Case Manager/Office Manager was informed of the finding. x. Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. A joint home visit with the DPCS was conducted on 8/14/25 at 0847 hours to Patient 3’s home. Review of the patient’s home folder was conducted with the DPCS. However, the contact information of the agency’s clinical manager was not available in the patient’s home folder. The DPCS acknowledged and confirmed the finding. #. Review of Patient 2’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/9/25. The patient was certified for home health services during the certification period from 7/9/25 to 9/6/25. The patient was discharged from the agency on 8/14/25. The POC, for the certification period from 7/9/25 to 9/6/25, cited SN visits 1W1, PT visits starting week 1 and OT visits starting week 1. A joint home visit with RN 2 was conducted on 8/14/25 at 1147 hours, to Patient 2’s home. Review of the patient’s home folder provided by the HHA included the admission packet. The admission packet showed “ Clinical Manager” and the agency’s business contact number. However, the admission packet failed to include the specific name and contact information of the agency’s clinical manager. On 8/20/25 at 1324 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the finding.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patient and/or caregiver was provided education as per the plan of care for three of eight sampled patients (Patients 4, 6, and 8). This failure had the potential for not providing the necessary care and services to these patients. Findings: 1. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. The POC, for the certification period from 5/29/25 to 7/27/25, showed to educate the patient on diabetic foot care, glucose monitoring, and medication compliance. However, the SN Visit Notes dated 6/3, 6/6, and 6/9/25, failed to show documented evidence to include specific instructions or teaching about diabetic foot care, glucose monitoring, or medication compliance. On 8/20/25 at 1338 hours, an interview and concurrent closed clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. 2. Review of Patient 4’s clinical record was initiated on 8/14/25. The clinical record showed the SOC was 6/26/25. The patient was certified for home health services during the certification period from 6/26/25 to 8/24/25. The POC, for the certification period from 6/26/25 to 8/24/25, showed to educate the patient on the importance of monitoring blood glucose levels regularly. However, the SN Visit Notes dated 6/3, 6/6, and 6/9/25, and the PT Visit Notes dated 7/15, 7/23, 7/25, 7/29, 8/5, and 8/12/25, failed to show documented evidence to include specific instructions or teaching about the importance of monitoring blood glucose levels regularly. On 8/20/25 at 1500 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. 3. Review of Patient 8’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 8/1/25. The patient was certified for home health services during the certification period from 8/1/25 to 9/29/25. The POC, for the certification period from 8/1/25 to 9/29/25, showed to provide diabetic teaching to the patient. However, the PT Visit Notes dated 8/6, 8/8, and 8/11/25, failed to show documented evidence to include specific instructions for diabetic teaching. On 8/20/25 at 1102 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s skilled professionals prepared accurate clinical notes for three of eight sampled patients (Patients 2, 5, and 6). This failure had the potential risk for substandard healthcare outcomes to these patients. Findings: #. Review of Patient 2’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/9/25. The patient was certified for home health services during the certification periods from 7/9/25 to 9/6/25. The patient was discharged from the agency on 8/14/25. The POC, for the certification period from 7/9/25 to 9/6/25, cited SN visits 1W1, PT visits starting week 1 and OT visits starting week 1. A joint home visit with RN 2 was conducted on 8/14/25 at 1147 hours, to Patient 2’s home. The visit was for the RN 2 to discharge the patient. Review of the OASIS E 1 Discharge Assessment dated 8/11/25 showed the RN 2 had performed the comprehensive assessment. However, review of the OASIS E 1 Discharge Assessment showed the date of assessment was 8/11/25 which was inconsistent with the actual discharge visit date. On 8/20/25 at 1336 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. #. Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The POC for the certification period from 5/29/25 to 7/27/25 showed the nurse had electronically signed and date the verbal SOC on 5/31/25. However, on the same section there was a documentation date of 5/29/25 which was inconsistent with the nurses electronic signature and date. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was asked as which date does the verbal SOC received. The Administrator/CEO replied, “don’t know which date to follow”. The Administrator/CEO was informed and acknowledged the findings. Review of the agency’s P&P titled Submission of Clinical Records dated April 2020 showed the agency shall ensure that all medical records are complete, accurate and timely. Documentation must reflect the care and services provided, comply with federal and state regulations, and support the integrity of patients health information. The procedure includes the documentation standards. The standards included all entries must be accurate, complete and legible. #. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. Review of the SN Visit Notes, showed the following: - On 6/3/25, under the Skilled Treatment Provided/Narrative, LVN 1 documented, “Patient tolerates dying medication. Well patients blood sugar entail due to patient.” - On 6/6/25, under the Skilled Treatment Provided/Narrative, LVN 1 documented, “Patient is continental bowels and bladder and patient has wound on left foot clean it better die, and applied Santel and apply nonstick dressing cover with 4 x4 wrap with Carex…” - On 6/9/25, under the Skilled Treatment Provided/Narrative, LVN 1 documented, “No respiratory distress noted lungs clear bilateral patient oxygen exaggeration in room air at 98%. Patient tolerates died of medication.” On 8/20/25 at 1407 hours, an interview and concurrent closed clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager stated she could not understand the nurse’s documentation and the documentation were inaccurate. The Intake Case Manager/Office Manager was informed and acknowledged the findings.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the HHA’s RN provided supervision to the LVN to ensure quality of care and services were provided for one of eight sampled patients (Patients 6). This failure had the potential for substandard health outcomes to this patient. Findings: Review of the agency’s P&P titled Responsibilities/Supervision of Clinical Services revised April 2018 showed licensed practical/vocational nurses will be supervised by a registered nurse making a visit to the home with or without the LPN/LVN every thirty (30) days unless state regulation requires more frequently. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. Review of the clinical record for Patient 6 showed the LVN did not provide services in accordance with the POC for this patient. Further review of the clinical record failed to show documented evidence the RN had conducted a supervisory visit to identify the LVN did not provide services in accordance with the POC. On 8/20/25 at 1358 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the finding.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on interview and clinical record review, the agency’s Administrator failed to be responsible for the day-to-day operations as the agency’s P&P. *Pain assessment was incomplete as per the agency’s P&P for two of eight sampled patients (Patients 1 and 5). *Wound assessment P&P was not followed for two of eight sampled patients (Patients 3 and 6). *The HHA failed to ensure the written agreement for one of three contractors (Contractor 3) included the required element related to the role of the service agency in the contract. These failures had the potential risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: Review of the agency’s Administrator’s Job Description revised April 2020 showed the Administrator had the responsibility to plan and direct operations to ensure the provision of adequate and appropriate care and services. #. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. The OASIS SOC Assessment dated 5/29/25, showed the patient had a left foot lateral fifth toe, left foot lateral fifth head toe, and left foot diabetic ulcer and a left amputation fourth toe surgical wound. However, the assessment did not include the wound measurements. In addition, review of the SN Visit Notes dated 6/3, 6/6, 6/9, 6/16, and 6/20/25, showed the SN were providing treatment to left foot ulcer. However, there was no documented evidence the SN had weekly wound assessments for the specific individual diabetic ulcers in the left foot fifth toe and left fourth toe amputation nor did it include the length, width, and depth of the wounds as per the agency’s P&P. On 8/20/25 at 1401 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. Findings: 1.Review of the agency’s titled Wound Assessment undated showed all patients receiving home health wound care will undergo a comprehensive wound assessment by a qualified agency Registered Nurse (RN) or Registered Physical Therapist (RPT) upon admission and at each subsequent visit. Develop an individualized care plan based on the assessment findings, physician orders, and evidence-based practice guidelines, ensuring it includes wound care interventions, patient/caregiver education, and monitoring parameters. Measure the wound at least weekly, and document any changes in size (length, width, depth, undermining and tunneling. x. Review of Patient 3’s clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. Review of the SOC OASIS dated 8/3/25 showed patient have a surgical wound on left leg. Documentation showed the size was 10 cm in length and 1 cm in width with staples. The SN performed a wet to dry dressing. *However, there was no documented evidence the weekly wound assessment was conducted on Week 2 (8/10/25 to 8/16/25) and an individualized care plan was developed based on assessment findings, physician orders, and evidence-based practice guidelines, ensuring it includes wound care interventions, patient/caregiver education and monitoring of parameters as per agency’s P&P. On 8/20/25 at 1021 hours, an interview and concurrent record review was conducted with the DPCS. The DPCS stated measurement of the wound was needed. The DPCS confirmed and acknowledged the above finding. 2.Review of the HHA’s services arranged by agreement for SNs was conducted on 8/19/25 at 1108 hours. The Terms of Service and Business Associate Agreement dated 4/30/25 for Contractor 3 does not include the role of the agency and contractor in patient admission process, patient assessment, the development, review, and revision of the POT or POC, the scheduling of visits or hours, discharge planning, the submission to the HHA of documentation of services provided and the responsibility of the contractor to applicable HHA policies. On 8/20/25 at 1537 hours, the Administrator acknowledged the finding. The agency P&P titled Pain Assessment revised April 2020, showed each patient will receive at least an initial pain assessment. When pain is identified, a more comprehensive pain assessment will be completed when warranted by the patient’s condition. Pain assessments will be documented to facilitate regular reassessment and follow up by clinicians. The procedure included when the patient or the clinician identifies pain, the following in-depth pain assessment information should be obtained whenever possible: Pain intensity using a rating scale (on a scale of 0-10: 0 = no pain; 10= unbearable pain). Pain intensity should include current pain, worst pain, and least pain using the scale. B. Pain location. C. Pain quality, patterns of radiation, and character. D. Pain onset, duration, variations, and patterns. E. Alleviating and aggravating factors. F. Present pain management regimen and effectiveness. G. Pain management history to include a medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response. #. Review of Patient 1’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/29/25. The patient was certified for home health services during the certification period from 7/29/25 to 9/26/25. The OASIS E1 Start of Care Assessment dated 7/29/25, showed the RN 1 had performed the initial comprehensive assessment. The patient was assessed to have an pain. However, the pain assessment was incomplete as the section for the pain scale, radiation, description/ location of pain was left blank. On 8/20/25 at 1106 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO reviewed the clinical record and acknowledged the finding. #. Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The OASIS E1 Start of Care Assessment dated 5/29/25, showed the RN 7 had performed the initial comprehensive assessment. The patient was assessed to have an pain described as ache. However, the pain assessment was incomplete as the section for the pain scale, radiation, location of pain was left blank. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the finding.”

“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 document review, the agency failed to employ qualified personnel, including assuring the development of personnel qualifications and policies. -The Administrator failed to have at least one year of supervisory or administrative experience in home health care or related programs and physical requirements as per job descriptions. -The Administrator failed to have an specific orientation and criminal background documentation as per the agency’s P&P. -The Administrator failed to ensure the DPCS had a TB testing prior to start date. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: Findings: Review of the DPCS personnel file was conducted on 8/20/25 at 0827 hours. The DPCS personnel file showed the DPCS was hired on 7/15/24. However, the DPCS’s TB skin test was taken on 8/9/24 and the result was read on 8/12/24. On 8/20/25 at 0900 hours, the Administrator stated the TB testing should be done with the application for employment. The Administrator acknowledged the above findings. Review of the agency’s P&P titled Orientation revised April 2020 showed all staff wil be required to attend an initial orientation program upon employment. Staff orientation promotes safe and effective job performance. The goal of orientation will be to address and instruct new staff regarding the agency’s mission, goals, organization-wide and relevant staffing or program specific policies and procedures, benefits, the performance appraisal process, competency testing, as well as individual responsibilities and relationships to other staff. #. Review of the Intake Case Manager/Office Manager personnel file was conducted on 8/20/25. The Intake Case Manager/Office Manager date of hire was 5/5/25. The employee file failed to show documented evidence of a specific orientation was provided as per the agency’s P&P. In addition, there was no documented evidence a background check was completed prior to the Intake Case Manager/Office Manager upon employment as per the agency’s P&P. On 8/20/25 at 0834 hours, an interview and concurrent document review was conducted with the Administrator/CEO. The Administrator/CEO verified there was no specific orientation for the Intake Case Manager/Office Manager and a background check completed because she was the daughter of the DPCS. The Administrator/CEO was informed and acknowledged the findings. Review of the agency’s P&P titled Selection/Hiring of Personnel revised April 2020, showed the policy defines the qualifications and competencies for staff positions based on its mission, population and care, treatment and service goals. The procedures included the hiring. The hiring process showed the applicable health screening requirements if required by law, regulation or organizational policy will be verified and all new personnel (clinical and non-clinical) must attend an orientation program prior to assuming job responsibilities. Depending on the personnel classification, a specific orientation program will be conducted which addresses job responsibilities and a further review of organization policies. A criminal background check will be obtained for positions required by law, regulation, or organizational policy. (Pursuant to Health and Safety Code Section 1728.1 (a)(2)(A) a criminal record clearance is required for the administrator and administrator designee). Verification of the above will be documented. Review of the Administrator Job Description undated showed the qualifications included a training and experience in health service administration and at least one year of supervisory or administrative experience in home health care or related health programs. The responsibilities includes to ensure compliance with the regulatory requirements, standards of practice, policies and procedures. The physical demands showed the physical requirements must be met by an employee to successfully perform the essential functions in this job descriptions. Review of the Administrator/CEO personnel file was conducted on 8/19/25. The Administrator/CEO date of hire was 6/13/23. Review of the Administrator/CEO resume showed the list of job experiences. The job experienced showed a Home Health Intake/HR from October 2014 to May 2015. However, there was no documented evidenced of the Administrator/CEO had a home health training and at least one year of supervisory experience in home health care or related health programs as per job descriptions. In addition, review of the Administrator/CEO personnel file failed to show documented evidenced of the physical screening was obtained as per job descriptions. Moreover, there was no documented evidenced of an specific orientation for an Administrator was provided as per P&P. Further review of the Administrators personnel file failed to show documented evidenced of the criminal background clearance was included in the file as per P&P. On 8/20/25 at 1010 hours an interview and concurrent document review was conducted with the Administrator/CEO. The Administrator/ CEO was asked if she had an administrative home health experienced and training for at least one year. The Administrator/ CEO replied, had another home health experienced as an intake supervisor from July 2019 to September 2019. It was not included on the resume because the agency was closed. The Administrator/ CEO was also asked if she had an orientation and physical exams prior to assuming the position. The Administrator/ CEO replied no. The Administrator/CEO was further ask if there was a criminal background documented on the file. The The Administrator/ CEO replied, no. The Administrator/ CEO was informed and acknowledged the findings.”

“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 agency failed to maintain accurate and complete clinical records for four of eight sampled patients (Patients 3, 6, 7, and 8). This failure had the potential for substandard quality of care due to incomplete or inaccurate clinical records. Findings: Findings: x.Clinical record review for Patient 3 was initiated on 8/13/25. The clinical record showed the SOC was 8/3/25. The patient was certified for home health services during the certification period from 8/3/25 to 10/1/25. Review of the Patient Consent for Care Admission Agreement dated 8/3/25 showed the patient name, the initial service and frequency of SN visit, patient signature, agency representative signature/title and date. However, the patient ID, the initial service and frequency of PT visit, authorization of payment, release of information and advance directives were blank. On 8/20/25 at 1021 hours, the DPCS was informed of the finding. The DPCS acknowledged and confirmed the finding. x.Closed clinical record review for Patient 7 was initiated on 8/15/25. The clinical record showed the SOC was 5/1/25. The patient was certified for home health services during the certification period from 5/1/25 to 6/29/25. a.Review of the Patient Consent for Care Admission Agreement dated 5/1/25, showed the electronic signature of the patient and agency representative. However, the patient name, address, date of birth, patient ID, the initial service(s) and visit frequencies, release of information, authorization for payment and advance directives were blank. b.Review of the RN OASIS SOC Notes dated 5/1/25, showed an OASIS Goals. However, the OASIS Goals were dated 4/22/25, SOC was dated 5/1/25. In addition, the RN OASIS SOC Notes dated 5/1/25, also showed on the section Reported to MD, indicated there is no need to report to the physician. On 8/20/25 at 1119 hours, the DPCS was informed of the finding. The DPCS stated on the section Reported to MD, the EMR could be populating the comment there is no need to report to physician. The DPCS had acknowledged and verified the findings. #. Review of Patient 8’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 8/1/25. The patient was certified for home health services during the certification period from 8/1/25 to 9/29/25. Review of the Patient Consent for Care Admission Agreement dated 8/3/25, showed the patient identification, authorization for payment, and release of information sections were left blank. On 8/20/25 at 1127 hours, an interview and concurrent clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings. #. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. Review of the Patient Consent for Care Admission Agreement dated 5/29/25, showed the patient’s name, date of birth, patient identification, address, date the consent was filled out, consent for treatment, release of information, authorization for payment, and advanced directives sections were left blank. On 8/20/25 at 1404 hours, an interview and concurrent closed clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the findings.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the completed discharge summaries were sent to the primary care practitioner within five business days of the discharge date for two of eight sampled discharged patients (Patients 2 and 5), and the completed transfer summary for three of eight sampled patients (Patients 2, 5, and 6). These failures had the potential for not providing the necessary care and services to these patients after discharge from the HHA. Findings: #. Review of Patient 2’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/9/25. The patient was certified for home health services during the certification periods from 7/9/25 to 9/6/25. The patient was discharged from the agency on 8/14/25. The POC, for the certification period from 7/9/25 to 9/6/25, cited SN visits 1W1, PT visits starting week 1 and OT visits starting week 1. A joint home visit with RN 2 was conducted on 8/14/25 at 1147 hours, to Patient 2’s home. The visit was for the RN 2 to discharge the patient. However, review of the clinical record failed to show documented evidenced of the physicians order for discharge. In addition, review of the clinical record failed to show documented evidenced of a discharge summary was developed and was sent to the physician as per P&P. On 8/20/25 at 1336 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator /CEO was asked if they needed an order for discharge. The Administrator/CEO reviewed the clinical record and replied, yes but none was documented. The Administrator/CEO was also asked if the discharge summary was developed. The Administrator/CEO replied, yes but none was documented. The Administrator/CEO was further asked if they needed to send the discharge summary to the physician. The Administrator/CEO replied, yes but none was created. The Administrator/CEO was informed and acknowledged the findings. #. Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. Review of the clinical record showed a faxed documentation from a hospital dated 8/18/24, showed the patient was admitted on 6/4/25. Review of the Non- OASIS ICD -10 Transfer Summary without Discharge (In Progress), showed the the patient was transferred to the hospital. The transfer date was 6/14/25. However, the transfer summary was performed more than two days from the hospital admission date as per P&P. Further review of the Non- OASIS ICD -10 Transfer Summary without Discharge (In Progress), showed the reason for the patients transfer. However, on the section for Care Summary, Goals Not Met & Reasons, Continuing Symptoms management needs and resources information provided to the patient for continuing needs were left blank. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was asked if they needed to complete a transfer OASIS. The Administrator/CEO replied, yes, should be a transfer non - discharge within 24 hours from the hospital admission. The Administrator/CEO was also asked if the OASIS transfer non - discharge was complete. The Administrator/CEO replied, no, the one that was created on 6/14 was incomplete and was late. Administrator/CEO informed and acknowledged the findings. Review of the agency’s P&P titled Patient Transfer/Discharge (undated) showed a transfer summary will be completed, a copy maintained in the patient record, and a copy forwarded to the receiving healthcare service provider. The transfer summary will include but not limited to: date of transfer; patient-identifying information; emergency contact; the destination of the patient being transferred; the date and name of the person receiving the transfer summary; the patient’s physician or allowed practitioner’s name and phone number; diagnosis related to the transfer; significant health history; transfer orders and instructions; a brief description of care/services provided and ongoing needs that cannot be met; and status of patient at the time of transfer. A completed transfer summary will be forwarded to receiving healthcare provider within two business days of a planned transfer if the patient’s care will be immediately continued in such healthcare facility. If the patient is still receiving care in the healthcare facility at the time when the HHA becomes aware of the transfer, a completed transfer summary will be forwarded to the receiving healthcare provider within two business days of becoming aware of an unplanned transfer. #. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. Review of the Communication Note dated 7/8/25, showed the Administrator called the patient and the patient stated he no longer needed home health services. However, further review of the clinical records did not show documented evidence the patient was discharged on 7/8/25 nor a discharge summary was completed. On 8/20/25 at 1412 hours, an interview and concurrent closed clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the finding. Review of the agency’s P&P titled Patient Transfer/Discharge (undated) showed a transfer summary will be completed, a copy maintained in the patient record, and a copy forwarded to the receiving healthcare service provider. The transfer summary will include but not limited to: date of transfer; patient-identifying information; emergency contact; the destination of the patient being transferred; the date and name of the person receiving the transfer summary; the patient’s physician or allowed practitioner’s name and phone number; diagnosis related to the transfer; significant health history; transfer orders and instructions; a brief description of care/services provided and ongoing needs that cannot be met; and status of patient at the time of transfer. A completed transfer summary will be forwarded to receiving healthcare provider within two business days of a planned transfer if the patient’s care will be immediately continued in such healthcare facility. If the patient is still receiving care in the healthcare facility at the time when the HHA becomes aware of the transfer, a completed transfer summary will be forwarded to the receiving healthcare provider within two business days of becoming aware of an unplanned transfer. 1. Review of Patient 6’s closed clinical record was initiated on 8/14/25. The closed clinical record showed the SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. The patient was discharged from the agency on 7/8/25. Review of the Communication Note dated 7/8/25, showed the Administrator called the patient and the patient stated he no longer needed home health services. However, further review of the clinical record did not show documented evidence the patient was discharged on 7/8/25, nor a discharge summary was completed. On 8/20/25 at 1412 hours, an interview and concurrent closed clinical record review was conducted with the Intake Case Manager/Office Manager. The Intake Case Manager/Office Manager was informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 8/13/25. The clinical record showed the SOC was 7/9/25. The patient was certified for home health services during the certification periods from 7/9/25 to 9/6/25. The patient was discharged from the agency on 8/14/25. The POC, for the certification period from 7/9/25 to 9/6/25, cited SN visits 1W1, PT visits starting week 1 and OT visits starting week 1. A joint home visit with RN 2 was conducted on 8/14/25 at 1147 hours, to Patient 2’s home. The visit was for the RN 2 to discharge the patient from the agency. However, review of the clinical record failed to show documented evidence of the physician’s order for discharge. In addition, review of the clinical record failed to show documented evidence of a discharge summary was completed and sent to the physician as per the agency’s P&P. On 8/20/25 at 1336 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator /CEO was asked if they needed an order for discharge. The Administrator/CEO reviewed the clinical record and stated yes, but none was documented. The Administrator/CEO was also asked if the discharge summary was completed. The Administrator/CEO replied none was documented. The Administrator/CEO was further asked if they needed to send the discharge summary to the physician. The Administrator/CEO replied yes. The Administrator/CEO was informed and acknowledged the findings. 3. Review of Patient 5’s clinical record was initiated on 8/14/25. The SOC was 5/29/25. The patient was certified for home health services during the certification period from 5/29/25 to 7/27/25. Review of the clinical record showed a faxed documentation from a hospital dated 8/18/24, showed the patient was admitted on 6/4/25. Review of the Non- OASIS ICD -10 Transfer Summary without Discharge (In Progress), showed the patient was transferred to the hospital. The transfer date was 6/14/25. However, the transfer summary was not performed with two days from the hospital admission date as per the agency’s P&P. Further review of the Non- OASIS ICD -10 Transfer Summary without Discharge (In Progress), showed the reason for the patients transfer. However, the sections for Care Summary, Goals Not Met & Reasons, Continuing Symptoms management needs and resources information provided to the patient for continuing needs were left blank. On 8/20/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was asked if they needed to complete a transfer OASIS. The Administrator/CEO replied yes, there should be a transfer non - discharge within 24 hours from the hospital admission. The Administrator/CEO was also asked if the OASIS transfer non - discharge was complete. The Administrator/CEO replied no, the one that was created on 6/14 was incomplete and late. The Administrator/CEO informed and acknowledged the findings.”