Centerwell Asian American Home Health

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Condition of Participation Not Met: 42 CFR §484.60 – Care Planning, Coordination of Services, and Quality of Care (Tag G0570) Based on interview and record review, for one of 14 sampled patients (Patient 1) who had a foley catheter (a thin, flexible tube threaded through the urethra into the bladder to drain urine), the agency failed to ensure an individualized plan of care to address urinary status when clinicians failed to provide required education to both the patient and the family regarding urinary health and catheter care. The cumulative effect of these failures had the potential to result in the delay of identification of urinary complications, delayed necessary interventions, and compromise the patient’s safety while receiving care in the home setting. As a result, the agency failed to meet the Condition of Participation at 42 CFR §484.60. (See also Tags G570, G572, G602, G606, and G610.) During a review of Patient 1’s “Home Health Certification and Plan of Care (HHCPOC)” for certification period 5/2/26-6/30/26, the “HHCPOC” indicated Patient 1 was admitted for home health services with diagnoses that included severe sepsis (a life-threatening medical emergency triggered when the body overreacts to an infection, causing widespread inflammation and acute damage to vital organs), acute cystitis without hematuria (a sudden inflammation of the bladder, most commonly caused by a bacterial infection, which occurs without visible blood in the urine), and obstructive reflux uropathy (a structural or functional blockage of urine flow anywhere in the urinary tract, which causes urine to back up and exert pressure on the kidneys). The “HHCPOC” also indicated that Patient 1 had previously been admitted to the acute hospital from 4/25/26 to 4/27/26 for severe sepsis, urinary retention, and urinary tract infection (UTI, is a bacterial infection anywhere in your urinary system, including the bladder, urethra, ureters, and kidneys). The “HHCPOC” included interventions to educate on urinary tract infection management, covering definition, risk factors, infection control, and symptom monitoring. During a concurrent interview and clinical record review on 6/1/26 at 1:50 p.m. with Administrator (ADM), ADM stated Patient 1’s care centered on the genitourinary system (the bodily network combining the urinary and reproductive organs) and weekly foley catheter flushing. ADM stated the visit notes lacked documentation of urinary assessments, symptoms, and risk evaluations for complications. ADM also stated there was no evidence that Patient 1 or family received education on identifying urinary tract infection symptoms, such as pain, fever, urine changes, or altered mental status. Additionally, records did not show instruction to family/caregivers about catheter care, including monitoring for infection signs, hygiene, securing the catheter, or when to report concerns. ADM emphasized the importance of documenting urine characteristics to prevent infection and recurrence of urosepsis (a life-threatening medical emergency that occurs when a bacterial urinary tract infection (UTI) spreads to the bloodstream). During a review of Patient 1’s “Visit Note Report (VNR)” dated 5/7/26, 5/14/26, and 5/19/26, the “VNRs” indicated assessments for indwelling/suprapubic catheter. Incontinence, and weekly foley flushes, with findings within normal limits. The nurse continued weekly foley flushes since no caregiver could learn this procedure, but there was no documentation about urinary drainage characteristics. The “VNR” date 5/29/26, edited on 6/2/26, indicated catheter site assessment, foley catheter irrigation, and education on UTI prevention and symptoms (cloudy urine, foul odor, fever, bladder pain). During a review of the agency’s policy and procedure (P&P) titled “Indwelling Urinary Catheter Care and Management” last reviewed 12/15/25, the P&P indicated to instruct the caregiver to wash the urinary meatus and perineal area with soap and water routinely as part of hygiene and the anal area after each bowel movement. The P&P also indicated to monitor intake and output, noting any changes in urine output, including volume and color. Documentation associated with indwelling urinary catheter care and management include assessment findings, patient and family/caregiver education, and maintenance care.”

“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 interviews and record reviews, the agency’s licensed nursing staff failed to fully assess patient status and provide necessary patient education for three of 14 sampled patients (Patients 7, 8, and 13) when Patient 7 did not receive education and training during a change in condition consistent with congestive heart failure; Patient 8 had dizziness and an elevated irregular heart rate during the start-of-care (SOC) assessment without documented follow-up assessment and monitoring, or education regarding the abnormal findings; and Patient 13 had low blood pressure on two occasions without licensed staff providing disease‑specific education and training needed for appropriate management. These failures placed Patients 7, 8, and 13 at risk for unrecognized condition changes and delayed interventions that could lead to unnecessary complications or hospitalizations. During a review of Patient 7’s “Home Health Certification and Plan of Care (HHCPOC)” for certification period 5/11/26 to 7/9/2026, the “HHCPOC” indicated Patient 7 was admitted for home health services with diagnoses including of sepsis due to enterococcus (a type of bacteria that normally lives in the gut), acute on chronic congestive heart failure ( CHF, a long‑term heart problem that suddenly gets worse, making it harder for the heart to fill with blood and causing fluid buildup in the body) and non-ST elevated myocardial infarction (NSTEMI, a mild to moderate heart attack caused by a partial blockage in one of the arteries). The “HHCPOC” also indicated interventions to educate on heart failure management, symptom monitoring and risk factors. During a review of Patient 7’s “Visit Note Report” (VNR) dated 5/11/26, “VNR” indicated Patient 7 had 2+ (a clinical rating for moderate fluid retention) edema (swelling) of both lower extremities. The “VNR” did not show the nurse provided education to Patient 7 and/or caregiver regarding edema management, or when to report changes in condition. During a review of Patient 7’s “VNR” dated 5/12/26, the “VNR” indicated Patient 7 had complaints of dizziness, shortness of breath, and had 1+ edema (a mild form of swelling). However, the “VNR” did not show the occupational therapist (OT) provided education to Patient 7 and/or caregiver regarding edema management and recognition of worsening CHF symptoms. The “VNR” also did not indicate the physician or agency was notified of Patient 7’s reported symptoms. During a review of Patient 7’s VNR dated 5/19/26, the VNR indicated Patient 7 had another episode of dizziness and 1+ edema on both lower extremities without documentation that the OT provided education to Patient 7 and/or the caregiver regarding edema management. During a concurrent interview and clinical record review on 6/3/26 at 1:00 p.m. with Clinical Manager (CM) 1, CM 1 stated there was no documented CHF education provided by the nurse to Patient 7 and/or the caregiver during the skilled nursing visits. CM 1 stated the skilled nurse mostly provided education regarding urinary tract infection (UTI) and hypertension (high blood pressure), but not CHF. CM 1 stated there was also no documentation showing the OT communicated Patient 7’s symptoms to the agency. CM 1 further stated lower extremity swelling, dizziness, and shortness of breath could have been indications of worsening CHF and that Patient 7 and/or the caregiver should have received education regarding recognition and reporting of symptoms to help prevent avoidable complications and hospitalizations. During a review of the agency’s undated record, titled, “Self-management plan zone tool…Heart Failure” (HF Tool), “HF Tool” indicated “Yellow Zone: Caution…Increased shortness of breath with activity or while lying flat…increased or new swelling in feet or legs…new or increased dizziness…Yellow Zone: Actions…Your symptoms may indicate that you need a visit from of your home health clinicians to evaluate symptoms and include a follow-up call with your physician…” During a review of Patient 8’s “HHCPOC” for the certification period 3/25/26 to 5/23/26, the HHCPOC indicated Patient 8 was admitted for home health services with diagnoses including complication of kidney transplant, chronic kidney disease (a long‑term condition where the kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood), and anemia in chronic kidney disease (occurring when damaged kidneys fail to produce enough erythropoietin, a hormone that stimulates red blood cell production). The “HHCPOC” indicated to assess or evaluate co‑morbidities, identify changes, and intervene to minimize complications. The “HHCPOC” also indicated the skilled nurse may perform two PRN (as needed) visits for medical urgency management. The “HHCPOC” further indicated for the licensed professional to report vital signs falling outside the following established parameters including pulse of more than 100 bpm. During a review of Patient 8’s “VNR” dated 3/25/26, the VNR indicated that during the SOC visit, Patient 8 had an elevated irregular heart rate (occurs when the electrical signals that coordinate your heartbeats malfunction) of 102 beats per minute (bpm) (normal heart rate is 60–100 bpm) and reported light dizziness. The “VNR” did not show documentation that the clinician assessed the cause of abnormal findings or provided patient education regarding elevated heart rate, irregular rhythm, or dizziness. The “VNR” further did not show documentation that the clinician requested, arranged, or scheduled a follow-up skilled nursing visit during the first week of care to reassess and monitor Patient 8’s abnormal findings. During a review of Patient 8’s “VNR” dated 3/31/26, the “VNR” indicated Patient 8 had another episode of irregular heart rhythm. The “VNR” did not show a documentation of reassessment, monitoring, or follow-up regarding Patient 8’s previous abnormal findings. During a concurrent interview and clinical record review on 6/3/26 at 1:23 p.m. with CM 1, CM 1 stated the clinician should have assessed the possible cause of Patient 8’s elevated heart rate and dizziness since Patient 8 had no known history atrial fibrillation (irregular heartbeat) and clinician should have provided Patient 8 education regarding the abnormal heart rate and rhythm. CM 1 stated that although the VNR dated 3/25/26 indicated the physician was notified, there was no documentation of the physician’s response, instructions, or records showing the clinician followed up on the notification found in Patient 8’s clinical record. CM 1 stated a follow-up visit should have been scheduled during the first week of care to reassess Patient’s 8’s abnormal findings and ensure Patient 8’s safety. During a review of Patient 13’s “HHPOC” for certification period 3/10/26 to 5/8/26, the “HHCPOC” indicated Patient 13 was admitted for home health services with diagnoses including Parkinson’s disease (a progressive neurological disorder of the central nervous system that primarily affects movement) and history of urinary tract infection (UTI). The “HHCPOC” indicated to provide education to minimize and manage identified risks of hospitalization and/or emergency department visit. The “HHCPOC” further indicated for licensed professionals to report vital signs falling outside the following the established parameters that included systolic blood pressure (SBP, the top or first number in a blood pressure reading that measures the maximum pressure the blood exerts against the artery walls each time the heart beats and pushes blood forward) of less than 90 mmHg (millimeters of mercury, measurement used for bp or blood pressure) and diastolic blood pressure (DBP, the bottom number in a bp reading that measures the pressure in the arteries when the heart muscle is resting between beats and refilling with blood) of less than 50 mmHg. During a review of Patient 13’s “VNR” dated 3/13/26, the “VNR” indicated Patient 13 had a blood pressure reading of 80/45 mmHg. The “VNR” indicated the clinician provided an educational tool to Patient 13 regarding activity and exercise; however, the “VNR” did not show Patient 13 was provided education specific to hypotension (low blood pressure). During a review of Patient 13’s “VNR” dated 3/19/26, the “VNR” indicated Patient 13 had another episode of hypotension with bp reading of 78/48 mmHg while sitting. The “VNR” further indicated Patient 13 appeared lethargic (drowsy, less responsive than usual), weak, and demonstrated a shuffling gait (small dragging steps) when walking. The “VNR” showed Patient 13 had a video appointment with the physician and documented, “daughter with patient and will update the dr. (doctor) about the vital signs.” The clinician documented the SN visit ended at 11:30 a.m.; however, the “VNR” did not show the clinician provided a specific education regarding hypotension including signs, symptoms, or when to report changes in condition while waiting for the appointment. The “VNR” also showed Patient 13 went to the emergency department and was later on admitted to acute care hospital. During a concurrent interview and clinical record review on 6/4/26 at 10:01 a.m. with the ADM, ADM stated on 3/13/26 visit, the clinician did not provide the correct educational tool for hypotension during the visit. ADM stated the clinicians should have provided education and instructions to Patient 13 and/or caregiver regarding actions to take while awaiting physician appointment scheduled between 11:30 a.m. and 12:00 p.m. while waiting for the physician’s appointment. ADM stated Patient 13 was subsequently hospitalized on 3/19/26 following the clinician’s visit. ADM stated severe low blood pressure may have been associated with sepsis (the body’s extreme, life-threatening response to an infection with symptoms including low bp in a more severe stage of sepsis). ADM stated education regarding hypotension was important to assist Patient 13 and/or caregiver in recognizing significant changes in condition, understanding when to seek medical attention, and obtaining timely treatment. During a review of the agency’s policy and procedures (P&P), titled, “Care Planning”, revised in March 2026, the P&P indicated “Professional disciplines (Registered Nurse, Physical Therapist, Occupational Therapist, Speech Therapist) must:…perform ongoing interdisciplinary assessments and required reassessments…provide ordered services, educate the patient/caregiver…document findings and patient progress/response to treatment…””

“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 interview and record review, the Home Health Agency (HHA) failed to notify the physician to obtain appropriate pain management medication orders when one of 14 sampled patients (Patient 12) reported experiencing pain rated from 4 to 6 out of 10 (10 being the highest, 1 the lowest) during 14 out of 15 home visits. The Visit Note Report (VNR)s indicated that medications relieved Patient 12’s pain; however, no medication was listed on the medication profile to manage Patient 12’s pain. This failure resulted in Patient 12 experiencing ongoing pain without adequate pain management and potential for delays in reaching established health goals. During a review of Patient 12’s document “Home Health Certification and Plan of Care” (HHCPOC), the HHCPOC indicated Patient 12’s Start of Care (SOC) was 4/27/26, with the current certification period 4/27/2026 to 6/25/2026 and multiple medical diagnoses including a sacral (tailbone area) pressure ulcer, chronic pain, and osteoarthritis. The HHCPOC also indicated a goal for Patient 12’s pain level to decrease to below 3 (Patient 12’s acceptable pain level was 3) by 6/20/26. A review of Patient 12’s VNRs dated 4/27/27, 4/29/26, 5/1/26, 5/4/25, 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/15/26, 5/18/26, 5/22/26, 5/27/26, 5/29/26, 6/1/26, and 6/3/26 indicated Patient 12 consistently experienced general body aches, lower back pain, and tailbone wound pain, with pain levels ranging from 4 to 6 out of 10 except on 5/18/26 that Patient 12 stated no pain. The VNPs indicated that the pain affected Patient 12’s sleep and daily activities. The VNPs also indicated that medications relieve the pain. During a phone interview on 6/4/26 at 9:55 a.m. with Registered Nurse (RN) 1, RN1 stated they were not sure what medication that Patient 12 was taking for pain. RN 1 stated Patient 12 might have been using over-the -counter medication and was unsure whether Patient 12 had any opioid medication for pain control. RN 1 also stated the home health staff should have contacted the physician to discuss care plan for pain management for Patient 12. During a concurrent interview and record review on 6/4/26 at 12:28 p.m. with Case Manager (CM) 1, Patient 12’s HHCPOC dated 4/27/26 was reviewed. The HHCPOC indicated that there was no medication for pain. CM 1 stated the staff should have contacted the physician to request stronger pain medication due to Patient 12 consistently verbalized pain during home visits. A review of Policy and Procedure (P&P) titled Care Planning (CP), revised in 3/2026, the P&P indicated the HHA will coordinate with all physicians/allowed practitioners involved in the Plan of Care (POC) throughout the episode of care. The P&P also indicated the POC serves to ensure effective utilization and management of services and resources to address a patient’s condition, skilled needs and unique situation in accordance with physician/allowed practitioner orders.”

“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 appropriate coordination of care and follow‑up for one of 14 sampled patients (Patient 8) when the licensed clinician did not obtain and/or document physician instructions, recommendations, or orders after notifying the physician of Patient 8’s elevated irregular heart rate and complaint of dizziness identified during the start‑of‑care (SOC) assessment. This failure had the potential to delay needed treatment, monitoring, and interventions, placing Patient 8 at risk of complications and possible re‑hospitalization. During a review of Patient 8’s “Home Health Certification and Plan of Care (HHCPOC)” for the certification period 3/25/26 to 5/23/26, the HHCPOC indicated Patient 8 was admitted for home health services with diagnoses including complication of kidney transplant, chronic kidney disease (a long‑term condition where the kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood), and anemia in chronic kidney disease (occurring when damaged kidneys fail to produce enough erythropoietin, a hormone that stimulates red blood cell production**)**. The HHCPOC indicated to assess or evaluate co‑morbidities, identify changes, and intervene to minimize complications. During a review of Patient 8’s “Visit Note Report (VNR)” dated 3/25/26, the VNR indicated that during the SOC visit, Patient 8 had an elevated irregular heart rate (occurs when the electrical signals that coordinate your heartbeats malfunction) of 102 beats per minute (bpm) (normal heart rate is 60–100 bpm) and reported light dizziness. The “VNR” indicated the physician was contacted; however, the VNR did not show documentation of physician instructions, recommendations, orders, or any direction received from the physician regarding Patient 8’s elevated heart rate and dizziness. During a review of Patient 8’s “VNR” dated 3/31/26, the “VNR” indicated Patient 8 had another episode of irregular heart rhythm. The “VNR” did not show a documentation regarding a follow up on the Patient 8’s abnormal findings. During a concurrent interview and clinical record review on 6/3/26 at 1:23 p.m. with Clinical Manager (CM) 1, CM 1 stated the clinician should have assessed the possible cause of Patient 8’s elevated heart rate and dizziness since Patient 8 had no known history atrial fibrillation (irregular heart beat) and clinician should have provided Patient 8 education regarding the abnormal heart rate and rhythm. CM 1 stated that although the VNR dated 3/25/26 indicated the physician was notified, there was no documentation of the physician’s response, instructions, or records showing the clinician followed up on the notification found in Patient 8’s clinical record. CM 1 stated the clinician should have documented the details of the communication with the physician so the agency would have been aware of the communication, including any instructions or orders received, to ensure continuity of care and appropriate clinical follow‑up could be implemented. During a review of the agency’s policy and procedures (P&P), titled “Physician/Allowed Practitioner Orders” revised in January 2026, the P&P indicated: “To ensure that all services provided by the agency are based on valid, timely, and properly documented orders from a physician or allowed practitioner…The physician/allowed practitioner will be contacted for any change in condition that may require changes in medications, treatment, or home health services…Physician/Approved Provider Protocols…Protocols for the care of patients with specific diagnoses may be used when specified by the physician/allowed practitioner…If patient assessment identifies any required additions or exceptions to the protocol, the home health agency must contact the physician/allowed practitioner for these specific orders related to the patient’s plan of care and document this communication within the patient’s medical record.””

“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 coordination of care for one of 14 sampled patients (Patient 7) when the occupational therapist (OT) did not communicate and coordinate with the physician and the agency when Patient 7 had changes in condition, including edema, dizziness, and shortness of breath during 5/12/26 and 5/19/26 visits. This failure placed Patient 7 at risk for delayed assessment and intervention, worsening of the condition, and hospitalization. During a review of Patient 7’s “Home Health Certification and Plan of Care (HHCPOC)” for the certification period 5/11/26 to 7/9/26, the “HHCPOC” indicated Patient 7 was admitted for home health services with diagnoses including sepsis due to enterococcus (a type of bacteria that normally lives in the gut), acute on chronic congestive heart failure (CHF, a long‑term heart problem that suddenly gets worse, making it harder for the heart to fill with blood and causing fluid buildup), and non‑ST elevated myocardial infarction (NSTEMI, a mild to moderate heart attack caused by a partial blockage in one of the arteries). The “HHCPOC” also indicated interventions to educate on heart failure management, symptom monitoring, and risk factors. During a review of Patient 7’s “Visit Note Report (VNR)” dated 5/12/26, the “VNR” indicated Patient 7 had complaints of dizziness, shortness of breath, and 1+ edema (a mild form of swelling). The “VNR” did not show that the clinician notified the physician or the agency regarding the reported change in condition. During a review of Patient 7’s “VNR” dated 5/19/26, the VNR indicated Patient 7 had another episode of “fainting/dizziness” and 1+ edema in both lower extremities. During a concurrent interview and clinical record review on 6/3/26 at 1:00 p.m. with Clinical Manager (CM) 1, CM 1 stated there was no documented care coordination or communication with the agency or the physician regarding Patient 7’s change in condition, including edema in both lower legs, dizziness, and shortness of breath. CM 1 stated Patient 7’s symptoms were consistent with worsening CHF. CM 1 stated changes in condition should have been communicated to the agency and physician to identify early interventions, prevent worsening of the condition, and avoid hospitalization. During a review of the agency’s policy and procedure (P&P), titled, “Coordination of Care - Case Conferences” revised in March 2026, the P&P indicated, “All healthcare providers - whether internal or external to the Company - associated with direct patient care must maintain close communication to ensure each patient receives coordinated care that meets their needs and supports the objectives identified in the Plan of Care...Case communication...Communication between team members may be face-to-face, via phone, other telecommunication technology and/or secure email including but not limited to...Contact between Clinical Associates involved in patient’s care...Contact with patient’s physician/allowed practitioner...Changes in the patient’s condition resulting in a need to revise/update the plan of care...Safety concerns impacting patient well-being and the plan of care...All communication will be documented in the patient’s medical record...””

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure one of 14 sampled patient (Patient 11) received education regarding newly prescribed medications when the physician prescribed iron and stool softener on 5/7/26 during a medical appointment. This failure placed Patient 11 at risk for improper medication use, adverse drug reactions, and unrecognized side effects. During a review of Patient 11’s “Home Health Certification and Plan of Care” (HHCPOC), the HHCPOC indicated Patient 11’s Start of Care was 3/10/26, with current certification period 5/9/2016 to 7/7/2026 and multiple medical diagnoses including heart failure and chronic respiratory failure. During a review of Patient 11’s “Visit Note Report” (VNR) dated 5/9/2026, the VNR indicated that the physician prescribed Docusate Sodium (Colace, a stool softener) 100mg and Ferrous Sulfate 325 mg on 5/7/2026 during a medical appointment. However, there was no documentation in the clinical record indicating that staff provided education to Patient 11 regarding newly prescribed medications. During an interview on 6/3/2026 at 2:10 p.m., the Clinical Manager (CM) 1 stated that staff should educate patients regarding newly prescribed medication, including its purpose, dosage, schedule, expected benefits, and potential side effects. During a review of the Policy and Procedure (P&P) titled “Care Planning”, revised in 3/2026, the P&P indicated Professional disciplines (registered nurses, physical therapists, occupational therapists, speech-language pathologists) must educate the patient/caregiver. During a review of the P&P titled “Patient Assessments”, revised in 1/2026, the P&P indicated the clinical manager, or appropriate professional designee will review all patient medications for potential adverse reactions, allergies, contraindications and significant side effects.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure that nursing staff followed accepted standards of practice when: 1. Registered Nurse (RN) 1 checked Patient 3’s temperature by placing the thermometer against Patient 4’s clothing, rather than in direct contact with Patient 3’s skin (axilla/armpit) and documented inaccurately in the clinical record. This failure had the potential to result in inaccurate temperature reading and prevents the clinician from properly assessing the patient’s clinical status. 2. RN 2 failed to accurately identify and document the correct anatomical location of Patient 4’s pressure ulcer (bed sore, localized skin and tissue injuries caused by prolonged pressure, friction, or shear). The pressure ulcer was recorded on the right proximal (top portion) thigh rather than the right hip. This failure had the potential to result in inaccurate clinical documentation and the potential for inappropriate treatment and monitoring. During a review of Patient 3’s “Home Health Certification and Plan of Care (HHCPOC)” for certification period 5/16/26 to 7/14/26, the “HHCPOC” indicated Patient 3 was admitted for home health services with diagnoses that included cellulitis (common, potentially serious bacterial infection of the skin and underlying tissues) of the right lower limb and fracture of the left femur (hip). During a home visit observation on 6/2/26 at 1:40 p.m. with RN 1, RN 1 checked Patient 3’s temperature by placing a thermometer in Patient 3’s axilla, directly over the Patient 3’s clothing rather than directly against the patient’s skin. Patient 3 wore a thick flannel shirt. RN 1 waited a few minutes before checking the thermometer, which read 96.5°F. RN 1 then asked Patient 3 to roll up his sleeves and placed the thermometer in his axilla. During a telephone interview on 6/3/26 at 10:54 a.m. with RN 1, RN 1 stated he did not follow proper technique in obtaining Patient 3’s temperature. During an interview on 6/4/26 at 10:26 a.m. with Clinical Manager (CM) 1, CM 1 stated that to properly measure a patient’s temperature, the clinician should place the thermometer directly against the patient’s skin. CM 1 stated that there are no formal policy and procedure for this method because it is considered a fundamental skill taught in school. Patient 3’s Visit Note Report from 6/2/26 indicated a temporal temperature (a body temperature reading taken using a temporal artery thermometer, a forehead scanning infrared thermometer) of 96.5°F. 2. During a review of Patient 4’s “HHCPOC” for certification period 5/22/26 to 7/20/26, the “HHCPOC” indicated Patient 4 had three existing pressure ulcers: a. Sacral area that became worse from stage 3 (a deep, open sore that has broken through the skin into the fat layer but hasn’t reached the muscle or bone) to stage 4 (full-thickness muscle loss exposing the muscle or bone). b. Stage 3 on the right hip. c. Stage 3 on the right mid back area. During a review of the Patient 4’s “VNR” dated 5/26/26, the “VNR” indicated a new wound developed on the “right hip”. The wound assessment indicated a stage 2 pressure ulcer on the right proximal thigh that measured 2 x 1.6 x 0.2 cm, rather than the right hip as initially indicated. During a review of the Patient 4’s “VNRs” dated 5/28/26 and 5/30/26, the “VNRs” indicated four pressure ulcers: stage 2 (partial thickness skin loss with a shallow open ulcer or blister) on the right proximal thigh treated with Medi honey, stage 2 on the lateral right proximal thigh treated with honey Thera, stage 4 on the coccyx (tailbone), and stage 3 on the right mid back. During a concurrent interview and record review on 6/3/26 at 3:10 p.m. with CM 1, CM 1 stated the clinician updated the wound assessment from 6/2/26 to indicate the newly developed pressure ulcer was on the right hip, not the thigh, as documented in the “VNRs”. CM 1 stated the importance of accurately documenting wound locations to prevent confusion for clinicians covering home visits.”