Our Duty Home Health, Inc.

“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 failed to ensure comprehensive assessment was completed no later than 5 days after the start of care for one of seven sampled patients (Patient 2). The deficient practice had the potential to result in patient’s needs are not identified causing delay of treatment, intervention, and provision of care and services. (Refer to G520) 2. the HHA failed to accurately assess the patient’s mobility status for one of seven sampled patients (Patient 2). The deficient practice resulted in the patient’s level of function and use of assistive device to ambulate were not updated on the POC. (Refer to G528) 3. The HHA failed to maintain an accurate, current medication profile for one of seven sampled patients (Patient 3). 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.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) compliance with Quality Assessment and Performance Improvement (QAPI, a data driven approach to improve the quality of care and services provided to patients) for the provided services to the patients as follows: 1. The Home Health Agency (HHA) failed to ensure performance improvement projects (PIP) were conducted annually. This failure had the potential to affect the quality of care provided to the home health certified patients. (Refer to G658). 2. The HHA governing body failed to provide documented evidence the QAPI program was being implemented by the agency annually. This failure has the potential to result in a substandard provision of patient care and services. (Refer to G660). The cumulative effect of this systemic practice resulted in the failure of the Home Health Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Quality Assessment and Performance Improvement for the provided services to patients certified to receive home health benefits.”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA- an official organization that provides clinical, medical, and therapeutic care directly to patients in their own homes) failed to ensure the Conditions of Participations (COP - conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) regarding Infection Prevention and Control was met as follows: The Home Health Agency (HHA) failed to maintain a written, coordinated, and active infection control program as required for every Medicare certified home health agency to tract, prevent, and control infections and communicable diseases. The deficient practice will result to severe patient harm, more hospital visits, and higher risk of death due to uncontained outbreaks both to infectious and communicable diseases. (Refer to G684). The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily (written law) mandated compliance with Federal regulation for Infection Prevention and Control to ensure the highest quality of care are being provided to patients Certified to receive the home health benefits.”

“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 two of two Certified Home Health Aides (CHHA 1, CHHA 2) completed their competency evaluation during the hiring process. The deficient practice resulted in the CHHA being hired lacking verification of essential knowledge, safety skills, and abilities to practice safely to provide the patient care services. (Refer to G768). 2.The HHA failed to maintain documentation of the certified home health aide (CHHA) training and in-services for two of two CHHA (CHHA 1, CHHA 2). The failure had the potential to result in patients provided improper CHHA care. (Refer to G778). 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 the highest quality of care are being provided to patients Certified to receive the home health benefits.”

“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: The Home Health agency (HHA), failed to ensure five of seven employees were qualified to provide services (RN1, LVN1, DOND, CHHA1 and CHHA2) to home health certified patients. This deficient practice had the potential to result in the provision of a substandard care and services that could affect the patient’s safety and well-being. (Refer to G952). 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.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA: an official organization that provides skilled medical, nursing, and therapeutic care to patients directly inside their own homes) failed to provide documented evidence all staff had participated the emergency preparedness drills (the steps taken to make sure patients and staff are safe before, during and after an emergency or natural disaster) annually. This deficient practice could lead to staffs’ lack of knowledge and not fully prepared to respond effectively in case an emergency does occur. On 7/29/2026, the HHA’s “Emergency Preparedness” binder was reviewed. The binder included emergency preparedness policies and procedures and a signature page for the review and approval of those policies dated 6/5/2020. The emergency preparedness binder did not include documentation to prove all staff participated in any emergency preparedness training or drills. During an interview on 7/29/2026, at 3:40 pm., the Administrator (ADMN) stated that they did have emergency preparedness drills and did not have a copy that the drills were conducted. ADMN stated that he was responsible for documenting that the drills were conducted annually and placing them in the Emergency Preparedness binder. The ADMN stated that it was important to conduct emergency drills to practice protocol to ensure the safety of staff and patients during an actual emergency. A review of the HHA’s Policy titled “Emergency Management, (undated), indicated the HHA will test the Emergency Operation Plan at least annually either to a response to an actual emergency or in a planned exercise... The HHA will activate Emergency Operation Plan twice a year; once as a tabletop exercise and once as an emergency operation drill.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure performance improvement projects (PIP) were conducted annually. This failure had the potential to affect the quality of care provided to the home health certified patients. During a concurrent record review and interview on 7/29/2026, at 3:15 pm., of the QAPI folder, with Administrator (ADMN) the last QAPI minutes was dated December 2023. ADMN stated we didn’t have any Performance improvement projects (PIP) done. ADMN stated this is important to do so you can improve the care for the patients and know what topics needed to be addressed. The HHA’S policy and procedure titled “Improving organizational performance (QAPI)” revised 05/2023, the policy and procedure indicated “Senior management as designated by the Governing Body will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance; to define expectations of the performance improvement activities; and to generate the plan and processes the organization will utilize to assess, improve and maintain quality of care and service including appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will be active participants in the organization’s performance improvement activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented and maintained, and is evaluated annually.””

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on interview and record review, the HHA governing body failed to provide documented evidence the QAPI program was being implemented by the agency annually. This failure has the potential to result in a substandard provision of patient care and services. During a review of the QAPI folder indicated the last QAPI (Quality Assurance and Performance Improvement: a data-driven, ongoing program mandated by Centers of Medicare/Medicaid Services CMS) minutes was in December 2023. During an interview on 7/29/2026 at 3:31pm., with ADMN, stated we are supposed to do QAPI quarterly, but this was not done. It is important to do quarterly QAPI so we can improve our services and track what we are doing wrong so we fix it and track it in order to improve our services. The HHA’S policy and procedure titled “Improving organizational performance (QAPI)” revised 05/2023, the policy and procedure indicated “Senior management as designated by the Governing Body will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance; to define expectations of the performance improvement activities; and to generate the plan and processes the organization will utilize to assess, improve and maintain quality of care and service including appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will be active participants in the organization’s performance improvement activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented and maintained, and is evaluated annually.””

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to maintain a written, coordinated, and active infection control program as required for every Medicare certified home health agency to tract, prevent, and control infections and communicable diseases. The deficient practice will result to severe patient harm, more hospital visits, and higher risk of death due to uncontained outbreaks. On 7/29/2026, the HHA’s Infection Control Program was requested from the Administrator (ADMN). The ADMN was unable to provide the survey team the Infection Control Program for the year of 2025 and 2026. The ADMN provided the Quality Assessment and Performance Improvement (QAPI: a data-driven, proactive framework required by the Centers for Medicare & Medicaid Services (CMS) for healthcare facilities—such as nursing homes, home health agencies, and hospices—to continuously monitor, evaluate, and elevate the quality of care and safety provided to patients.) Project from 2024. The 2024 QAPI project included COVID19 (a contagious respiratory illness caused by the virus SARS-CoV-2. It spreads mainly through the air via droplets and small particles when an infected person breathes, talks, coughs, or sneezes) compliance and Tuberculosis (TB: a contagious bacterial infection caused by Mycobacterium tuberculosis. It mainly attacks the lungs, but it can also harm other body parts like the brain, kidneys, or spine. TB spreads through the air when a sick person coughs, sneezes, or talks.) monitoring chart audits as their Infection Control Program. During an interview on 7/31/2026, at 12:50pm., ADMN confirmed that Infection Control Plan was not done annually as per policy and the last year that it was done was 2024. The ADMN stated that it is important to maintain the program because it is used for patient safety. The ADMN stated that the HHA needs to develop an infection control program annually to ensure that they are monitoring infections to help prevent their patients from getting infections. A review of the HHA’s Policy and Procedure titled “Infection Control Plan”, dated May 2023, indicated to determine the effectiveness of the infection control plan, the HHA will measure, assess, improve and redesign (as appropriate) the surveillance, identification, prevention and control function annually through its performance improvement program… The infection control plan will be monitored and evaluated in the annual program evaluation and in conjunction with the review of the organization’s safety and performance improvement activities.”

“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 record review and interview, the HHA failed to ensure two of two Certified Home Health Aides (CHHA 1, CHHA 2) completed their competency evaluation during the hiring process. The deficient practice resulted in the CHHA being hired lacking verification of essential knowledge, safety skills, and abilities to practice safely to provide the patient care services. a. During a concurrent interview and record review on 7/29/2026 at 4:14 pm of CHHA 1’s employee file with ADMN, the employee file contained an employment application. There were no credentials, background check, onboarding orientation, CPR card, in-services, performance evaluations, competency evaluations, and health clearance. The employee application indicated CHHA 1 was employed as of 10/24/2022. ADMN stated, “CHHA 1 is currently seeing one patient.” The ADMN stated, “the employee file should have been completed with onboarding orientation, background check, job description, credentials, CPR card, annual in-services, performance evaluations.” ADMN stated, “it important because we don’t know who CHHA 1 is, we don’t know what her skill set is, and she is visiting our patients. I am responsible for HR and this should have been done.” During a concurrent record review and interview on 7/30/2026 at 2:03 pm of CHHA 1’s employee file, with DPCSD, there was no orientation, no competency evaluations, no performance evaluations, no yearly in-services, no credentials, no health clearance, and no background check. DPCSD stated, “all these documents are important to have because of patient safety. The patient can get hurt potentially and we won’t know her proficiently level, and we need a background check to make sure CHHA 1 is not a criminal.” b. During concurrent interview and record review on 7/29/2026 at 3:50 pm., of Certified Home Health Aide (CHHA) CHHA 2’s employee file with ADMN, CHHA 2 was hired on 2/19/2026. The employee file did not contain a job description, onboarding orientation, health clearance. ADMN stated, “I am the HR, I just haven’t gotten around to doing employee files.” ADMN stated CHHA 2 is contracted and we don’t have any additional orientation information, just whatever was given to them with their agency. It is important to have onboarding orientation because we know that our employees know how to care for the patients for the safety of the patients. During a concurrent record review and interview on 7/30/2026 at 2:06 pm., of CHHA 2, with DPCSD, there was no orientation, job description, health clearance. DPCSD stated, this is important to have because of patient safety. The patient can get hurt potentially and we won’t know her proficiently level. During a record review of the HHA’s policy and procedure, titled “ Personnel Record Contents”, revised Nov 2022, indicated: New Hire Documents: A. Evidence of pre-employment interview (Optional) B. Individual job qualifications C. Employment application H. Verification of education/training I. Statement of formal training for non-professionals (Optional) J. Orientation checklist (completed) K. Initial competency assessments L. Signed job description 0. Criminal background check Performance Evaluations/Counseling Documents: A. Performance evaluation F. Training/award certificates”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review the HHA failed to ensure the comprehensive assessment was completed no later than 5 days after the start of care for one of seven sampled patients (Patient 2). The deficient practice had the potential to result in patient’s needs are not identified causing delay of treatment, intervention, and provision of care and services. During a record review of Patient 2’s Patient Profile sheet indicated a start of care date of 07/24/2026, with a primary diagnosis of essential hypertension ( high blood pressure). During a record review of Patient 2’s medical record, indicated there was no comprehensive skilled nurse assessment in the record. During an interview on 7/31/2026 at 12 pm., with Director of Patient Care Services Designee (DPCSD) stated Patient 2 was admitted on 7/24/2026. DPCSD stated the comprehensive assessment was not done yet. DPCS stated the comprehensive assessment needs to be completed no later than 5 days after the start of care. During a record review of the HHA’s policy and procedure titled, “ Initial and Comprehensive Assessment”, revised May 2023, the policy and procedure indicated, “The comprehensive assessment shall be completed in a timely manner, consistent with the patients’ immediate needs, but no later than five (5) calendar days after the start of care.””

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on observation, interview and record review, the HHA failed to ensure an accurate patient assessment was completed to reflect the current mobility status of one of seven sampled patients (Patient 2). The deficient practice resulted in the patient’s level of function and use of assistive device to ambulate was not updated on the POC. During a record review of Patient 2’s Patient Profile sheet indicated a start of care date of 07/24/2026, with a primary diagnosis of essential hypertension ( high blood pressure). During a joint home visit observation on 7/30/2026, at 11:40 am., at Patient 2’s residence with Licensed Vocational Nurse 2 (LVN 2), Patient 2 was observed walking without the use of assistive device to open the door and lifting chair from one location and placing it 5 feet over with steady gait and no shortness of breath. Patient 2 was observed walking 30 feet without shortness of breath. After patient sat down the oxygen saturation was assessed by LVN 2 and it was 98% on room air with unlabored breathing. During a concurrent interview and record review on 7/31/2026, at 12:30 pm., of Patient 2’s skilled nurse visit note dated 7/28/2026 with DPCSD, the skilled visit note indicated home bound status, poor endurance/easily fatigability, required assistance device to ambulate, shortness of breath with ambulating more than 20 feet, poor ambulation, prone to falls, weakness. DPCSD stated the Patient 2 was admitted on 7/24/2026. DPCSD stated, “I did the nurse visit on 7/28/2026. I observed Patient 2 walked without a walker. Patient 2 went to the bathroom and back.” When asked if that matches with her documentation for 7/28/2026 as it pertains to her ambulation and home bound status, DPCSD stated, “no the documentation is not accurate. When I was there Patient 2 got up to use the bathroom and she wasn’t using any assistive device to ambulate and walk.” During a record review of the HHA’s policy and procedure titled, “ Clinical/Service Data Collection”, revised May 2023, the policy and procedure indicated, “Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided.” During a record review of the HHA’s policy and procedure titled, “ Initial and Comprehensive Assessment”, revised May 2023, the policy and procedure indicated, “The registered nurse shall conduct the initial and comprehensive assessment visit to determine the immediate care and support needs of the patient and for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to maintain an updated medication profile for one out of 7 sampled patients (Patient 3). This failure had the potential to cause medication errors and adverse side effects to medications. A review of Patient 3’s Patient profile (face sheet: a document of a patient’s personal information such as diagnoses, date of birth, and address) indicated a start of care date (SOC) of 5/8/2026. Patient 3’s diagnoses included type 2 diabetes (a disease where too much sugar is in the blood which can lead to serious health problems), Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions), dementia (brain condition that can cause memory loss and impaired judgment), depression (a mental disorder characterized by a loss of interest in activities, causing significant impairment in daily life), osteoarthritis of knee (the most common joint condition, caused by the breakdown of protective cartilage that cushions bone ends. It leads to pain, stiffness, and swelling, most frequently in the hands, knees, hips, and spine and hypertension (high blood pressure). A review of Patient 3’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 7/7/2026 to 9/4/2026. Patient 3 was to receive skilled nursing home visit twice a week for 2 weeks (2wk2) and then once a week for 7 weeks (1wk7). The POC indicated that the skilled nurse (SN) is to continue to assess/instruct patient/patient care giver (PCG) on new/changed medications. On 7/31/2026, at 11:25 am., a medication reconciliation (is the process of comparing a patient’s medication orders to all the medications that the patient has been taking) was conducted with the Director of Nursing Designee (DOND) at the nursing facility Patient 3 lives. During the medication reconciliation, the following medication discrepancies (a difference or lack of agreement between two or more things that should match or be equal) were found. The following medications were on Patient 3’s medication profile (an organized, up-to-date record of all the medicines a person takes) from the HHA dated 7/7/2026 to 9/4/2026, but they were not listed on the medication profile from the nursing facility: 1. Diclofenac (a nonsteroidal anti-inflammatory drug (NSAID) used to treat mild-to-moderate pain, joint inflammation, and stiffness) 1% topical gel, apply topically to affected area’s (knees) twice daily. 2. Lactobacillus reuteri (a supplement used to support digestive health and boost immune function) 100 million cell (unit of measurement) chewable tablet. Take 1 tablet by mouth once daily. 3. Lidocaine 4% topical patch (local anesthetics used to numb nerve endings in the skin and provide targeted, temporary relief for minor muscle aches, joint pain, or specific nerve pain) trans-dermally (transfer of medication through the skin) to affected areas (knees) once daily. 4. Magnesium hydroxide (a medication to help your bowels move-laxative) 400milligrams (mg-unit of measurement)/5 milliliter (ml-unit of measurement) oral suspension 30ml once daily. 5. Humulin R regular insulin (medication to treat diabetes) 100 unit/ml injection solution inject subcutaneously (under the skin). 6. Olanzapine (medication to treat depression) 5mg tablet. Take 1 tablet by mouth twice a day. The following medications were listed Patient 3’s medication profile from the nursing facility dated 7/1/2026, but were not listed on the agency’s medication profile from the HHA: 1. Docusate sodium (stool softener) 100mg tablet. Take 2 tablets (200mg) once a day for bowel regimen. 2. Cranberry (supplement) 450mg tablet. Take 1 tablet by mouth once a day. 3. Trazadone (medication to help with sleep) 100mg tablet, Take 1 tablet by mouth once a day at bedtime. 4. Olanzapine 2.5mg tablet. Take 1 tablet by mouth once a day at bedtime. During an interview on 7/31/2026, at 11:18 am., Licensed Vocational Nurse 1, (LVN 1) confirmed she visited Patient 3 once a week. LVN 1 stated when she goes, she asks the med tech (staff member at the nursing facility who passes out medication to patients) or the Administrator if Patient 3 has any new medications and that she looks at the medication list in the facility and the HHA list but does not look at the physical medications. LVN 1 stated that if there was a change, she will report it to the HHA office so they can update the medication list. During an interview on 7/31/2026 at 1:45pm, the DON designee (DOND) stated the visiting nurses are supposed to make sure that the medication list from the HHA was the same as the medication list at the nursing facility. The DOND stated that the visiting nurse needs to confirm that both lists are the same and visualize the medications in the med cart. The DOND stated that both med lists should be the same, because the HHA needs to know what medications are being given by the nursing facility to make sure that they are giving the correct medications to prevent medication errors. A review of the HHA’s policy titled “Medication Profile”, dated 5/2023, indicated that patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new and/or discontinued medications. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are preformed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.”

“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 record review and interview, the HHA failed to maintain documentation of the CHHA training and inservices for two of two CHHA (CHHA 1, CHHA 2). The failure had the potential to result in patients getting improper CHHA care. a. During concurrent interview and record review on 7/29/2026 at 3:50 pm of Certified Home Health Aide (CHHA) CHHA 2’s employee file with ADMN, CHHA 2 was hired on 2/19/2026. The employee file did not contain a job description, onboarding orientation, health clearance. ADMN stated, “I am the HR, I just haven’t gotten around to doing employee files.” ADMN stated CHHA 2 is contracted and we don’t have any additional orientation information, just whatever was given to them with their agency. It is important to have onboarding orientation because we know that our employees know how to care for the patients for the safety of the patients. During a concurrent record review and interview on 7/30/2026 at 2:06 pm of CHHA 2, with DPCSD, there was no orientation, job description, health clearance. DPCSD stated, this is important to have because of patient safety. The patient can get hurt potentially and we wont know her proficiently level. b. During a concurrent interview and record review on 7/29/2026 at 4:14 pm of CHHA 1’s employee file with ADMN, the employee file only contained an employment application. There was no credentials, no background check, no onboarding orientation, no CPR card, no annual in-services, no performance evaluations, no competency evaluations, no health clearance. The employee application indicates CHHA 1 was employed as of 10/24/2022. ADMN stated, “CHHA 1 is currently seeing one patient.” The ADMN stated, “the employee file should have been complete with onboarding orientation, background check, job description, credentials, CPR card, annual in-services, performance evaluations.” ADMN stated, “it important because we don’t know who CHHA 1 is, we don’t know what her skill set is, and she is visiting our patients. I am responsible for HR and this should have been done.” During a concurrent record review and interview on 7/30/2026 at 2:03 pm of CHHA 1’s employee file, with DPCSD, there was no orientation, no competency evaluations, no performance evaluations, no yearly in-services, no credentials, no health clearance, and no background check. DPCSD stated, “all these documents are important to have because of patient safety. The patient can get hurt potentially and we wont know her proficiently level, and we need a background check to make sure CHHA 1 is not a criminal.””

“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 record review and interview, the Home Health agency (HHA), failed to ensure five of seven employees were qualified to provide home health services (RN1, LVN1, DOND, CHHA1 and CHHA2). This deficient practice had the potential to result in the provision of a substandard care and services that could affect the patient’s safety and well-being. b. During concurrent interview and record review on 7/29/2026 at 3:50 pm of Certified Home Health Aide (CHHA) CHHA 2’s employee file with ADMN, CHHA 2 was hired on 2/19/2026. The employee file did not contain a job description, onboarding orientation, health clearance. ADMN stated, “I am the HR, I just haven’t gotten around to doing employee files.” ADMN stated CHHA 2 is contracted and we don’t have any additional orientation information, just whatever was given to them with their agency. It is important to have onboarding orientation because we know that our employees know how to care for the patients for the safety of the patients. During a concurrent record review and interview on 7/30/2026 at 2:06 pm of CHHA 2, with DPCSD, there was no orientation, job description, health clearance. DPCSD stated, this is important to have because of patient safety. The patient can get hurt potentially and we wont know her proficiently level. c. During a concurrent interview and record review on 7/29/2026 at 4:14 pm of CHHA 1’s employee file with ADMN, the employee file only contained an employment application. There was no credentials, no background check, no onboarding orientation, no CPR card, no annual in-services, no performance evaluations, no competency evaluations, no health clearance. The employee application indicates CHHA 1 was employed as of 10/24/2022. ADMN stated, “CHHA 1 is currently seeing one patient.” The ADMN stated, “the employee file should have been complete with onboarding orientation, background check, job description, credentials, CPR card, annual in-services, performance evaluations.” ADMN stated, “it important because we don’t know who CHHA 1 is, we don’t know what her skill set is, and she is visiting our patients. I am responsible for HR and this should have been done.” During a concurrent record review and interview on 7/30/2026 at 2:03 pm of CHHA 1’s employee file, with DPCSD, there was no orientation, no competency evaluations, no performance evaluations, no yearly in-services, no credentials, no health clearance, and no background check. DPCSD stated, “all these documents are important to have because of patient safety. The patient can get hurt potentially and we wont know her proficiently level, and we need a background check to make sure CHHA 1 is not a criminal.” During a record review of the HHA’s policy and procedure, titled “ Personnel Record Contents”, revised Nov 2022, indicated, “The content of the personnel files for regular full or part-time personnel will include: Benefit Documents (not applicable for per diem personnel) A. Insurance entitlement/declination B. Insurance change forms C. Beneficiary information D. Flexible benefit plan election form E. Insurance correspondence F. Requests for leaves of absences G. Leave of absence correspondence H. Paid days off documentation (Optional) I. 401 (K) enrollment/documentation (Optional) General Documents A. Skills and Experience Inventory B. Signed standards of conduct C. Verified professional licensure or certification/aide registry D. CPR certification (professional personnel) Note: Online CPR certification is acceptable with in-person verification of competency E. Continuing education documentation New Hire Documents A. Evidence of pre-employment interview (Optional) B. Individual job qualifications C. Employment application D. Resume E. References (2)(0ptional) F. Diploma (copy) or educational transcripts G. Specialty practice certification certificates H. Verification of education/training I. Statement of formal training for non-professionals ( Optional) J. Orientation checklist (completed) K. Initial competency assessments L. Signed job description M. Condition of employment N. Signed and dated confidentiality statement 0. Criminal background check and national sex offender registry, if applicable and a copy of the criminal record statement (LIC 508 form) (kept in separate file) P. Driver’s license and proof of auto insurance, if applicable. Q.Completed 1-9 form which has been verified by the employer and two {2) forms of acceptable identification R. Malpractice coverage for independent contractors S. OIG exclusion list verification, if applicable Compensation Documents A. State and Federal W-4 B. Salary increase profiles (Optional) C. Salary documentation (Optional) D. Personnel status human resources profiles Performance Evaluations/Counseling Documents A. Performance evaluations {annual) B. Organization personnel performance observation reports {clinical only) C. Ongoing competency assessments D. Personnel counseling/disciplinary documentation E. Personnel performance plans F. EEOC/legal claims or correspondence G. Training/award certificates Personnel Termination Documents A. Termination profile B. Exit interview summary C. Request for transfer D. Unemployment separation records E. Unemployment claims 2. The content of a separate file, which includes health information will contain: A. Short and long-term disability forms B. Workers’ compensation reports and correspondence C. TB test documentation D. Physician’s statement of health E. HBV vaccination/HBV refusal documentation F. COVID-19 vaccination or exemption documentation (including weekly COVID-19 test results) Per Diem and Contract 1. The content of the personnel files for per diem and contract personnel will include: Benefit Documents (not applicable for per diem personnel) “Direct Care” Documents A. Skills and Experience Inventory B. Signed standards of conduct . C. Verified professional licensure or certification D. CPR certification (professional personnel) Note: Online CPR certification is acceptable with in-person verification of competency E. Certificates of training, in-service education and competency training New Hire Documents A. Employment application, if applicable B. References C. Acknowledgement of temporary employment D. Orientation checklist (completed) E. Signed job description F. Signed and dated confidentiality and conflict of interest statements G. Criminal background check and national sex offender registry, if applicable (kept In separate file) and a copy of the criminal record statement (LIC 508 form) (kept in separate file) H. Driver’s license and proof of auto insurance, if applicable I. Completed 1-9 form which has been verified by the employer and two (2) forms of acceptable identification, if applicable (kept in a separate folder) J. Malpractice coverage for independent contractors K. 1-9 form which has been verified by the employer and two (2) forms of acceptable identification L. OIG exclusion list verification, if applicable Compensation Documents A. State and federal W-4 (if applicable) B. Salary increase profiles C. Salary documentation D. Personnel status profiles Performance Evaluations/Counseling Documents A. Performance evaluation B. Performance Observation Reports (direct care only) C. Personnel counseling/disciplinary documentation D. Personnel performance plans E. EEOC/legal claims or correspondence F. Training/award certificates Termination Documents A. Termination profile B. Exit interview summary C. Unemployment separation records D. Unemployment claims 2. The content of a separate file, which includes health information will contain: A. Workers’ compensation reports and correspondence B. TB test documentation C. Physician’s statement of health D. HBV vaccination/HBV declination documentation E. COVID-19 vaccination or exemption documentation (including weekly COVID-19 test results) F. Results of pre-employment physical CA” a. During a record review on 7/29/2026, Registered Nurse 1’s (RN 1) employee file was reviewed and indicated that they were hired on 4/14/2026. RN1’s employee file was missing a background check, CPR license and initial onboarding education/trainings (a structured program that a company provides at time of hire that gives important information to new employees that aim to equip them with the knowledge and tools required to succeed in their hired job position). During an interview on 7/31/2026, at 11:45am, RN1 confirmed that she does have a current CPR license that expires February 2027. RN1 stated that she never received any in-service or on-board training when she was hired. b. During a record review on 7/29/2026, Licensed Vocational Nurse 1’s (LVN1) employee file was reviewed and indicated that they were hired on 12/11/2023. LVN1’s employee file was missing her LVN license, background check, on-boarding trainings, physical (a medical evaluation form that is used to determine if the employee can safety preform essential functions required for the job) and tuberculosis (TB) test (a test that is used to detect an infectious disease prior to starting a new job). During an interview on 7/31/2026, at 11:18am, LVN 1 Confirmed that she did have a current nursing license that expires February 2027. LVN 1 stated that she thinks she did the on-boarding training online, she did not recall doing any in-person. c. During a record review on 7/29/2026, Director of Nursing Designee’s (DOND) employee file was reviewed and indicated that they were hired on 9/19/2022. The DOND had a CPR license that expired on 11/2025. During an interview on 7/29/2026, at 3:20pm, DOND confirmed that she had not renewed her CPR license yet. During an interview on 7/29/2026, at 3:20pm, the Administrator (ADMN) confirmed that the Employee files were not up to date. ADMN stated that he cannot confirm that he ran background checks on the employee. ADMN stated that the background checks are import to verify that the employees do not have a criminal history to keep the patients safe. The ADMN stated that he is considered HR (human resource: a business department responsible for managing the employment work life, such as the hiring process) and is responsible for ensuring the employee files are updated. a. During a record review on 7/29/2026, Registered Nurse 1’s (RN 1) employee file was reviewed and indicated that they were hired on 4/14/2026. RN1’s employee file was missing a background check, CPR license and initial onboarding education/trainings (a structured program that a company provides at time of hire that gives important information to new employees that aim to equip them with the knowledge and tools required to succeed in their hired job position). During an interview on 7/31/2026, at 11:45am, RN1 confirmed that she does have a current CPR license that expires February 2027. RN1 stated that she never received any in-service or on-board training when she was hired. b. During a record review on 7/29/2026, Licensed Vocational Nurse 1’s (LVN1) employee file was reviewed and indicated that they were hired on 12/11/2023. LVN1’s employee file was missing her LVN license, background check, on-boarding trainings, physical (a medical evaluation form that is used to determine if the employee can safety preform essential functions required for the job) and tuberculosis (TB) test (a test that is used to detect an infectious disease prior to starting a new job). During an interview on 7/31/2026, at 11:18am, LVN 1 Confirmed that she did have a current nursing license that expires February 2027. LVN 1 stated that she thinks she did the on-boarding training online, she did not recall doing any in-person. c. During a record review on 7/29/2026, Director of Nursing Designee’s (DOND) employee file was reviewed and indicated that they were hired on 9/19/2022. The DOND had a CPR license that expired on 11/2025. During an interview on 7/29/2026, at 3:20pm, DOND confirmed that she had not renewed her CPR license yet. During an interview on 7/29/2026, at 3:20pm, the Administrator (ADMN) confirmed that the Employee files were not up to date. ADMN stated that he cannot confirm that he ran background checks on the employee. ADMN stated that the background checks are important to verify that the employees do not have a criminal history to keep the patients safe. The ADMN stated that he is considered HR (human resource: a business department responsible for managing the employment work life, such as the hiring process) and is responsible for ensuring the employee files are updated. d. During concurrent interview and record review on 7/29/2026 at 3:50 pm of Certified Home Health Aide (CHHA) CHHA 2’s employee file with ADMN, CHHA 2 was hired on 2/19/2026. The employee file did not contain a job description, onboarding orientation, health clearance. ADMN stated, “I am the HR, I just haven’t gotten around to doing employee files.” ADMN stated CHHA 2 is contracted and we don’t have any additional orientation information, just whatever was given to them with their agency. It is important to have onboarding orientation because we know that our employees know how to care for the patients for the safety of the patients. During a concurrent record review and interview on 7/30/2026 at 2:06 pm of CHHA 2, with DPCSD, there was no orientation, job description, health clearance. DPCSD stated, this is important to have because of patient safety. The patient can get hurt potentially and we wont know her proficiently level. e. During a concurrent interview and record review on 7/29/2026 at 4:14 pm of CHHA 1’s employee file with ADMN, the employee file only contained an employment application. There was no credentials, no background check, no onboarding orientation, no CPR card, no annual in-services, no performance evaluations, no competency evaluations, no health clearance. The employee application indicates CHHA 1 was employed as of 10/24/2022. ADMN stated, “CHHA 1 is currently seeing one patient.” The ADMN stated, “the employee file should have been complete with onboarding orientation, background check, job description, credentials, CPR card, annual in-services, performance evaluations.” ADMN stated, “it important because we don’t know who CHHA 1 is, we don’t know what her skill set is, and she is visiting our patients. I am responsible for HR and this should have been done.” During a concurrent record review and interview on 7/30/2026 at 2:03 pm of CHHA 1’s employee file, with DPCSD, there was no orientation, no competency evaluations, no performance evaluations, no yearly in-services, no credentials, no health clearance, and no background check. DPCSD stated, “all these documents are important to have because of patient safety. The patient can get hurt potentially and we won’t know her proficiently level, and we need a background check to make sure CHHA 1 is not a criminal.” During a record review of the HHA’s policy and procedure, titled “ Personnel Record Contents”, revised Nov 2022, indicated, “The content of the personnel files for regular full or part-time personnel will include: Benefit Documents (not applicable for per diem personnel) A. Insurance entitlement/declination B. Insurance change forms C. Beneficiary information D. Flexible benefit plan election form E. Insurance correspondence F. Requests for leaves of absences G. Leave of absence correspondence H. Paid days off documentation (Optional) I. 401 (K) enrollment/documentation (Optional) General Documents A. Skills and Experience Inventory B. Signed standards of conduct C. Verified professional licensure or certification/aide registry D. CPR certification (professional personnel) Note: Online CPR certification is acceptable with in-person verification of competency E. Continuing education documentation New Hire Documents A. Evidence of pre-employment interview (Optional) B. Individual job qualifications C. Employment application D. Resume E. References (2)(0ptional) F. Diploma (copy) or educational transcripts G. Specialty practice certification certificates H. Verification of education/training I. Statement of formal training for non-professionals ( Optional) J. Orientation checklist (completed) K. Initial competency assessments L. Signed job description M. Condition of employment N. Signed and dated confidentiality statement 0. Criminal background check and national sex offender registry, if applicable and a copy of the criminal record statement (LIC 508 form) (kept in separate file) P. Driver’s license and proof of auto insurance, if applicable. Q.Completed 1-9 form which has been verified by the employer and two {2) forms of acceptable identification R. Malpractice coverage for independent contractors S. OIG exclusion list verification, if applicable Compensation Documents A. State and Federal W-4 B. Salary increase profiles (Optional) C. Salary documentation (Optional) D. Personnel status human resources profiles Performance Evaluations/Counseling Documents A. Performance evaluations {annual) B. Organization personnel performance observation reports {clinical only) C. Ongoing competency assessments D. Personnel counseling/disciplinary documentation E. Personnel performance plans F. EEOC/legal claims or correspondence G. Training/award certificates Personnel Termination Documents A. Termination profile B. Exit interview summary C. Request for transfer D. Unemployment separation records E. Unemployment claims 2. The content of a separate file, which includes health information will contain: A. Short and long-term disability forms B. Workers’ compensation reports and correspondence C. TB test documentation D. Physician’s statement of health E. HBV vaccination/HBV refusal documentation F. COVID-19 vaccination or exemption documentation (including weekly COVID-19 test results) Per Diem and Contract 1. The content of the personnel files for per diem and contract personnel will include: Benefit Documents (not applicable for per diem personnel) “Direct Care” Documents A. Skills and Experience Inventory B. Signed standards of conduct . C. Verified professional licensure or certification D. CPR certification (professional personnel) Note: Online CPR certification is acceptable with in-person verification of competency E. Certificates of training, in-service education and competency training New Hire Documents A. Employment application, if applicable B. References C. Acknowledgement of temporary employment D. Orientation checklist (completed) E. Signed job description F. Signed and dated confidentiality and conflict of interest statements G. Criminal background check and national sex offender registry, if applicable (kept In separate file) and a copy of the criminal record statement (LIC 508 form) (kept in separate file) H. Driver’s license and proof of auto insurance, if applicable I. Completed 1-9 form which has been verified by the employer and two (2) forms of acceptable identification, if applicable (kept in a separate folder) J. Malpractice coverage for independent contractors K. 1-9 form which has been verified by the employer and two (2) forms of acceptable identification L. OIG exclusion list verification, if applicable Compensation Documents A. State and federal W-4 (if applicable) B. Salary increase profiles C. Salary documentation D. Personnel status profiles Performance Evaluations/Counseling Documents A. Performance evaluation B. Performance Observation Reports (direct care only) C. Personnel counseling/disciplinary documentation D. Personnel performance plans E. EEOC/legal claims or correspondence F. Training/award certificates Termination Documents A. Termination profile B. Exit interview summary C. Unemployment separation records D. Unemployment claims 2. The content of a separate file, which includes health information will contain: A. Workers’ compensation reports and correspondence B. TB test documentation C. Physician’s statement of health D. HBV vaccination/HBV declination documentation E. COVID-19 vaccination or exemption documentation (including weekly COVID-19 test results) F. Results of pre-employment physical CA””