Apollo Home Health Care Inc.

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the clinical records were complete and authenticated for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential for substandard care provided to these patients as their clinical information was not complete. Findings: Review of Patient 3’s health record was conducted on 1/6/26. The health record showed the patient’s SOC was 8/1/25. The patient received home health services during the certification period from 8/1/25 to 9/29/25, and 11/29/25 to 1/27/26. Review of Patient 3’s Recertification (follow-up) assessment dated 9/25/25 showed the signature field was blank. Review of Patient 3’s CHHA Supervisory visit dated 8/8/25, 8/22/25, 9/5/25,9/19/25, 2/2/25, 12/16/25, and 12/30/25 showed the RN Supervisor’s signature was blank Review of Patient 3’s Supervisory visits for home health aide services dated 8/23/25, 9/5/25,9/19/25, 12/2/25, 12/16/25,and 12/30/25 showed the Clinical Supervisor’s signature was blank. On 1/7/26 at 1330 hours, an interview and concurrent clinical record review were conducted with the Director of Patient Care Services (DPCS). The DPCS stated the nurse should have signed the documentation as soon as possible after completing the form on the same day. The DPCS acknowledged and verified the findings. The agency P&P titled Verification of Physicians Order undated showed to ensure that accurate physician (or other authorized licensed independent practitioner) orders and prescriptions are obtained in accordance with state and federal law and regulation. The procedure includes signed orders will be placed in the clinical record within 30 days of initiation of the order, unless otherwise specified by applicable state law and regulation. The unsigned copy of the order will be removed by the chart. 1. Review of Patient 1’s clinical record was initiated on 1/2/26. The clinical record showed the SOC was 9/21/25. The patient was certified for home health services during the certification periods from 9/21/25 to 11/19/25 and 11/20/25 to 1/18/26. *Review of the Start of Care dated 9/21/25, showed RN 2 had performed an assessment. However, the section for the attestation signature and date were left blank. *Review of the Recertification (follow-up) assessment dated 11/15/25, showed RN 2 had performed an assessment. However, the section for the attestation signature and date were left blank. On 1/7/26 at 1353 hours and interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was asked if thy needed to sign and date the form. The Administrator Designee reviewed the clinical record and replied, yes, this should have been signed and dated on the same day of the assessment and for the agency to file a claim. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 1/6/26. The clinical record showed the SOC was 9/5/25. The patient was certified for home health services during the certification periods from 9/5/25 to 11/3/25 and 11/4/25 to 1/2/26. a. Review of the Start of Care dated 9/5/25, showed the DPCS had performed an assessment. However, the section for the attestation signature and date were left blank. *The POC for the certification periods from 9/5/25 to 11/3/25 showed a verbal SOC orders. The verbal SOC was electronically signed by the DPCS. The sections for the physicians name and address was documented. However, the section for the physicians signature, date and time was left blank. *Review of the Order/Telephone Order dated 9/22 and 10/13/25 showed a Medication Order. The verbal order was electronically signed by the DPCS and LVN 2. The physicians name was documented. However, the verbal order failed to show documented evidenced of the physicians electronic signature and date as the sections were left blank. On 1/7/26 at 1416 hours and interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. b. Review of the Recertification (follow-up) assessment dated 10/30/25, showed RN 1 had performed an assessment. However, the section for the attestation signature and date were left blank. *The POC for the certification periods from 11/4/25 to 1/2/26 showed a verbal SOC orders. The verbal SOC was electronically signed by the DPCS. The sections for the physicians name and address was documented. However, the section for the physicians signature, date and time was left blank. *Review of the Order/Telephone Order dated 10/30/25 showed a Recertification Order. The verbal order was electronically signed by the DPCS. The physicians name was documented. However, the verbal order failed to show documented evidenced of the physicians electronic signature and date as the sections were left blank. *Review of the Therapy Order dated 11/17/25 showed a therapy order visit frequency. The order was electronically signed by the PT. However, the section for the physician signature and date was left blank. On 1/7/26 at 1422 hours and interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. The agency’s P&P titled Verification of Physicians Order undated showed the purpose is to ensure that accurate physician (or other authorized licensed independent practitioner) orders and prescriptions are obtained in accordance with state and federal law and regulation. The procedure includes signed orders will be placed in the clinical record within 30 days of initiation of the order, unless otherwise specified by applicable state law and regulation. The unsigned copy of the order will be removed by the chart. 1. Review of Patient 1’s clinical record was initiated on 1/2/26. The clinical record showed the SOC was 9/21/25. The patient was certified for home health services during the certification periods from 9/21/25 to 11/19/25 and 11/20/25 to 1/18/26. *Review of the Start of Care dated 9/21/25, showed RN 2 had performed an assessment. However, the section for the attestation signature and date were left blank. *Review of the Recertification (follow-up) assessment dated 11/15/25, showed RN 2 had performed an assessment. However, the section for the attestation signature and date were left blank. On 1/7/26 at 1353 hours and interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was asked if they needed to sign and date the form. The Administrator Designee reviewed the clinical record and stated yes. The Administrator Designee stated this should have been signed and dated on the same day of the assessment and for the agency to file a claim. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 1/6/26. The clinical record showed the SOC was 9/5/25. The patient was certified for home health services during the certification periods from 9/5/25 to 11/3/25 and 11/4/25 to 1/2/26. a. Review of the Start of Care dated 9/5/25, showed the DPCS had performed an assessment. However, the section for the attestation signature and date were left blank. *The POC, for the certification period from 9/5/25 to 11/3/25, showed the verbal SOC orders electronically signed by the DPCS. The section for the physician’s name and address were documented. However, the section for the physicians signature, date, and time were left blank. *Review of the Order/Telephone Order dated 9/22 and 10/13/25, showed a medication order. The verbal order was electronically signed by the DPCS and LVN 2. The physician’s name was documented. However, the verbal order failed to show documented evidence of the physician’s electronic signature and date as the sections were left blank. On 1/7/26 at 1416 hours and interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. b. Review of the Recertification (follow-up) assessment dated 10/30/2t verbal SOC orders electronically signed by the DPCS. The sections for the physician’s name and address were documented. However, the section for the physician’s signature, date and time were left blank. *Review of the Order/Telephone Order dated 10/30/25, showed a recertification order. The verbal order was electronically signed by the DPCS. The physician’s name was documented. However, the verbal order failed to show documented evidenced of the physician’s electronic signature and date as the sections were left blank. *Review of the Therapy Order dated 11/17/25 showed a therapy order visit frequency. The order was electronically signed by the PT. However, the section for the physician’s signature and date were left blank. On 1/7/26 at 1422 hours, and interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 3. Review of Patient 3’s health record was conducted on 1/6/26. The health record showed the patient’s SOC was 8/1/25. The patient received home health services during the certification period from 8/1/25 to 9/29/25, and 11/29/25 to 1/27/26. Review of Patient 3’s Recertification (follow-up) assessment dated 9/25/25, showed the signature field was blank. Review of Patient 3’s CHHA Supervisory visit dated 8/8, 8/22, 9/5, 9/19, 12/16, and 12/30/25 showed the RN Supervisor’s signature was blank Review of Patient 3’s Supervisory visits for home health aide services dated 8/23, 9/5, 9/19, 12/2, 12/16, and 12/30/25 showed the Clinical Supervisor’s signature was blank. On 1/7/26 at 1330 hours, an interview and concurrent clinical record review were conducted with the Director of Patient Care Services. The DPCS stated the nurse should have signed the document as soon as possible after completing the form on the same day. The DPCS acknowledged and verified the findings.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the patient and PCG were provided with the correct toll-free state hotline established by the State to file the complaints for one of three sampled patients (Patient 1). This failure had the potential risk of violating the patient’s rights to be informed of the availability of the state hotline information to this patient. Findings: The agency’s P&P titled Rights and Responsibilities undated showed the procedure include the availability of the applicable toll-free home health agency hotline and other sources to receive questions or complaints. Review of Patient 1’s clinical record was initiated on 1/2/26. The clinical record showed the SOC was 9/21/25. The patient was certified for home health services during the certification periods from 9/21/25 to 11/19/25 and 11/20/25 to 1/18/26. The POC, for the certification period from 11/20/25 to 1/18/26, cited SN visits 1W9 (one visit a week for nine weeks) for overall body system assessment. A joint home visit with RN 1 was conducted on 1/6/26 at 1000 hours, to Patient 1’s home. Review of the patient’s home folder provided by the HHA included the admission packet. The admission packet showed the Patient Consent for Care and Treatment and the Patient Handbook. However, the Patient Handbook included the state home health care hotline number for LA county instead of Orange County where the agency located. On 1/6/26 at 1025 hours, an interview and concurrent document review was conducted with RN 1 and the PCG. RN 1 was asked if they knew the state phone number to file for a complaint. RN 1 showed the phone number listed on the patients handbook. RN 1 was asked to call the number. The number was for LA county instead of Orange County. RN 1 was informed and acknowledged the finding. On 1/7/26 at 1317 hours, the finding was shared with the Administrator Designee. The Administrator Designee acknowledged the finding.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the review of the medications included all of the patient’s current medications to identify any potential adverse effects and drug reactions for one of three sampled patients (Patient 1). This failure posed the risk for not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for this patient. Findings: Review of the agency’s P&P titled Medication Profile undated showed patient who are receiving medications will have a current, accurate medication profile in the clinical record. Medication profile will be updated for each change to reflect current medication and new and/or discontinued medications. 1. Review of Patient 1’s clinical record was initiated on 1/2/26. The clinical record showed the SOC was 9/21/25. The patient was certified for home health services during the certification periods from 9/21/25 to 11/19/25 and 11/20/25 to 1/18/26. The Medication Profile for the certification periods from 11/20/25 to 1/18/26, showed the patient’s medications included the following: -pantoprazole (used to treat GERD) 40 mg tablet delayed release one tablet by mouth twice daily -tamsulosin (used for neurogenic bladder) 0.4 mg capsule one capsule by mouth once daily -Sucralfate malate (protective agent) polymerized 1 gram/10 ml mucosal paste one tablet by mouth three times daily before meals A joint home visit with RN 1 was conducted on 1/6/26 at 1000 hours, to the patient’s home. Review of the patient’s medications included the following: -Pantoprazole 40 mg tablet delayed release one tablet by mouth twice daily. However, the written instructions on the medication bottle was to take once daily. -tamsulosin 0.4 mg capsule one capsule by mouth once daily. However, the written instructions on the medication bottle was to take one capsule 1/2 hours following the same meal each day. -Sucralfate malate polymerized 1 gram/10 ml mucosal paste one tablet by mouth three times a daily before meals. However, the patient was not taking this medication. In addition, the patient was taking the following medications: -Vitamin D3 (supplement) 2000 IU take one tablet daily with water in a meal -Calcium with D3 (supplement) 600 mg one tablet one to two times a day with water in a meal -fluconazole (antifungal) 200 mg tablet take one tablet by mouth once weekly. However, these medications were not listed in the medication profile. On 1/6/26 at 1038 hours, an interview and concurrent clinical record review was conducted with RN 1 and the PCG. The PCG was asked if the sucralfate malate was available. The PCG stated the patient do not have sucralfate and the patient was not taking it. RN 1 was informed and acknowledged the findings. On 1/7/26 at 1317 hours, the Administrator Designee was informed and acknowledged the findings.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for two of three sampled patients (Patients 2 and 3). This failure had the potential for not addressing the care needs for these patients. Findings: 1. Review of Patient 2’s clinical record was initiated on 1/2/26. The clinical record showed the SOC was 9/5/25. The patient was certified for home health services during the certification periods from 9/5/25 to 11/3/25 and 11/4/25 to 1/2/26. Review of the PT Initial Evaluation dated 10/29/25, showed the PT visits frequency was 2W3. Review of the Recertification (follow-up) assessment dated 10/30/25, showed the professional services included SN visits 1W9. However, the section for the PT visit frequency was left blank. On 1/7/26 at 1422 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was asked if the PT services needed to be included on the recertification assessment. The Administrator Designee reviewed the clinical record and replied, it was missed. The Administrator Designee was informed and acknowledged the finding. 2. Review of Patient 3’s clinical record was conducted on 1/6/26. The clinical record showed the patient’s SOC was 8/1/25. The patient received home health services during the certification period from 9/30/25 to 11/28/25. Review of Patient 3’s Recertification (follow-up) assessment dated 9/25/25,showed the sections for care preferences/patient’s personal goals, discipline goals, and target dates for achievement, nursing goals, and discharge plans were left blank. On 1/7/26 at 1330 hours, an interview and concurrent clinical record review were conducted with the Director of Patient Care Services. The DPCS stated the admission nurse assigned to the patient would need to complete the assessment within 72 hours. The DPCS verified the findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the POC included specific information related to nutritional requirements, DME, and supplies for one of three sampled patients (Patient 1). This failure created the risk of not addressing the care needs for this patient. Findings: The agency’s P&P title Care Planning Process undated showed based on the assessment and conclusions the plan of care will include, but not limited to identified patient problems and needs including nutritional requirements, equipment, and supplies. Review of Patient 1’s clinical record was initiated on 1/2/26. The clinical record showed the SOC was 9/21/25. The patient was certified for home health services during the certification periods from 9/21/25 to 11/19/25 and 11/20/25 to 1/18/26. The POC, for the certification period from 11/20/25 to 1/18/26, cited SN visits 1W9 for overall body system assessment. The POC included the sections for DME, supplies and nutritional requirement. However, these sections were left blank. On 1/7/26 at 1353 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record and interview, the agency failed to ensure the physician’s orders were authenticated for one of three sampled patients (Patient 3). This failure had the potential to affect the accuracy and legality of the clinical record. Review of the agency’s P&P titled Verification of Physician Order undated showed the signed orders are to be placed in the clinical record within 30 days of initiation of the order, unless otherwise specified by applicable state law and regulation. The policy also showed the unsigned copy of the order will be removed from the record. Review of Patient 3’s clinical was conducted on 1/6/26. The clinical record showed the patient’s SOC was 8/1/25. The patient received home health services during the certification periods from 8/1/25 to 9/29/25, 9/30/25 to 11/28/25, and 11/29/25 to 1/27/26. Review of Patient 3’s telephone order for admission dated 8/1/25, showed the physician’s order was not signed. Review of Patient 3’s telephone order for the recertification assessment dated 9/25/25, showed the physician’s order was not signed. Review of Patient 3’s telephone order for recertification assessment dated 11/27/25, showed the physician’s order was not signed. On 1/7/26 at 1330 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed there was no physician signature on the above telephone orders. The DPCS stated the physician’s orders should be signed as soon as possible. The DPCS stated if the physician has not signed the order by the next day, the office staff should email or fax the physician to follow up and obtain the signature. The DPCS acknowledged and verified the above findings.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review, the agency failed to revise and update the POC for one of three sampled patients (Patient 2). This failure created the risk for not providing the necessary care and services to this patient. Findings: The agency’s P&P titled Care Planning Process undated showed the patient plan of care will be developed or revised within five working days of the initiation of each service or of the reassessment of the patient. The plan of care will be revised as frequently as deemed necessary by the clinician based on the ongoing assessments of the patient. Revision dates will be noted on the plan of care. Review of Patient 2’s clinical record was initiated on 1/6/26. The clinical record showed the SOC was 9/5/25. The patient was certified for home health services during the certification periods from 9/5/25 to 11/3/25 and 11/4/25 to 1/2/26. a. Review of the Communication Note dated 1/30/25, showed the patient was referred to PT for evaluation and treatment. Further review of the clinical record showed the PT Initial Evaluation was conducted on 10/29/25. Documentation showed the PT visit frequency was cited 2W3. However, the POC for the certification period from 11/4/25 to 1/2/26, failed to include PT services. On 1/7/26 at 1416 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the finding.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the CHHA’s written plan of instruction was communicated to the physician for one of three sampled patients (Patient 3). This failure had the potential for the patient for not providing the necessary care and services to the patient. Findings: Review of Patient 3’s clinical record was conducted on 1/6/26. The clinical record showed the patient’s SOC was 8/1/25. The patient received home health services during the certification periods from 8/1/25 to 9/29/25, 9/30/25 to 11/28/25, and 11/29/25 to 1/27/26. Review of Patient 3’s admission order dated 8/1/25, showed CHHA to observe/assess: personal care hygiene, ADL assistance, and other assigned task as per CHHA practice standard; the recognition of abnormal parameters; and to report to SN/MD if SBP greater than 160 mmHg or lesser than 90 mmHg, DBP greater than 90 mmHg or lesser than 60 mmHg, heart rate greater than 100 beats/min or lesser than 60 beats/min, and respiration greater than 24 or lesser than 14 breath/min, temperature above 100 or lower than 96 degrees Fahrenheit, pain greater than 7 from a scale of 0-10, and any reported fall/injury or other significant findings. Review of the Home Health Aide Care Plan during the certification period from 8/1/25 to 9/29/25, showed to notify RN Supervisor if any of the following vital signs occurred: -Temperature: if greater than or equal to 100 degrees Fahrenheit, or less than or equal to 96 degrees Fahrenheit -Pulse: if greater than or equal to 100 beats per minute, or less than or equal to 50 beats per minute. -Respiratory Rate: if greater than or equal to 25 breath per minute, or less than or equal to 12 breath per minute -Blood Pressure: if SBP greater than or equal to 160 mmHg or less than or equal to 90 mmHg and if DBP greater than or equal 100 mmHg or less than 60 mmHg On 1/7/26 at 1330 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS stated the CHHA did not take the vital signs and the licensed nurse usually performed this task. The physician’s order for the plan of care requiring the CHHA to report abnormal vital signs should be clarified and documented. The plan of care for the HHA should have been revised and communicated with the physician. The DPCS acknowledged and verified the above findings.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide a written instruction outlining the visit schedule for one of three sampled patients (Patient 1). This failure had the potential for not providing the necessary information to this patient. Findings: Review of Patient 1’s clinical record was initiated on 1/2/26. The clinical record showed the SOC was 9/21/25. The patient was certified for home health services during the certification periods from 9/21/25 to 11/19/25 and 11/20/25 to 1/18/26. The POC, for the certification period from 11/20/25 to 1/18/26, cited SN visits 1W9 for overall body system assessment. A joint home visit with RN 1 was conducted on 1/6/26 at 1000 hours, to Patient 1’s home. Review of the patient’s home folder was conducted with RN 1. However, there was no documented evidence of written instructions outlining the SN visit schedules. On 1/6/26 at 1025 hours, an interview and concurrent document review was conducted with RN 1 and the PCG. RN 1 was asked if a visit schedule was available in the home folder. RN 1 stated it should be in the handbook. RN 1 checked/reviewed the handbook and the home folder. RN 1 stated RN 1 did not see it, there was no calendar, only the flow sheet. The PCG was asked if the agency provided a visit calendar. The PCG stated no. RN 1 was informed and acknowledged the finding. On 1/7/26 at 1317 hours, the finding was shared with the Administrator Designee. The Administrator Designee acknowledged the finding.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patients received care and services as per the written plan of care for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. Findings: Review of Patient 3’s clinical record was initiated on 1/6/25. The clinical record showed the SOC was 8/1/25. The patient was certified for home health services during the certification periods from . Review of the Home Health Certification and Plan of Care for the certification period from 11/29/2025 to 01/27/2026 indicated that the skilled nurse was to perform an overall body systems assessment with a focus on cardiovascular, endocrine, integumentary, musculoskeletal, mental, neurological, gastrointestinal, genitourinary systems, as well as competence and comprehension levels. Review of Nursing Progress Notes dated 12/05/2025 showed that the sections for mental status, motor/musculoskeletal, skilled teaching/instructions, and patient/caregiver response were left blank. Review of Nursing Progress Notes dated 12/12/2025 showed that the section for pain was left blank. Review of Nursing Progress Notes dated 12/25/2025 showed that the section for genitourinary was left blank. On 01/07/2026 at 1330 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS stated that the nurse should have completed all assessments. The DPCS was informed of and acknowledged the findings. 1. Review of Patient 1’s clinical record was initiated on 1/2/26. The clinical record showed the SOC was 9/21/25. The patient was certified for home health services during the certification periods from 9/21/25 to 11/19/25 and 11/20/25 to 1/18/26. a. Review of the certification period from 9/21/25 to 11/19/25, showed the physician ordered services. The services included OT cited as 1W8. Review of the Occupational Therapy Visit Notes dated 9/30, 10/6, 10/14, 10/30 and 11/10/25. Further review of the clinical record showed the an Occupational Therapy 30 day Functional Re-assessment was conducted on 10/21/25. However, there was no documented evidenced of the OT had performed an initial assessment as ordered in the POC. On 1/7/26 at 1322 hours, an interview and concurrent clinical review was conducted with the Administrator Designee. The Administrator Designee was asked if the OT initial assessment was completed as ordered in the POC. The Administrator Designee reviewed the clinical record and replied should be completed within five days from the order. The Administrator Designee was also asked if there was a documentation of the initial assessment. The Administrator Designee replied, needed to get it from the agency. The Administrator Designee was informed and acknowledged the findings. b. The POC for the certification periods from 11/20/25 to 1/18/26 cited SN visit 1W9 for overall body system assessment with focus on cardiovascular. Review of the Nursing Progress Notes dated 11/20, 12/5, 12/12 and 12/20/25, showed the SN had performed a body system assessment. However, the section for the cardiovascular assessment was left blank. On 1/7/26 at 1353 hours, an interview and concurrent clinical review was conducted with the Administrator Designee. The Administrator Designee was asked if the cardiovascular system was assessed. The Administrator Designee reviewed the clinical record and replied should be completed. The Administrator Designee was also asked if the POC was followed. The Administrator Designee replied, no. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 1/6/26. The clinical record showed the SOC was 9/5/25. The patient was certified for home health services during the certification periods from 9/5/25 to 11/3/25 and 11/4/25 to 1/2/26. The POC for the certification periods from 11/4/25 to 1/2/26 cited SN visit 1W9 for overall body system assessment. Review of the Nursing Progress Notes dated 11/4, 11/24, and 12/1/25 showed the SN had performed a body system assessment. However, the section for the respiratory and EENT assessment was left blank. On 1/7/26 at 1422 hours, an interview and concurrent clinical review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the CHHA provided care and services in accordance with the POC for one of three sampled patients (Patient 3). This failure had the potential risk for not providing the necessary care and services to the patient. Findings: Review of Patient 3’s clinical record was conducted on 1/6/26. The clinical record showed the patient’s SOC was 8/1/25. The patient received home health services during the certification period from 8/1/25 to 9/29/25, 9/30/25 to 11/28/25, and 11/29/25 to 1/27/26. Review of Patient 3’s order for admission dated 8/1/25, showed CHHA visits two times per week. Review of Patient 3’s Home Health Certification and Plan of Care during certification period from 9/30/25 to 11/28/25, showed CHHA visits two times per week. However, the clinical record showed the CHHA conducted one visit instead of two visits during Week 9 (11/23/25 to 11/29/25). On 1/7/26 at 1330 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed of the missing the missing CHHA visit for Week 9 (11/23/25 to 11/29/25). The DPCS stated there was no documented evidence explaining why the visit was not conducted and no documentation of rescheduling the missed visit. The staff should document the reason for any missed visit and make an attempt to reschedule the visit. The DPCS acknowledged and verified the above findings.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s P&Ps were implemented as evidenced by: - There was no pressure injury wound photograph documented for one of three sampled patients (Patient 2). - The missed visit was not rescheduled and communicated with the physician for one of three sampled patients (Patient 2). - The TB screening was not completed for the DPCS. - The 90 days performance evaluation, pre-employment physical, and TB screening were not completed for RN 2. - The pre-employment physical was not completed for LVN 1. - The pre-employment physicals and TB testing were completed more than 6 months prior to hiring date for CHHA 1. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: 1. The agency’s P&P titled Wound Care Management Program undated showed to obtain the initial photo of the wound at the start of care or during the first (1st) week of SOC, monthly, thereafter, and/or any significant clinical changes noted. Review of Patient 2’s clinical record was initiated on 1/6/26. The clinical record showed the SOC was 9/5/25. The patient was certified for home health services during the certification periods from 9/5/25 to 11/3/25 and 11/4/25 to 1/2/26. a. Review of the Start of Care OASIS dated 9/5/25, showed the patient was assessed to have the Stage 2 right buttock pressure injury. The wound assessment included a section for a photo taken. However, the section for the photo taken was documented as “No” which was inconsistent with the agency’s P&P. On 1/7/26 at 1416 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was asked if they needed to take the wound photograph upon initial assessment. The Administrator Designee stated there should be a photograph but none was documented. The Administrator Designee was informed and acknowledged the finding. b. Review of the Recertification (follow-up) assessment locked date 11/4/25, showed the patient was assessed to have an right buttock open superficial wound. However, the section for the photo taken was documented as “No” which was inconsistent with the P&P. Further review of the Wound Care Notes dated 12/22/25, showed the patient’s Stage 1 left buttock pressure injury was resolved and a new red hip redness was identified. However, the section for the photo taken was documented as “No” which was inconsistent with the agency’s P&P. On 1/7/26 at 1422 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. c. The agency’s P&P titled Missed Visits undated showed the missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit is missed and not rescheduled the clinician will notify the physician and clinical supervisor of the missed visit and reason for missed visit. The PT Initial Evaluation dated 10/29/25, cited PT visits 2W3. Review of the clinical record failed to show documented evidence of the PT visits during Week 1 (11/4/25 to 11/8/25). Further review of the PT Therapy Progress Notes showed a visit was conducted one time during Week 2 (11/9/25 to 11/15/25), instead of two times as cited. On 1/7/26 at 1422 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was asked if they needed to re-schedule a missed visit. The Administrator Designee stated there should be a communication note for the missed visit. The Administrator Designee was also asked if they needed to notify the MD of the missed visit. The Administrator Designee stated yes, they should. The Administrator Designee was informed and acknowledged the findings. 2. The agency’s P&P titled Categories/Qualifications of Personnel revised May 2023 showed the the organization defines the qualifications, competencies, health status, and type of staffing needed to fulfill its mission. The Health Requirements Personnel with Patient Contacts included a written health assessment of each employee who has direct patient contact shall be required as a prerequisite of employment, be performed within six months prior to employment or within 15 days of assuming employment with the agency. The written health assessment report shall verify the employee is free from health conditions which would interfere with the employee’s ability to perform assigned duties. Contain verification that the employee is free from signs and symptoms of infectious disease and provide a tuberculosis screening which shall be administered to all new employees who have direct patient contact. The agency’s P&P titled Selection/ Hiring of Personnel revised May 2023 showed the procedure included hiring. The individual seeking employment will complete an application. An offer of employment will be contingent upon a current physical and TB test/chest X-ray. The agency’s P&P titled Performance Evaluation revised May 2023 showed the performance evaluations will be completed on all personnel during the probationary period. Review of the personnel files was conducted on 1/7/26, showed the following: a. The DPCS’s personnel file showed the hiring date was 7/6/23. However, there was no TB testing result prior to the hiring date. b. RN 2 ’s personnel file showed the hiring date was 9/15/25. However, there was no documented evidence of the 90 day performance evaluation completed after the hiring date. In addition, there was no pre-employment physical examination and TB screening were completed prior to the hiring date. c. LVN 1’s personnel file showed the hiring date was 9/8/25. However, there was no pre-employment physical examination completed prior to the hiring date. d. CHHA 1’s personnel file showed the hiring date was 8/18/25. Review of the personnel file showed a pre-employment physical examination was conducted on 1/10/25. The TB skin test result was on 1/8/25. However, the pre-employment physical examination and TB testing results were more than six months prior to hiring date. On 1/7/26 at 0917 hours, an interview and concurrent document review was conducted with the Intake Coordinator/ HR assistant. The Intake Coordinator/HR Assistant was asked as to the timeline of the completion of the pre-employment physicals and TB testing. The Intake Coordinator/HR Assistant stated they should be completed 14 days prior to date of hire and then annually. The Intake Coordinator/HR Assistant was also asked as to the timeline for the probationary period in relation to performance evaluation. The Intake Coordinator/ HR Assistant stated they needed to do the 90 days performance evaluation during probationary period and annually. The Intake Coordinator/HR Assistant was informed and acknowledged the findings. On 1/7/26 at 1247 hours, the Administrator Designee was informed and acknowledged the findings.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to communicate the missed visit to the clinical supervisor or physician as per the POC and P&P for one of three sampled patients (Patient 2). This failure had the potential risk of not addressing and providing the appropriate care needs for this patient. Findings: Review of the agency’s P&P titled Missed Visits (undated) showed the purpose of the policy is to ensure that missed visits are documented and does not affect the quality of patient care. Missed visits will be communicated to the clinical supervisor and patient’s physician. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. Clinical record review for Patient 2 was initiated on 9/18/25. The clinical record showed the SOC was 5/27/25. The patient was certified for home health services during the certification period from 7/26/25 to 9/23/25. The Home Health Certification and Plan of Care dated 7/28/25, for the certification period 7/26/25 to 9/23/25, showed SN visit 1W7 (one visit a week for seven weeks), to start on the week of 7/27/25. However, there was no documented evidence a visit was conducted during the week of 9/7/25 to 9/13/25, as per the POC. There was no documented evidence the clinical supervisor and physician were notified of the missed visit; and an attempt was made to reschedule the missed visit within the same week. On 9/19/25 at 1146 hours, an interview and concurrent clinical record review was conducted with the RN/Care Coordinator. The RN/Care Coordinator was informed and acknowledged the finding.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on interview and record review, the agency’s Administrator failed to be responsible for the day-to-day operations related to ensuring TB screening was completed six months prior to employment or with 15 days of assuming employment; and annually thereafter for four personnel (RN 1, LVNs 1 and 2, and CHHA 1) who had direct patient contact. This failure had the potential for not providing quality of care and services to the patients receiving services at the HHA. Findings: Review of the agency’s P&P titled Categories/Qualifications of Personnel revised 5/2023 showed the organization defines the qualifications, competencies, health status, and type of staffing needed to fulfill its mission. A written health assessment of each employee who has direct patient contact shall be performed within six months prior to employment or within 15 days of assuming employment with the agency. The written health assessment report shall provide for a tuberculosis screening which shall be administered to all new employees who have direct patient contact and annually thereafter using a test for tuberculosis infection that is recommended by the federal Centers for Disease Control and Prevention and licensed by the federal Food and Drug Administration. Review of the personnel files was conducted on 9/19/25 and showed the following: -RN 1’s personnel file showed the hiring date was 3/31/25. A TB screening questionnaire dated 3/31/25, was completed by RN 1. RN 1 had a chest x-ray on 7/20/25. However, there was no documented evidence a TB screening was completed prior to employment. -LVN 1’s personnel file showed the hiring date was 12/4/23. LVN 1 had a TB test dated 1/18/24, more than 15 day after assuming employment. In addition, there was no documented evidence an annual TB test was completed thereafter. -LVN 2’s personnel file showed the hiring date was 6/23/25. LVN 2 had a PPD test on 10/31/24, more than six months prior to employment. -CHHA 1 personnel file showed hiring date was 8/18/25. CHHA had a PPD test on 1/8/25, more than six months prior to employment. On 9/19/25 at 1128 hours, an interview and concurrent agency document review was conducted with the HR personnel. The HR personnel verified the TB testing should be completed six months prior to employment or within 15 days of assuming the position. All direct care staff should have a TB testing. The HR was informed and acknowledged the above findings.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the agency failed to maintain an accurate and complete clinical record for one of three sampled patients (Patient 3). This failure had the potential for substandard quality of care due to incomplete or inaccurate clinical record. Findings: Clinical record review for Patient 3 was initiated on 9/19/25. The clinical record showed the SOC was 8/29/25. The patient was certified for home health services during the certification period from 8/29/25 to 10/27/25. Review of the SOC Assessment for certification period 8/29/25 to 10/27/25, showed Patient 3 had severe mental retardation. Review of the Patient Consent for Treatment dated 8/29/25, showed the patient’s name, initial, and signature for the space provided for patient’s initials and signature; and the name of the patient’s representative was blank. There was no documentation to identify if it was the patient, parent, legal guardian or representative who signed the consent. On 9/19/25 at 1146 hours, an interview and concurrent clinical record review was conducted with the RN/Care Coordinator. The RN/Care Coordinator stated the Administrator of facility signed the consent. Patient 3’s family member gave an authorization to the Administrator to sign the consent. The RN/Care Coordinator was informed and acknowledged the finding.”