Comfort Care Home Health

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to update the comprehensive assessment at discharge for two of five sampled patients (Patient 3 and Patient 14). This deficient practice placed the patients at risk of lapses in continuity of care, adverse health outcomes, and compromised patient safety after discharge by not knowing the patients’ health care needs and progress in meeting care plan goals. 2. During a review of Patient 14’s clinical record titled, “Home Health Certification and Plan of Care”, it indicated an SOC of 4/24/2026 with a principal diagnosis of essential (primary) hypertension (elevated blood pressure). During a review of Patient 14’s clinical record titled, “Doctor’s Order” dated 8/3/2026, it indicated Patient 14 was discharged on 8/3/2026. During a review of Patient 14’s clinical record titled, “Physician Discharge Summary”, dated 8/3/2026, it did not indicate a copy of the summary was mailed, emailed, or faxed within five days of discharge to the physician. During a review of the HHA’s policy and procedure (P&P) titled “Reassessment/Update of the Comprehensive Assessment,” revised 3/2019, the P&P indicated: The comprehensive assessment must be updated and revised as frequently as the patient’s condition warrants. Minimally, the comprehensive assessment must be updated and revised upon discharge from the agency within 2 calendar days of the discharge date. During a review of the HHA’s P&P titled “Discharge Summary,” revised 1/2018, the P&P indicated: Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record. The discharge summary may include the status of problems identified at admission and during the provision of care, progress towards goals/desired outcomes, medical status at discharge including continuing symptom management needs, the reason for discharge, and the date of discharge including when the physician and patient were informed. The discharge summary will be completed and submitted within 72 hours of discharge, and a copy will be provided to the patient’s primary care practitioner within 5 business days of the patient’s discharge. During an interview on 8/13/2026 at 3:53 p.m. with the Administrator (ADM), the ADM stated that the discharge comprehensive assessment was completed within 72 hours of discharge for all patients that had been discharged from the HHA. The ADM stated that the discharge comprehensive assessment, which included the discharge summary, was used to document a patient’s goals and progress towards meeting those goals and to validate that a patient no longer needed home health services. The ADM further stated that the discharge comprehensive assessment was to be sent to the primary care provider within five (5) business days of discharge. 1. During a review of Patient 3’s clinical record titled, “Home Health Certification and Plan of Care,” for the certification period 5/22/2026 through 7/20/2026, the “Home Health Certification and Plan of Care” indicated a start of care (SOC) date of 1/22/2026 with principal diagnosis of pressure-induced deep tissue damage to the left heel (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Patient 3’s clinical record titled, “Nurse Notes: 7/15/2026 Discharge,” dated 7/15/2026, the “Nurse Notes: 7/15/2026 Discharge” indicated a discharge date of 7/15/2026. During a concurrent interview and record review on 8/13/2026 at 3:57 p.m. with the ADM, Patient 3’s clinical record was reviewed and did not contain documented evidence of the discharge comprehensive assessment. The ADM stated that the discharge comprehensive assessment was not in Patient 3’s clinical record because it had not been completed. The ADM stated that the discharge comprehensive assessment should have been completed within 72 hours of discharge and sent to Patient 3’s physician within 5 business days of the discharge date. The ADM stated this process ensures documentation of Patient 3’s health care needs, reflects the patient’s (Patient 3) progress towards care plan goals, and confirms that Patient 3 was safe for discharged from the HHA.”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard 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 therapeutics service to a patient at home) failed to ensure the clinical manager provided clinical oversight of all patient care services for three of seven sample selected patients (Patient 3, Patient 7, and Patient 8). This failure had the potential to result in patients not meeting their goals, hospitalization, and worsening health care conditions. 1. During a record review of Patient 3’s record titled SOC Worksheet, it indicated a start of care date on 1/22/2026. During a concurrent interview and record review on 6/9/2026 at 3:33 p.m., with the DPCS 2, the DPCS 2 reviewed Patient 3’s medical record. The DPCS 2 stated there was no recertification doctor’s order for the certification period 5/22/2026-7/20/2026. During an interview on 6/9/2026 at 3:43 p.m., with the DPCS 2, stated it was the responsibility of the Director of Patient Care Services to get the order from the doctor to recertify Patient 3 for HHA services. The importance of the doctor’s order for recertification was so everyone to know what needed to be done for the patient. The DPCS 2 stated she reviewed Patient 3’s medical records and there was no document in the record to support the HHA received a recertification order. The DPCS 2 stated they were providing services without a doctor’s order. The DPCS 2 stated, legally, the doctor can say the services were not ordered if there was no documented doctor’s order. During an observation of the home visit on 6/10/2026, at 11:30 a.m., with Licensed Vocational Nurse 2 (LVN 2), provided wound care to Patient 3’s left heel. During a concurrent interview and record review on 6/10/2026 at 12:04 p.m. with LVN 2, LVN 2 reviewed Patient 3’s record titled, Home Health Certification and Plan of Care (POC) for certification period 5/22/2025-7/20/2026. LVN 2 stated she provided wound care according to the doctor’s orders the HHA sent her the day of the home visit, 6/10/2026 through text messaging and not the wound care as indicated in the POC. LVN 2 stated she did not know why the orders received from the HHA, and the wound care provided to Patient 3, were not in the plan of care. During a concurrent interview and record review on 6/11/2026 at 1:08 p.m. with DPCS 2, DPCS 2 reviewed Patient 3’s medical records and stated there were no wound care orders in the record. The DPCS 2 stated the wound care orders would have been included in the recertification order for the certification period beginning on 5/22/2026. However, there were no recertification orders for Patient 3. The DPCS 2 further stated that the importance of having orders was to validate the treatment provided, was coming from the doctor and so the doctor is aware of the patient condition. The risk of not having doctor’s orders for wound care for Patient 3 was not receiving the treatment ordered by the doctor which can result in the wound not healing or getting worse. During a concurrent interview and record review on 6/11/2026 at 1:13 p.m. with DPCS 2, DPCS 2 reviewed Patient 3’s record titled Home Health Certification and Plan of Care (POC) for certification period 5/22/2025-7/20/2026. The record indicated the SN was to assess and monitor the wound for signs of infection and deterioration. Further review of the record also indicated the SN was to perform wound care 3 times a week. The DPCS 2 stated the SN needed to assess and document the wound assessment every SN visit. Assessment involved wound size, appearance, discharge and any sign and symptoms of infection. The DPCS 2 stated the importance of wound assessment was to determine if the treatment was effective. If the wound was not assessed, lack of assessment placed the patient at risk of the wound not healing and infection which can cause hospitalization or death. The DPCS 2 then reviewed Patient 3’s record titled Clinical Note, dated 5/23/2026. The DPCS 2 stated there was no wound assessment and wound care documented in the record. The DPCS 2 stated the SN did not follow the POC. During a concurrent interview and record review on 6/11/2026 at 1:20 p.m. with DPCS 2, DPCS 2 reviewed Patient 3’s record titled, Clinical Note, dated 5/28/2026. The DPCS 2 stated there was no wound assessment and wound care documented in the record. The DPCS 2 stated the SN did not follow the POC. During a concurrent interview and record review on 6/11/2026 at 1:21 p.m. with DPCS 2, DPCS 2 reviewed Patient 3’s record titled, Clinical Note, dated 5/30/2026. The DPCS 2 stated there was no wound assessment and wound care documented in the record. The DPCS 2 stated the SN did not follow the POC. During a concurrent interview and record review on 6/11/2026 at 1:30 p.m. with DPCS 2, DPCS 2 reviewed Patient 3’s record titled Home Health Certification and Plan of Care (POC) for certification period 5/22/2025-7/20/2026. The record indicated the SN was to check Patient 3’s oxygen saturation levels (the percentage of oxygen in the blood. Done by placing a measuring device on the finger) every visit. The DPCS 2 then reviewed Patient 3’s records titled, Clinical Note dated 5/23/2026, 5/28/2026, and 5/30/2026. All the notes indicated Patient 3 was experiencing shortness of breath (SOB). The DPCS 2 stated the notes did not indicate Patient 3’s oxygen saturation was monitored. The DPCS 2 stated it was important to monitor Patient 3’s oxygen saturation levels because Patient 3 was experiencing shortness of breath. The oxygen levels would have determined if Patient 3 needed oxygen. Patient 3 could have fallen, passed out, and/or experienced difficulty breathing if her oxygen levels were low. 2. During a record review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care (POC)” dated from 4/13/2026 to 6/11/2026, indicated a start of care of 2/12/2026, with a primary diagnosis of polyarthritis (joint pain, swelling and stiffness on five or more joints). The form also indicated Patient 7 was to have Certified Home Health Aide (CHHA) home visits once a week for nine weeks. The form did not indicate the task for the CHHA. During a record review of Patient 7’s medical record form titled “Supplemental Plan of Treatment” dated from 4/21/2026 to 6/11/2026, indicated Patient 7 was to have CHHA home visits once a week for nine weeks. Some of the tasks the CHHA had was to assist with ROM (range of motion) exercise, light housekeeping, and maintenance of patient care areas. During a record review of Patient 7’s medical record form titled “Home Health Assignment Sheet Parameters to Notify Manager” undated, form inside Patient 7’s home HHA folder, indicated it was incomplete. The form did not indicate: the name, frequency, and duration of the CHHA, the goals for care, blood pressure, pulse rate, respiration rate, or temperature parameters, any precautionary or other pertinent patient information, or any special and safety measures. Lastly, the form did not indicate it was signed or dated by an HHA staff member. During a concurrent observation, interview and record review on 6/10/2026 at 1:30 p.m. at Patient 7’s residence, Patient 7’s medical record form titled “Home Health Assignment Sheet Parameters to Notify Manager” undated, was reviewed with Patient 7. Patient 7 stated that she (Patient 7) was not aware of the form and that Certified Home Health Aide 4 (CHHA4) assist her (Patient 7) in the shower, washing her (Patient 7) hair, and taking the blood pressure. Patient 7 stated she (Patient 7) was not aware that CHHA4 was able to perform light housekeeping or nail care. During an interview on 6/10/2026 at 1:30 p.m. with the DPCS2, DPCS2 stated that it was important to create a Certified Home Health Aide (CHHA) plan of care (POC - a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) to ensure the CHHAs follow the patients plan of care. The DPCS2 stated that the patients should also be aware of what their CHHA plan includes because they are participants in their care. Lastly, DPCS2 stated that patients had the potential to lack care thereby placing the patients at risk of infection and/or hospitalization. 3. During a record review of Patient 8’s record titled, SOC Worksheet indicated a start of care date on 5/12/2026. During a record review of Patient 8’s referral order, dated 4/22/2026, indicated the HHA was to provide Physical Therapy (PT), Occupational Therapy (OT), and Nursing services for medication and skin management. During a concurrent interview and record review on 6/9/2026 at 1:25 p.m. with DPCS 2, DPCS 2 reviewed Patient 8’s record titled, Home Health Certification and Plan of Care (POC), for certification period 5/12/2026-7/10/2026. The record indicated Patient 8 had heart failure (the heart is unable to pump blood effectively to the body). Further review of the record indicated empty sections for medication, supplies, safety measures, nutritional requirements, allergies, functional limitations, activities permitted, mental status, prognosis, orders for disciplines and treatments, goals, and nurse’s signature. The DPCS 2 stated the POC was not completed and needed to have been completed by the 7th day from the start of care, which was 5/20/2026. During a concurrent interview and record review on 6/9/2026 at 1:26 p.m. with DPCS 2, DPCS 2 reviewed Patient 8’s record titled, Comprehensive Adult Assessment, dated 5/12/2026. The DPCS 2 stated based on the assessment, the nurse should have spoken to the doctor and received an order for medication management, nutrition, diabetic management, glucose management, and insulin management. The DPCS stated the comprehensive assessment was used to create the plan of care. During a concurrent interview and record review on 6/9/2026 at 1:43 p.m. and 2:02 p.m., with DPCS 2, DPCS 2 reviewed Patient 8’s medical records. The DPCS 2 stated there were no admission orders in the medical record. Admission orders were important, so the HHA knew exactly what to do with the patient and to accurately write the plan of care. Without doctor’s admission order, Patient 8 was at risk of not getting adequate care. Essentially, non-compliance with the treatment plan. The DPCS 2 stated Patient 8 was not getting OT services and did not know the reason why. During an interview on 6/11/2026, at 11:00 a.m., with the Administrator (ADM), the ADM stated that Patient 8 was not receiving nursing services because Patient 8 probably refused the services. During an interview on 6/11/2026 at 11:07 a.m. with the OM, the OM stated Patient 8’s caregiver “probably” refused nursing services. The OM reviewed Patient 8’s medical records and stated there was no documentation to indicate Patient 8’s refusal of nursing services and no indication Patient 8’s doctor was informed of the refusal. During an interview on 6/11/2026 at 11:09 a.m., with the DPCS 2, the DPCS 2 stated Patient 8’s doctor needed to have been informed of refusal of nursing services, obtain an order to discontinue nursing services. All communication between staff and doctors needed to be documented. During a record review of the HHA’s document titled, Clinical Director/Director of Patient Care Services, dated January 2018, indicated, “The Clinical Director is responsible for the overall direction of home health clinical services. The Clinical Director establishes, implements and evaluates goals and objectives for home health services that meet and promote the standards of quality and contribute to the total organization and philosophy. The Clinical Director also serves as the Clinical Manger for the purposes of meeting the Medicare Conditions of Participation.””

“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 patient’s clinical records were completed and authenticated (formally signed and dated by the responsible healthcare staff) for two of seven sampled patients (Patient 3 and Patient 8). This failure had the potential of patients’ clinical records being compromised and privacy of the patient information will be disclosed by unauthorized personnel accessing the patients’ clinical record. During an interview on 6/9/2026 at 11:15 a.m. with the Administrator (ADM), stated that skilled nurses (SNs) take their personal laptops to the HHA to document their visit notes. The ADM stated the SNs print their notes to be placed in the patients hard copy medical record. During an interview on 6/9/2026 at 12:35 p.m. with the Director of Patient Care Services (DPCS2), stated SNs document their home visit notes on a hard copy then bring or email the hard copy to the Office Manager (OM). The OM then uploads the hard copy into the HHA Electronic Medical Record (EMR). DPCS2 stated that SN visit notes should be in the patient’s medical record within 5 days of the visit to develop a care plan. During an interview on 6/9/2026 at 12:41 p.m. with the Office Manager (OM), the OM stated that SNs (skilled nurse) type their home visit notes in the office computers using a PDF (Portable Document Format – a universal file format that preserves a document exact layout, fonts, and images). The OM stated that the SN home visit notes are uploaded in the HHAs EMR (electronic medical record), then are printed and placed into the patients hard copy medical record. During an interview on 6/9/2026 at 12:52 p.m. with DPCS2, stated that nurses log into their personal email, use a SN visit note template to document in Google Docs (an electronic document supported by Google-registered trademark), print out their notes to be uploaded into the HHAs EMR. DPCS2 stated that she considers their typed name, under their personal email while using Google Docs, acceptable. DPCS2 stated that when SN type their names using their personal email, Google Docs, they authenticate the SN home visit note. DPCS2 stated that she was able to verify the nurse who wrote the patient note by asking the author and looking at the cameras in the HHA. During an interview on 6/9/2026 at 1:18 p.m. with DPCS2, stated that the SN’s unique identifier was their personal email. During an interview on 6/11/2026 at 11:28 a.m. with LVN3, stated she sees patients on an on-call basis. LVN3 stated that the Office Manager (OM) provided her with the password to document her patient visit notes in the HHA’s electronic medical record system (EMR). 1. During a record review of Patient 3’s record titled SOC Worksheet, it indicated a start of care date on 1/22/2026. During a concurrent interview and record review on 6/9/2026 at 12:04 p.m. with Director of Patient Care Services 2 (DPCS 2), reviewed Patient 3’s record titled, Home Health Certification and Plan of Care (POC) for certification period 5/22/2025-7/20/2026. The DPCS 2 stated the POC was not signed. The POC was supposed to be signed by a Registered Nurse (RN) by 5/20/2026. There was no documented evidence the RN signed the POC for certification period 5/22/2025-7/20/2026. 2. During a record review of Patient 8’s record titled, Home Health Certification and Plan of Care, for certification period 5/12/2026-7/10/2026, indicated a start of care date on 5/12/2026 with a primary diagnosis of heart failure. During a concurrent interview and record review on 6/9/2026, at 1:10 p.m., with the DPCS 2, reviewed Patient 8’s record titled, Comprehensive Adult Nursing Assessment, dated 5/12/2026. The DPCS 2 stated the record was an electronic PDF form. The nurse had to type the information or click on a box to enter the information, using Google drive (an electronic storage system). All the information entered was typed on a keyboard, therefore, it was considered electronic writing. The DPCS 2 stated, “yes, we are using electronic methods to type a note.” The DPCS 2 stated the typed note was verified/authenticated by typing in the name of the nurse who typed the note. The DPCS 2 stated an EMR required a username and password to finalize the note, as a method of validating the note. The EMR requires a password to ensure it is the actual nurse assigned to the patient-the one who wrote the note. The DPCS 2 stated legal documents can be signed electronically. The validation that legal records are signed is a verbiage that says, “electronically signed”. The DPCS 2 stated patient records were considered legal documents, therefore, the signature of the document needed to indicate the record was signed electronically. The DPCS stated Patient 8’s Comprehensive Adult Nursing Assessment, dated 5/12/2026, did not indicate the record was signed electronically. During a record review of the HHA’s undated document titled, Medical Record Entries and Authentication Policy, indicated, “Authentication Requirements Acceptable authentication methods include handwritten signatures, electronic signatures, and secure electronic authentication processes approved by the Agency. Electronic signatures shall be unique to the user and shall not be shared.” During a record review of the HHA’s undated document titled, Person or Entity Authentication, indicated, “The Organization will maintain a documented authentication process for verifying the identity of any person or entity of any person...The Organization will use appropriate authentication methods to confirm that only properly authenticated and authorized persons or entities access ePHI...The authentication processes may include...Uniquely identifiable authentication identifiers in order to track the identifier to a workforce member.””

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: The HHA failed to ensure four of seven sample patients (Patient 3, Patient 7, Patient 8, and Patient 9) received all services listed in their Plan of Care (POC - a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitation, and supportive care provided to a patient at home). This failure had the potential to result in patients not receiving the ordered care thereby delaying their recovery. 1a. During a review of Patient 3’s clinical record titled, SOC (Start of Care) Worksheet, the SOC indicated Patient 3 had a start of care date on 1/22/2026. During a concurrent interview and record review on 6/9/2026 at 3:33 p.m.with the Director of Patient Care Services (DPCS 2), Patient 3’s medical record was reviewed. The DPCS 2 stated there was no recertification doctor’s order for the certification period 5/22/2026-7/20/2026 in Patient 3’s medical record. During an interview on 6/9/2026 at 3:43 p.m. with the DPCS 2, the DPCS 2 stated it was the responsibility of the DPCS to get the order from the doctor to recertify Patient 3 for HHA services. The importance of the doctor order for recertification was for everyone to know what needed to be done for the patient. The DPCS 2 stated she reviewed Patient 3’s medical records and there was no document in the record to support the HHA received a recertification order. The DPCS 2 stated they were providing services without a doctor’s order. The DPCS 2 stated, legally, the doctor can say the services were not ordered if there was no documented doctor’s order. During an observation of the home visit on 6/10/2026 at 11:30 a.m., observed Licensed Vocational Nurse 2 (LVN 2) providing wound care to Patient 3’s left heel. LVN 2 removed the dressing (a type of bandage) on Patient 3’s left heel, cleaned with normal saline (a type of salt-based solution), pat dry, and applied medihoney (an ointment that is used for wound care) on an alginate dressing (a special kind of bandage) to the left heel. LVN 2 applied sterile gauze (a type of bandage) and wrapped the left heel with Kerlix (a type of bandage). During a concurrent interview and record review on 6/10/2026 at 12:04 p.m. with LVN 2, LVN 2 reviewed Patient 3’s record titled, Home Health Certification and Plan of Care (POC) for certification period 5/22/2025-7/20/2026. The record indicated the skilled nurse (SN) was to perform wound care as follows: “Cleanse with normal saline, gently pat dry, apply Betadine (a type of cleaning solution) ointment as a moisture barrier wrap with ABD (a type of bandage), rolled gauze, secure with tape, cover with dry dressing/non-adherent dressing…”. LVN 2 stated she provided wound care according to the doctor’s orders the HHA sent her the day of the home visit, 6/10/2026 through text messaging. LVN 2 stated she did not know why the orders received from the HHA, and the wound care provided to Patient 3, were not in the plan of care. During an interview on 6/11/2026 at 1:07 p.m., with the Office Manager (OM), the OM stated the wound care order for Patient 3 came from the wound care specialist. The OM stated the wound care order was documented in the wound care specialist record. During a concurrent interview and record review on 6/11/2026 at 1:08 p.m. with the DPCS 2, the DPCS 2 reviewed Patient 3’s record titled, Professional Wound Specialist, dated 6/5/2026. The DPCS 2 stated there were no wound care orders in the document. The DPCS 2 reviewed Patient 3’s medical records and stated there were no wound care orders in the record. The DPCS 2 stated the wound care orders would have been included in the recertification order for the certification period beginning on 5/22/2026. However, there were no recertification orders for Patient 3. The DPCS 2 further stated that the importance of having orders was to validate the treatment provided, was coming from the doctor and so the doctor is aware of the patient condition. The risk of not having doctor’s orders for wound care for Patient 3 was not receiving the treatment ordered by the doctor which can result in the wound not healing or getting worse. 1b. During a concurrent interview and record review on 6/11/2026 at 1:13 p.m. with the DPCS 2, the DPCS 2 reviewed Patient 3’s record titled Home Health Certification and Plan of Care (POC) for certification period 5/22/2025-7/20/2026. The record indicated the SN was to assess and monitor the wound for signs of infection and deterioration. Further review of the record also indicated the SN was to perform wound care 3 times a week. The DPCS 2 stated the SN needed to assess and document the wound assessment every SN visit. Assessment involved wound size, appearance, discharge and any sign and symptoms of infection. The DPCS 2 stated the importance of wound assessment was to determine if the treatment was effective. If the wound was not assessed, lack of assessment placed the patient at risk of the wound not healing and infection which can cause hospitalization or death. The DPCS 2 then reviewed Patient 3’s record titled Clinical Note, dated 5/23/2026. The DPCS 2 stated there was no wound assessment and wound care documented in the record. The DPCS 2 stated the SN did not follow the POC. During a concurrent interview and record review on 6/11/2026 at 1:20 p.m. with the DPCS 2, the DPCS 2 reviewed Patient 3’s record titled, Clinical Note, dated 5/28/2026. The DPCS 2 stated there was no wound assessment and wound care documented in the record. The DPCS 2 stated the SN did not follow the POC. During a concurrent interview and record review on 6/11/2026 at 1:21 p.m. with the DPCS 2, the DPCS 2 reviewed Patient 3’s record titled, Clinical Note, dated 5/30/2026. The DPCS 2 stated there was no wound assessment and wound care documented in the record. The DPCS 2 stated the SN did not follow the POC. 1c. During a concurrent interview and record review on 6/11/2026 at 1:30 p.m. with the DPCS 2, the DPCS 2 reviewed Patient 3’s record titled Home Health Certification and Plan of Care (POC) for certification period 5/22/2025-7/20/2026. The record indicated the SN was to check Patient 3’s oxygen saturation levels (the percentage of oxygen in the blood. Done by placing a measuring device on the finger) every visit. The DPCS 2 then reviewed Patient 3’s records titled, Clinical Note dated 5/23/2026, 5/28/2026, and 5/30/2026. All the notes indicated Patient 3 was experiencing shortness of breath (SOB). The DPCS 2 stated the notes did not indicate Patient 3’s oxygen saturation was monitored. The DPCS 2 stated it was important to monitor Patient 3’s oxygen saturation levels because Patient 3 was experiencing shortness of breath. The oxygen levels would have determined if Patient 3 needed oxygen. Patient 3 could have fallen, passed out, and/or experienced difficulty breathing if her oxygen levels were low. 2. During a record review of Patient 7’s medical record form titled, “Home Health Certification and Plan of Care (POC)”, dated from 4/13/2026 to 6/11/2026, indicated a start of care of 2/12/2026, with a primary diagnosis of polyarthritis (joint pain, swelling and stiffness on five or more joints). The form also indicated Patient 7 was to have Skilled Nurse (SN) visits twice a week for two weeks then, once a week for seven weeks, starting 4/13/2026. During a concurrent interview and record review on 6/9/2026 at 2:30 p.m. with the DPCS 2, Patient 7’s medical record was reviewed, the DPCS 2 stated that LVN 4 conducted SN home visits for Patient 7 on Wednesdays. The DPCS 2 stated that LVN4 was at the HHA last week but did not leave Patient 7’s SN visit note for that week. The last SN visit note was on 5/27/2026. During an interview on 6/10/2026 at 1:18 p.m. with Patient 7, Patient 7 stated a “shower nurse” named “CHHA4” (Certified Home Health Aide - state-certified caregiver who provides hands-on, personal healthcare and daily living assistance to elderly, chronically ill, or disabled individuals directly in their homes) comes to her home every Wednesday. Patient 7 stated that there are other nurses from the HHA that visit her once or maybe twice a month, but not weekly like her assigned shower nurse. 3. During a record review of Patient 8’s record titled, SOC Worksheet, the document indicated a start of care date on 5/12/2026. During a record review of Patient 8’s referral order, dated 4/22/2026, the document indicated the HHA was to provide Physical Therapy (PT), Occupational Therapy (OT), and Nursing services for medication and skin management. During a concurrent interview and record review on 6/9/2026 at 1:25 p.m. with the DPCS 2, the DPCS 2 reviewed Patient 8’s record titled, Home Health Certification and Plan of Care (POC), for certification period 5/12/2026-7/10/2026. The record indicated Patient 8 had heart failure (the heart is unable to pump blood effectively to the body). Further review of the record indicated blank sections for medication, supplies, safety measures, nutritional requirements, allergies, functional limitations, activities permitted, mental status, prognosis, orders for disciplines and treatments, goals, and nurse’s signature. The DPCS 2 stated the POC was not completed and needed to have been completed by the 7th day from the start of care, which was 5/20/2026. During a concurrent interview and record review on 6/9/2026 at 1:26 p.m. with the DPCS 2, the DPCS 2 reviewed Patient 8’s record titled, Comprehensive Adult Assessment, dated 5/12/2026. The DPCS 2 stated based on the assessment, the nurse should have spoken to the doctor and received an order for medication management, nutrition, diabetic management, glucose management, and insulin management. The DPCS stated the comprehensive assessment was used to create the plan of care. During a concurrent interview and record review on 6/9/2026 at 1:43 p.m. and 2:02 p.m., with the DPCS 2, the DPCS 2 reviewed Patient 8’s medical records. The DPCS 2 stated there were no admission orders in the medical record. Admission orders were important, so the HHA knew exactly what to do with the patient and to accurately write the plan of care. Without doctor’s admission order, Patient 8 was at risk of not getting adequate care. Essentially, non-compliance with the treatment plan. The DPCS 2 stated Patient 8 was not getting OT services and did not know the reason why. During an interview on 6/11/2026, at 11 a.m., with the Administrator (ADM), the ADM stated that Patient 8 was not receiving nursing services because Patient 8 probably refused the services. During an interview on 6/11/2026 at 11:07 a.m. with the OM, the OM stated Patient 8’s caregiver “probably” refused nursing services. The OM reviewed Patient 8’s medical records and stated there was no documentation to indicate Patient 8’s refusal of nursing services and no indication Patient 8’s doctor was informed of the refusal. During an interview on 6/11/2026 at 11:09 a.m., with the DPCS 2, stated Patient 8’s doctor should have been informed of patient’s refusal of nursing services, and obtain an order to discontinue the services. The DPCS 2 stated all communication between staff and doctors needed to be documented. 4a. During a record review of Patient 9’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/19/2026 to 6/17/2026, indicated a start of care of 12/20/2025. The form also indicated Patient 9 was to have Skilled Nurse (SN) visits twice a week for two weeks then, once a week for seven weeks. During an interview on 6/9/2026 at 12:35 pm with DPCS 2, stated SN visit notes should be in the patient’s medical record within 5 days of the visit to develop a care plan. During a concurrent interview and record review on 6/9/2026 at 2:38 p.m. with the DPCS 2, Patient 9’s medical chart was reviewed. Patient 9’s medical record indicated no nursing notes for home visits on 5/20/2026, 5/27/2026, and 6/3/2026. DPCS 2 stated that License Vocational Nurse 4 (LVN 4) conducted SN visits weekly, but “there are no nursing notes nor missed visit documentation for home visits on 5/20/2026, 5/27/2026, and 6/3/2026. If there are no nursing notes, it is not possible to plan for patient care and the Interdisciplinary Team (IDT - a collaborative group of medical professionals and support staff who work together to plan, deliver, and evaluate unified patient care) cannot evaluate and plan for the patient’s future care.” During an interview on 6/9/2026 at 3:10 pm with LVN 4, stated, “I submitted Patient 9’s nursing notes for home visits on 5/20/2026 & 5/27/2026 to the office, but I don’t remember when I submitted them. I have not submitted Patient 9’s nursing notes for a home visit on 6/3/2026. The notes are due within a week, but it takes me 10-14 days to submit them. Without nursing notes, the treatment plan may not be followed, the patient may not get the care they require, and the patient could end up in the hospital.” 4b. During a record review of Patient 9’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/19/2026 to 6/17/2026, indicated a start of care of 12/20/2025. The form also indicated Patient 9 was to have Certified Home Health Aide (CHHA – state-certified caregiver who provides hands-on, personal healthcare and daily living assistance to elderly, chronically ill, or disabled individuals directly in their homes) visits twice a week for nine weeks. During an interview on 6/9/2026 at 12:35 pm with the DPCS 2, stated CHHA visit notes should be in the patient’s medical record within 5 days of the visit to develop a care plan. During a concurrent interview and record review on 6/9/2026 at 2:38 p.m. with the DPCS 2, Patient 9’s medical record was reviewed. Patient 9’s medical record indicated no CHHA notes for home visits on 6/1/2026 and 6/4/2026. DPCS 2 stated CHHA 4 conducted home visits for Patient 9 twice a week, but “there are no CHHA notes nor missed visit documentation for home visits on 6/1/2026 and 6/4/2026. If there are no CHHA notes, it is not possible to plan for patient care and the Interdisciplinary Team (IDT - a collaborative group of medical professionals and support staff who work together to plan, deliver, and evaluate unified patient care) cannot evaluate and plan for the patient’s future care.” 4c. During an interview on 6/10/2026 at 2 pm with Patient 9, Patient 9 stated, “I need physical therapy, but I’ve only seen them for six evaluations and six visits in the last 5 months.” During a concurrent interview and record review on 6/11/2026 at 12:18 pm with DPCS 2, Patient 9’s “Therapy Order,” dated 5/16/2026 was reviewed. The Therapy Order indicated physical therapy (PT - healthcare treatment designed to help individuals recover, improve, or maintain their physical movement, strength, and function) for Patient 9 once a week for one week, then twice a week for two weeks, then once a week for one week, starting week of 5/15/2026. The DPCS stated a physical therapist evaluated Patient 9 on 5/15/2026, performed PT once on 5/19/2026, and “there are no other PT notes or missed visit documentation.” DPCS 2 stated if PT orders are not followed, “Patient 9’s arthritis may worsen and result in more pain, physical decline and becoming completely bed bound.” During a review of the agency’s Policy and Procedure Titled, “Rights/Responsibilities”, revised 1/2018, indicated that “Each patient will be an active, informed participant in his/her plan of care...the organization shall ensure that the patient receives all services outlined in the plan of care.” During a review of the agency’s Policy and Procedure Titled, “Care Planning Process”, revised 1/2018, indicated that “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.” During a review of the agency’s Policy and Procedure Titled, “Care Planning Process”, revised 1/2018, indicated that“Based on the assessment and conclusions, the plan of care will include, but not be limited to: Patient specific interventions and education; all patient care orders from all physicians involved in the plan of care, including verbal orders; specific services and treatments to be provided; all pertinent diagnosis; all medications…” During a review of the agency’s Policy and Procedure Titled, “Care Planning Process”, revised 1/2018, indicated that “The patient and family/caregiver will participate in decisions regarding the plan of care whenever possible.” During a review of the agency’s Policy and Procedure Titled, “Care Planning Process”, revised 1/2028, indicated that “The organization shall provide the patient and caregiver with a copy of written instructions outlining: visit schedule…, patient medication… schedule/instructions, any treatment to be administered...” During a review of the agency’s Policy and Procedure Titled, “Timely Submission of Patient Documentation Policy”, not dated, indicated that “All clinical personnel shall complete and submit patient documentation within Agency – establish timeframe. Documentation shall accurately reflect services rendered and be submitted timely for clinical review, care coordination, quality assurance, and billing. Visit notes, start of care, recertification, resumption of care, and discharge documentation shall be completed and submitted within 14 days of the visit.””

“Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. 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 therapeutics service to a patient at home) failed to ensure that patient clinical records were safeguarded through a secured platform for six of seven sample patients (Patient 3, Patient 7, Patient 8, Patient 9, Patient 11, and Patient 12). This failure had the potential to result in unauthorized access to confidential patient information because the data was not fully encrypted (a method to protect sensitive information from hackers, spies, and unauthorized access) during transit to the patient’s electronic medical records. During an interview on 6/9/2026 at 12:41 p.m. with the Office Manager (OM), the OM stated that SNs (skilled nurse) type their home visit notes in the office computers using a PDF (Portable Document Format – a universal file format that preserves a document exact layout, fonts, and images). The OM stated that the SN home visit notes are uploaded in the HHAs EMR (electronic medical record), then are printed and placed into the patients hard copy medical record. During an interview on 6/9/2026 at 12:52 p.m. with the Director of Patient Care Services 2 (DPCS 2), the DPCS 2 stated that nurses log into their personal email, use a SN visit note template to document in Google Docs (an electronic document supported by Google-registered trademark), then they print out their notes to be uploaded into the HHAs EMR. The DPCS2 stated that she (DPCS 2) considers their (staff) typed name, under their (staff) personal email while using Google Docs, acceptable. The DPCS 2 stated that when SN type their (staff) names using their(staff) personal email, Google Docs, they (staff) authenticate the SN home visit note. The DPCS 2 stated that she (DPCS 2) was able to verify the nurse who wrote the patient note by asking the author and looking at the cameras in the HHA. During an interview on 6/9/2026 at 1:18 p.m. with the DPCS2, the DPCS2 stated that the SN’s unique identifier was their personal email. 1. During a record review of Patient 3’s record titled SOC (Start of Care) Worksheet, the document indicated a start of care date on 1/22/2026. During a concurrent observation and interview on 6/10/2026 at 12:04 p.m. with Licensed Vocational Nurse 2 (LVN 2), an observation of the text message indicated a photo of wound care treatment sent to a standard phone text message. LVN 2 stated that the HHA had sent her wound care orders through text messaging, to her (LVN 2) personal phone, for the 6/10/2026 home visit. During a record review of the HHA’s undated form titled, “Access Controls: Technical Safeguards”, indicated, “Texting of personal information or any ePHI must be accomplished through a secure text messaging platform. 2. The platform should include, at a minimum, the following components A. Secure sign-on process; B. Encrypted messaging...”. 2. During a record review of Patient 7’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 4/13/2026-6/11/2026, the document indicated a start of care date on 2/12/2026 with a primary diagnosis of polyarthritis (joint pain, swelling and stiffness on five or more joints). During a record review of Patient 7’s medical record titled, “Recertification/Follow-up Assessment”, dated 4/11/2026, the document did not indicate that it was electronically signed or had a wet signature of the nurse completing the form. The form indicated Registered Nurse 1’s (RN1) name was typed under section “Person completing this form (signature/title)”. 3. During a record review of Patient 8’s record titled, Home Health Certification and Plan of Care, for certification period 5/12/2026-7/10/2026, the document indicated a start of care date on 5/12/2026 with a primary diagnosis of heart failure. During an interview on 6/9/2026, at 12:52 p.m. with the OM, the OM stated the nurse sent Patient 8’s comprehensive assessment through email (an electronic method of sending documents) on 5/29/2026. During a record review of the HHA’s document title, Gmail, dated 5/29/2026, indicated Patient 8’s full name in the subject line and two (2) attachments. The attachments included Patient 8’s comprehensive assessment and medication list. During a concurrent interview and record review on 6/9/2026, at 1:10 p.m. with the DPCS 2, the DPCS 2 reviewed Patient 8’s record titled, Comprehensive Adult Nursing Assessment, dated 5/12/2026. The DPCS 2 stated the record was an electronic PDF form. The nurse had to type the information or click on a box to enter the information, using Google drive (an electronic storage system). All the information entered was typed on a keyboard, therefore, it was considered electronic writing. The DPCS 2 stated, “yes, we are using electronic methods to type a note.” The DPCS 2 stated the typed note is verified/authenticated by typing in the name of the nurse who typed the note. The DPCS 2 stated an EMR requires a username and password to finalize the note, as a method of validating the note. The EMR requires a password to ensure it is the actual nurse assigned to the patient-the one who wrote the note. The DPCS 2 stated legal documents can be signed electronically. The validation that legal records are signed is a verbiage that says, “electronically signed”. The DPCS 2 stated patient records were considered legal documents, therefore, the signature of the document needed to indicate the record was signed electronically. The DPCS stated Patient 8’s Comprehensive Adult Nursing Assessment, dated 5/12/2026 did not indicate the record was signed electronically. 4. During a record review of Patient 9’s medical record titled, “Home Health Certification and Plan of Care” (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home), dated 4/19/2026 to 6/17/2026, indicated a start of care of 12/20/2025, with a primary diagnosis of polyarthritis, unspecified. During a concurrent interview and record review on 6/9/2026 at 1:12 pm with the DPCS 2, Patient 9’s “Comprehensive Adult Nursing Assessment”, dated 4/17/2026, and nine “General Patient Communications” for physician’s orders, dated 5/12/2026, were reviewed. The “Comprehensive Adult Nursing Assessment” did not indicate it was electronically signed or had a wet signature of the physician initiating the verbal order under the section “Physician Signature for Verbal Order or see Plan of Care/Verbal Orders”. The “Comprehensive Adult Nursing Assessment” did not indicate it was electronically signed or had a wet signature of the person receiving the verbal order under the section “Signature/Title of Person Who Received Verbal Order.” The “Comprehensive Adult Nursing Assessment” did not indicate it was electronically signed or had a wet signature of Nurse 1 under the section “Person Completing This Form (signature/title). The form indicated Registered Nurse 1’s (RN1) name was typed under section “Person completing this form (signature/title)”. The nine “General Patient Communications” for physician’s orders indicated no electronic or wet signature of the physician completing the form. DPCS 2 stated, the only way they “authenticate their documents is by typing their name, but they do not say “electronically signed.” Wet signatures are not on every document. 5. During a record review of Patient 11’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 4/16/2026 to 6/14/2026, indicated a start of care date on 2/12/2026 with a primary diagnosis of hereditary and idiopathic neuropathy (peripheral nerve damage). During a record review of Patient 11’s medical record titled, “Recertification/Follow-up Assessment”, dated 4/12/2026, the document did not indicate that it was electronically signed or had a wet signature of the nurse completing the form. The document indicated Registered Nurse 1’s (RN1) name was typed under section “Person completing this form (signature/title)”. 6. During a record review of Patient 12’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 3/25/2026 to 5/23/2026, indicated a start of care date on 3/25/2026 with a primary diagnosis of type II diabetes (body unable to resist or make insulin causing sugar buildup in the blood). During a record review of Patient 12’s medical record titled, “Discharge Assessment”, dated 5/22/2026, the document did not indicate that it was electronically signed or had a wet signature of the nurse completing the form. The document indicated Registered Nurse 2’s (RN2) name was typed under section “Person completing this form (signature/title)”. During a record review of the HHA’s Policies and Procedure titled, “Rights/Responsibilities”, revised 1/2018, the Policies and Procedure indicated, “The patient will be informed verbally and in writing during the initial evaluation visit...M. The right to privacy, security, and respect of property and person.” During a record review of the HHA’s Policies and Procedure titled, “Access Controls: Technical Safeguards”, not dated, indicated, “The Organization will ensure that ePHI (electronic patient health information) systems support, and are installed with technical safeguards, to control and restrict access to such ePHI systems to persons and software programs that are authorized to have such access.””

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. 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 therapeutics service to a patient at home) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding Patient Rights were met as follows: 1. The Home Health Agency (HHA) failed to investigate and resolve a complaint submitted by a patient’s family, for one of seven sampled patients (Patient 5). This deficient practice interfered with the patients and family’s right to have concerns addressed in a timely manner. (Refer to G478) 2. The HHA failed to ensure that it’s established process for receiving, investigating, and documenting complaints and grievances from patients and/or their representatives was followed for one of seven sampled patients (Patient 5). This deficient practice placed Patient 5, as well as other patients, at risk for unresolved grievances, which could potentially impact patient safety and quality of care. (Refer to G484) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal Regulations for Patient Rights to ensure highest quality health care is provided to patients assessed to receive home health services.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Comprehensive Assessment of Patients was met as follows: 1. The HHA nursing staff failed to assess the pressure ulcer wound (injuries to the skin due to prolong pressure on the skin) for one of seven sampled patients (Patient 3). This failure had the potential to result in undetected changes in the condition of the wound, leading to delayed healing and an increased risk of infection, thereby prolonging the patient’s pain and discomfort. (Refer to G528) 2. The HHA failed to properly assess the continuing need for home care services for two of seven sampled patients (Patient 1 and Patient 6). This deficient practice resulted in the provision of unnecessary home health services to patients who did not need skilled nursing services. (Refer to G532) 3. The HHA failed to maintain an accurate, current medication profile for two of seven sampled patients (Patient 1 and Patient 6). This failure had the potential to place the patients at risk for medication errors and adverse drug reactions (a harmful, unintended reaction to a medication). (Refer to G536) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulations for Comprehensive Assessment of patients to ensure the highest quality of care was being provided to patients certified to receive home health care and services.”

“Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for home health aide services as follows: 1. The HHA failed to ensure that Certified Home Health Aides (CHHAs) were evaluated for competency prior to providing care for three of seven sampled patients (Patient 1, Patient 3, and Patient 7). (Refer to G768). This failure resulted in patients receiving services from incompetent CHHAs, which had the potential to lead to patient injury and substandard care. 2. The HHA failed to maintain documentation of the CHHAs training records for three of seven sampled patients who were receiving CHHA service (Patient 1, Patient 3, and Patient 7. (Refer to G778). This failure resulted in the agency being unable to prove staff competency, ensure patient safety, and comply with the federal regulation. 3. The HHA failed to generate a written plan of care related to CHHA’s responsibilities for two of seven sampled patients (Patient 1 and Patient 7). (Refer to G798). This failure resulted in the patients receiving CHHA services without a written plan of care that served as a guidance for the aides. 4. The HHA failed to ensure that the care provided by CHHAs were supervised for one of seven sampled patients (Patient 1). (Refer to G808). This failure had the potential to result in endangering patients’ health and well-being. The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for home health aide services to ensure home health benefits and services were furnished in accordance with accepted standards of practice.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for the Organization and Administration of Services as follows: 1. The HHA’s administrator (ADM) failed to ensure the process of addressing, documenting, and investigating complaints and/or grievances by patient and/or patient family or caregiver was completed for one out of seven sampled patients (Patient 5). (Refer to G948). This deficient practice placed Patient 5 and other patients at risk that grievances presented to the HHA will not be addressed and resolved, potentially compromising patient safety. 2. The HHA’s ADM failed to ensure that the HHA employed qualified Certified Home Health Aides (CHHAs) for three of seven sampled patients (Patient 1, Patient 3, and Patient 5). (Refer to G952). This failure resulted in patients receiving services from incompetent CHHAs, which may lead to patient injury, patient neglect, and substandard quality of care. The cumulative effect of these systemic practices resulted in the failure of the agency to deliver statutorily (written law) mandated Federal compliance for Organization and Administration of Services to ensure the highest quality of care were provided to patients certified to receive home health care and service.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for clinical records as follows: 1. The HHA failed to ensure the clinical records included complete and accurate assessments from the most recent home health admission, clinical notes, plans of care, and physician orders that reflected the patients’ current health status for three of seven sampled patients (Patient 1, Patient 3, and Patient 7). (Refer to G1012). This failure resulted in patients not having complete clinical records, placing patient safety at risk by increasing the chance of errors in medication, treatment, and diagnoses, increasing the risk for a lack in continuity of care, and poor coordination between clinicians such as nurses and physicians. 2. The HHA failed to ensure that discharged patients had a discharge summary that included the information on the physician responsible for the home health plan of care, reason for admission, type of services provided and frequency, medications at the time of discharge, patient outcomes, and post-discharge instruction for one of seven sampled patients (Patient 5). (Refer to G1022). This failure might affect the patient’s continuity of care and safety post discharge. The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for clinical records to ensure home health benefits and services were furnished in accordance with accepted standards of practice.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. 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 that Certified Home Health Aides (CHHAs) were evaluated for competency prior to providing care for three of seven sampled patients (Patient 1, Patient 3, and Patient 7). This failure resulted in patients receiving services from incompetent CHHAs, which had the potential to lead to patient injury and substandard care. a. During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 11/9/2025 to 1/17/2026, the POC indicated that Patient 1 was admitted to the HHA on 11/9/2025 with a primary diagnosis of spondylosis without myelopathy (age-related wear and tear of the spine that causes pain and stiffness, but crucially does not compress the spinal cord or cause significant neurological damage). The POC indicated that Patient 1 was to receive CHHA visits twice a week for nine weeks. b. During a review of Patient 3’s POC for the certification period of 3/23/2026 to 5/21/2026, the POC indicated that Patient 3 was admitted to the HHA on 1/22/2026 with a primary diagnosis of encounter for change or removal of non-surgical dressing (visits to address dressings on wounds not created by surgery, such as injuries, chronic ulcers, or pressure sores). The POC indicated that Patient 3 was to receive CHHA visits once a week for nine weeks. c. During a review of Patient 7’s Supplemental Plan of Treatment (a document that adds, modifies, or clarifies orders within a patient’s existing plan of care) for the certification period of 2/20/2026 to 4/12/2026, the Supplemental Plan of Treatment indicated that Patient 7 was admitted to the HHA on 2/12/2026 with a primary diagnosis of spondylosis without myelopathy or radiculopathy (age-related wear-and-tear in the lower spine, involving degenerative discs and facet joint arthritis, without causing nerve compression or spinal cord damage). The Supplemental Plan of Treatment indicated that Patient 7 was to receive CHHA visits once a week for eight weeks. During a review of CHHA 1’s employee file, the employee file did not have information on CHHA 1’s date of hire. The Personnel File Checklist found in CHHA 1’s employee file was entirely blank. The Initial Competency Assessment Skills Checklist for CHHA 1 only had CHHA 1’s name on it. The Competency Validation by Preceptor column was blank. The Initial Competency Assessment Skills Checklist for CHHA 1 was not signed and dated by a supervisor or preceptor. The Home Health Aide Pre-Employment Examination was missing from CHHA 1’s employee file. The Performance Evaluation form found in CHHA 1’s employee file indicated 3 (satisfactory performance) and 4 (superior performance) ratings for the CHHA responsibilities evaluated; however, it did not list the name of the employee whose performance being evaluated or the name of the evaluator; the form was also undated. During a telephone interview with CHHA 1 on 4/15/2026 at 1:28 p.m., CHHA 1 stated she had been working for the HHA for more than one year but less than two years. CHHA 1 stated she currently visited 3 patients per week from the HHA. CHHA 1 stated that her responsibilities included giving patients shower or bed bath, dressing patients, checking patient’s skin, and transferring or helping family member transfer patients such as from bed to wheelchair. CHHA 1 stated she remembered receiving orientation from the HHA’s office manager (OM). When CHHA 1 was asked if she completed Initial Competency Assessment Skills Checklist or reviewed the Home Health Aide Pre-Employment Examination with the agency’s Director of Patient Care Services (DPCS) or the Director of Patient Care Services Designee (DPCSD), CHHA 1 stated she did not remember. During a concurrent interview and record review with the Administrator (ADM) on 4/15/2026 at 3:19 p.m., the ADM reviewed CHHA 1’s employee file. The ADM could not provide the date of hire for CHHA 1. The ADM stated that CHHA 1 had been providing patient care since November 2024. The ADM stated, “CHHA 1 was probably hired a week before the first patient visit in November 2024.” The ADM acknowledged that the HHA did not complete the Initial Competency Assessment Skills Checklist and the Home Health Aide Pre-Employment Examination for CHHA 1. The ADM stated that the Initial Competency Assessment Skills Checklist and Home Health Aide Pre-Employment Examination were supposed to be done with the Director of Patient Care Services (DPCS) or the DPCS Designee (DPCSD) before a new hire was assigned patients. The ADM stated the purpose of completing the Initial Competency Assessment Skills Checklist and Home Health Aide Pre-Employment Examination was to ensure that the CHHA was competent to perform his or her duties safely. When the ADM was asked whose Performance Evaluation form was filed in CHHA 1’s employee file, the ADM stated, “It’s supposed to be the Performance Evaluation form for CHHA 1, but since there’s no employee name then it can’t be confirmed who it belongs to.” The ADM stated that performance evaluation was supposed to be done every 3 or 4 months. Per ADM, performance evaluation needs to be done to ensure the employee was competent and met the standards for patient care. The ADM stated that the failure to validate a CHHA’s competence in performing his or her duties could result in negative outcomes, such as patient injuries, patient abuse or neglect, and legal consequences for the agency. During a review of CHHA 2’s employee file, the employee file indicated that CHHA 2 was hired on 3/3/2023. The Home Health Aide Pre-Employment Examination for CHHA 2 was blank, with only CHHA 2’s name and date of hire on the document. There was a Performance Evaluation form for CHHA 2, dated 3/3/2023, reviewed by the DPCS. The Performance Evaluation indicated a rating of 3 (satisfactory performance) for the CHHA responsibilities listed in the form. During a review of CHHA 3’s employee file, the employee file indicated that CHHA 3 was hired on 1/10/2024. The Home Health Aide Pre-Employment Examination for CHHA 3 was blank, with only CHHA 3’s name and date of hire on the document. There was a Performance Evaluation form for CHHA 3, dated 1/10/2024, reviewed by the DPCS. The Performance Evaluation indicated a rating of 2 (inconsistent performance) for the CHHA responsibilities listed in the form. During a concurrent interview and record review with the DPCSD on 4/16/2026 at 11:55 a.m., the DPCSD reviewed CHHA 2’s and CHHA 3’s employee files. The DPCSD stated that performance evaluation was determination if an employee was acting according to standards of their job description. The DPCSD stated, “Performance evaluation is very important for patient care safety, it’s the measure of how the staff is performing. It’s how we can be sure the staff can provide safe patient care. Through performance evaluation, we can evaluate their performance and provide the necessary training or in-service that they need.” When the DPCSD was asked how often Performance Evaluation should have been done for CHHA, the DPCSD stated that newly hired CHHAs were on probation for 60-90 days, they would get evaluated at the end of their probation, and annually after. During a concurrent interview and record review with the ADM on 4/16/2026 at 2:16 p.m., the ADM reviewed the employee files of CHHA 2 and CHHA 3. The ADM stated that the Home Health Aide Pre-Employment Examination was supposed to be completed by the CHHA after they were hired, but before they visited and provided services to a patient. After completing the Home Health Aide Pre-Employment Examination, the CHHA was supposed to review it with the DPCS or DPCSD to ensure they understood how to care for their patients properly. During a review of the HHA’s Policy and Procedure (P & P), titled “Job Description Summary – Certified Home Health Aide,” revised January 2018, the P & P indicated that the one of the position qualifications was a competency evaluation that meets the requirements of §484.80(c). During a review of the HHA’s P & P, titled “Performance Evaluation,” revised January 2018, the P & P indicated that performance evaluations would be completed on all employees as follows: During the probationary period.Triennially, based on personnel’s annual evaluation date.After a promotion and/or transfer.Other occasions, as performance warrants.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). 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 provide written patient care instructions for the Certified Home Health Aides (CHHA) care and services, for two of seven sampled patients (Patient 1 and Patient 7). This failure resulted in the CHHAs providing services to the patients without proper guidance, potentially compromising patient safety and the quality of care. Findings: a. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 11/19/2025. During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) document for the certification period starting from 11/19/2025 to 1/17/2026, and for the period starting from 1/18/2026 to 3/18/2026, the POC indicated Patient 1 had a diagnosis that included spondylosis without myelopathy (age-related wear and tear of the spine causing pain, stiffness, and reduced mobility), hypertensive heart disease (a condition with damage to your heart from having high blood pressure), heart failure (a condition where the heart muscle cannot pump blood efficiently enough to meet the body’s needs for oxygen and nutrients), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The POC included an order for the skilled nurse (SN) to visit Patient 1 twice a week for 2 weeks and then once a week for 7 weeks, and for CHHA to visit twice a week for nine weeks. During a concurrent interview and record review, on 4/17/2026 at 11:00 a.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD reviewed Patient 1’s POC records and CHHA weekly activity logs and notes. The DPCSD stated Patient 1 received CHHA services twice a week from November 2025 to February 2026. The DPCSD could not provide Patient 1’s CHHA care plan or written patient care instructions when requested. DPCSD stated Patient 1 should have a CHHA care plan prepared by a registered nurse as a guide for daily care and ensures patient safety. b. During a review of Patient 7’s Supplemental Plan of Treatment (a medical document that adds, modifies, or clarifies orders within a patient’s existing plan of care) for the certification period of 2/20/2026 to 4/12/2026, the Supplemental Plan of Treatment indicated that Patient 7 was admitted to the HHA on 2/12/2026 with a primary diagnosis of spondylosis without myelopathy or radiculopathy (age-related wear-and-tear in the lower spine, involving degenerative discs and facet joint arthritis, without causing nerve compression or spinal cord damage). The Supplemental Plan of Treatment indicated that Patient 7 was to receive CHHA visits once a week for eight weeks. The Supplemental Plan of Treatment did not specify the tasks or responsibilities of the CHHA regarding Patient 7. During a telephone interview with Patient 7 on 4/16/2026 at 1:43 p.m., Patient 7 stated that she was referred to the home health by her physician following a hospitalization. Patient 7 stated that her physician wanted her to receive physical therapy to help her regain her strength. Patient 7 stated that she had “a shower lady,” a nurse, and a physical therapist from the HHA. Patient 7 stated, “The shower lady helps me with shower and dressing. She applies lotion, too.” Per Patient 7, the “shower lady” and the nurse visits her once a week. During a record review of an untitled document, dated 3/28/2026, the document indicated that it was completed by CHHA 2. The document had Patient 7’s name on it. The document listed activities such as assist bath-chair, personal care, assist with dressing, hair care, skin care, and shave/groom. During a record review of an untitled document, dated 4/1/2026, the document indicated that it was completed by CHHA 2. The document had Patient 7’s name on it. The document listed activities such as assist bath-chair, personal care, assist with dressing, hair care, skin care, and shave/groom. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 4/16/2026 at 2:36 p.m., the DPCSD reviewed Patient 7’s clinical records. The DPCSD confirmed that the untitled documents dated 4/1/2026 and 3/28/2026 were the CHHA notes completed by CHHA 2 after CHHA 2’s visits to Patient 7’s home. The DPCSD stated the agency did not include instructions or orders for the CHHA because “it depends on what the patient or family wants.” The DPCSD stated that the patient or family might want the CHHA to do different things on each visit. The DPCSD stated the CHHA had to check on the CHHA note what activities they assisted the patient with, but there were no specific instructions to guide the CHHA. During a review of the HHA’s policy and procedure (P&P) titled “Home Health Aide Plan of Care,” revised January 2018, the P&P indicated each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned role. The home health aide plan of care will be individualized to the specific patient and will include at least the type of services/procedures to be provided, such as hands on personal care, the performance of simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in administering medications ordinarily self-administered.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. 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 therapeutics service to a patient at home) failed to investigate and resolve a complaint submitted by a patient’s family for one of seven sampled patients (Patient 5). This failure interfered with the patient and their family’s right to have their concerns addressed in a timely manner. Findings: During a closed record review (an evaluation of patient medical records after the patient has been discharged) of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 9/10/2024. During a closed record review of Patient 5’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) document for the certification period starting from 7/7/2025 to 9/4/2025, the POC indicated Patient 5 had a diagnosis that included hypertensive heart disease (refers to heart conditions caused by long-term, unmanaged high blood pressure) and type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar). The POC included an order for the skilled nurse (SN) to visit Patient 5 twice a week for 2 weeks and then once a week for 7 weeks, and for the certified home health aide (CHHA) to visit twice a week for 1 week and then once a week for 8 weeks. During a phone interview with Patient 5’s family member (FM 1), on 4/16/2026 at 8:16 a.m., FM 1 stated that on 8/14/2025, she (FM 1) reported and complained to the HHA’s Administrator (ADM) about CHHA 1’s handling of a bed transfer, which caused Patient 5 to be injured and sent to an acute hospital. During an interview, on 4/16/2026 at 12:20 p.m., with the ADM, the ADM stated FM 1 called on 8/14/2025 to complain about CHHA 1’s handling of Patient 5’s bed transfer. The ADM was asked for a copy of the investigation report of the complaint but was unable to provide one. During a review of the agency’s policy and procedure (P&P) titled, Complaint Resolution, revised March 2019, the P&P indicated that this policy is to provide for a prompt and equitable resolution of complaints by patients and employees. The Agency will investigate complaints made by a patient, the patient’s representative (if any) and the patient’s caregivers and family, including but not limited to, the following topics: -Treatment of care that is (or fails to be) furnished, is furnished inconsistently or is furnished inappropriately. - Mistreatment, neglect or verbal, mental, sexual and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of Comfort Care Home Health. - The lack of respect for property and/or person by anyone who is furnishing services on behalf of Comfort Care Home Health. During a review of the agency’s P&P titled, Patient Bill of Rights and Responsibilities, revised March 2019, the P&P indicated Comfort Care Home Health will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment. Patients have the right to have complaints investigated. Comfort Care Home Health will investigate complaints made by a patient, the patient’s representative (if any) and the patient’s caregivers and family.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and 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 therapeutics service to a patient at home) failed to ensure the process for addressing and documenting complaints/grievances by the patient and/or family or caregivers was completed for one out of seven sampled patients (Patient 5). This deficient practice placed Patient 5 and other patients at risk that the grievances presented to the HHA will not be addressed and resolved, potentially compromising patient safety. Findings: During a closed record review (an evaluation of patient medical records after they have been discharged) of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 9/10/2024. During a closed record review of Patient 5’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) document for the certification period starting from 7/7/2025 to 9/4/2025, the POC indicated Patient 5 had a diagnosis that included hypertensive heart disease (refers to heart conditions caused by long-term, unmanaged high blood pressure) and type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar). The POC included an order for the skilled nurse (SN) to visit Patient 5 twice a week for 2 weeks and then once a week for 7 weeks, and for the certified home health aide (CHHA) to visit twice a week for 1 week and then once a week for 8 weeks. During a phone interview with Patient 5’s family member (FM 1), on 4/16/2026 at 8:16 a.m., FM 1 stated that on 8/14/2025, she (FM 1) reported and complained to the HHA’s Administrator (ADM) about CHHA 1’s handling of a bed transfer, which caused Patient 5 to be injured and sent to an acute hospital. During an interview, on 4/16/2026 at 12:20 p.m., with the ADM, the ADM stated FM 1 called on 8/14/2025 to complain about CHHA 1’s handling of Patient 5’s bed transfer. The ADM further stated that FM 1 filed a grievance, but the agency failed to document the complaint in a grievance log in order to find a resolution to the issue as per the agency’s policy. During a review of the agency’s policy and procedure (P&P) titled, Complaint Resolution, revised March 2019, the P&P indicated that this policy is to provide for a prompt and equitable resolution of complaints by patients and employees. Agency will document both the existence of the complaint and the resolution of the complaint. Comfort Care Home Health maintains records of grievances/complaints and their outcomes and includes this information in the annual Quality Assurance/Performance Improvement report. A summary of the grievances/complaints will be reported quarterly to the governing body/owner.”

“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 therapeutics service to a patient at home) nursing staff failed to assess the pressure ulcer wound (injuries to the skin due to prolong pressure on the skin) for one of seven sampled patients (Patient 3). This failure had the potential to result in undetected changes in the wound condition, leading to delayed healing and an increased risk of infection, thereby prolonging the patient’s pain and discomfort. Findings: During a review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 1/19/2025. During a review of Patient 3’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) document for the certification period starting from 3/23/2026 to 5/21/2026, the POC indicated Patient 3 had a diagnosis that included encounter for change or removal on non-surgical dressing, blister (a bubble of fluid under the skin) left foot, and type 1 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). The POC included an order for the skilled nurse (SN) to visit Patient 3 twice a week for 2 weeks and then once a week for 7 weeks, for a full skilled nursing assessment, observation and evaluation of all bodily systems, and to perform on every visit an assessment of the blister on the left foot/heel for indications of impaired healing, including absence of a healing ridge, presence of drainage or purulent exudate (a thick, foul-smelling wound drainage) and delayed or prolonged inflammatory response. During a review of the Patient 3’s clinical record titled, Progress Notes, dated 3/6/2026 and authored by the wound care specialist nurse practitioner (NP 1), NP 1 assessed Patient 3’s wound as a deep tissue pressure injury (DTI, a serious form of pressure injury characterized by localized, purple or maroon discolored intact skin, or a blood-filled blister) of the left heel. During a concurrent interview and record review, on 4/17/2026 at 11:00 a.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD reviewed Patient 3’s skilled nurse Clinical Note dated 4/4/2026, 4/7/2026, 4/9/2026 and 4/11/2026. The DPCSD stated and acknowledged there was no documented evidence Patient 3’s left heel DTI was assessed which includes wound staging, wound location, size, presence and/or amount of drainage and peri-wound (tissue surrounding a wound) condition. The DPCSD stated skilled nurses should perform wound assessments on every visit to evaluate the wound type, stage, and severity to track healing, provide appropriate treatments and prevent complications. During a review of the HHA’s undated clinical record titled, Comfort Care Home Health Inc, the record indicated the agency shall provide safe, effective, and evidence-based wound care services under the direction of a physician or authorized practitioner. All wound care shall be performed by qualified personnel within their scope of practice. The procedure is to conduct comprehensive assessment upon admission including wound location, size (length, width, depth), tissue type (granulation, slough, eschar), drainage amount and type, odor, periwound skin condition and pain level. During a review of the agency’s policy and procedure (P&P) titled, Reassessment/Update of the Comprehensive Assessment, revised March 2019, the P&P indicated each patient will have appropriate reassessments performed and documented. Staff will additionally reassess each patient with each home visit on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided. Such reassessments will be documented on discipline-specific visit notes.”

“Continuing need for home care CFR(s): 484.55(c)(3) The patient’s continuing need for home care; 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 therapeutics service to a patient at home) failed to properly assess the continuing need for home care services for two of seven sampled patients (Patient 1 and Patient 6). This deficient practice resulted in the provision of unnecessary home health services to patients who did not require skilled nursing services. a. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 11/19/2025. During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) document for the certification period starting from 11/19/2025 to 1/17/2026, the POC indicated Patient 1 had a diagnosis that included spondylosis without myelopathy (age-related wear and tear of the spine causing pain, stiffness, and reduced mobility, heart failure (a condition where the heart muscle cannot pump blood efficiently enough to meet the body’s needs for oxygen and nutrients), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The POC included an order for the skilled nurse (SN) to visit Patient 1 twice a week for 2 weeks and then once a week for 7 weeks, for comprehensive skilled nursing assessment (a detailed, holistic evaluation of a patient’s physical, mental, emotional, and social health conducted by a licensed nurse, usually a registered nurse to create a personalized care plan, observation and evaluation of all body systems, to asses vital signs (measures the basic functions of the body that includes body temperature, blood pressure, pulse [heart rate] and respiratory [breathing] rate), pain level, and ability to perform activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The POC goal indicated Patient 1 will be free of any falls/injuries/hospitalizations, skin integrity will remain intact during episode in care and maintaining vital signs within normal parameters and will demonstrate compliance with medication and diet. The discharge planning indicated to discharge Patient 1 when Patient 1’s medical condition stabilizes and when maximum functional potential is reached. During a review of Patient 1’s Physical Therapy (PT, a healthcare specialty focused on improving movement, reducing pain, and restoring physical function through targeted exercises, manual techniques, and education) Discharge Summary form, dated 12/18/2025, the PT Discharge Summary indicated Patient 1 has reached all goals set on last evaluation, was independent for transfers and ambulation, able to commute w/bus, was not homebound and was therefore discharged from home health physical therapy. During a joint home visit, on 4/15/2026 at 12:00 p.m., with licensed vocational nurse (LVN 1) at Patient 1’s residence, Patient 1 was observed awake, alert, oriented x 3 (person, place and time), and was ambulatory with a steady gait without using an assistive device. Patient 1 was observed with no wounds, and had no medical lines or catheters (thin, flexible tubes inserted into the body to deliver fluids, medication, nutrition, or to drain fluids like urine). During an interview, Patient 1 stated, “I’m very self-sufficient, and able to care for myself alone.” Patient 1 reported taking his medications daily, had no recent falls or hospitalizations, and attends doctor appointments regularly by taking the bus or train. During a concurrent interview and record review, on 4/17/2026 at 11:00 a.m., with the Director of Patient Care Services Designee (DPCSD), Patient 1’s OASIS (or Outcome and Assessment Information Set, a standardized, comprehensive assessment tool used in home health care to evaluate adult patient clinical/functional status) Nurse Recertification form (a mandatory, comprehensive assessment conducted every 60 days to evaluate a patient’s continued need for services, update their plan of care, and determine ongoing Medicare payment) dated 1/17/2026, and skilled nursing clinical note for the month of December 2025 and January 2026 were reviewed by the DPCSD. The DPCSD stated Patient 1 had no recent hospitalizations, no falls or wound care, and normal vital signs, and had no documented need for skilled nursing care. However, DPCSD stated Patient 1 was recertified for multiple 60 days of continuous skilled nursing services. b. During a review of Patient 6’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 3/25/2026 to 5/23/2026, the POC indicated that Patient 6 was admitted to the HHA on 1/24/2026 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque buildup narrows the heart’s natural arteries, restricting blood flow without causing chest pain). The POC indicated that Patient 6 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and then one SN visit per week for seven weeks. The POC indicated that the patient’s stated goal was to maintain stable blood pressure. The POC indicated that the blood pressure parameters to notify the physician were if the systolic (the top or first number in a blood pressure reading) was greater than 160 mmHg (millimeters of mercury, a manometric unit of pressure) or lower than 90 mmHg or if the diastolic (the bottom number in blood pressure reading) was greater than 90 mmHg or lower than 60 mmHg. During a review of Clinical Note, dated 3/28/2026, Patient 6’s blood pressure was 141/80 mmHg. During a review of Clinical Note, dated 3/31/2026, Patient 6’s blood pressure was 145/75 mmHg. During a review of Clinical Note, dated 4/4/2026, Patient 6’s blood pressure was 140/79 mmHg. During a review of Clinical Note, dated 4/7/2026, Patient 6’s blood pressure was 145/77 mmHg. During a joint home visit observation with Licensed Vocational Nurse 1 (LVN 1) on 4/15/2026 at 10:30 a.m., at Patient 6’s residence, Patient 6 was observed alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 6 was observed walking independently inside the home. Patient 6 stated she lived with her husband, who was observed watching TV in the living room. During interview with Patient 6 on 4/15/2026 at 11:10 a.m., Patient 6 stated that she checked her blood pressure every morning, before she took her blood pressure medications. Patient 6 stated that her blood pressure had been stable. When Patient 6 was asked if her systolic blood pressure was often higher than 160 mmHg or lower than 60 mmHg, or if her diastolic blood pressure was often higher than 90 mmHg or lower than 60 mmHg, Patient 6 stated that her systolic and diastolic were never that high or low. Patient 6 stated that she took the last Amlodipine Besylate (a prescription medication to treat high blood pressure) 5 mg (milligram, a measurement unit) tablet that morning. Per Patient 6, she had ordered a refill for Amlodipine and the pharmacy would deliver it later. During an interview with the DPCSD on 4/17/2026 at 1:15 p.m., when the DPCSD was asked about the skilled needs of Patient 6 that caused Patient 6 to require home health, the DPCSD stated she was not familiar with the patient. The DPCSD then asked the Administrator (ADM) regarding Patient 6’s skilled needs. The ADM stated that sometimes Patient 6 felt weak after taking Capecitabine (an oral chemotherapy drug to treat breast cancer) 500 mg, so the nurse needed to administer her medications. When asked to show the documentation regarding Patient 6 feeling weak after taking Capecitabine and that she needed another person to help her take her other oral medications, the ADM could not provide them. The ADM stated that she (ADM) would discharge Patient 6 at the end of the current certification period because she (Patient 6) no longer had skilled needs. During a review of the agency’s policy and procedure (P&P) titled, Discharge Criteria, revised March 2019, the P&P indicated patients are discharged by agency based on specifically defined criteria. Patient will be discharged from services as follows: The discharge is appropriate because…measurable outcomes and goals set forth in the plan of care have been achieved…the patient no longer needs the HHA services. Patient is no longer homebound.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to maintain an accurate, current medication profile for two of seven sampled patients (Patient 1 and Patient 6). This failure had the potential to place the patients at risk for medication errors and adverse drug reactions (a harmful, unintended reaction to a medication). Findings: a. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 11/19/2025. During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) document for the certification period starting from 3/19/2026 to 5/17/2026, the POC indicated Patient 1 had a diagnosis that included unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), heart failure (condition where the heart muscle cannot pump blood efficiently enough to meet the body’s needs for oxygen and nutrients), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The POC included an order for the skilled nurse (SN) to visit Patient 1 once a week for 1 week, twice a week for 2 weeks and then once a week for 6 weeks, for comprehensive skilled nursing assessment (a detailed, holistic evaluation of a patient’s physical, mental, emotional, and social health conducted by a licensed nurse, usually a registered nurse to create a personalized care plan, observation and evaluation of all body systems, monitor vital signs (measures the basic functions of the body that includes body temperature, blood pressure, pulse [heart rate] and respiratory [breathing] rate), evaluate pain levels, and evaluate therapeutic response to medications, ensure medication and diet regimen compliance. During a joint home visit, on 4/15/2026 at 12:00 p.m., at Patient 1’s residence with the licensed vocational nurse (LVN 1), Patient 1 was observed awake, alert, oriented x 3 (to person, place and time), and was ambulatory with a steady gait without using an assistive device. During a review of Patient 1’s current medications with LVN 1, the following medications were found at the patient’s residence and currently prescribed to Patient 1 that were not on the current medication profile that was provided by the HHA: - Breztri inhaler, take 2 inhales twice a day for COPD, filled date 4/1/2026 - Vitamin B complex 1 capsule daily, filled date 4/1/2026 - Sacubitril-Valsartan 24-26 mg (milligram, unit of measurement) ½ tablet twice daily, filled date 4/1/2026 - Carbidopa/Levodopa 25-100 mg 1 tablet twice daily, filled date 4/1/2026 - Omeprazole 20 mg 1 capsule twice daily, filled date 4/1/2026 - Tamsulosin 0.4 mg 1 capsule twice daily, filled date 4/1/2026 - Divalproex sodium 250 mg 1 tablet twice daily, filled date 4/1/2026 - Primidone 50 mg 1 tablet daily at bedtime, filled date 4/1/2026 - Potassium chloride 20 mEq (milliequivalent, a unit of measurement) 1 tablet daily, filled date 4/1/2026 - Danazol 50 mg 1 capsule daily, filled date 4/1/2026 - Atorvastatin 20 mg 1 tablet at bedtime, filled date 4/1/2026 - Loperamide 2 mg 2 tablets for anti-diarrhea after first loose stool, followed by 1 tablet, filled date 4/1/2026 - Fluticasone propionate nasal spray 50 mg 2 sprays in each nostril every morning, filled date 4/1/2026 - Nitroglycerin 0.4 mg tablet 1 tablet sublingually every 5 minutes as needed for chest pain x 3 doses, filled date 4/1/2026 - Digoxin 125 mcg (microgram, unit of measurement) 1 tablet daily, filled date 4/1/2026 - Ondansetron 4 mg 1 tablet every 4 hours as needed for nausea and vomiting, filled date 4/1/2026 - Escitalopram 5 mg 1 tablet daily, filled date 4/1/2026 - Vyzulta 0.024 % ophthalmic solution 1 drop both eyes at bedtime, filled date 4/1/2026 Furthermore, during Patient 1’s medication review with LVN 1, the medication profile was compared and the following medications were still on the medication list, but had already been discontinued (d/c) by Patient 1’s physician, according to LVN 1. - Pantoprazole 40 mg 1 tablet daily, d/c date 4/3/2026. - Tamsulosin 0.4 mg 1 tablet daily, d/c date 4/3/2026. - Escitalopram 10 mg 1 tablet daily, d/c date 4/3/2026. - Ferrous sulfate 325 mg 1 tablet daily, d/c date 4/3/2026. - Donepezil 10 mg 1 tablet daily at bedtime, d/c date 4/3/2026. - Vitamin D2 50,000 international units 1 capsule weekly, d/c date 4/3/2026. - Valsartan 40 mg 1 tablet two times a day, d/c date 4/3/2026. - Spironolactone 25 mg 1 tablet daily, d/c date 4/3/2026. - Memantine 10 mg 1 tablet two times daily, d/c date 4/3/2026. During an interview, on 4/17/2026 at 11:00 a.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated patient’s medication profile should have been reconciled and updated during every SN visit to prevent having an inaccurate patient medication list and preventing medication errors. b. During a review of Patient 6’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 3/25/2026 to 5/23/2026, the POC indicated that Patient 6 was admitted to the HHA on 1/24/2026 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque buildup narrows the heart’s natural arteries, restricting blood flow without causing chest pain). The POC indicated that Patient 6 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and then one SN visit per week for seven weeks. The POC indicated that the SN would be responsible to provide detailed medication information, including purpose, dose, administration route, frequency, and side effects. During a joint home visit observation with Licensed Vocational Nurse 1 (LVN 1) on 4/15/2026 at 10:30 a.m., at Patient 6’s residence, Patient 6 was observed alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 6 walking independently inside the home. During a joint visit, a medication review was conducted with LVN 1 through concurrent observation and record review. A bottle of Capecitabine (an oral chemotherapy drug used to treat advanced breast, colorectal, and gastric cancers) 500 milligrams (mg, a measurement unit), was observed in the home. The prescription label indicated: take three tablets by mouth every morning and three tablets by mouth every evening for 14 days, followed by 7 days off, repeating every 21 days. The label further indicated the medication was filled on 4/1/2026. Capecitabine 500 mg was not found listed on Patient 6’s Drug Regimen Review. Further review of Patient 6’s Drug Regimen Review indicated an order for Gabapentin (a prescription medication used to treat nerve pain and seizures) 500 mg, with instructions to take three tablets orally in the morning and three tablets in the evening daily. However, Gabapentin 500 mg was not found at Patient 6’s home at the time of the visit. During an interview with Patient 6 (in her native language) on 4/15/2026 at 11:10 a.m., Patient 6 stated that she had never heard of or taken Gabapentin. Patient 6 stated that she had been taking Capecitabine for a while. Patient 6 stated that Capecitabine was not a newly prescribed medication. During an interview with LVN 1 on 4/15/2026 at 11:15 a.m., LVN 1 stated that she (LVN 1) had never visited Patient 6 before, therefore she (LVN 1) did not know why Capecitabine 500 mg was not listed in Patient 6’s Drug Regimen Review or why the Drug Regimen Review listed Gabapentin 500 mg, which the patient never took. During a concurrent interview and record review with the DPCSD on 4/17/2026 at 11:58 a.m., the DPCSD reviewed Patient 6’s Drug Regimen Review. The DPCSD stated that medication reconciliation should be completed at every visit. The DPCSD further stated that if a discrepancy is identified between the medications on hand and those listed on the Drug Regimen Review, the nurse is responsible for contacting the patients primary care provider (PCP, a healthcare professional – usually a doctor, but sometimes a nurse practitioner or physician assistant – who provides, coordinates, and manages an individual’s comprehensive, long-term health needs) to obtain an order for any new or changed medications. The DPCSD stated that, following PCP approval, the visiting nurse is responsible for updating the patient’s medication profile (the Drug Regimen Review) in the electronic record platform. The DPCSD stated that maintaining an accurate and current medication profile is essential, particularly for patients who are forgetful or have cognitive impairment (e.g., dementia) to ensure that caregivers and family members are aware of the patient’s prescribed medications. The DPCSD stated, “The medication profile serves as a guide.” During a review of the HHA’s policy and procedure (P&P) titled “Medication Reconciliation,” revised March 2018, the P&P indicated Comfort Care Home Health will reconcile patient’s medications at time of admission and on an ongoing basis in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to revise and update the plan of care to reflect the most current wound status and treatment order, for one of seven sampled patients (Patient 3). This failure had the potential to result in missed services and/or confusion about what services the patient was prescribed that could affect the patient’s quality of care and well-being. Findings: During a review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 1/19/2025. During a review of the Patient 3’s clinical record titled, Wound Care Visit, dated 3/6/2026 and authored by a wound care specialist nurse practitioner (NP 1), NP 1 assessed and staged Patient 3’s left heel wound as a deep tissue injury (DTI, a serious form of pressure injury characterized by localized, purple or maroon discolored intact skin, or a blood-filled blister). The Wound Care Visit notes further indicated an updated wound treatment order to the left heel DTI as follows: Cleanse with wound cleanser, apply betadine (an antiseptic designed to kill bacteria and viruses on the skin to prevent or treat infections) to the eschar (a thick, dry, black, or brown layer of dead tissue) and apply medihoney (sterilized honey used to treat wounds) to granular tissue (new connective tissue that form on the surfaces of a wound during the healing process). Apply cut to fit calcium alginate (dressing that accelerates the process of wound healing) to wound. Cover with ABD pad (a type of wound dressing), wrap with kerlix (a type of wound dressing), secure with tape three times a week and as needed for soiling. During a review of Patient 3’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) document for the certification period starting from 3/23/2026 to 5/21/2026, the POC indicated Patient 3 had a diagnosis that included encounter for change or removal on non-surgical dressing, blister (a bubble of fluid under the skin) left foot, and type 1 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). The POC included an order for the skilled nurse (SN) to visit Patient 3 twice a week for 2 weeks and then once a week for 7 weeks, for a full skilled nursing assessment, observation and evaluation of all bodily systems, and to perform on every visit assessment of blister on the left foot/heel for indications of impaired healing, including absence of a healing ridge, presence of drainage or purulent exudate (a thick, foul-smelling wound drainage) and delayed or prolonged inflammatory response. The POC further indicated wound care treatment on the left heel/foot as follows: cleanse with normal saline (NS, a mixture of water and salt used to irrigate the wound), pat dry, apply betadine, ABD, rolled gauze, secure with tape. During a concurrent interview and record review, on 4/17/2026 at 11:00 a.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD reviewed Patient 3’s Home Health Certification and POC form for the certification period starting from 3/23/2026 to 5/21/2026. The DPCSD stated and acknowledged that the wound care treatment plan on the current POC was not updated to the current wound treatment as ordered by NP 1 on 3/6/2026. The DPCSD stated the POC should be revised and updated as soon as the agency receives a new physician order to ensure patient safety and prevent confusion among staff who provide care and service to the patient at home. During a review of the HHA’s policy and procedure (P&P) titled “Plan of Care – CMS #485 and Physician Orders,” revised March 2018, the P&P indicated each patient must received an individualized written plan of care, including any revisions or additions. All patient care orders, including verbal orders, must be recorded in the plan of care. The plan will be revised to reflect any verbal order received during the 60-day certification period so that all Agency staff are working from a current plan.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to notify the patient’s attending physician of discharge needs and failed to obtain a physician discharge order for one of two sampled discharged patients (Patient 5). This deficient practice resulted in incomplete documentation that did not accurately reflect the patient’s health status at discharge and created the potential that discharge planning needs were not identified and that the patient’s plan of care was not communicated to the attending physician. During a review of Patient 5’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 7/7/2025 to 9/4/2025, the POC indicated that Patient 5 was admitted to the HHA on 9/10/2024 with a primary diagnosis of hypertensive heart disease (a condition with damage to the heart from years of unmanaged or undermanaged high blood pressure) without heart failure. The POC indicated that Patient 5 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and one SN visit per week for seven weeks. The POC indicated that Patient 5 was also to receive Certified Home Health Aide (CHHA, a trained healthcare professional who provides personal care and daily living assistance to patients in their homes under the supervision of a nurse) visits twice a week for one week, and then once a week for eight weeks. The POC indicated that Patient 5 was recertified for comprehensive skilled nursing assessment, observation, and evaluation of all body systems; The SN was to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen, home safety issues, and psychosocial adjustment. The POC did not specify the orders for the CHHA. During a telephone interview with CHHA 1 on 4/15/2026 at 1:28 p.m., CHHA 1 stated that she visited Patient 5 weekly to assist her with a bed bath, dressing, grooming, and skin care such as checking the skin and applying lotion. During a telephone interview with Family Member 1 (FM 1) on 4/14/2026 at 12:30 p.m., FM 1 stated that she (FM 1) was the primary caregiver for Patient 5. FM 1 stated that she informed the HHA that Patient 5 would be transferred to another HHA (HHA 2) because she (FM 1) was not happy with the care that Patient 5 received. During a review of a document titled General patient Communication: 09/30/2025 – Discharge for Patient 5, the document indicated that on 9/30/2025 the HHA received a call from HHA 2 that Patient 5 was transferring to HHA 2 as of 10/1/2025. The document was not signed and dated. During a concurrent interview and record review with the Director of Patient Care Designee (DPCSD) on 4/17/2026 at 11:35 a.m., the DPCSD was asked about the discharge process for a patient or family requesting a transfer of a patient to another agency. The DPCSD stated that if the patient was already accepted by another HHA, such as Patient 5, the HHA would coordinate with the accepting HHA, provide endorsement regarding the patient’s condition, send the physician orders and the most current plan of care. The HHA would conduct an in-office discharge, which means that an in-home Registered Nurse (RN) visit would not be necessary since the patient was already accepted by another HHA. The DPCSD stated there had to be a discharge order from the physician, as well as a discharge summary completed by the HHA discharging the patient. The DPCSD then reviewed the following document for Patient 5: General patient Communication: 09/30/2025 – Discharge, and other clinical records for Patient 5 related to Patient 5’s discharge. The DPCSD stated the document was a communication note and not a physician order or a discharge summary. The DPCSD stated there was no discharge order or communication with a physician regarding the discharge for Patient 5. The DPCSD stated that a discharge order from a physician was required to ensure the discharge was appropriate and safe for the patient. During a review of the HHA’s undated Policy and Procedure (P & P), titled “Physician Notification During Patient Discharge,” the P & P indicated the following: Notify physician via phone, fax, or secure EHR.Include patient identifiers, discharge date, reason, condition, medications, and follow-up needs.Document date, time, method, and response.During a review of the HHA’s Policy and Procedure (P & P), titled “Patient Bill of Rights and Responsibilities,” revised March 2019, the P & P indicated that the agency discharge criteria were as follows: Patient/family requests discharge.Types of services provided and frequency of services.Patient’s outcomes in meeting goals in the plan of care.Patient/family post-discharge instructions.Medications at time of discharge.”

“Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. 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 maintain documentation of the CHHAs training records for three of seven sampled patients who were receiving CHHA service (Patient 1, Patient 3, and Patient 7). This failure resulted in the agency being unable to prove staff competency, ensure patient safety, and comply with the federal regulation. a. During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 11/9/2025 to 1/17/2026, the POC indicated that Patient 1 was admitted to the HHA on 11/9/2025 with a primary diagnosis of spondylosis without myelopathy (age-related wear and tear of the spine that causes pain and stiffness, but crucially does not compress the spinal cord or cause significant neurological damage). The POC indicated that Patient 1 was to receive CHHA visits twice a week for nine weeks. b. During a review of Patient 3’s POC for the certification period of 3/23/2026 to 5/21/2026, the POC indicated that Patient 3 was admitted to the HHA on 1/22/2026 with a primary diagnosis of encounter for change or removal of non-surgical dressing (visits to address dressings on wounds not created by surgery, such as injuries, chronic ulcers, or pressure sores). The POC indicated that Patient 3 was to receive CHHA visits once a week for nine weeks. c. During a review of Patient 7’s Supplemental Plan of Treatment (a document that adds, modifies, or clarifies orders within a patient’s existing plan of care) for the certification period of 2/20/2026 to 4/12/2026, the Supplemental Plan of Treatment indicated that Patient 7 was admitted to the HHA on 2/12/2026 with a primary diagnosis of spondylosis without myelopathy or radiculopathy (age-related wear-and-tear in the lower spine, involving degenerative discs and facet joint arthritis, without causing nerve compression or spinal cord damage). The Supplemental Plan of Treatment indicated that Patient 7 was to receive CHHA visits once a week for eight weeks. During a review of CHHA 1’s employee file, the employee file did not have information on CHHA 1’s date of hire. The Personnel File Checklist found in CHHA 1’s employee file was entirely blank. The “Annual In-Service Training – CHHA/HHA (CMS Required – 12 hours)” form in CHHA 1’s employee file did not indicate if the in-service topics were completed. The columns for RN initials and Date were blank. The following undated certificates were found in CHHA 1’s employee file: Emergency training, infection control, and Covid 19/ hand hygiene. Each certificate indicated the training was one hour long. The certificates indicated the trainings were provided by the Director of Patient Care Services (DPCS). During a concurrent interview with the Administrator (ADM) on 4/15/2026 at 3:19 p.m., the ADM reviewed CHHA 1’s employee file. The ADM could not provide the date of hire for CHHA 1. The ADM stated that CHHA 1 had been providing patient care since November 2024. The ADM stated, “CHHA 1 was probably hired a week before the first patient visit in November 2024.” During a review of CHHA 2’s employee file, the employee file indicated that CHHA 2 was hired on 3/3/2023. The “Annual In-Service Training – CHHA/HHA (CMS Required – 12 hours)” form in CHHA 2’s employee file did not indicate if the in-service topics were completed. The columns for RN initials and Date were blank. The following undated certificates were found in CHHA 2’s employee file: Emergency training, infection control, and Covid 19/hand hygiene. Each certificate indicated the training was one hour long. The certificates indicated the trainings was provided by the DPCS. During a review of CHHA 3’s employee file, the employee file indicated that CHHA 3 was hired on 1/10/2024. The “Annual In-Service Training – CHHA/HHA (CMS Required – 12 hours)” form in CHHA 3’s employee file did not indicate if the in-service topics were completed. The columns for RN initials and Date were blank. The following undated certificates were found in CHHA 3’s employee file: Emergency training, infection control, and Covid 19/hand hygiene. Each certificate indicated the training was one hour long. The certificates indicated the trainings was provided by the DPCS. During a review of the HHA’s In-Service binder, the binder did not have documentation on whether the HHA provided in-services to the CHHAs. There was no documentation on when or if in-services were conducted, what the topics were, which clinical supervisor provided the in-services, or who attended them. During an interview with the Administrator (ADM) on 4/16/2026 at 2:28 p.m., the ADM stated, “The DPCS gave the in-service, but it wasn’t documented.” The ADM stated that if the in-services were not documented, they were not done. The ADM stated that documentation on in-services was very important because they served as proof that the CHHA had received the required training. During a review of the HHA’s Policy and Procedure (P & P), titled “Home Health Aide Training,” revised January 2018, the P & P indicated that all files must contain: Copy of competency training and/or evaluation.Competency orientation skills checklist.Inservice records.Annual performance reviews.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. 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 Certified Home Health Aides (CHHA) care was supervised for one of seven sample patients (Patient 1) This failure had the potential to result in endangering patients’ health and well-being. Findings: During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 11/19/2025. During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) document for the certification period starting from 11/19/2025 to 1/17/2026, and for the period starting from 1/18/2026 to 3/18/2026, the POC indicated Patient 1 had a diagnosis that included spondylosis without myelopathy (age-related wear and tear of the spine causing pain, stiffness, and reduced mobility), hypertensive heart disease (a condition with damage to your heart from having high blood pressure), heart failure (a condition where the heart muscle cannot pump blood efficiently enough to meet the body’s needs for oxygen and nutrients), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The POC included an order for the skilled nurse (SN) to visit Patient 1 twice a week for 2 weeks and then once a week for 7 weeks, and for CHHA to visit twice a week for nine weeks. During a concurrent interview and record review, on 4/17/2026 at 11:00 a.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD reviewed Patient 1’s POC records and CHHA weekly activity logs. The DPCSD stated Patient 1 received CHHA services twice a week from November 2025 to February 2026. The DPCSD stated CHHA supervisory visits are to be conducted every two weeks by a registered nurse to ensure the CHHA is following Patient 1’s care plan. The DPCSD stated that in the case of Patient 1, it was not done consistently every 2 weeks. The DPCSD stated that without CHHA supervisory visits, the HHA does not know if the patient has any concerns or issues with the CHHA. During a review of the HHA’s policy and procedure (P&P) titled “Home Health Aide Supervisory Visits,” revised January 2018, the P&P indicated the registered nurse or other appropriate skilled professionals 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 frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted at least every fourteen (14) days or less if patient is receiving skilled services.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) administrator (ADM) failed to ensure the process of addressing, documenting, and investigating complaints and/or grievances by patient and/or patient family or caregiver was completed for one of seven sampled patients (Patient 5). This deficient practice placed Patient 5 and other patients at risk that grievances presented to the HHA will not be addressed and resolved, potentially compromising patient safety. Findings: During a closed record review (an evaluation of patient medical records after they have been discharged) of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 9/10/2024. During a closed record review of Patient 5’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) document for the certification period starting from 7/7/2025 to 9/4/2025, the POC indicated Patient 5 had a diagnosis that included hypertensive heart disease (refers to heart conditions caused by long-term, unmanaged high blood pressure) and type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar). The POC included an order for the skilled nurse (SN) to visit Patient 5 twice a week for 2 weeks and then once a week for 7 weeks, and for the certified home health aide (CHHA) to visit twice a week for 1 week and then once a week for 8 weeks. During a phone interview with Patient 5’s family member (FM 1), on 4/16/2026 at 8:16 a.m., FM 1 stated that on 8/14/2025, she (FM 1) reported and complained to the HHA’s Administrator (ADM) about CHHA 1’s handling of a bed transfer, which caused Patient 5 to be injured and sent to an acute hospital. During an interview, on 4/16/2026 at 12:20 p.m., with the ADM, the ADM stated FM 1 called on 8/14/2025 to complain about CHHA 1’s handling of Patient 5’s bed transfer. The ADM was asked for a copy of the investigation report of the complaint but was unable to provide one. The ADM further stated that FM 1 filed a grievance, but the agency failed to document the complaint in a grievance log in order to find a resolution to the issue as per the agency’s policy. During a review of the agency’s policy and procedure (P&P) titled, Complaint Resolution, revised March 2019, the P&P indicated that this policy is to provide for a prompt and equitable resolution of complaints by patients and employees. The Agency will document both the existence of the complaint and the resolution of the complaint. The Agency will investigate complaints made by a patient, the patient’s representative (if any) and the patient’s caregivers and family, including but not limited to, the following topics: -Treatment of care that is (or fails to be) furnished, is furnished inconsistently or is furnished inappropriately. - Mistreatment, neglect or verbal, mental, sexual and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the Agency. - The lack of respect for property and/or person by anyone who is furnishing services on behalf of the Agency. During a review of the agency’s P&P titled, Patient Bill of Rights and Responsibilities, revised March 2019, the P&P indicated the Agency will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment. Patients have the right to have complaints investigated. The Agency will investigate complaints made by a patient, the patient’s representative (if any) and the patient’s caregivers and family. During a review of the agency’s record titled, Job Description for Executive Director/Administrator, the record indicated the Executive Director/Administrator are responsible for planning, coordinating, managing and directing all activities and programs of Home Health Agency, to ensure the provision of adequate and appropriate care and services.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on interview and record review, the Home health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that Certified Home Health Aides (CHHAs) were competent to provide care for three of seven sampled patients (Patient 1, 3, and 5). (Refer to G952). This deficient practice resulted in patients receiving services from CHHAs whose competency had not been adequately verified, which has the potential to lead to patient injury, patient neglect, and substandard quality of care. a. During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 11/9/2025 to 1/17/2026, the POC indicated that Patient 1 was admitted to the HHA on 11/9/2025 with a primary diagnosis of spondylosis without myelopathy (age-related wear and tear of the spine that causes pain and stiffness, but crucially does not compress the spinal cord or cause significant neurological damage). The POC indicated that Patient 1 was to receive CHHA visits twice a week for nine weeks. b. During a review of Patient 3’s POC for the certification period of 3/23/2026 to 5/21/2026, the POC indicated that Patient 3 was admitted to the HHA on 1/22/2026 with a primary diagnosis of encounter for change or removal of non-surgical dressing (visits to address dressings on wounds not created by surgery, such as injuries, chronic ulcers, or pressure sores). The POC indicated that Patient 3 was to receive CHHA visits once a week for nine weeks. c. During a review of Patient 7’s Supplemental Plan of Treatment (a document that adds, modifies, or clarifies orders within a patient’s existing plan of care) for the certification period of 2/20/2026 to 4/12/2026, the Supplemental Plan of Treatment indicated that Patient 7 was admitted to the HHA on 2/12/2026 with a primary diagnosis of spondylosis without myelopathy or radiculopathy (age-related wear-and-tear in the lower spine, involving degenerative discs and facet joint arthritis, without causing nerve compression or spinal cord damage). The Supplemental Plan of Treatment indicated that Patient 7 was to receive CHHA visits once a week for eight weeks. During a review of CHHA 1’s employee file, the employee file did not have information on CHHA 1’s date of hire. The Personnel File Checklist found in CHHA 1’s employee file was entirely blank. The Initial Competency Assessment Skills Checklist for CHHA 1 only had CHHA 1’s name on it. The Competency Validation by Preceptor column was blank. The Initial Competency Assessment Skills Checklist for CHHA 1 was not signed and dated by a supervisor or preceptor. The Home Health Aide Pre-Employment Examination was missing from CHHA 1’s employee file. The Performance Evaluation form found in CHHA 1’s employee file indicated 3 (satisfactory performance) and 4 (superior performance) ratings for the CHHA responsibilities evaluated; however, it did not list the name of the employee whose performance being evaluated or the name of the evaluator; the form was also undated. During a concurrent interview and record review with the Administrator (ADM) on 4/15/2026 at 3:19 p.m., the ADM reviewed CHHA 1’s employee file. The ADM could not provide the date of hire for CHHA 1. The ADM stated that CHHA 1 had been providing patient care since November 2024. The ADM stated, “CHHA 1 was probably hired a week before the first patient visit in November 2024.” The ADM acknowledged that the HHA did not complete the Initial Competency Assessment Skills Checklist and the Home Health Aide Pre-Employment Examination for CHHA 1. The ADM stated that the Initial Competency Assessment Skills Checklist and Home Health Aide Pre-Employment Examination were to be done with the Director of Patient Care Services (DPCS) or the DPCS Designee (DPCSD) before a new hire was assigned patients. The ADM stated the purpose of completing the Initial Competency Assessment Skills Checklist and Home Health Aide Pre-Employment Examination was to ensure that the CHHA was competent to perform his or her duties safely. When the ADM was asked whose Performance Evaluation form was filed in CHHA 1’s employee file, the ADM stated, “It’s supposed to be the Performance Evaluation form for CHHA 1, but since there’s no employee name then it can’t be confirmed who it belongs to.” The ADM stated that performance evaluation was to be done every 3 or 4 months. Per the ADM, a performance evaluation needs to be done to ensure the employee was competent and meets the standards for patient care. The ADM stated that the failure to validate a CHHA’s competence in performing his or her duties could result in negative outcomes, such as patient injuries, patient abuse or neglect, and legal consequences for the agency. During a review of CHHA 2’s employee file, the employee file indicated that CHHA 2 was hired on 3/3/2023. The Home Health Aide Pre-Employment Examination for CHHA 2 was blank, with only CHHA 2’s name and date of hire on the document. There was a Performance Evaluation form for CHHA 2, dated 3/3/2023, reviewed by the DPCS. The Performance Evaluation indicated a rating of 3 (satisfactory performance) for the CHHA responsibilities listed in the form. During a review of CHHA 3’s employee file, the employee file indicated that CHHA 3 was hired on 1/10/2024. The Home Health Aide Pre-Employment Examination for CHHA 3 was blank, with only CHHA 3’s name and date of hire on the document. There was a Performance Evaluation form for CHHA 3, dated 1/10/2024, reviewed by the DPCS. The Performance Evaluation indicated a rating of 2 (inconsistent performance) for the CHHA responsibilities listed in the form. During a concurrent interview and record review with the DPCSD on 4/16/2026 at 11:55 a.m., the DPCSD reviewed CHHA 2’s and CHHA 3’s employee files. The DPCSD stated that performance evaluation was determination if an employee was acting according to standards of their job description. The DPCSD stated, “Performance evaluation is very important for patient care safety, it’s the measure of how the staff is performing. It’s how we can be sure the staff can provide safe patient care. Through performance evaluation, we can evaluate their performance and provide the necessary training or in-service that they need.” When the DPCSD was asked how often Performance Evaluation should have been done for the CHHA, the DPCSD stated that newly hired CHHAs were on probation for 60-90 days, they would get evaluated at the end of their probation, and annually after. During a concurrent interview and record review with the ADM on 4/16/2026 at 2:16 p.m., the ADM reviewed the employee files of CHHA 2 and CHHA 3. The ADM stated that the Home Health Aide Pre-Employment Examination was to be completed by the CHHA after they were hired, but before they visited and provided services to a patient. After completing the Home Health Aide Pre-Employment Examination, the CHHA was to review it with the DPCS or DPCSD to ensure they understood how to care for their patients properly. The ADM stated that ensuring that the HHA’s staff were qualified and competent, especially the ones who were providing patient care, was the responsibility of the Administrator and Director of Patient Care Services (DPCS). During a review of the HHA’s Policy and Procedure (P & P), titled “Job Description Summary – Executive Director/Administrator,” revised November 2017, the P & P indicated that the Executive Director/Administrator’s responsibilities included: Recruiting, employing, and retaining qualified personnel to maintain appropriate staffing levels.Ensuring personnel development including orientation, in-service education, and continuing education. During a review of the HHA’s P & P, titled “Job Description Summary – Clinical Director,” revised November 2017, the P & P indicated that the Clinical Director’s responsibilities included: Hires, evaluates, and terminates organization personnel.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the clinical records included complete and accurate assessments from the most recent home health admission, clinical notes, plans of care, and physician orders that reflected the patients’ current health status for three of seven sampled patients (Patient 1, Patient 3, and Patient 7). This failure resulted in patients not having complete clinical records, placing patient safety at risk by increasing the chance of errors in medication, treatment, and diagnoses, increasing the risk for a lack in continuity of care, and poor coordination between clinicians such as nurses and physicians. a. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 11/19/2025. During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) document for the certification period starting from 11/19/2025 to 1/17/2026, and for period starting from 1/18/2026 to 3/18/2026, the POC indicated Patient 1 had a diagnosis that included spondylosis without myelopathy (age-related wear and tear of the spine causing pain, stiffness, and reduced mobility), hypertensive heart disease (a condition with damage to your heart from having high blood pressure), heart failure (a condition where the heart muscle cannot pump blood efficiently enough to meet the body’s needs for oxygen and nutrients), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The POC included an order for the skilled nurse (SN) to visit Patient 1 twice a week for 2 weeks and then once a week for 7 weeks, and for CHHA to visit twice a week for nine weeks. During a concurrent interview and record review, on 4/17/2026 at 11:00 a.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD reviewed Patient 1’s POC records and CHHA weekly activity logs and notes. The DPCSD stated Patient 1 received CHHA services twice a week from November 2025 to February 2026. DPCSD could not provide Patient 1’s CHHA care plan or written patient care instructions when requested. DPCSD stated Patient 1 should have a CHHA care plan prepared by a registered nurse as a guide for daily care and ensures patient safety. The DPCSD further stated CHHA supervisory visits are to be conducted every two weeks by a registered nurse to ensure the CHHA is following Patient 1’s care plan. The DPCSD stated that in the case of Patient 1, it was not done consistently every 2 weeks. The DPCSD stated that without CHHA supervisory visits, the HHA does not know if the patient has any concerns or issues with the CHHA. b. During a review of Patient 3’s Face Sheet, the Face Sheet indicated a start of care (SOC) date of 1/19/2025. During a review of Patient 3’s Home Health Certification and POC document for the certification period starting from 3/23/2026 to 5/21/2026, the POC indicated Patient 3 had a diagnosis that included encounter for change or removal on non-surgical dressing, blister (a bubble of fluid under the skin) left foot, and type 1 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). The POC included an order for the skilled nurse (SN) to visit Patient 3 twice a week for 2 weeks and then once a week for 7 weeks, for a full skilled nursing assessment, observation and evaluation of all bodily systems, and to perform on every visit an assessment of blister on the left foot/heel for indications of impaired healing, including absence of a healing ridge, presence of drainage or purulent exudate (a thick, foul-smelling wound drainage) and delayed or prolonged inflammatory response. During a review of the Patient 3’s clinical record titled, Progress Notes, dated 3/6/2026 and authored by a wound care specialist nurse practitioner (NP 1), NP 1 assessed Patient 3’s wound as a pressure injury of deep tissue (DTI, a serious form of pressure injury characterized by localized, purple or maroon discolored intact skin, or a blood-filled blister) of the left heel. During a concurrent interview and record review, on 4/17/2026 at 11:00 a.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD reviewed Patient 3’s Recertification/Follow-up Assessment form dated 3/21/2026, the Home Health Certification and POC form for the certification period starting from 3/23/2026 to 5/21/2026, and skilled nurse Clinical Note dated 4/4/2026, 4/7/2026, 4/9/2026 and 4/11/2026. The DPCSD stated that under Section M Skin Conditions of the Recertification/Follow-up Assessment form, the wound assessment and wound treatment documented was not accurate. The DPCSD stated and acknowledged that the wound care treatment plan on the current POC dated 3/23/2026 to 5/21/2026 was not updated to the current wound treatment as ordered by NP 1 on 3/6/2026. The DPCSD stated the POC should be revised and updated as soon as the agency receives a new physician order to ensure patient safety and prevent confusion among staff who provide care and service to the patient at home. The DPCSD further stated and acknowledged there was no documented evidence Patient 3’s left heel DTI was assessed for wound staging, wound location, size, presence and/or amount of drainage and peri-wound (tissue surrounding a wound) condition. The DPCSD stated skilled nurses should perform wound assessments on every visit to evaluate the wound type, stage, and severity to track healing, provide appropriate treatments and prevent complications. c. During a review of Patient 7’s Supplemental Plan of Treatment (a medical document that adds, modifies, or clarifies orders within a patient’s existing plan of care) for the certification period of 2/20/2026 to 4/12/2026, the Supplemental Plan of Treatment indicated that Patient 7 was admitted to the HHA on 2/12/2026 with a primary diagnosis of spondylosis without myelopathy or radiculopathy (age-related wear-and-tear in the lower spine, involving degenerative discs and facet joint arthritis, without causing nerve compression or spinal cord damage). The Supplemental Plan of Treatment indicated that Patient 7 was to receive CHHA visits once a week for eight weeks. The Supplemental Plan of Treatment did not specify the tasks or responsibilities of the CHHA regarding Patient 7. During a telephone interview with Patient 7 on 4/16/2026 at 1:43 p.m., Patient 7 stated that she was referred to the home health by her physician following a hospitalization. Patient 7 stated that her physician wanted her to receive physical therapy to help her regain her strength. Patient 7 stated that she had “a shower lady,” a nurse, and a physical therapist from the HHA. Patient 7 stated, “The shower lady helps me with shower and dressing. She applies lotion, too.” Per Patient 7, the “shower lady” and the nurse visits her once a week. Patient 7 stated there was another nurse who came twice a month, Registered Nurse 1 (RN 1). During a review of Patient 7’s clinical records, an untitled document, dated 3/28/2026, indicated that it was completed by CHHA 2. The document had Patient 7’s name on it. The document listed activities such as assist bath-chair, personal care, assist with dressing, hair care, skin care, and shave/groom. During a review of Patient 7’s clinical records, an untitled document, dated 4/1/2026, indicated that it was completed by CHHA 2. The document had Patient 7’s name on it. The document listed activities such as assist with bath-chair, personal care, assist with dressing, hair care, skin care, and shave/groom. During a record review of Patient 7’s clinical records, there was only one Supervisory Visit of Home Health Care Staff noted; the Supervisory Visit of Home Health Care Staff was dated 3/14/2026. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 4/16/2026 at 2:36 p.m., the DPCSD reviewed Patient 7’s clinical records. The DPCSD confirmed that the untitled documents dated 4/1/2026 and 3/28/2026 were the CHHA notes completed by CHHA 2 after CHHA 2’s visits to Patient 7’s home. When the DPCSD was asked if there were CHHA missed visits for the certification period of 2/20/2026 to 4/12/2026, the DPCSD stated that there were no missed visits, but there were only 2 CHHA notes submitted. The DPCSD stated that visit notes were to be submitted within five to seven business days after a visit was completed. The DPCSD stated that timely submission of clinical records was important. The DPCSD stated, “If we don’t take credit for the task we completed, the office has no way of verifying what services were provided.” The DPCSD stated that clinical documentation also served as a tool to coordinate patient care. The DPCSD stated that Supervisory Visit was done by RN 1 every 2 weeks, but there was only one Supervisory Visit note submitted. The DPCSD then provided the survey team with a Weekly Activity Log that indicated RN 1 visited Patient 7 on 2/12/2026 and 2/21/2026. The DPCSD stated that there was to be Supervisory Visit notes for 2/12/2026 and 2/21/2026 but RN 1 had not submitted them. During a review of the HHA’s undated Policy and Procedure (P & P), titled “Contents of Clinical Record,” the P & P indicated the following: 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 the organization and contract personnel. Staff notes will be submitted within 7 days of the clinical visit date with patient. This pertains to RN, LVN, Aide, MSW, and Therapy. During a review of the HHA’s undated clinical record titled, Comfort Care Home Health Inc, the record indicated the agency shall provide safe, effective, and evidence-based wound care services under the direction of a physician or authorized practitioner. All wound care shall be performed by qualified personnel within their scope of practice. The procedure is to conduct a comprehensive assessment upon admission including wound location, size (length, width, depth), tissue type (granulation, slough, eschar), drainage amount and type, odor, periwound skin condition and pain level. During a review of the agency’s policy and procedure (P&P) titled, Reassessment/Update of the Comprehensive Assessment, revised March 2019, the P&P indicated each patient will have appropriate reassessments performed and documented. Staff will additionally reassess each patient with each home visit on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided. Such reassessments will be documented on discipline-specific visit notes. During a review of the HHA’s P&P titled “Plan of Care – CMS #485 and Physician Orders,” revised March 2018, the P&P indicated each patient must received an individualized written plan of care, including any revisions or additions. All patient care orders, including verbal orders, must be recorded in the plan of care. The plan will be revised to reflect any verbal order received during the 60-day certification period so that all Agency staff are working from a current plan. During a review of the HHA’s P&P titled “Home Health Aide Supervisory Visits,” revised January 2018, the P&P indicated the registered nurse or other appropriate skilled professionals 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 frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted at least every fourteen (14) days or less if patient is receiving skilled services. During a review of the HHA’s P&P titled “Home Health Aide Plan of Care,” revised January 2018, the P&P indicated each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned role. The home health aide plan of care will be individualized to the specific patient and will include at least the type of services/procedures to be provided, such as hands on personal care, the performance of simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in administering medications ordinarily self-administered.”

“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 that discharged patients had a discharge summary that included the information regarding the physician responsible for the home health plan of care, reason for admission, type of services provided and frequency, medications at the time of discharge, patient outcomes, and post-discharge instruction for one of seven sampled patients (Patient 5). This failure had the potential to affect the patient’s continuity of care and safety post discharge. During a review of Patient 5’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 7/7/2025 to 9/4/2025, the POC indicated that Patient 5 was admitted to the HHA on 9/10/2024 with a primary diagnosis of hypertensive heart disease (a condition with damage to the heart from years of unmanaged or undermanaged high blood pressure) without heart failure. The POC indicated that Patient 5 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and then one SN visit per week for seven weeks. The POC indicated that Patient 5 was also to receive Certified Home Health Aide (CHHA, a trained healthcare professional who provides personal care and daily living assistance to patients in their homes under the supervision of a nurse) visits twice a week for one week, and then once a week for eight weeks. During a review of a document, titled General Patient Communication: 9/30/2025 - Discharge, the document indicated that Patient 5 was transferred to another home health agency as of 10/1/2025. The document was not signed and dated. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 4/17/2026 at 11:35 a.m., the DPCSD reviewed the following document for Patient 5: General patient Communication: 09/30/2025 – Discharge, and other clinical records for Patient 5 related to Patient 5’s discharge. The DPCSD stated the General patient Communication: 09/30/2025 – Discharge was a communication note and not a physician order or a discharge summary. The DPCSD stated that there was no discharge summary completed for Patient 5 upon discharge. The DPCSD stated that completing a discharge summary was important so that everyone involved in the patient’s care was aware of the services received by the patient and that the patient was in stable condition at discharge. During a review of the HHA’s Policy and Procedure (P & P), titled “Discharge Summary,” revised March 2018, the P & P indicated that a discharge summary form would be completed by the Skilled Nurse, Medical Social Worker, and/or Therapist. The discharge summary would include, but not limited to the following: Discharge date.Reason for discharge.Patient’s discharge condition.”