Integrity Home Health Care Services, Inc.

“Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This Condition is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the condition of participation (CoP- a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Reporting Outcome and Assessment Information Set (OASIS, a standardized data collection tool used by HHA to measure patient outcomes, quality improvement and reimbursement rate) Information were met as follows: The HHA failed to ensure the OASIS were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completing the comprehensive assessment for 33 of 58 OASIS patients’ data collection from 10/1/2025 to 7/28/2026. This failure resulted in a 56.9% error summary report of the OASIS data leading to delayed comprehensive assessment of the patient identified needs, including prompt or timely interventions, treatment, and continuity of care for patients certified to receive home health benefits (Refer to G372). The HHA failed to ensure the patient’s data information entered in the OASIS accurately reflect the patient’s status at the time of discharge from the HHA, for one of two sampled patients (Patient 6). This failure resulted in misinformation of Patient 6’s clinical outcomes achieved from the home health services that could lead to unsafe discharge of the patient (Refer to G374).”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the condition of participation (CoP- a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Comprehensive Patient Assessments were met as follows: The HHA failed to ensure, for one of seven sampled patients (Patient 3), Patient 3’s comprehensive assessment accurately reflected the patient’s current condition and care needs for managing her insulin medication (medication that manages and lowers blood sugar levels) administration and proper monitoring of her blood sugar levels on a daily basis. This failure resulted in an inaccurate care planning and delivery of inappropriate care that addresses Patient 3’s needs and health risk and may delay achieving the patient’s treatment goal for discharge (Refer to G528).”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the condition of participation (CoP- a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Care Planning, Coordination of Services, and Quality of Care were met as follows: The HHA failed to ensure, for three of seven sampled patients (Patient 1, Patient 4, and Patient 5), the patients received home health services as written on the patients’ plan of care when: 1. Patient 1 and Patient 5’s medical social worker (MSW, a trained professional who helps people prevent and cope with problems in their everyday lives, connecting them with essential community resources, and providing counseling or crisis intervention) evaluation was not conducted within five days after the physician’s order in accordance with the HHA’s policy and procedure. 2. There was no documented evidence that Patient 4’s Physical Therapy (PT, a medical treatment that restores movement and improves physical function through prescribed exercise and patient education) missed visit on 7/16/2026 was rescheduled. These failures had the potential to result in missed identification of the patients’ mental/psychosocial needs and essential aid or community resources for the patient. In addition, these failures had the potential to result on delayed treatment that could lead to patient harm, deterioration or exacerbation of patient’s medical condition, unplanned hospitalization and/or death (Refer to G572). The HHA failed to ensure, for two of seven sampled patients (Patient 1 and Patient 2), the following: 1. The HHA conducted a complete and accurate medication reconciliation (a process of comparing a patient’s current medication against the medication order to prevent error like omission, duplication, or harmful drug interaction) review to maintain an updated current medication profile for Patient 1 when, Patient 1’s medication profile did not include: a. Pantoprazole (antacid) 20 milligram (mg) tablet, one tablet by mouth daily, as prescribed by the physician. b. Losartan (use for treatment of high blood pressure) 50 mg tablet, one tablet by mouth daily, as prescribed by the physician. c. Linaclotide (use for constipation) 145 microgram (mcg) capsule, take one capsule daily, as prescribed by the physician. 2. Assess Patient 2’s blood sugar during the home visit as indicated in Patient 2’s plan of care. These failures had the potential for Patient 1 to have an ineffective drug therapy and at risk for adverse drug events due to medication omission and incorrect dosage. In addition, Patient 2 was placed at increased risk for complications related to hypoglycemia (low blood sugar) / hyperglycemia (high blood sugar), delays in medical treatment related to uncontrolled blood glucose (Refer to G580). The HHA failed to revised the plan of care to reflect the patient’s updated comprehensive assessment, for one of seven sampled patients (Patient 1) when, Patient 1 had a resumption of care on 6/18/2026, after being discharged from the hospital due to urinary tract infection (UTI, bladder infection) and was on intravenous (IV, given through the veins) antibiotic. This failure resulted in Patient 1 to not have an individualized goal-oriented plan of care to provide a means for interdisciplinary communication for the patient’s care and addressed the needs and risks of the patient (Refer to G592). The HHA failed to integrate the medication order received from an outpatient palliative care (specialized medical care that relieves pain, symptoms, and stress caused by a serious illness) clinic into the plan of care, for one of seven sampled patients (Patient 3), when Patient 3’s palliative care physician changed the pantoprazole (a medication that reduces the amount of acid the stomach makes) dose from 40 mg tablet, take 1 tablet by mouth twice daily to pantoprazole 40 mg tablet, take 1 tablet by mouth every other day. This failure had the potential for Patient 3 to have an ineffective drug therapy and at risk for adverse drug events due to medication omission and incorrect dosage (Refer to G604). The HHA failed to ensure, for one of seven sampled patients (Patient 2), Patient 2’s care giver (CG 2) received an ongoing education and training from HHA regarding the patient’s medication management and blood sugar (BS, measurement of level of sugar in the blood) monitoring, as indicated in Patient 2’s plan of care. This failure had the potential to result in an unsafe care that could increase the risk of medication mismanagement, complications related to hypoglycemia (low blood sugar) / hyperglycemia (high blood sugar), delays in medical treatment and hospitalization of the patient (Refer to G610).”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the condition of participation (CoP- a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Quality Assessment and Performance Improvement were met as follows: The HHA failed to demonstrate a process and provide documented evidence that the Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) program was measuring, analyzing, and tracking quality indicators (are specific, quantifiable metrics that can be tracked over time) that enabled the facility to assess processes of care, home health services (a specialized care that delivers skilled nursing and other therapeutic services to a patient’s personal residence), and operations for five of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5). This failure resulted in the facility’s QAPI program to not have a system that effectively assess and identify needs for improvement in providing quality and safe care, monitor the quality of care and services provided, and/or implement effective performance improvement activities that could result for the home health patients to suffer from inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to the deterioration, emergency hospitalization and death of the patients. (Refer to G642). The HHA’s QAPI program failed to ensure that its performance improvement activities focused on high-risk (areas of care where problems are more likely to cause serious harm to a patient’s health or safety), high-volume (areas of care or services that are frequently provided by the HHA to patients), or problem-prone (areas of care that are more likely to result in poor patient outcomes due to the type of care, patient condition, or past performance issues) areas of care. This failure resulted in the HHA’s inability to establish a system that identifies areas of concern in patient care and correct performance issues which could directly or potentially lead to medical errors, adverse events, progressive deterioration, emergent hospitalization, or death. (Refer to G646). The HHA’s QAPI program failed to conduct its performance improvement projects that reflects the scope, performance, and/or problem area of the HHA’s patient outcomes that needed improvement for quality and safe patient care. This failure resulted in the HHA’s inability to have a system to identify areas of concern in patient care and implement effective performance improvements; which could result in the HHA’s patients suffering from inadequate care, a lack of identification of medical errors and adverse events, and an increased risk for deterioration, emergency hospitalization, or death (Refer to G658). The HHA’s Governing Body (GB, designated individuals that hold legal authority and internal oversight of quality assessment, performance improvement, and patient safety standards) failed to ensure the QAPI program focuses on quality indicators (are specific, quantifiable metrics that can be tracked over time) related to improved outcomes, and takes actions that address the HHA’s performance in providing quality and safe patient care. This failure resulted in the facility’s QAPI program to not have a system that effectively assesses and identifies needs for improvement in providing quality and safe care, monitors the quality of care and services provided, and/or implements effective performance improvement activities; which could result in the home health patients suffering from inadequate quality of care, unsafe patient care, and an increased risk of medical errors and adverse events that can lead to the deterioration, emergency hospitalization, and death of the patients. (Refer to G660).”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the condition of participation (CoP- a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Skilled Professional Services were met as follows: The HHA failed to conduct an assessment in accordance with the patients’ needs, plan of care, and the facility’s policy and procedure for one of seven sampled patients (Patient 1) when, the Director of Patient Care Services (DPCS) did not assess Patient 1’s skin integrity after Patient 1 informed the DPCS that she had skin irritation and redness on the left (L) underarm, L upper back of the leg, and lower abdomen (under the abdominal folds) during the home visit. This failure had the potential to result in Patient 1’s skin irritation and redness to worsen and/or developed skin injuries, delays in wound treatment that could lead to Patient 1 suffering from increased pain, wound infection, reduced mobility, and hospitalization (Refer to G706).”

“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 Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Outcome and Assessment Information Set (OASIS, a standardized data collection tool used by HHA to measure patient outcomes, quality improvement and reimbursement rate) were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completing the comprehensive assessment for 33 of 58 OASIS patients’ data collection from 10/1/2025 to 7/28/2026. This failure resulted in a 56.9% error summary report of the OASIS data leading to delayed comprehensive assessment of the patient identified needs, including prompt or timely interventions, treatment, and continuity of care for patients certified to receive home health benefits. During an interview on 7/27/2026 at 2:35 pm, with the Director of Patient Care Services (DPCS), the DPCS stated the Registered Nurse (RN) completes the patient’s OASIS assessment, then he (DPCS) electronically submits the completed OASIS to the CMS system. The DPCS stated he submits the OASIS as it gets completed and he does not have a system in place to monitor when submissions are due for each of the patient’s OASIS. During a concurrent interview and record review, on 7/28/2026 at 9:45 am, with the DPCS, the DPCS stated the “HHA Error Summary by Agency report,” dated 10/1/2025 to 7/28/2025, indicated a 56.9% error rate. The DPCS stated 33 of 58 submitted OASIS assessments to the CMS system were submitted past the 30 days after the completion of the OASIS. The DPCS stated that several OASIS data were submitted late because the HHA had no tracking system to monitor when OASIS assessments are due for submission. The DPCS stated that it is important to submit OASIS assessments on time to meet federal regulations and for proper billing requirements. A review of the HHA’s policy and procedure (P&P) titled, “OASIS Data Transmission,” dated 11/ 2023, the P&P indicated, “the organization will adhere to all OASIS data transmission requirements…The organization will encode and transmit completed OASIS data for each applicable patient within thirty (30) days of the M0090 date, date assessment completed…The organization may take up to thirty (30) calendar days after the date of completion of the comprehensive assessment to enter the OASIS data into their computers using…software that conforms to all CMS data transmission specifications available on the OASIS website…All OASIS data items must be complete…in order to accurately compute the information necessary for billing Medicare patients…A tracking mechanism will be utilized by the organization to ensure accuracy and timeliness of OASIS data and transmission.””

“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 Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the patient’s data information entered in the Outcome and Assessment Information Set (OASIS, a standardized data collection tool used by HHA to measure patient outcomes, quality improvement and reimbursement rate) accurately reflect the patient’s status at the time of discharge from the HHA, for one of two sampled patients (Patient 6). This failure resulted in misinformation of Patient 6’s clinical outcomes achieved from the home health services that could lead to unsafe discharge of the patient. Findings: During a concurrent interview and record review, on 7/27/2026 at 10:11 AM, with Registered Nurse 1 (RN 1), RN 1 stated she was the nurse assigned to do the home visit of Patient 6 and she was the one who discharge Patient 6 on 5/8/2026. RN 1 stated Patient 6’s “Order/Telephone Order Discharge from Agency,” dated 5/8/2026, indicated, “Reasons: Called patient to schedule RN assessment visit, patient replied, she is no longer interested in the service and requested for discharge. Tried to schedule one last visit for safe discharge, but patient refused, no specific reason was given a this time. Risks and benefits were explained, patient verbalized understanding. MD notified, orders given below...Order/Telephone Orders: Discharge patient from (name of HHA).” During a concurrent interview and record review on 7/27/2026 at 10:11 AM, with RN 1, Patient 6’s “Skilled Nurse (SN) Visit Note” was reviewed. RN 1 stated Patient 6’s SN visit was last conducted on 4/29/2026. RN 1 stated there was no SN visit note on 5/8/2026 because Patient 6 refused the visit. During a concurrent interview and record review, on 7/27/2026 at 10:11 AM, with RN 1, RN 1 stated she was the one who completed Patient 6’s OASIS assessment for discharge on 5/8/2026 (Patient 6 refused the visit). RN 1 stated Patient 6’s “Patient Assessment: OASIS E2 (Full),” dated 5/8/2026, the OASIS indicated, “Reason for Assessment: Discharge from agency...Start of Care Date: 01/13/2026...Assessment Completed: 05/08/2026 Time In: 1330 pm (1:30 PM) Time Out: 1430 pm (2:30 PM)...Discharge from agency...SUMMARY OF CARE...Patient seen, purpose of visit discussed-care; Patient consented to care. Patient medication review done, no side effect, medication error, reaction, complications, interactions and complications observed by skilled nurse, verbalized by patient at this time. Skilled nurse assessed and observed patients all body system, vital sign monitored and recorded. Patient/ caregiver able to verbalize understanding on disease process, complication and signs and symptoms to report to MD...Progress towards goals at this time. MD notified...Indicate reason for discharge: Patient-centered goals achieved...” During an interview on 7/27/2026 at 10:11 AM, with RN 1, RN 1 stated the information she entered on Patient 6’s OASIS for discharge assessment was not accurate. The discharge assessment should have been 4/29/2026 (the last SN visit to Patient 6) and not 5/8/2026. RN 1 stated the reason for discharge should have been “requested to stop services” and not “goals achieved.” RN 1 stated it was important to enter accurate information in the patient’s OASIS to reflect the patient actual condition and the care provided to the patient for a safe discharge. During a review of the HHA’s policy and procedure (P&P) titled, “OASIS Data Transmission,” dated 11/2023, the P&P indicated, “...OASIS data is collected and completed by the qualified clinician as part of the comprehensive assessment at the required time points (i.e. start of care, resumption of care, follow-up, transfer to inpatient facility with or without discharge, discharge to community, and death at home.)...The encoded OASIS data must accurately reflect the patient’s status at the time of assessment...The organization must electronically transmit accurate, complete and encoded OASIS data for each patient...””

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure, for three of seven sampled patients (Patient 1, Patient 4, and Patient 5), received home health services as written on the patients’ plan of care when: 1. Patient 1 and Patient 5’s medical social worker (MSW, a trained professional who helps people prevent and cope with problems in their everyday lives, connecting them with essential community resources, and providing counseling or crisis intervention) evaluation was not conducted within five days after the physician’s order in accordance with the HHA’s policy and procedure. 2. There was no documented evidence that Patient 4’s Physical Therapy (PT, a medical treatment that restores movement and improves physical function through prescribed exercise and patient education) missed visit on 7/16/2026 was rescheduled. These failures had the potential to result in missed identification of the patients’ mental/psychosocial needs and essential aid or community resources for the patient. In addition, these failures had the potential to result on delayed treatment that could lead to patient harm, deterioration or exacerbation of patient’s medical condition, unplanned hospitalization and/or death. Findings: 1a. During a review of Patient 1’s “Home Health Certification and Plan of Care,” for the certification period of 5/25/2026 to 7/23/2026, the plan of care indicated Patient 1’s start of care (SOC) was 5/25/2026, with diagnosis that included hypertensive heart disease (a condition with damage to the heart due to unmanaged high blood pressure), atherosclerosis heart disease (a condition where fatty plaque builds up in the heart arteries), gastroesophageal reflux disease (GERD, a condition where stomach acid flows back up into the esophagus [food pipe]), and constipation...MSW 1-2 visits until end of cert (certification) period.” During a review of Patient 1’s, “Patient Assessment OASIS E2 (Full),” dated 5/25/2026, the assessment indicated, “Section E - Behavior...MSW referral made...Patient requires assistance with follow-up regarding application process. Skilled Nursing Facility (SNF) has initiated application. Medical Social Worker (MSW) to follow up and assist patient with coordination of resources, application status, and ongoing psychosocial needs.” During a review of Patient 1’s, “Communication note,” dated 6/4/2026 (10 days after the MSW referral order), the note indicated, “MSW called agency (HHA) report that patient declined MSW services at this time. MD made aware and notified.” During an interview on 7/24/2026 at 1:20 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated social worker referral should be initiated within five days after it was ordered. The DPCS stated there were no other communication notes in Patient 1’s record from MSW 1 except the 6/4/2026 note. The DPCS stated MSW 1 was late in contacting Patient 1 for MSW referral because it was more than five days after the referral order. During an interview on 7/24/2026 at 3 p.m., with MSW 1, MSW 1 stated when he receives a referral form HHA, he would make an arrangement to see the patient within 24 hours. MSW 1 stated he contacted Patient 1 on 5/27/2026 and the patient told him to call again on 6/4/2026. MSW 1 stated when he called Patient 1 on 6/4/2026, the patient refuse MSW services. MSW 1 stated he must have forgotten to document the 5/27/2026 attempt to see Patient 1. MSW 1 stated if there was no documentation, there was no evidence it occurred and the HHA would not be aware if Patient 1’s MSW referral was conducted timely. During an interview on 7/24/2026 at 3 p.m., with MSW 1, MSW 1 stated all attempts to see the patient and the patient’s refusal or request when to be seen should be documented to ensure that the patient was receiving services timely as ordered by the physician and that the HHA team would be aware of what the patient’s psychosocial condition and what resources the patient needs. 1b. During a review of Patient 5’s “Home Health Certification and Plan of Care,” for the certification period of 5/12/2026 to 7/10/2026, the plan of care indicated Patient 5’s SOC was 5/12/2026, with diagnoses that included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control), hypertensive heart disease (a condition with damage to the heart due to unmanaged high blood pressure), atherosclerosis heart disease (a condition where fatty plaque builds up in the heart arteries), end stage renal disease (irreversible kidney failure), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The plan of care further indicated, “Orders for Discipline and Treatments…MSW 1-2 visits until end of cert period.” During a review of Patient 5’s “Communication Note,” dated 5/12/2026, authored by the Director of Patient Care Services (DPCS), the note indicated, “Skilled nurse (SN) report patient is requesting to see MSW to access the public benefit programs…patient may also get benefit for grief with MSW visit.” During an interview on 7/27/2026 at 11:12 AM, with MSW 1, MSW 1stated he called Patient 5 on 5/22/2026 (10 days after the MSW referral was ordered). MSW 1 stated Patient 5 inquired about more information on support groups and resources near her home location and refused social work services at that time. MSW 1 stated that he made a mistake of not documenting Patient 5’s refusal for MSW services. MSW 1 stated it was important to document all the patient’s interaction so that the HHA would be updated on the patient’s needs and care. During a concurrent interview and review, on 7/27/2026 at 8:50 AM, with the Director of Patient Care Services (DPCS), the DPCS stated Patient 5’s calendar visit indicated MSW 1 was scheduled to visit the patient on 5/22/2026 (10 days after MSW referral was ordered). The DPCS stated there was no MSW progress note to indicate the visit made by MSW 1 to Patient 5 on 5/22/2026. During a review of the HHA’s policy and procedure (P&P) titled, “Availability of Services,” dated 11/2023, the P&P indicated, “additional discipline initial assessments will be provided within five (5) business days of the start of care or date of the physician’s (or other authorized licensed independent practitioner’s) order.” 2. During a review of Patient 4’s, “Home Health Certification and Plan of Care,” for certification period 7/4/2026 to 9/1/2026, the plan of care (POC) indicated Patient 4’s start of care (SOC) was 1/5/2026, with diagnosis that included bilateral primary osteoarthritis of hip (a disease where both hip joints degenerate) and muscle weakness generalized. The POC further indicated, “Physical Therapy (PT, a medical treatment that restores movement and improves physical function through prescribed exercise and patient education) to Eval (evaluate) and follow up treatment. Start on week of 7/5/2026.” During a review of Patient 4’s “PT Initial Evaluation,” dated 7/7/2026, the evaluation indicated Patient 4’s PT visits would be twice a week, for four weeks. During a review of Patient 4’s “Missed Visit” note, dated 7/16/2026, the note indicated, “Missed Visit Report. Reason for missed visit No Answer Door/Phone...” During a review of Patient 4’s “Communication Notes,” dated 7/16/2026, indicated, “Subject: Missed Visit…Comments: Missed Visit Report Reason for missed visit No Answer Door/Phone… ” During an interview on 7/24/2026 at 3:45 PM, with the Director of Patient Care Services (DPCS), the DPCS stated that if the patient had a missed PT visit, the PT would notify the HHA, and the HHA would notify the physician. The DPCS stated the PT should make an attempt to re-schedule the missed visit with the patient and if re-scheduling the missed visit was unsuccessful, the PT should notify the HHA and the HHA would notify the physician. The DPCS stated that all missed visits and the attempt to reschedule the missed visit should be documented in the patient’s record. During a concurrent interview and record review, on 7/24/2026 at 3:45 PM, with the DPCS, the DPCS stated Patient 4’s record had no documented evidence that Patient 4’s PT missed visit on 7/16/2026 was attempted to reschedule, to meet Patient 4’s PT treatment visits in accordance with the patient’s POC. The DPCS stated it is important for the patient to complete their PT therapy, as indicated in their POC, to achieve their treatment goals. During an interview, on 7/27/2026 at 10:24 AM, with Physical Therapist 1 (PT 1), PT 1 stated that if there was a missed visit, a missed visit note would be documented , and the HHA would be notified. PT 1 stated the patient would be contacted directly to re-schedule the patient’s missed visit within the week the visit was missed. If the attempt to reschedule the patient’s missed visit was unsuccessful, the HHA would be notified. PT 1 stated all missed visits and the attempt to reschedule the missed visit should be documented in the patient’s record. During a review of the HHA’s policy and procedure (P&P) titled, “Missed Visits,” dated 11/2023, the P&P indicated, “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. If a visit is missed and not rescheduled the clinician will...Notify the physician and clinical supervisor of the missed visit and reason for missed visit...The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits. If a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and physician.””

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on interview and record review, the facility failed to demonstrate a process and provide documented evidence the facility’s Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) program was measuring, analyzing, and tracking quality indicators (are specific, quantifiable metrics that can be tracked over time) that enabled the facility to assess processes of care, home health services (a specialized care that delivers skilled nursing and other therapeutic services to a patient’s personal residence), and operations for five of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5). This failure resulted in the facility’s QAPI program not having a system that could effectively assess and identify needs for improvement in providing quality and safe care, monitor the quality of care and services provided, and/or implement effective performance improvement activities which could result for the home health patients to suffer from inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to the deterioration, emergency hospitalization and death of the patients. On 7/28/2026 at 3:48 PM., the Department called an Immediate Jeopardy (IJ, a situation in which the agency’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Director of Patient Care Services Administrator (DPCS) and the Registered Nurse (RN) Consultant for failing to demonstrate a process and provide documented evidence that the facility’s QAPI program was measuring, analyzing, and tracking quality indicators that enabled the facility to assess processes of care, hospice services, and operations for five of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5). Findings: During a concurrent interview and record review, on 7/28/2026 at 9:55 AM, with the DPCS, the DPCS stated the facility’s QAPI project for 2026 were: to work on marketing to increase patient admission, to increase hiring of home health staff, and to work on timely submission of the patients’ Outcome and Assessment Information Set (OASIS, a standardized data collection tool used by Medicare certified agencies to measure patient health status, daily functioning, and clinical outcomes). The DPCS stated the QAPI projects were selected based on the facility’s admission data (total number of patient admission), number of hired employees by the facility, and the OASIS submission error report. During a concurrent interview and record review, on 7/28/2026 at 9:55 AM, with the DPCS, the DPCS stated the “2026 QAPI Audits,” indicated the following data were obtained: - for 1st Quarter (January to March 2026), “current census 8 (patients), admission unduplicated 4 (patients), admission duplicated 0, discharge 0, incident report (fall) 0, grievance/complaint 0, infection (patients) 0, infection (staff) 0, wound 0, medication error 0.” - for 2nd Quarter (April to June 2026), “current census 12, admission unduplicated 9, admission duplicated 0, discharge 5, incident report (fall) 1, grievance/complaint 1, infection (patients) 1, infection (staff) 0, wound 0, medication error 0.” The DPCS stated the QAPI audit data information gathered from the facility’s electronic medical record (EMR). The DPCS stated there were no other sources that were used to obtain the facility’s QAPI audit data. The DPCS could not verbalize how the collected data from the EMR was used to plan for the QAPI 2026 project and what possible issues could be found in the data that needed to be addressed or any concerns that could affect the patient’s quality of care and safety. During an interview on 7/28/2026 at 9:55 AM, with the DPCS, the DPCS could not verbalize the process for how the collected data audits were measured, track and analyze. The DPCS stated there were no other source of quality indicators used for the QAPI projects except the data gathered from the facility’s EMR. The DPCS stated the home health staff, nor the patients were involved in giving an input on the quality improvement needed by the facility or what QAPI project should the facility work on to address the patient’s needs, quality and safe care. The DPCS stated that QAPI was a quality assurance that addressed patient care issues to be able for the facility to provide care efficiently on an optimal level. During a review of the facility’s “Quality Assessment and Performance Improvement (QAPI) Plan,” undated, the QAPI plan indicated, “the purpose of the home health QAPI Plan is to provide a strategy for the systematic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization provides appropriate, high-value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations... OBJECTIVES...To measure, analyze and track quality indicators, including adverse events, to enable the assessment of processes of care, home health services and operations. To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement. To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that it is sustained…” During a concurrent interview and record review, on 7/28/2026 at 9:55 AM, with the DPCS, the DPCS stated the facility’s QAPI project for 2026 were: To work on marketing to increase patient admissionTo increase hiring of home health staffTo work on timely submission of the patients’ Outcome and Assessment Information Set (OASIS, a standardized data collection tool used by Medicare certified agencies to measure patient health status, daily functioning, and clinical outcomes). The DPCS stated the QAPI projects were selected based on the facility’s admission data (total number of patient admission), number of hired employees by the facility, and the OASIS submission error report. During a concurrent interview and record review, on 7/28/2026 at 9:55 AM, with the DPCS, reviewed the agency’s 2026 QAPI Audit. The DPCS stated the 2026 QAPI Audits indicated the following data were obtained: For 1st Quarter (January to March 2026), “current census 8 (patients), admission unduplicated 4 (patients), admission duplicated 0, discharge 0, incident report (fall) 0, grievance/complaint 0, infection (patients) 0, infection (staff) 0, wound 0, medication error 0.”For 2nd Quarter (April to June 2026), “current census 12, admission unduplicated 9, admission duplicated 0, discharge 5, incident report (fall) 1, grievance/complaint 1, infection (patients) 1, infection (staff) 0, wound 0, medication error 0.”The DPCS stated the QAPI audit data information was gathered from the facility’s electronic medical record (EMR). The DPCS stated there were no other sources that were used to obtain the facility’s QAPI audit data. The DPCS could not verbalize how the collected data from the EMR was used to plan for the QAPI 2026 project and what possible issues could be found in the data that needed to be addressed or any concerns that could affect the patient’s quality of care and safety. During an interview on 7/28/2026 at 9:55 AM, with the DPCS, the DPCS could not verbalize the process for how the collected data audits were measured, tracked and analyzed. The DPCS stated there were no other source of quality indicators used for the QAPI projects except the data gathered from the facility’s EMR. The DPCS stated the home health staff, nor the patients were involved in giving any input on the agency’s quality improvement needs or what QAPI projects the agency should work on to address patient’s needs, quality and safe care. The DPCS stated that QAPI is for quality assurance that addresses patient care issues in order for the facility to provide care efficiently on an optimal level. During a review of the facility’s “Quality Assessment and Performance Improvement (QAPI) Plan,” undated, the QAPI plan indicated, “the purpose of the home health QAPI Plan is to provide a strategy for the systematic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization provides appropriate, high-value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations... OBJECTIVES...To measure, analyze and track quality indicators, including adverse events, to enable the assessment of processes of care, home health services and operations. To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement. To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that it is sustained…””

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency’s (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) Quality Assessment and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) program failed to ensure that its performance improvement activities focused on high-risk (areas of care where problems are more likely to cause serious harm to a patient’s health or safety), high-volume (areas of care or services that are frequently provided by the HHA to patients), or problem-prone (areas of care that are more likely to result in poor patient outcomes due to the type of care, patient condition, or past performance issues) areas of care. This failure resulted in the HHA’s inability to establish a system that identifies areas of concern in patient care and correct performance issues which could directly or potentially lead to medical errors, adverse events, progressive deterioration, emergent hospitalization, or death. During a concurrent interview on 7/28/2026 at 10 AM, with the Director of Patient Care Services (DPCS), the DPCS stated that the facility’s QAPI projects for 2026 were: marketing to increase patient admission, hiring more home health staff, and working on timely submission of the patients’ Outcome and Assessment Information Set (OASIS, a standardized data collection tool used by Medicare certified agencies to measure patient health status, daily functioning, and clinical outcomes). During a concurrent interview on 7/28/2026 at 10 AM, the DPCS stated the HHA’s QAPI project for 2026 were selected because there was a lack of patient admission, the facility needed to hire more staff, and patient OASIS were submitted late. The DPCS could not verbalize how the projects correlated to patient safety and quality of care. The DPCS stated that QAPI is for quality assurance that addresses patient care issues in order for the facility to provide care efficiently on an optimal level. During a review of the HHA’s policy and procedure (P&P) titled, “Improving Organizational Performance,” dated 11/2023, the P&P indicated that the purpose is to “…establish patient outcomes as the primary focus of the organization’s performance improvement activities.” The procedure indicated to, “focus on high risk, high volume, and problem-prone areas. Consider incidence, prevalence, and severity of problems in those areas and lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients.””

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency’s (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) Quality Assessment and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) program failed to conduct performance improvement projects that reflects the scope, performance, and/or problem area of the HHA’s patient outcomes that needed improvement for quality and safe patient care. This failure resulted in the HHA’s inability to have a system to identify areas of concern in patient care and implement effective performance improvements; which could result in the HHA’s patients suffering from inadequate care, a lack of identification of medical errors and adverse events, and an increased risk for deterioration, emergency hospitalization, or death. During a concurrent interview and record review, on 7/28/2026 at 9:51 AM with the Director of Patient Care Services (DPCS), the DPCS stated the facility’s QAPI project for 2026 were: - To work on marketing to increase patient admission - To increase hiring of home health staff - To work on timely submission of the patients’ Outcome and Assessment Information Set (OASIS, a standardized data collection tool used by Medicare certified agencies to measure patient health status, daily functioning, and clinical outcomes). The DPCS stated the QAPI projects were selected based on the facility’s admission data (total number of patient admissions), number of hired employees by the facility, and the OASIS submission error report. During a concurrent interview and record review, on 7/28/2026 at 9:55 AM, with the DPCS, the DPCS stated the HHA’s “2026 QAPI Audits,” undated, indicated the following data were obtained: - For 1st Quarter (January to March 2026), “current census 8 (patients), admission unduplicated 4 (patients), admission duplicated 0, discharge 0, incident report (fall) 0, grievance/complaint 0, infection (patients) 0, infection (staff) 0, wound 0, medication error 0.” - For 2nd Quarter (April to June 2026), “current census 12, admission unduplicated 9, admission duplicated 0, discharge 5, incident report (fall) 1, grievance/complaint 1, infection (patients) 1, infection (staff) 0, wound 0, medication error 0.” The DPCS stated the QAPI audit data information was gathered from the facility’s electronic medical record (EMR). The DPCS stated there were no other sources that were used to obtain the facility’s QAPI audit data. The DPCS could not verbalize how the collected data from the EMR was used to plan for the QAPI 2026 project and what possible issues could be found in the data that needed to be addressed or any concerns that could affect the patient’s quality of care and safety. During a review of HHA’s QAPI program for 2026, the program did not have documented evidence that the QAPI project for 2026 was monitored for the performance and/or result of the projects from 1/2026 to 6/2026. During a review of the HHA’s policy and procedure (P&P) titled, “Improving Organizational Performance,” dated 11/2023, the P&P indicated, “Purpose: To establish patient outcomes as the primary focus of the organization’s performance improvement activities; To improve organizational performance by focusing on high risk, high volume, and problem prone areas… Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications…” During a review of the HHA’s, “Quality and Assessment Performance Improvement (QAPI) Plan,” undated, the plan indicated, “Objectives: To show measurable improvement indicators that demonstrate an improvement in patient outcomes … To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement; To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that it is sustained… The QAPI committee is responsible for evaluating and prioritizing QAPI activities based on the aggregation of analysis of data collected.” During a review of the HHA’s P&P titled, “Clinical Record Review,” dated 11/2023, the P&P indicated, “The record review shall reflect the scope of the QAPI program to show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care…Results will be utilized for improvements in patient care and incorporated into performance improvement plans and activities.””

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency’s (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) Governing Body (GB, designated individuals that hold legal authority and internal oversight of quality assessment, performance improvement, and patient safety standards) failed to ensure the Quality Assessment and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) program focuses on quality indicators (are specific, quantifiable metrics that can be tracked over time) related to improved outcomes, and takes actions that address the HHA’s performance in providing quality and safe patient care. This failure resulted in the facility’s QAPI program to not have a system that effectively assesses and identifies needs for improvement in providing quality and safe care, monitors the quality of care and services provided, and/or implements effective performance improvement activities; which could result in the home health patients suffering from inadequate quality of care, unsafe patient care, and an increased risk of medical errors and adverse events that can lead to the deterioration, emergency hospitalization, and death of the patients. During an interview on 7/28/2026 at 9:51 AM, with the Director of Patient Care Services (DPCS), the DPCS stated the HHA’s GB and QAPI committee have two members only: the DPCS and Registered Nurse 1 (RN 1, who was also the Administrator of the HHA). The DPCS stated that they do not have any licensed nurse employees and that they (DPCS and RN 1) were the ones doing the home visits of all the HHA patients. During an interview on 7/28/2026 at 9:55 AM, with the DPCS, the DPCS stated that the GB and QAPI meetings were combined and conducted quarterly. The DPCS stated that in the GB and QAPI meeting, the result of the QAPI audits was presented. The DPCS stated there were no discussion during the meetings regarding the details of the audit results or any issues or concerns identified to address and improve the HHA’s performance in providing quality and safe patient care. During an interview on 7/28/2026 at 9:55 AM, with the DPCS, the DPCS stated the lack of staffing resulted in him (DPCS) and RN 1 to focus on doing patient care and have affected their time to have an oversight of the QAPI program to ensure quality and safe care were provided to the patients. During a review of the facility’s policy and procedure (P&P) titled, “Governing Body,” dated 11/2023, the P&P indicated, “The governing body will assume full legal authority, decision-making and accountability for…its quality assessment and performance improvement (QAPI) program…Relevant findings of performance improvement activities are consistently provided to the Governing Body to allow for oversight of the quality assessment and performance improvement (QAPI) program. The governing body will ensure the following: 1. That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; 2. That the organizational-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; 3. That clear expectations for safety are established, implemented, and maintained…””

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Outcome and Assessment Information Set (OASIS, a standardized data collection tool used by HHA to measure patient outcomes, quality improvement and reimbursement rate) data were authenticated with a signature of the author who completed the OASIS, for two of seven sampled patients (Patient 1 and Patient 6). This failure resulted in an incomplete and invalid OASIS that could lead to unsafe patient care, medication and treatment care error, and delayed care due to lack of information and verification of who completed the patients’ OASIS. Findings: 1. During a review of Patient 1’s “Home Health Certification and Plan of Care,” for the certification period of 5/25/2026 to 7/23/2026, the plan of care indicated Patient 1’s start of care (SOC) was 5/25/2026, with diagnosis that included hypertensive heart disease (a condition with damage to the heart due to unmanaged high blood pressure), atherosclerosis heart disease (a condition where fatty plaque builds up in the heart arteries), gastroesophageal reflux disease (GERD, a condition where stomach acid flows back up into the esophagus [food pipe]), and constipation. During a review of Patient 1’s “Patient Assessment Oasis 2,” dated 6/18/2026, the OASIS indicated Patient 1 had a resumption of care (ROC) after the patient was discharge from the hospital on 6/17/2026. The OASIS further indicated, “I have personally reviewed all of the above information and hereby, certify, affirm, and declare that the above information is complete, true, accurate, and correct...signature above/printed name below (there was no name and signature of the author who completed the OASIS).” During an interview on 7/23/2026 at 8:42 AM, with the Director of Patient Care Services (DPCS), the DPCS stated he was the assigned visiting nurse for Patient 1. The DPCS stated he was the one who went to evaluate Patient 1 for SOC and ROC. 2. During a concurrent interview and record review, on 7/27/2026 at 10:11 AM, with Registered Nurse 1 (RN 1), RN 1 stated she was the one who completed Patient 6’s OASIS assessment for discharge on 5/8/2026. RN 1 stated Patient 6’s “Patient Assessment: OASIS E2 (Full),” dated 5/8/2026, indicated, “Reason for Assessment: Discharge from agency...Start of Care Date: 01/13/2026...Assessment Completed: 05/08/2026 Time In: 1330 pm (1:30 PM) Time Out: 1430 pm (2:30 PM)...Discharge from agency...SUMMARY OF CARE...Patient seen, purpose of visit discussed-care; Patient consented to care. Patient medication review done, no side effect, medication error, reaction, complications, interactions and complications observed by skilled nurse, verbalized by patient at this time. Skilled nurse assessed and observed patients all body system, vital sign monitored and recorded. Patient/ caregiver able to verbalize understanding on disease process, complication and signs and symptoms to report to MD...Progress towards goals at this time. MD notified...Indicate reason for discharge: Patient-centered goals achieved...” RN 1 stated Patient 6’s OASIS was not signed to indicate the information were complete, true, accurate, and correct. During an interview on 7/27/2026 at 10:11 AM, with RN 1, RN 1 stated she must have forgotten to sign Patient 6’s OASIS. RN 1 stated by signing the OASIS means, she was authenticating that she completed the OASIS and the information she wrote in the OASIS were correct. During a review of the HHA’s policy and procedure (P&P) titled, “OASIS Data Transmission,” dated 11/2023, the P&P indicated, “OASIS data is collected and completed by the qualified clinician as part of the comprehensive assessment at the required time points (i.e. start of care, resumption of care, follow-up, transfer to inpatient facility with or without discharge, discharge to community, and death at home).” During a review of the HHA’s policy and procedure (P&P) titled, “Contents of Clinical Record,” dated 11/2023, the P&P indicated, “A clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel...Signed and dated progress notes for each discipline rendering service. Clinical notes shall be signed and incorporated into the patient’s health record at least every seven working days...” During a review of the HHA’s policy and procedure (P&P) titled, “Clinical Record Review,” the P&P indicated, “The clinical record review will consist of a process based on the following guidelines...All records will be reviewed using a clinical record review tool to...Determine that data is reliable, valid, and accurate...””

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency, (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure, for one of seven sampled patients (Patient 3), Patient 3’s comprehensive assessment accurately reflected the patient’s current condition and care needs for managing her insulin medication (medication that manages and lowers blood sugar levels) administration and proper monitoring of her blood sugar levels on a daily basis. This failure resulted in an inaccurate care planning and delivery of inappropriate care that addresses Patient 3’s needs and health risk and may delay achieving the patient’s treatment goal for discharge. During a review of Patient 3’s “Home Health Certification and Plan of Care,” for the certification period of 7/1/2026 to 8/29/2026, the plan of care indicated Patient 3’s start of care (SOC) was 11/3/2025, with a principal diagnosis of Type 2 Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control) with “Skilled nurse (SN) visits frequency: 2wk1 (two times a week for 1 week); 1wk8 (once a week for 8 weeks) for skilled observation and evaluation of patient current medical conditions...” During a concurrent observation and interview on 7/22/2026 at 2 PM, with the Registered Nurse (RN 1), Patient 3, and Patient 3’s caregiver (CG 3), RN 1 was observed conducting Patient 3’s home visit. CG 3 stated that Patient 3 checks her own blood sugar with her blood sugar monitoring device and administers her own insulin medication. CG 3 stated that he helps monitor Patient 3’s blood sugar levels by keeping a log of the patient’s every blood sugar check. Patient 3 stated CG 3 would prepare her insulin dose, and she self-administers her own insulin injections. During an interview with RN 1 on 7/24/2026 at 11:25 AM, RN 1 stated that she was planning to discharge Patient 3 from home health services since Patient 3 and CG 3 were compliant with insulin administration and monitoring blood sugar levels. During a review of Patient 3’s “Home Health Certification and Plan of Care,” dated 6/28/2026 for recertification period 7/1/2026 to 8/29/2026, the “60 Days Summary of Care (a summary of what happened with the patient in the past 60 days or prior certification period),” indicated, “Patient is diabetic with insulin dependent and unable to manage her insulin administration via subcutaneously and proper blood sugar monitoring via fingerstick on a daily basis at this time...Patient caregiver has lack of knowledge on...insulin administration via subcutaneously, proper blood sugar monitoring via fingerstick...” During a review of Patient 3’s “Nursing Progress Note,” for 5/5/2026, 5/8/2026, 5/12/2026, 5/19/2026, 5/26/2026, 6/2/2026, 6/9/2026, 6/16/2026, and 6/23/2026, the notes indicated, “patient/caregiver able to manage insulin administration via subcutaneously as well as blood sugar monitoring via fingerstick on a daily basis.” During a concurrent interview and record review, on 7/24/2026 at 11:25 AM with the Director of Patient Care Services (DPCS), the DPCS stated Patient 3’s “Order/Telephone Order Recertification Assessment,” dated 6/28/2026 indicated, “Patient (Patient 3) is diabetic with insulin dependent and unable to manage her insulin administration via subcutaneously and proper blood sugar monitoring via fingerstick on a daily basis at this time.” The DPCS stated the order recertification assessment indicated another assessment that “Patient/patient caregiver able to monitor blood sugar via fingerstick as well as insulin administration via fingerstick on a daily basis and MD notified.” During a concurrent interview and record review, on 7/24/2026 at 11:25 AM with the DPCS, the DCPS stated the order recertification summary was Patient 3’s “60 Days Summary of Care” sent to the HHA physician. The DPCS stated the recertification assessment has inaccurate information with two conflicting assessments (Patient 3 was unable to manage her insulin administration / BS testing and that Patient 3 and CG 3 was able to manage insulin administration / BS testing). The DPCS stated that having an accurate assessment of the patient’s condition and needs were important in order for the patient to receive the appropriate care he/she needed. During a review of the HHA’s policy and procedure (P&P) titled, “OASIS Data Transmission,” dated 11/2023, the P&P indicated, “the encoded OASIS data must accurately reflect the patient’s status at the time of assessment.” During a review of the HHA’s P&P titled, “Initial and Comprehensive Assessment,” dated 11/2023, indicated, “the comprehensive assessment shall be completed in a timely manner, consistent with the patient’s immediate needs...all baseline data to be used in measuring the patient’s progress towards goals and other relevant information will be documented in the patient’s clinical record, including...the patient’s and family/caregiver’s educational needs, abilities, motivation, and readiness to learn..” During a review of the HHA’s P&P titled, “60-Day Summary Report,” dated 11/2023, indicated, “Information in the 60-day summary report to the physician may include...reason for admission or last recertification, as applicable...a summary of the patient’s response to treatment...a summary of changes to the plan of care...why recertification for ongoing care is necessary...””

“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 observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure, for two of seven sampled patients (Patient 1 and Patient 2), the following: 1. The HHA conducted a complete and accurate medication reconciliation (a process of comparing a patient’s current medication against the medication order to prevent error like omission, duplication, or harmful drug interaction) review to maintain an updated current medication profile for Patient 1 when, Patient 1’s medication profile did not include: a. Pantoprazole (antacid) 20 milligram (mg) tablet, one tablet by mouth daily, as prescribed by the physician. b. Losartan (use for treatment of high blood pressure) 50 mg tablet, one tablet by mouth daily, as prescribed by the physician. c. Linaclotide (use for constipation) 145 microgram (mcg) capsule, take one capsule daily, as prescribed by the physician. 2. Assess Patient 2’s blood sugar during the home visit as indicated in Patient 2’s plan of care. These failures had the potential for Patient 1 to have an ineffective drug therapy and at risk for adverse drug events due to medication omission and incorrect dosage. In addition, Patient 2 was placed at increased risk for complications related to hypoglycemia (low blood sugar) / hyperglycemia (high blood sugar), delays in medical treatment related to uncontrolled blood glucose. On 7/24/2026 at 11:38 AM, the California Department of Public Health (CDPH) identified an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, and death of a resident) regarding failure to ensure that HHA staff conducted a complete and accurate medication reconciliation review to maintain an updated current medication profile for Patient 1 and failed to ensure treatments were administered as ordered by the physician for Patient 2. The IJ was issued in the presence of the Administrator and the Director of Patient Care Services (DPCS). On 7/28/2026 at 5:22 PM, the IJ was removed in the presence of the DPCS after the HHA submitted an acceptable IJ Removal Plan, verified, and confirmed the HHA’s implementation of the IJ Removal Plan and that the IJ situation was no longer present. The IJ Removal Plan dated 7/28/2026 at 5:22 PM, included the following: On 7/27/2026, immediately upon identification of the IJ, the DPCS assigned the Registered Nurse (RN) to conduct an in-home comprehensive reassessment of Patient 1. The RN performed a complete medication reconciliation, by comparing the patient’s medications with the current physician orders, Plan of Care, medication bottles, pharmacy labels, hospital discharge instructions (when applicable), and information provided by the patient and caregiver. The RN verified that Patient 1’s medication profile accurately reflects every current medication. Any discrepancies or clinically significant findings was reported to the physician immediately. The RN obtained, implemented, and documented all new or clarified physician orders. The patient and caregiver received an individualized education regarding medication administration, medication purpose, side effects, adverse reactions, medication compliance, and the importance of maintaining an accurate medication list.On 7/27/2026, immediately upon identification of the IJ, the DPCS assigned the RN to conduct an in-home reassessment of Patient #2. The RN performed a comprehensive nursing assessment in accordance with the physician’s orders and the patient’s individualized Plan of Care. During the reassessment and every subsequent skilled nursing visit, the nurse will assess whether the patient or caregiver is completing blood glucose monitoring as instructed in the Plan of Care. The nurse will review the available blood glucose log, glucometer history, or patient and caregiver report and document the dates, frequency, reported results, trends, and any readings outside the physician-ordered parameters. Any reported blood glucose reading outside the physician-ordered parameters, failure or inability of the patient or caregiver to perform the ordered monitoring, lack of diabetic supplies, signs or symptoms of hypoglycemia or hyperglycemia, or other clinically significant finding will be reported to the physician on the same day. The nurse will obtain, implement, and document any new or clarified physician orders. On 7/25/2026 and 7/26/2026, the RNs completed in-home reassessments and comprehensive medication reconciliation visits for 10 of the remaining 11 active patients. During each visit, the RN directly compared all medications present in the patient’s home with the current physician orders, Plan of Care, agency medication profile, pharmacy labels, discharge instructions, and information provided by the patient or caregiver. Seven (7) patients had medication profiles that were accurate and consistent with the medications present in the home and the current physician orders. Three (3) patients were identified with medication discrepancies. Each discrepancy was immediately reported to the physician, clarification was obtained, and the medication profile and Plan of Care were updated to accurately reflect the physician’s current orders. All clarified orders were implemented as directed. No additional medication reconciliation deficiencies or patient safety concerns were identified during the completed reviews after the corrective actions were completed. Effective 7/25/2026, the DPCS will maintain a tracking log documenting all 11 active patients, including the date of each reassessment, medication reconciliation findings, identified discrepancies, physician notification, corrective actions taken, and completion date to verify 100% completion and ensure ongoing compliance. On 7/24/2026, a qualified independent Registered Nurse clinical consultant/educator who was not involved in the deficient practice provided mandatory education to the Administrator, Director of Patient Care Services (DPCS), and all licensed clinical staff. The education included medication reconciliation, comprehensive drug regimen review, medication profile accuracy, assessment of medication effectiveness and compliance, identification of adverse drug reactions, physician notification, implementation of physician orders, diabetic assessment and patient education in accordance with physician orders, and documentation requirements under the Medicare Conditions of Participation. Effective 7/26/2026, the HHA will implement a standardized Medication Reconciliation and Drug Regimen Review Checklist to be completed during admissions, resumptions of care, recertifications, significant changes in condition, hospital discharges, and whenever medications are initiated, discontinued, or changed. The DPCS will review each completed checklist during daily chart audits. Missing or incomplete documentation will require immediate correction, focused re-education, repeat competency validation, and continued monitoring until sustained compliance is demonstrated. Beginning on 7/27/2026, the DPCS will audit 100% of medication reconciliation documentation and skilled nursing visit notes daily for 30 consecutive days. Any identified deficiency will result in immediate correction, focused staff re-education, repeat competency validation, and continued 100% auditing until sustained compliance is achieved. Following 30 consecutive days of full compliance, the agency will audit a minimum of 10% of medication reconciliation records monthly for three additional months, with findings reviewed through the Quality Assessment and Performance Improvement (QAPI) Program. Findings: 1. During a review of Patient 1’s “Home Health Certification and Plan of Care,” for the certification period of 5/25/2026 to 7/23/2026, the plan of care indicated Patient 1’s start of care (SOC) was 5/25/2026, with diagnosis that included hypertensive heart disease (a condition with damage to the heart due to unmanaged high blood pressure), atherosclerosis heart disease (a condition where fatty plaque builds up in the heart arteries), gastroesophageal reflux disease (GERD, a condition where stomach acid flows back up into the esophagus [food pipe]), and constipation. During a review of Patient 1’s “Patient Assessment Oasis 2,” dated 6/18/2026, the assessment indicated Patient 1 had a resumption of care after the patient was discharge from the hospital on 6/17/2026. During a concurrent observation and interview, on 7/21/2026 at 11 AM, with the DPCS, the DPCS was observed conducting Patient 1’s medication reconciliation during a home visit. The DPCS stated he completed the medication reconciliation and there was no discrepancy in Patient 1’s medication. During a concurrent interview and record review, on 7/21/2026 at 11:10 AM, with the DPCS and Patient 1, Patient 1’s medication reconciliation was conducted during a home visit. Patient 1 stated she had a new medication and brought out a medication bottle of pantoprazole 20 mg tablet, to take one tablet by mouth, daily. Patient 1 stated that the pantoprazole 20 mg was prescribed by her physician after she came back from the hospital (Patient 1 return from the hospital on 6/17/2026). Patient 1’s “Patient Medication Profile,” episode period: 5/25/2026 to 7/23/2026, indicated the following medications: - On 6/18/2026, Losartan 25 mg tablet, one tablet by mouth, daily. Patient 1’s medication bottle indicated Losartan 50 mg tablet, take one tablet by mouth daily, was filled on 1/12/2025. - On 6/18/2026, Linaclotide 290 mcg capsule, take one capsule by mouth, daily. Patient 1’s medication bottle indicated Linaclotide 145 mcg capsule, take one capsule daily, was filled on 7/11/2026. Patient 1’s medication profile did not include pantoprazole 20 mg tablet, to take one tablet by mouth, daily. During an interview on 7/21/2026 at 11 AM, with Patient 1, Patient 1 stated she takes Losartan 50 mg as indicated on the medication bottle. Patient 1 stated she does not take her Losartan when her blood pressure (BP) was low. Patient 1 stated she does not check her BP and that she knows if her BP was low if she has a headache and does not feel good at all. Patient 1 stated she knows how to take her BP but she cannot take it because she does not have a BP machine and the HHA did not give her one. During an interview on 7/21/2026 at 11 AM, with Patient 1, Patient 1 stated she asked her physician to lower the dose of Linaclotide to 145 mcg because the 290 mcg dose was too high for her and it gives her diarrhea. Patient 1 stated her physician lowered her Linaclotide to 145 mcg. During an interview on 7/23/2026 at 8:42 AM, with the DPCS, the DPCS stated Patient 1’s medication profile list had discrepancy from the patient’s medication for Losartan, Linaclotide, and pantoprazole. The DPCS stated it was concerning that Patient 1 does not take her BP and just go by her symptoms to hold her Losartan dose. The DPCS stated he was aware that the patient did not received a BP machine to check her BP. During an interview on 7/23/2026 at 8:42 AM, with the DPCS, the DPCS stated the patient’s medication reconciliation should be conducted every home visit to ensure the patient was taking the correct medication as ordered by the physician. The DPCS stated during the medication reconciliation, the patient’s medication profile list would be compared to the patient’s medication bottle to check for any discrepancy in the medication order and dose. The DPCS stated if an issue was identified during the medication reconciliation, the physician would be notified to get the correct medication order and/or the pharmacy would be informed for medication refill, if needed. The DPCS stated conducting medication reconciliation was important to ensure patient safety from any adverse drug interaction or drug toxicity, and to prevent the patient from being over medicated or under medicated. During a review of Patient 1’s “Home Health Certification and Plan of Care,” for certification period of 5/25/2026 to 7/23/2026, the plan of care indicated, “DME and supplies…blood pressure machine…” During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile,” dated November 2023, indicated, “Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinue medications...A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will be performed by qualified personnel and will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy. Deviations from taking medications as ordered will be documented in clinical notes, and the physician (or other authorized licensed independent practitioner) will be notified.” During a review of the facility’s P&P titled, “Safe/Effective Use of Medications” dated November 2023, indicated, “Patients and family/caregivers will receive information regarding the safe and effective use of medications, in accordance with applicable organization policies...(name of the facility) will encourage patient and family/caregiver participation in his/her own care and will provide teaching about the correct administration of medications by the patient or family/caregiver as ordered by the attending physician (or other authorized licensed independent practitioner) or purchased over the counter...The components of the medication assessment used to determine patient and family/caregiver knowledge and skill related to medication administration will include, but will not be limited to: A. Name, dosage, route, duration, time and usage of medication, intended use as well as expected actions of drug therapy.” During a review of the facility’s P&P titled, “Safe/Effective Use of Equipment and Supplies,” dated November 2023, indicated, “Upon admission, the patient assessment will document the use of any medical equipment or supplies being used in the home…he clinician will, through interview and observation, determine patient and family/caregiver level of understanding of the use of any equipment and supplies ordered for care, treatment, and service.” 2. During a review of Patient 2’s, “Home Health Certification and Plan of Care,” for certification period 06/03/2026 to 08/01/2026, the plan indicated Patient 2’s start of care (SOC) was 6/3/2026, with diagnosis that included type 2 diabetes mellitus (a condition that prevents the body from utilizing sugar properly, causing unstable levels of sugar in the blood). The plan of care further indicated, “Orders for Discipline and Treatments…SN (skilled nurse) for skilled assessment/observation...blood sugar monitoring every visit and report Blood Sugar greater than 300 milligram/deciliter (mg/dl) and less than 70 mg/dl to MD (physician) due to Diabetes Mellitus.” During a concurrent observation and interview, on 7/22/2026 at 10 AM, with Registered Nurse 1 (RN 1) and Patient 2, RN 1 was observed conducting Patient 2’s home visit. RN 1 checked Patient 2’s vital signs (blood pressure, temperature, heart rate, and oxygen saturation). RN 1 did not check Patient 2’s blood sugar level (BS, measurement of level of sugar in the blood). Patient 2 stated that it was his caregiver (CG 2) who checks his blood sugar. RN 1 did not asked Patient 2 of his blood sugar test result log to review Patient 2’s blood sugar results that was taken by CG 2. During an interview on 7/23/2026 at 10:42 AM, with RN 1, RN 1 stated that CG 2 knows how to check blood sugar and that CG 2 will call the HHA if there were any issues. RN 1 stated she did not check the log for Patient 2’s blood sugar results during the home visit. During an interview on 7/24/2026 at 12:15 PM, with RN 1, RN 1 stated she should check the patient’s blood sugar or blood sugar results for each visit, as indicated in the plan of care, to know if the patient’s blood sugar level is within parameters. RN 1 stated if there were issues with the patient’s BS results, the physician would be notified. A review of the HHA’s P&P titled, “Ongoing Assessments,” dated 11/2023, the P&P indicated, “The scope and intensity of ongoing assessments will be determined by the patient’s diagnoses, condition, desire for care, response to previous care, and the care setting. Procedure: 1. During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter. 2. Using the standards of care identified by the organization, the clinician will reassess the patient...L. Progress toward goals and patient needs and problems M. Compliance to treatment and/or medications. 3. Re-assessments should focus on: A. Patient’s response to care B. Changes in patient condition C. Changes in patient diagnoses D. Changes in patient’s care environment or support systems...5. Based on each reassessment, the plan of care, including problems, needs, goals and outcomes will be reviewed and revised accordingly by the clinician.” A review of the P&P titled, “Monitoring Patient’s Response/Reporting to Physician,” dated 11/2023, the P&P indicated, “During each home visit, the clinician will monitor the patient’s response to care against the established goals including, but not limited to care interventions and treatments, medications, and teaching...The patient’s physician will be contacted on the same day when...changes that have occurred regarding diagnosis, prognosis, or treatment (including procedures, medications, precautions, and limitations).””

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to revised the plan of care to reflect the patient’s updated comprehensive assessment for one of seven sampled patients (Patient 1) when, Patient 1 had a resumption of care on 6/18/2026, after being discharged from the hospital due to urinary tract infection (UTI, bladder infection) and was on intravenous (IV, given through the veins) antibiotic. This failure resulted in Patient 1 to not have an individualized goal-oriented plan of care to provide a means for interdisciplinary communication for the patient’s care and addressed the needs and risks of the patient. Findings: During a review of Patient 1’s “Home Health Certification and Plan of Care,” for the certification period of 5/25/2026 to 7/23/2026, the plan of care indicated Patient 1’s start of care (SOC) was 5/25/2026, with diagnosis that included hypertensive heart disease (a condition with damage to the heart due to unmanaged high blood pressure), atherosclerosis heart disease (a condition where fatty plaque builds up in the heart arteries), gastroesophageal reflux disease (GERD, a condition where stomach acid flows back up into the esophagus [food pipe]), and constipation...Skilled nurse (SN) visits frequency: 2wk2 (two times a week for two weeks); 1wk7 (once a week for seven weeks) for skilled observation and evaluation of patient current medical conditions...” During a review of Patient 1’s “Patient Assessment Oasis 2,” dated 6/18/2026, the assessment indicated, “Reason for Assessment: Resumption of care (after inpatient stay)...Resumption of Care Date: 06/18/2026...Section H - Bladder and Bowel...Disease Management Problems: Patient (Patient 1) had history of hospitalization due to her current medical conditions (UTI) recently discharge from hospital on 6/17/2026 with IV infusion via midline (a longer type of peripheral IV catheter used to give fluids and medicine) (single lumen at upper arm) daily...Patient has skin irritation at left armpit and topical as directed by MD (physician)...Section N - Medications...INVANZ (antibiotic) 1 gram via infusion via MIDLINE every 24 hours start on 6/18/2026...” During a review of Patient 1’s “Patient Medication Profile,” for episode period of 5/25/2026 to 7/23/2026, the medication profile indicated the following medications: - “6/18/2026, Nystatin (an antifungal medication) 100,000 unit/gram (u/g) topical powder apply over affected area as needed for skin irritation…L (left) armpit skin redness/irritation: cleanse area with normal saline pat dry with sterile gauze apply nystatin powder…daily as needed for skin irritation.” - “6/18/2026, Silver sulfadiazine 1% topical cream use as direct by the MD over affected area.” - “6/18/2026, INVANZ (antibiotics) 1 gram via infusion midline (single lumen at upper arm) daily...start on 06/18/2026 until finish on 6/22/2026 then remove MIDLINE site after completion of antibiotic as directed by MD (physician)” During an interview on 7/23/2026 at 8:42 AM, with the Director of Patient Care Services (DPCS), the DPCS stated Patient 1 was hospitalized during the current certification period (5/25/2026 to 7/23/2026), and was seen on 6/18/2026 for resumption of care after the patient was discharge from the hospital on 6/17/2026. The DPCS stated Patient 1 was hospitalized due to UTI and on IV antibiotic. The DPCS stated Patient 1’s SN visit was change from 2wk2; 1wk7 to daily visit from 6/18/2026 to 6/22/2026 for Patient 1’s IV antibiotic infusion. During a concurrent interview and record review, on 7/23/2026 at 8:42 AM, with the DPCS, the DPCS stated Patient 1’s “Home Health Certification and Plan of Care,” for the certification period of 5/25/2026 to 7/23/2026, was not updated to reflect Patient 1’s assessment from, “Patient Assessment Oasis 2 (Resumption of Care),” dated 6/18/2026. The DPCS stated Patient 1’s plan of care should reflect the changes on SN visit’s frequency, and the care plan should address treatment intervention and goals regarding Patient 1’s UTI management and prevention, IV midline care, IV antibiotic infusion, and skin integrity management and prevention of skin breakdown. The DPCS stated a care plan should be individualized based on the patient’s assessment, needs, and risk for continuity of care and for the HHA staff to know what treatment or care interventions were needed to help the patient reached their goal. During a review of the HHA’s policy and procedure (P&P) titled, “Care Planning Process,” dated 11/2023, the P&P indicated, “A written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days or as patient’s condition warrants. The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient...The plan of care will be reviewed more frequently than every 60 days when a patient elects a transfer to another home health organization, a significant change occurs in the patient’s condition, or a patient is discharged and readmitted during the same 60-day period...All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including but not limited to...A. Individualized patient needs and resultant problems related to care, functional status, and family/caregiver support system B. Changes in patient’s condition C. Clinical drug monitoring, as appropriate...G. Patient and caregiver education and training that the organization will provide specific to the patient’s care needs...The plan of care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient. Revision dates will be noted on the plan of care...””

“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 Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to integrate the medication order received from an outpatient palliative care (specialized medical care that relieves pain, symptoms, and stress caused by a serious illness) clinic into the plan of care for one of seven sampled patients (Patient 3), when Patient 3’s palliative care physician changed the pantoprazole (a medication that reduces the amount of acid the stomach makes) dose from 40 mg tablet, take 1 tablet by mouth twice daily to pantoprazole 40 mg tablet, take 1 tablet by mouth every other day. This failure had the potential for Patient 3 to have an ineffective drug therapy and at risk for adverse drug events due to medication omission and incorrect dosage. During a concurrent observation, interview, and record review, on 7/22/2026 at 2:05 pm, with Registered Nurse 1 (RN 1) and Patient 3’s caregiver (CG 3), RN 1 was observed to performed Patient 3’s medication reconciliation during a home visit. Patient 3’s pantoprazole medication bottle indicated to take pantoprazole 40 mg tablet, take 1 tablet by mouth every other day. Patient 3’s plan of care dated 6/28/2026, included a medication order for pantoprazole 40 mg tablet, take 1 tablet by mouth twice daily. CG 3 stated Patient 1’s palliative physician changed the pantoprazole dose to every other day and that is what Patient 1 had been taking. During a concurrent interview and record review, on 7/27/2026 at 10 am, with RN 1, RN1 stated that when a patient received new medication order from the patient’s other physicians (outside of HHA), the RN should inform the patient’s responsible physician (from HHA) to include the new medication order in the patient’s plan of care and update the patient’s medication profile with the new medication order. RN 1 stated Patient 3’s current medication profile indicated pantoprazole 40 mg tablet, 1 tablet by mouth twice daily. RN 1 stated it was not updated to the new medication order given by Patient 3’s palliative physician. RN 1 stated she forgot to notify the HHA physician to change the order of Patient 3’s pantoprazole to 40 mg tablet, take 1 tablet by mouth every other day. During a review of the HHA’s policy and procedure (P&P) titled, “Verification of Physician Orders,” dated 11/2023, the P&P indicated, “an order or prescription will be verified when there is a question or discrepancy in the order/prescription and when the order is communicated by someone other than the physician or his/her agent.” During a review of the HHA’s P&P titled, “Physician Participation in Plan of Care,” dated 11/2023, the P&P indicated, “if a patient is under the care of more than one (1) physician, the nurse will be responsible to the designated primary physician. All other physicians (or other authorized licensed independent practitioner) should be made aware of the services being provided to the patient. The referring physician will be informed of the involvement of additional consulting physician, when applicable.””

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure, for one of seven sampled patients (Patient 2), Patient 2’s care giver (CG 2) received an ongoing education and training from HHA regarding the patient’s medication management and blood sugar (BS, measurement of level of sugar in the blood) monitoring, as indicated in Patient 2’s plan of care. This failure had the potential to result in an unsafe care that could increase the risk of medication mismanagement, complications related to hypoglycemia (low blood sugar) / hyperglycemia (high blood sugar), delays in medical treatment and hospitalization of the patient. During a review of Patient 2’s, “Home Health Certification and Plan of Care,” for certification period 06/03/2026 to 08/01/2026, the plan indicated Patient 2’s start of care was 06/03/2026, with diagnosis that included type 2 diabetes mellitus (DM, a condition that prevents the body from utilizing sugar properly, causing unstable levels of sugar in the blood). The plan of care further indicated, “Orders for Discipline and Treatments: SN (skilled nurse) to instruct patient/patient caregiver on: - Disease process, causes, s/s (signs and symptoms), complications, review and teach patient about ordered medications regarding effects, side effects, dosages, and timing; assess effectiveness of current medications, compliance with ordered medications… - Proper blood sugar monitoring via fingerstick (using a medical device to obtain a blood sample), proper disposal of sharps (the medical device to obtain the blood sample) into sharp containers in the home and skin/foot care…check your blood sugar, if blood sugar milligrams per deciliter (mg/dl) drink a glass of orange juice; have candy if outdoor, call your md (physician)/nurse if you don’t know what to do; if you feel very sick, go to ER (emergency room) if time permits or call 911. Report Blood sugar greater 300mg/dl or less 70mg/dl to MD… - Signs and symptoms of hypoglycemia, including hunger, shakiness, palpitations (feeling of racing heartbeat), weakness, headache, irritability, nervousness, and visual disturbances; signs and symptoms of hyperglycemia, possible ketoacidosis (medical emergency when the body cannot use the sugar in the blood for energy), including fatigue, malaise, flushed face, nausea and vomiting, marked thirst fruity breath, and changes in mentation (process of thinking)….Goals/Rehabilitation Potential/Discharge Plans/Referral Plan/Other Notes: - Patient caregiver will be able to return demonstration proper blood sugar testing/ monitoring/machine calibration, using aseptic technique with observance of standard precautions and verbalized understanding of proper skin/foot care within 6-8 weeks… - By the end of the plan of treatment patient/caregiver… will comply with diet/ medication regimen.” During a concurrent observation and interview, on 7/22/2026 at 10 AM, with Registered Nurse 1 (RN 1) and Patient 2, RN 1 was observed conducting Patient 2’s home visit. Patient 2 stated CG 2 was the one who checks his blood sugar and prepares his medication. Patient 2 stated CG 2 goes to work, and that CG 2 comes in the morning, before her work and in the evening, after her work to check on him. During an interview on 7/22/2026 at 5:38 p.m., with CG 2, CG 2 stated she was the caregiver for Patient 2. CG 2 stated she prepares Patient 2’s medications, check his blood pressure (BP) and BS. CG 2 stated she never met the visiting nurse of Patient 2 because she was not always home when they come and visit Patient 2. CG 2 stated she knows that she needed to be home to be able to learn what the visiting nurse was teaching regarding Patient 2’s care. During an interview on 7/23/2026 at 10:42 AM, with RN 1, RN 1 stated she was the assigned visiting nurse to Patient 2. RN 1 stated Patient 2 was oriented but forgetful and needed help with his care. RN 1 stated CG 2 oversees all Patient 2’s care, medication management, and BS monitoring. RN 1 stated CG 2 had not been present during her home visits to Patient 2 because CG 2 was at work when she comes to see the patient. During an interview on 7/23/2026 at 10:42 AM, with RN 1, RN 1 stated that CG 2, who was involved in Patient 2’s care, should receive one-on-one teaching and training regarding the care of the patient. RN 1 stated CG 2 should be able to return demonstrate what was taught to her to confirm that CG 2 understood the patient’s care plan and that CG 2 was competent to perform Patient 2’s medication management and BS monitoring. During a review of the HHA’s policy and procedure (P&P) titled, “Patient Education Process,” dated 11/2023, the P&P indicated, “Patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate. The scope of teaching will be determined by assessing the needs, abilities, learning preferences, and readiness to learn of the patient and family/caregiver, as well as by the plan of care, goals and established outcomes. Education will be the responsibility of each clinician…The clinician will assess, plan, implement, and evaluate the following on each patient and family/caregiver, as appropriate:…the pertinent information needed by the patient and family/caregiver in relation to the care being rendered…the level of knowledge of the patient and family/caregiver in relation to the diagnoses, plan of care, required activities by patient and family/caregiver, lifestyle changes, etc. The patient’s and family/caregiver’s knowledge, skills, and behaviors will be assessed during home visits through an interactive process.” During a review of HHA’s P&P titled, “Safe/Effective Use of Medications,” date 11/2023, the P&P indicated, “Upon admission, the patient and family/caregiver will be assessed as to his/her knowledge and skill required for safe and effective use of medications. The components of the medication assessment used to determine patient and family/caregiver knowledge and skill related to medication administration will include, but will not be limited to:…preparation, self-administration, and use of medication, including over-the-counter products…Documentation of patient and family/caregiver instructions in the clinical record will include:…return demonstrations.””

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to conduct an assessment in accordance with the patients’ needs, plan of care, and the facility’s policy and procedure for one of seven sampled patients (Patient 1) when, the Director of Patient Care Services (DPCS) did not assess Patient 1’s skin integrity after Patient 1 informed the DPCS that she had skin irritation and redness on the left (L) underarm, L upper back of the leg, and lower abdomen (under the abdominal folds) during the home visit. This failure had the potential to result in Patient 1’s skin irritation and redness to worsen and/or developed skin injuries, delays in wound treatment that could lead to Patient 1 suffering from increased pain, wound infection, reduced mobility, and hospitalization. On 7/24/2026 at 11:56 AM, the California Department of Public Health (CDPH) identified an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, and death of a resident) regarding failure to ensure that HHA staff conducted an assessment in accordance with the patients’ needs, plan of care, and the facility’s policy and procedure when Patient 1’s skin integrity was not assessed after the patient informed the Director of Patient Care Services (DPCS) that she had skin irritation and redness on the L underarm, L upper back of the leg, and lower abdomen (under the abdominal folds). On 7/28/2026 at 6:05 PM, the IJ was removed in the presence of the DPCS after the HHA submitted an acceptable IJ Removal Plan, verified, and confirmed the HHA’s implementation of the IJ Removal Plan and that the IJ situation was no longer present. The IJ Removal Plan dated 7/28/2026 at 6:05 PM, included the following: On 7/23/2026, a Registered Nurse (RN) completed an in-home recertification visit and comprehensive nursing reassessment of Patient 1. The RN performed a head-to-toe assessment, medication reconciliation, and direct visualization of the reported skin concerns. The integumentary assessment identified skin irritation beneath the left axilla (armpit), beneath the left, right and mid lower anterior abdominal folds, and on the left posterior upper leg. The RN assessed and documented the location, appearance, skin integrity, moisture, pain, surrounding tissue, and signs or symptoms of infection. No open wounds, drainage, odor, infection, increased pain, functional decline, hospitalization, emergency department visit, or other adverse consequences related to the delayed assessment were identified. On 7/23/2026, the physician was notified of the findings and a new order was obtained for Nystatin Cream 100,000 units/gram, to be applied to the affected areas daily as needed. The patient and caregiver were instructed to clean the affected areas with soap and water, dry the areas thoroughly, apply Nystatin Cream as ordered, maintain proper moisture control, inspect the skin daily, and report worsening redness, pain, drainage, odor, skin breakdown, fever, or other signs of infection. On 7/25/2026, a follow-up nursing visit was completed. The medication reconciliation confirmed that all medications present in the home remained consistent with the medication reconciliation completed on 7/23/2026 and the repeat skin assessment showed slight improvement in the affected areas. No additional adverse consequences, medication discrepancies, or clinically significant findings were identified, and no additional physician orders were required. The DPCS reviewed the reassessment, medication reconciliation, physician notification, new physician order, interventions, patient and caregiver education, follow-up assessment, and clinical documentation and verified completion of all corrective actions. On 7/25/2026 and 7/26/2026, the RN completed comprehensive in-home reassessments for 10 of the remaining 11 active patients. Each reassessment included a review of the patient’s current condition, Plan of Care, physician orders, skilled nursing documentation, medication profile, recent hospitalization (when applicable), patient and caregiver reports, OASIS documentation, and assessment of identified clinical risk factors. One (1) patient was identified with a skin concern requiring further assessment. The affected area was directly visualized, the physician was notified, appropriate orders were obtained, implemented, and documented. No systemic deficiencies similar to those identified for Patient #1 were found during the completed reassessments. On 7/24/2026, the independent RN clinical consultant provided mandatory education to the Administrator, Director of Patient Care Services (DPCS), and all licensed clinical staff. Independent education was required because the Administrator and DPCS participated in patient care activities associated with the deficient practice identified under 42 CFR §484.75(b)(1) (G706). Effective 7/25/2026, the HHA implemented a standardized Skilled Nursing Ongoing Assessment Checklist to be completed during every skilled nursing visit. The completed checklist will become a permanent part of the patient’s clinical record. It will be filed or uploaded with the corresponding skilled nursing visit note on the same day as the visit and no later than the end of the clinician’s workday. The clinician will submit the completed checklist and skilled nursing visit documentation to the DPCS for review by the end of the same business day. The DPCS will review the checklist and corresponding visit note during the agency’s daily clinical record audit. Beginning 7/27/2026, the DPCS will audit 100% of skilled nursing visit notes daily for 30 consecutive days. Audit findings will be documented on a standardized audit tool. After 30 consecutive days of full compliance, the agency will transition to auditing at least 10% of skilled nursing visits monthly for three additional months, with results reviewed through the Quality Assessment and Performance Improvement (QAPI) Program. Findings: During a review of Patient 1’s “Home Health Certification and Plan of Care,” for the certification period of 5/25/2026 to 7/23/2026, the plan of care indicated Patient 1’s start of care (SOC) was 5/25/2026, with diagnosis that included hypertensive heart disease (a condition with damage to the heart due to unmanaged high blood pressure), atherosclerosis heart disease (a condition where fatty plaque builds up in the heart arteries), gastroesophageal reflux disease (GERD, a condition where stomach acid flows back up into the esophagus [food pipe]), and constipation. During a review of Patient 1’s “Patient Assessment Oasis 2,” dated 6/18/2026, the assessment indicated Patient 1 had a resumption of care after the patient was discharge from the hospital on 6/17/2026. During a review of Patient 1’s “Patient Medication Profile,” for episode period of 5/25/2026 to 7/23/2026, the medication profile indicated the following medications: - “Nystatin (an antifungal medication) 100,000 unit/gram (u/g) topical powder apply over affected area as needed for skin irritation…L (left) armpit skin redness/irritation: cleanse area with normal saline pat dry with sterile gauze apply nystatin powder…daily as needed for skin irritation.” - “Silver sulfadiazine 1% topical cream use as direct by the MD over affected area.” During a concurrent observation and interview on 7/21/2026 at 11 AM, with the DPCS, the DPCS was observed conducting a home visit to Patient 1. Patient 1 stated she lives alone and her caregiver (CG 1) comes in the morning to help her get out of the bed and take a shower then CG 1 returns at night to put her back to bed. Patient 1 stated she needed CG 1 because it was important for her to take a good shower every day due to her skin irritation and redness on the back of her upper L leg, under her abdominal fold and L underarm. Patient 1 stated, “I had holes (wounds) under my abdomen (skin under the abdominal fold) before” and “I don’t not want that to happen again.” During a concurrent observation and interview on 7/21/2026 at 11 AM, with the DPCS and Patient 1, Patient 1 was observed taking out her phone, opened the photos on her phone, and showed the photos. Patient 1 stated the photos were her skin irritation and redness that she took a photo of. Patient 1 told the DPCS that he can look at her skin so he could check the skin irritation and redness. The DPCS told Patient 1, “its ok” “no need to look at it” “I have photos I can show.” The DPCS did not assess Patient 1’s skin irritation and redness on the L underarm, L upper back of the leg, and lower abdomen (under the abdominal folds) during Patient 1’s home visit. During an interview on 7/21/2026 at 4:30 PM, with CG 1, CG 1 stated that Patient 1 had skin irritation and redness on the back of the upper L leg, L underarm, and on the skin under the abdominal fold. CG 1 stated she gave a shower to Patient 1 this morning (7/21/2026) and she applied the silver sulfadiazine cream (an antibiotic topical cream used to prevent and treat wound infection) on Patient 1’s irritated red skin. CG 1 stated, “the skin on the legs and underarm were not bad,” pinkish in color. CG 1 stated the skin under the abdominal flap was “angry red, it was very red.” During an interview on 7/23/2026 at 8:42 AM, with the DPCS, the DPCS stated during a routine home visit the nurse would check the patient’s vital signs and will perform focus assessment only, will assess what the patient was admitted for. The DPCS stated the nurse should do an additional assessment if the patient reported any issue or concern with their health and condition during the home visit. During an interview on 7/23/2026 at 8:42 AM, with the DPCS, the DPCS stated if the patient verbalizes that he/she has skin irritation and redness, the nurse should assess the patient’s skin, take measurements and photos of the skin irritation and redness. The DPCS stated the physician should be notified to get an order for skin care or wound care. The DPCS stated if the skin irritation and redness was not assessed it could worsen and could cause an infection or sepsis and hospitalization of the patient. The DPCS stated he did not do an assessment on Patient 1’s skin to check on the patient’s irritation and redness on the skin after Patient 1 informed him during the home visit. During a review of the HHA’s policy and procedure (P&P) titled, “Ongoing Assessments,” dated 11/2023, the P&P indicated, “The scope and intensity of ongoing assessments will be determined by the patient’s diagnoses, condition, desire for care, response to previous care, and the care setting. Procedure: 1. During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter. 2. Using the standards of care identified by the organization, the clinician will reassess the patient for:...E. Skin integrity...” During a review of the HHA’s P&P titled, “Monitoring Patient’s Response/Reporting to Physician,” dated 11/2023, the P&P indicated, “During each home visit, the clinician will monitor the patient’s response to care against the established goals including, but not limited to care interventions and treatments, medications, and teaching...The patient’s physician will be contacted on the same day when...changes that have occurred regarding diagnosis, prognosis, or treatment (including procedures, medications, precautions, and limitations).””

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the supervising Registered Nurse (RN) documented the HH Aide’s supervisory visit (an on-site evaluation by a nurse to oversee a home health aide or patient care plan) to ensure the HH Aide was providing safe and effective care in accordance with the patient’s plan of care, for one of one sampled patients (Patient 6). This failure had the potential to result in an unsafe care due to lack of RN supervision that ensure the HH Aide was competent and efficient in providing care in accordance with the patient’s written plan of care. During a concurrent interview and record review, on 7/27/2026 at 10:11 AM, with Registered Nurse 1 (RN 1), RN 1 stated Patient 6’s “Patient Assessment: OASIS E2 (Full),” dated 5/8/2026, the OASIS indicated Patient 6’s start of care was on 1/13/2026, had a recertification for period 3/14/2026 to 5/12/2026, and was discharge on 05/08/2026. During a concurrent interview and record review, on 7/27/2026 at 9:43 AM, with RN 1, RN 1 stated Patient 6’s calendar visit, for certification period of 3/14/2026 to 5/12/2026, indicated that Patient 6 was seen by HH Aide twice a week from 3/17/2026 to 5/5/2026. During an interview on 7/27/2026 at 9:43 AM, with RN 1, RN 1 stated when a patient was being seen by HH Aide, a supervisory visit would be conducted by the RN or Licensed Vocational Nurse (LVN) and the result of the supervisory visit would be documented on the Skilled Nurse (SN) visit notes. RN 1 stated during the supervisory visit, the HH Aide’s work would be evaluated to ensure the HH Aide was competent, providing safe care, and following the patient’s plan of care. RN 1 stated the documentation of the supervisory visit should indicate what task of HH Aide was supervised and what was the result of the supervision. During a concurrent interview and record review, on 7/27/2026 at 9:43 AM, with RN 1, RN 1 stated she was the visiting RN assigned to Patient 6 and that the patient was seen twice a week for two weeks then once a week. RN 1 stated Patient 6’s SN notes, dated from 3/16/2026 to 4/29/2026, indicated, “Nursing Progress Note...Supervisory Visits: Scheduled / Unscheduled (was blank, no selection)...CHHA (Certified HH Aide): Present / Not Present (was blank, no selection)...” RN 1 stated the SN notes did not have documentation of what was supervised and what was the result of the supervisory visit for HH Aide. During a review of the HHA’s policy and procedure (P&P) titled, “Home Health Aide Supervisory Visits,” undated, the P&P indicated, “The registered nurse or other appropriate skilled professional that is familiar with the patient, the patient’s plan of care, and the written patient care instructions must conduct supervisory visits to the patient’s residence at regular intervals...The supervisory assessment must be completed as an in-person visit, or on the rare occasion by using a two-way audio-video telecommunications technology system that allows for real-time interaction between the registered nurse (or other appropriate skilled professional) and the patient, not to exceed one (1) virtual supervisory assessment per patient in a sixty (60) day episode...Supervisory visits and overall supervision will be documented in the clinical record...A. Supervisory visits will be documented on a supervisory visit form. Each supervisory visit shall contain documentation to ensure that the aide is furnishing care in a safe and effective manner, including, but not limited to, the following elements: 1. Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or another appropriate skilled professional. 2. Maintaining an open communication process with the patient, representative, caregivers, and family. 3. Demonstrating competency with assigned tasks 4. Complying with infection prevention and control policies and procedures 5. Reporting changes in the patient’s condition 6. Honoring patient rights...””

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure a discharge summary was sent to the patient’s primary care practitioner (PCP) after the patient was discharge from the HHA, for two of two sampled patients (Patient 6 and Patient 7). This failure resulted in Patient 6 and Patient 7’s PCP not having information of the patients’ progress and status of care received from the HHA and could lead to not have continuity of care and follow-up treatment causing deterioration of the patient’s condition and rehospitalization. During a review of the HHA’s “Patient Discharge History,” from 7/1/2025 to 7/20/2026, the discharge history indicated the following: - Patient 6’s start of care (SOC) was 1/13/2026 and was discharged on 5/8/2026, with a reason of, “Patient Refused Service.” - Patient 7’s SOC was 2/20/2026 and was discharged on 6/1/2026, with a reason of, “Patient Moved out of Area.” During a concurrent interview and record review, on 7/28/2026 at 9:55 AM, with the Director of Patient Care Services (DPCS), the DPCS stated Patient 6 and Patient 7’s record did not include a discharge sxummary after the patients were discharge from the HHA. The DPCS stated a patient should have a discharge summary that would be sent to the patient’s PCP after discharge from the HHA. The DPCS stated that it is important for the patient’s PCP to have a discharge summary so the PCP would know what was done on their patient, their progress and the needs of patient after being discharge from the HHA. During a review of the HHA’s policy and procedure (P&P) titled, “Discharge Summary,” dated 11/2023, the P&P indicated, “Each patient discharged from a service and/or from the organization will have a written discharge summary completed and filed in the clinical record...A copy of the discharge summary and any necessary medical information will be provided to the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five (5) business days of the patient’s discharge.””