Agb Home Health, Inc.

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Patient Rights was met as follows: 1. The Home Health Agency (HHA) failed to ensure one of seven sampled patients (Patient 1) discharged from home health services was conducted safely and appropriately to facilitate continuity of care for the patient certified to receive home health benefits. This failure had the potential to result in Patient 1 experiencing pain, discomfort and anxiety that could impact on the patient’s quality of care and well-being. (Refer to G454). 2. The Home Health Agency (HHA) failed to ensure one of seven sampled patients (Patient 7) has the right to refuse services and be discharged from home health services as requested. Patient 7/caregiver had requested to be discharged during the period of 9/17/2025. HHA failed to conduct the discharge assessment visit. Patient 7 was still listed as an active patient of the HHA. This failure resulted in confusion of Patient 7/caregiver and did not know the status if the Medicare home health benefits had been continued or terminated. (Refer to G460). 3. The HHA failed to ensure one of seven sampled patients (Patients 1) representative/care giver was made aware Patient 1 was being considered for discharge. This failure had the potential to result in Patient 1’s representative/care giver experience grief, stress and uncertainty. Refer to (G464). 4. The HHA failed to provide one of seven sampled patients (Patient 1) representative/care giver information of providers that may be able to provide Patient 1 continued services. This failure had the potential to result in Patient 1 missing the required treatment and care for her (Patient 1) tracheostomy (tube inserted into the trachea to facilitate breathing) and gastrostomy (tube inserted into the stomach to provide nourishment). (Refer to G468). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Patient Rights to ensure highest quality health care is provided to certified patients assessed to receive home health services.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1.The HHA failed to ensure a comprehensive assessment was completed for one of seven sampled patients (Patient 4). This failure resulted in provision of HHA services without identifying the needs of the patient. (Refer to G520). 2. The HHA failed to review and document all the medications and treatments the patient was currently using for two of seven sampled patients (Patient 2, Patient 5). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. (Refer to G536). 3. The HHA failed to ensure a Registered Nurse updated the comprehensive assessment for the recertification period for three of seven sampled patients (Patient 2, Patient 3, and Patient 6). This deficient practice had the potential to result in decline in health status by not assessing the patient’s current needs. (Refer to 544). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Comprehensive Assessment of patients to ensure home health care benefits are verified for eligibility to patients provided home health services.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Care Planning, Coordination, and Quality of Care was met as follows: 1. The HHA failed to ensure the Plan of Care (POC) was developed or followed for four of seven sampled patients (Patient 4, Patient 5, Patient 6, Patient 7). This failure placed patients at risk for health status decline by not providing the services as indicated in the POC (Refer to G572). 2. The HHA failed to include information required in the plan of care for four of seven sampled patients (Patient 2, Patient 3, Patient 4, Patient 6). This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. (Refer to G574). 3. The HHA failed to ensure the physician reviewed and revised one of seven sample patients (Patient 1) individualized plan of care. This failure had the potential to result in Patient 1 receiving inappropriate or lacking appropriate services. (Refer to G588). 4. The HHA failed to provide written information regarding the plan of care and medication list for one of seven patients (Patient 5). This deficient practice resulted in patients and their representatives not knowing their care team or their treatment course. (Refer to G612). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.”

“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 observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patients personal residence/home), 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 over 65 years of age and for certain younger people with disabilities]), regarding Organization and administration of services was met as follows: The HHA failed to ensure the agency’s Director of Patient Care Services (DPCS) provided patient care oversight by: 1. Failing to ensure that the recertification (a mandatory, periodic process where a physician confirms a patient still meets the eligibility criteria for home health services), assessment was completed within the last five (5) days for every 60 days starting from the admission date of four of seven (7) patients (Patient 2, Patient 3, Patient 5, and Patient 6). 2. Failing to ensure that a Plan of Care (PoC, the detailed roadmap for a patient’s treatment) was developed for three of seven (7) patients (Patient 2, Patient 3, and Patient 6) for Patient 2, within seven days of the recertification date of 9/29/2025; for Patient 3, within seven days from the admission date of 5/10/2025 and the recertification date of 9/7/2025; for Patient 6, within the periods of 10/4/2025 to 12/2/2025, and 8/5/2025 to 10/3/2025. 3. Failing to ensure that the PoC for one of seven patients (Patient 5) was followed when Patient 5’s POC indicated a need for a glucometer, monitoring blood glucose levels, and ensured Patient 5 obtained prescribed diabetic medication when insurance issues were encountered. The HHA did not monitor Patient 5’s weight and did not notify Patient 5’s physician for changes in condition of edema of the lower extremities. (Refer to G958). As a result of the non-compliance, Patient 2, Patient 3, Patient 5, and Patient 6 were placed at increased risk for missed and or receiving delayed care, inaccurate assessments and plan of care, which can result in serious harm, hospitalization and or death. The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with federal regulation for Organization and administration of services to ensure it provided the necessary care and services to the patients.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Clinical Records was met as follows: 1.The HHA failed to ensure seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7) clinical records included all the medical records of the care provided. This failure resulted in an incomplete clinical record. (Refer to G1012). 2. The HHA failed to send all necessary medical information to the primary care practitioner within 5 days of discharge for one of seven sampled patients (Patient 1). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. (Refer to G1022). 3. The HHA failed to ensure patient care records were complete and authenticated for five of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 7). This failure resulted in patients’ medical records being modified by people not involved in patients’ care. (Refer to G1024). The cumulative effect of these systemic practices resulted in the failure of the HHA to ensure the provision of quality health care in a safe environment.”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure a Registered Nurse updated the comprehensive assessment for three of seven sampled patients (Patient 2, Patient 3, Patient 6.) This deficient practice had the potential to result in decline in health status by not assessing the patient’s needs. During an interview on 10/8/2025 at 4:04 p.m. with the Director of Patient Care Services (DPCS) stated that she was lacking at ensuring patients nursing comprehensive assessments and plans of care were completed. The DPCS stated that patients’ initial and recertification comprehensive nursing assessments were conducted by one of the three HHAs registered nurses, depending on who was scheduled. During an interview on 10/9/2025 at 11:40 a.m. with the Administrator (ADM), the ADM stated that the HHA has three registered nurses (RN) on staff, all of whom have the per diem (by the day) status. The ADM stated that the RNs do not have set hours, they are on call, and work based on their availability. The ADM stated that the DPCS has zero patients assigned to her at this time. The ADM stated that Registered Nurse 1 (RN1) and Registered Nurse 2 (RN2) have never been to the HHA in person and that RN1 has one patient assigned and RN2 has no patient assigned at this time. 1. During a record review of Patient 2’s medical record form titled “Patient Profile by Episode” indicated an admission date of 7/31/2025 with an admitting diagnosis of other specified disorder of brain. During a record review of Patient 2’s medical record form titled “Recertification (follow – up) assessment” dated from 9/29/2025 to 11/27/2025, the Recertification (follow – up) assessment form did not indicate it was completed or had a registered nurse signature or name. During a concurrent interview and record review on 10/8/2025 at 10 a.m. with the DPCS of Patient 2’s medical record, the DPCS stated that she did Patient 2’s recertification nursing assessment on 9/27/2025. DPCS stated that Patient 2’s recertification nursing assessment form dated 9/27/2025 was not completed or signed. The DPCS stated that Patient 2’s recertification comprehensive assessment was to be completed before the end of the first certification period. The DPCS stated her signature would validate and verify the form. The DPCS stated that it was important to conduct comprehensive nursing assessments to assess the patients’ needs and to determine continuation of home health services was needed. The DPCS stated that, at this time she (DPCS) does not know if Patient 2 requires home health services. 2. During a record review of Patient 3’s medical record form titled “Patient Demographics” indicated an admission date of 5/10/2025 with an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. During a record review of Patient 3’s medical record form titled “Recertification (follow – up) assessment” dated from 7/9/2025 to 9/6/2025, the Recertification (follow – up) assessment form did not indicate it was completed, nor did it have a registered nurse signature or name. During a record review of Patient 3’s medical record form titled “Recertification (follow – up) assessment” dated from 9/7/2025 to 11/5/2025, the Recertification (follow – up) assessment form did not indicate it was completed or had a registered nurse signature or name. During a concurrent interview and record review on 10/8/2025 at 11:45 a.m. with the DPCS of Patient 3’s medical record, stated Patient 3’s recertification comprehensive nursing assessments for dates 7/9/2025 to 9/6/2025 and 9/7/2025 to 11/5/2025 were not completed. The DPCS stated the information that was on both forms was auto populated from the initial comprehensive nursing assessment. The DPCS stated that a comprehensive nursing assessment is required to identify patients’ needs and to evaluate if the patient requires continued home health services. The DPCS stated that the recertification assessment was to be completed at least a week before the recertification date by a registered nurse. 3. During a record review of Patient 6’s Patient Profile indicated a start of care date on 6/6/2025, with a primary diagnosis of mechanical complication of other urinary catheter (a tube inserted in the body used to drain urine). During an interview on 10/7/2025 at 1 p.m., Patient 6’s caregiver (CG 1) stated Patient 6 was receiving nursing services every week. CG 1 stated the nurse checks Patient 6’s blood pressure, heart rate and temperature. CG 1 stated Patient 6 sometimes had her dressings (a special kind of bandage) changed sometimes. During a concurrent interview and record review on 10/8/2025 at 9:58 a.m., with the Intake Coordinator (IC), the IC reviewed Patient 6’s record titled, “Recertification (follow-up) Assessment”, for certification period 10/4/2025 to 12/2/2025. The record did not indicate documentation of an assessment and there was no signature on the record. The IC stated the HHA was unable to find a registered nurse (RN) for the recertification visit. The IC stated she did not notify the DPCS that an RN was not available for a recertification assessment visit. The IC stated she was not sure why she did not notify the DPCS about this. During a concurrent interview and record review on 10/8/2025, at 3:23 p.m., with the DPCS, the DPCS reviewed Patient 6’s record titled, “Recertification (follow-up) Assessment”, for certification period 10/4/2025 to 12/2/2025. The record did not indicate documentation of an assessment and there was no signature on the record. The DPCS stated the record was incomplete and was missing an assessment. The DPCS stated the assessment identified what the needs of the patient were. The DPCS stated that a recertification assessment was not done for the reason of communication issue with scheduling. The DPCS stated the HHA did not know what the needs of Patient 6 were currently. During a concurrent interview and record review on 10/8/2025, at 3:30 p.m., with the DPCS, the DPCS reviewed Patient 6’s record titled, “Recertification (follow-up) Assessment”, for certification period 8/5/2025 to 10/3/2025. The record did not indicate documentation of an assessment and there was no signature on the record. The DPCS stated there was no reassessment done for this certification period. The DPCS stated an RN should have done the recertification assessment. During a record review of the HHAs form titled “Reassessment/Recertification” revised 10/2019, indicated “The comprehensive assessment must be updated and revised every second calendar month, beginning with the start of care. A comprehensive assessment… must be performed to measure patient progress toward outcomes. The total plan of care must be renewed at least every 60 days, or more often as warranted by the condition of the patient… The recertification statement must indicate the patients continuing need for home health services.””

“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 observation, interview, and record review, the HHA failed to ensure the Plan of Care (POC) was developed and implemented for four of seven sampled patients (Patient 4, Patient 5, Patient 6, Patient 7). This failure resulted in the HHA not being able to create a comprehensive plan of care based on the needs identified during the initial assessment that could place these patients at risk for health status decline and provision of a substandard quality of care. 1. During a record review of Patient 4’s document titled, Patient Profile, indicated a start of care on 7/12/2025, with a diagnosis of essential hypertension (high blood pressure). The record indicated Patient 4 was discharged from the HHA on 8/28/2025. During a concurrent interview and record review on 10/9/2025, at 10:25 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 4’s record titled, OASIS admission assessment for certification period 7/12/2025 to 9/9/2025. The DPCS stated the OASIS assessment was the comprehensive assessment, but it was not done. The comprehensive assessment was used to formulate the plan of care. During a concurrent interview and record review on 10/9/2025, at 10:33 a.m., with the Director DPCS, the DPCS reviewed Patient 4’s record titled, Home Health Certification and Plan of Care, for certification period 7/12/2025 to 9/9/2025. The record indicated, “P.T. (physical therapy) to evaluate and develop Plan of Care treatment, establish visit frequency and goals post eval.” The DPCS stated Patient 4 was admitted to the HHA for PT and nurse visits. During an interview on 10/9/2025, at 10:40 a.m., with the Intake Coordinator (IC) stated PT did not see Patient 4 and did not know the reason why. During an interview on 10/9/2025, at 10:42 a.m., the DPCS stated the risk for Patient 4 not receiving PT services was delay in mobility and improvement with activities of daily living (bathing, eating, walking, etc.). During an interview on 10/9/2025, at 1:23 p.m., with Patient 4 stated she was not offered PT services. 2. During a record review of Patient 5’s Patient Profile indicated a start of care date on 8/28/2025, with a primary diagnosis of Type 2 diabetes (too much sugar in the blood). Patient 5’s diagnoses included Congestive Heart Failure (CHF-the heart unable to pump blood effectively). 2a. A review of Patient 5’s record titled, “Home Health Certification and Plan of Care”, dated 8/28/2025 to 10/26/2025 indicated, “Skilled nurse to perform/train/instruct/supervise patient/pcg (primary caregiver) blood sugar monitoring via finger stick using glucometer machine (a machine that reads blood sugar levels). During an observation of the home visit on 10/7/2025, at 10:10 a.m., the DPCS provided care to Patient 5. There was no glucometer observed in Patient 5’s home. During an interview at the home visit on 10/7/2025, at 11:26 a.m., with Patient 5’s caregiver (CG 2) stated Patient 5 did not check her blood sugar because Patient 5 did not have a glucometer. During an interview on 10/8/2025, at 11:45 a.m., with the IC stated she was not told by the nurse to order a glucometer, and glucometer supplies for Patient 5. During an interview on 10/8/2025, at 1:15 p.m., with LVN 1 stated she was the visiting nurse for Patient 5. LVN 1 stated she did not know if Patient 5 had a glucometer. During a concurrent interview and record review on 10/8/2025, at 3:10 p.m., with the DPCS stated there was no documented evidence of teaching about checking blood sugar levels with a glucometer. The DPCS stated monitoring blood sugar levels with a glucometer was important so the HHA can see an actual blood sugar level. To identify where the blood sugar levels are, so the HHA knows if the treatment is working or if the dosage of the diabetic medication needs to change. This was important to prevent complication of diabetes such as coma, generalized weakness, kidney damage, or damage to other organs. 2b. During an observation of the home visit on 10/7/2025, at 10:10 a.m., the DPCS provided care to Patient 5. DPCS did not assess Patient 5’s blood glucose levels. During a concurrent interview and record review on 10/7/2025, at 11:35 a.m., with the DPCS stated she did not check Patient 5’s blood sugar during the visit because it was not ordered. Patient 5’s record titled, “Home Health Certification and Plan of Care”, dated 8/28/2025 to 10/26/2025 was then shown to the DPCS. The record indicated, “Skilled nurse to perform/train/instruct/supervise patient/PCG (primary caregiver) blood sugar monitoring via finger stick using glucometer machine (a machine that reads blood sugar levels) ...Endocrine: Skilled nurse to monitor blood glucose levels at each visit, assessing for signs and symptoms of hypo/hyperglycemia…” The DPCS stated the intervention that was supposed to be in the POC was to teach signs and symptoms of hypoglycemia (low blood sugar). The DPCS stated it was the wrong wording in the POC. Further review of the record indicated that the DPCS had signed the POC. The DPCS stated she had signed the POC but had not thoroughly reviewed it. The DPCS stated the signature on the document validated the information written on the POC. During a concurrent interview and record review on 10/8/2025, at 2:58 p.m., with the DPCS, the DPCS reviewed Patient 5’s record titled Nursing Progress Note, dated 9/3/2025. The record did not indicate Patient 5’s blood sugar levels were assessed and monitored. The DPCS stated the POC was not followed because Patient 5’s blood sugar was not assessed and monitored at this visit. During an interview on 10/7/2025, at 11:45 a.m., with the DPCS, the DPCS stated the risks of not monitoring the blood sugar was an increase of sugar in the blood (hyperglycemia), which can cause ketoacidosis (a life-threatening complication) delayed healing, vision problems, risk of falls, which increases the chance of hospitalization. 2c. During an observation of the home visit on 10/7/2025, at 10:10 a.m., the DPCS provided care to Patient 5. At the conclusion of the visit, the DPCS did not assess and monitor Patient 5’s weight. During a concurrent interview and record review on 10/7/2025, at 11:40 p.m., with the DPCS, the DPCS reviewed Patient 5’s record titled, “Home Health Certification and Plan of Care, dated 8/28/2025 to 10/26/2025. The record indicated, “Cardiopulmonary: Skilled nurse to assess and monitor…weight at each visit, reporting abnormal findings…weight gain greater than 2 pounds in 24 hours...”. The DPCS stated this intervention meant that the nurse was to ask the patient for the weight to see if there was an increase in weight. An increase in weight meant there was more fluids in the body, which can make congestive heart failure (CHF) worse such as shortness of breath and hospitalization. The DPCS stated she had not assessed Patient 5’s weight during the visit because she had forgotten. The DPCS stated the nurses were supposed to document the weight assessment every visit. During a concurrent interview and record review on 10/8/2025, at 3 p.m., with the DPCS, the DPCS reviewed Patient 5’s records titled, Nursing Progress Note, dated 8/28/2025, 9/18/2025, and 9/23/2025. The records did not indicate a weight was assessed and monitored. The DPCS stated the POC was not followed because the nursing progress notes did not have a weight documented, nor evidence the weight was assessed and monitored. 2d. During a record review of Patient 5’s “Home Health Certification and Plan of Care, dated 8/28/2025 to 10/26/2025, indicated, “Skilled Nurse to report to PMD (primary doctor)…edema (fluid build up in the tissues, causing swelling) greater than 2+ (plus, a measurement of how much is swelled) unrelieved by medication or management…”. During a concurrent interview and record review on 10/8/2025, at 3 p.m., with the DPCS, the DPCS reviewed Patient 5’s record titled, Nursing Progress Note, dated 8/28/2025. The record indicated 2+ pitting edema in the lower legs. The DPCS stated there was no documented evidence the nurse notified the doctor of the edema. The DPCS stated the doctor needed to be notified so the doctor was aware Patient 5 was having a symptom of fluid retention. The doctor needed to know this information to determine if a change of medication or treatment was needed. The risk of 2+ edema in the lower legs for Patient 5 was worsening of CHF. Excess fluid can cause water in the lungs, making it difficult to breathe. The DCS stated the POC was not followed. During a concurrent interview and record review on 10/8/2025, at 3 p.m., with the DPCS, the DPCS reviewed Patient 5’s record titled, Nursing Progress Note, dated 9/18/2025 and 9/23/2025. The record indicated 2+ pitting edema in the lower legs. The DPCS stated there was no documented evidence the nurse notified the doctor as indicated in the POC, and therefore, the POC was not followed. 2e. During a review of Patient 5’s “Home Health Certification and Plan of Care”, for certification period 8/28/2025 to 10/26/2025, indicated, “Skilled nurse to instruct/supervise patient/pcg on the disease process…disease management, medications…skilled nurse to assess patient’s understanding and adherence to prescribed diabetic medications…” Durning a concurrent observation, interview, and record review on 10/7/2025, at 10:55 a.m., with the DPCS, the DPCS reviewed the medications Patient 5 was taking using Patient 5’s Medication Profile, for episode 8/28/2025 to 10/26/2025. During the review, Patient 5’s diabetic medication Dapagliflozin propanediol 10 mg (mg-milligram, unit of measurement) tablet was not at home. Patient 5’s CG 1 stated Patient 5 was not taking the medication due to the insurance not covering the medication. CG 1 stated the doctor was supposed to change the order and talk to the pharmacy about the medication. CG 1 stated Patient 5 had not taken the medication since she left the rehabilitation center in August 2025. During an interview on 10/8/2025, at 3:17 p.m., with the DPCS, the DPCS stated there was a discrepancy in the coordination of care. The DPCS stated Patient 5’s son did not notify the HHA that he (the son) had spoken to Patient 5’s doctor and was waiting for a response. The DPCS stated if the visiting nurse had reviewed Patient 5’s medications at home, the nurse would have noticed the medication was not there. The HHA would have notified the doctor and ask the doctor for an alternative medication for the patient. The risk of not taking the diabetic medication placed Patient 5 at risk of hyperglycemia (high blood sugar levels) and she could have had diabetes related complications. Patient 5 was placed at risk of health decline. 2f. During a review of Patient 5’s “Home Health Certification and Plan of Care”, for certification period 8/28/2025 to 10/26/2025, indicated, “Skilled nurse to instruct/supervise patient/pcg on the disease process…disease management, medications…”. Durning a concurrent observation, interview, and record review on 10/7/2025, at 10:55 a.m., with the DPCS, the DPCS reviewed the medications Patient 5 was taking using Patient 5’s Medication Profile, for episode 8/28/2025 to 10/26/2025. The DPCS confirmed Patient 5 was taking the following medications: Metoprolol succinate ER (extended release) 25 mg, take one tablet by mouth once daily for high blood pressure. Hold if SBP (systolic blood pressure) is less than 110 or HR (heart rate) less than 60. Furosemide (a diuretic) 20 mg tablet. Take one tablet by mouth once daily for CHF (congestive heart failure). Hold if SPB is less than 100 or if diarrhea/dehydration occurs. During a concurrent interview and record review on 10/7/2025, at 11:25 a.m., with the DPCS, the DPCS reviewed documents inside the HHA folder given to Patient 5 at admission. The DPCS stated there was no blood pressure log at the home. During an interview on 10/7/2025, at 11:45 a.m., with the DPCS, the DPCS stated the HHA was supposed to have Patient 5 keep a log of the daily blood pressure to ensure Patient 5 was administering the blood pressure medications as ordered. That way, the HHA could see if the patient or caregiver needed re-education on how to take the blood pressure medication. 2g. During a review of Patient 5’s “Home Health Certification and Plan of Care”, for certification period 8/28/2025 to 10/26/2025, indicated, “Safety measures...Infection Control Measures”. During an observation of the home visit on 10/7/2025, at 10:10 a.m., the DPCS provided care to Patient 5. There was no glucometer observed in Patient 5’s home. During an interview at the home visit on 10/7/2025, at 11:26 a.m., with Patient 5’s caregiver (CG 2), the CG 2 stated Patient 5 did not check her blood sugar because Patient 5 did not have a glucometer. During an interview on 10/8/2025, at 1:15 p.m., with LVN 1, LVN 1 stated she was the visiting nurse for Patient 5. LVN 1 stated she did not know if Patient 5 had a glucometer. LVN 1 stated she checked Patient 5’s blood sugar levels using a glucometer she had bought herself. LVN 1 stated she also bought the lancets (needle used to prick the skin, to obtain a blood sample) and strips for the glucometer. LVN 1 stated the glucometer was used on multiple patients. Each patient got a clean lancet and strip. LVN 1 stated she would clean the glucometer between each patient use with alcohol. During a record review of LVN 1’s glucometer manufacturer recommendation manual, dated 2009, indicated, “Do Not use alcohol or another solvent to clean your meter”. During an interview on 10/8/2025, at 1:45 p.m., with the DPCS, the DPCS stated blood sugar levels were supposed to be checked with the patients own glucometer to avoid infection. The DPCS stated infection could happen through blood transmission. If the blood sample is not done with good technique, infection could happen. The strip contains blood. The strip is attached to the glucometer, potential blood pathogen (bacteria, virus) can travel outside where the glucometer is held. Blood can get in and outside the glucometer. The DPCS stated LVN 1’s practice of using the glucometer with multiple patients were not acceptable standards of care. LVN 1 placed Patient 5 at risk for blood transmission related infections such as Hepatitis B, Hepatitis C, and HIV. 2h. During a review of Patient 5’s “Home Health Certification and Plan of Care”, for certification period 8/28/2025 to 10/26/2025, indicated, “PT Evaluation and treatment...OT (Occupational Therapy) Evaluation and treatment”. During an interview on 10/8/2025, at 2:45 p.m., with the DPCS, the DPCS stated the PT evaluation was done on 9/25/2025. The DPCS stated she did not know why the PT visit was late, and it was probably a communication issue. The DPCS stated this was a delay in service, which could result in delay of function improvement. The DPCS stated Patient 5 had not received OT services because the OT service had not been scheduled, probably due to a communication issue as well. The DPCS stated the plan of care had not been followed. 3. During a record review of Patient 6’s Patient Profile indicated a start of care date on 6/6/2025, with a primary diagnosis of mechanical complication of other urinary catheter (a tube inserted in the body used to drain urine). During an interview on 10/7/2025 at 1:00 p.m., Patient 6’s caregiver (CG 1) stated Patient 6 was receiving nursing services every week. CG 1 stated the nurse checked Patient 6’s blood pressure, heart rate and temperature. CG 1 stated Patient 6 had her dressings (a special kind of bandage) changed sometimes. During a concurrent interview and record review on 10/8/2025, at 3:23 p.m., with the DPCS, the DPCS reviewed Patient 6’s record titled, “Home Health Certification and Plan of Care,” for certification period 10/4/2025 to 12/2/2025. The DPCS stated the POC had not been done. There were no doctor’s orders, no interventions documented. The DPCS stated the POC was supposed to be done by 10/4/2025. The DPCS stated the POC was important because it provided a guide and interventions needed to assure the care was done and followed thoroughly, so the HHA avoids any incidents such as falls, infections, hospitalization, complications and death. 4. During a record review of Patient 7’s document titled, Patient Profile, indicated a start of care on 8/29/2025, with a primary diagnosis of laceration (cut) without foreign body of right forearm. During a record review of Patient 7’s document titled, Home Health Certification and Plan of Care, for certification period 8/29/2025 to 10/27/2025, indicated, “DME and supplies...Wounds: Normal saline (salt water), Xeroform (a type of bandage), 4x4 gauze (a type of bandage), kerlix (a type of bandage), coban (a type of bandage), bath bench. During an interview on 10/9/2025, at 2:25 p.m., with Patient 7’s caregiver (CG 3), the CG 3 stated the HHA had not given Patient 7 wound supplies. CG 3 stated the visiting nurse was always missing a wound care supply, so CG 3 bought wound supplies for Patient 7. CG 3 stated a shower chair was requested but the visiting nurse told CG 3 it was better if CG 3 purchased it because it would take weeks before getting it through the HHA. During an interview on 10/9/2025, at 2:50 p.m., with the Administrator (ADM), the ADM stated the HHA did not have any evidence that wound supplies were ordered and provided to Patient 7. The ADM stated the shower chair was not ordered for Patient 7. A record review of the HHA’s document titled, Care Planning Process, dated 10/2019, indicated, “Policy: A written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days, or as patient’s condition warrants...Services to be provided will be based on the prioritized needs of the patient. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to determine if goals have been achieved.””

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to provide written information regarding the plan of care POC) and medication list for one of seven patients (Patient 5). This deficient practice resulted in patients and their representatives not knowing their care team or their treatment course. During a record review of Patient 5’s Patient Profile indicated a start of care date on 8/28/2025, with a primary diagnosis of Type 2 diabetes (too much sugar in the blood). The record also indicated Patient 5’s diagnoses included Congestive Heart Failure (CHF-the heart unable to pump blood effectively). During a concurrent observation, interview and record review at the home visit on 10/7/25 at 10:47 a.m., with the Director of Patient Care Services (DPCS), an observation of the home indicated the presence of an HHA binder provided to Patient 5 on admission. The DPCS reviewed the contents of the binder and stated there was no plan of care and medication list present. The DPCS stated the POC and medication list was supposed to be printed and given to Patient 5, so patient knows the services being received and what the current medications are. A record review of the HHA’s document titled, Care Planning Process, dated 10/2019, indicated, “The organization shall provide the patient and caregiver with a copy of written instructions outlining...Visit schedule...Patient medication schedule/instructions...”.”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence/home), failed to: ensure the agency’s Director of Patient Care Services (DPCS), provided patient care oversight by: 1. Failing to ensure that the recertification (a mandatory, periodic process where a physician confirms a patient still meets the eligibility criteria for home health services), assessment was completed within the last five (5) days for every 60 days starting from the admission date of four of seven (7) patients (Patient 2, Patient 3, Patient 5, and Patient 6). 2. Failing to ensure that a Plan of Care (PoC, the detailed roadmap for a patient’s treatment) was developed for three of seven (7) patients (Patient 2, Patient 3, and Patient 6) for Patient 2, within seven days of the recertification date of 9/29/2025; for Patient 3, within seven days from the admission date of 5/10/2025 and the recertification date of 9/7/2025; for Patient 6, within the periods of 10/4/2025 to 12/2/2025, and 8/5/2025 to 10/3/2025. 3. Failing to ensure that the PoC for one of seven patients (Patient 5) was followed when Patient 5’s POC indicated a need for a glucometer, monitoring blood glucose levels, and ensured Patient 5 obtained prescribed diabetic medication when insurance issues were encountered. The HHA did not monitor Patient 5’s weight and did not notify Patient 5’s physician for changes in condition of edema of the lower extremities. As a result of the non-compliance, Patient 2, Patient 3, Patient 5, and Patient 6 have the potential to experience delayed and/or missed care, decline in health, that could result in serious harm, hospitalization, and death due to not assessing/identifying the needs of the patients and developing an individualized plan of care. 1. Failing to ensure that the recertification (a mandatory, periodic process where a physician confirms a patient still meets the eligibility criteria for home health services), assessment was completed within the last five (5) days for every 60 days starting from the admission date of four of seven (7) patients (Patient 2, Patient 3, Patient 5, and Patient 6). 2. Failing to ensure that a Plan of Care (PoC, the detailed roadmap for a patient’s treatment) was developed for three of seven (7) patients (Patient 2, Patient 3, and Patient 6) for Patient 2, within seven days of the recertification date of 9/29/2025; for Patient 3, within seven days from the admission date of 5/10/2025 and the recertification date of 9/7/2025; for Patient 6, within the periods of 10/4/2025 to 12/2/2025, and 8/5/2025 to 10/3/2025. 3. Failing to ensure that the PoC for one of seven patients (Patient 5) was followed when Patient 5’s POC indicated a need for a glucometer, monitoring blood glucose levels, and ensured Patient 5 obtained prescribed diabetic medication when insurance issues were encountered. The HHA did not monitor Patient 5’s weight and did not notify Patient 5’s physician for changes in condition of edema of the lower extremities. As a result of the non-compliance, Patient 2, Patient 3, Patient 5, and Patient 6 have the potential to experience delayed and/or missed care, decline in health, that could result in serious harm, hospitalization, and death due to not assessing/identifying the needs of the patients and developing an individualized plan of care. On 10/9/2025, at 3:35 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Administrator (ADM) and Director of Patient Care Services (DPCS), and Intake Coordinator, related to the hospice agency’s failure to ensure the DPCS provided oversight, that a recertification assessment was completed within the last five (5) days for every 60 days starting from the admission date and ensure that a Plan of Care was developed of four of seven (7) patients (Patient 2, Patient 3, Patient 5, and Patient 6). The HHA failed for the DPCS to ensure that the PoC for Patient 5, which indicated a need for a glucometer, monitoring blood glucose levels, monitoring weight, notifying Patient 5 physician for changes in condition including edema of the lower extremities, and ensuring Patient 5 was able to obtain Patient 5’s prescribed diabetic medication. On 10/9/2025, at 4:30 p.m., the agency was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team completed the survey task and conducted an exit conference in the presence of the agency’s Administrator, DPCS, and Intake Coordinator, with the IJ situation not removed. On 10/21/2025 the agency submitted an acceptable IJ removal plan. On 10/22/2025 the survey team conducted an onsite verification of the written IJ removal plan. Based on an interview and record review the IJ removal plan was not implemented. The survey team conducted an exit conference with the Administrator Designee and Intake Coordinator with the IJ was not removed. On 10/31/2025 the survey team conducted a second onsite verification of the written IJ removal plan. On 10/31/2025 at 2:56 pm, the IJ was removed in the presence of the agency’s ADM Designee, DPCS and QA. Findings: During an interview on 10/8/2025 at 4:04 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that she (DPCS) oversees the HHAs nursing staff. The DPCS stated the HHA uses an electronic application (EA, a collaboration and messaging platform for teams using text messages). The DPCS stated after a skilled nurse visit (in general), the visiting nurse (in general) would write a text message in the EA, and she (DPCS) reads them. The DPCS stated that if she (DPCS) reads any concerning information or issues, she (DPCS) then assures the Intake Coordinator (IC) informs Medical Doctor 1 (MD1). The DPCS stated she (DPCS) was lacking at ensuring patients’ (in general) nursing comprehensive assessments and plans of care were completed. The DPCS stated the HHA contracts and outside vendor to review patients’ medical records to identify the HHAs standards. The DPCS stated that the IC and her (DPCS) were responsible for documenting patients’ plan of care. The DPCS stated that patients’ initial and recertification comprehensive nursing assessments were conducted by one of the three HHAs registered nurses, depending on who was scheduled. During an interview on 10/9/2025 at 11:40 a.m., with the Administrator (ADM), the ADM stated that the HHA has three registered nurses (RN) on staff, all of whom have the per diem (by the day) status. The ADM stated that the RNs do not have set hours, they are on call, and work based on their availability. The ADM stated the DPCS has zero patient assigned to her at this time. The ADM stated that Registered Nurse 1 (RN1) and Registered Nurse 2 (RN2) had never been to the HHA in person and that RN1 has one patient assigned and RN2 has no patient assigned at this time. During an interview on 10/9/2025, at 12:03 p.m., the DPCS stated she (DPCS) worked at the HHA anywhere between 20 to 30 hours per week. During an interview on 10/9/2025 at 1:17 p.m., with the Medical Director 1 (MD1), MD1 stated that he (MD1) was the Medical Director of the HHA. MD1 stated that his (MD1) primary responsibility was to provide oversight over the patients care plans. MD1 stated he writes his notes and relied on the nursing staff to document in the patient’s medical record. During review of the HHA’s document titled, Job Description for the DPCS, dated 10/2019, indicated, “The Clinical Director is responsible for the overall direction of home health clinical services. The Clinical Director establishes, implements and evaluates goals and objectives for home health services that meet and promote standards of quality and contribute to the total organization and philosophy...Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel...If functioning as Clinical Manager, would provide oversight of all patient care services and personnel including making patient and personnel assignments; coordinating patient care; coordinating referrals; assuring patient needs are continually assessed: and assuring the development, implementation, and updates of the individualized plan of care.” A. During a record review of Patient 2’s medical record form titled “Patient Profile by Episode” indicated Patient 2’s admission date of 7/31/2025 with an admitting diagnosis of other specified disorder of brain. A1. During a review of Patient 2’s medical record titled “Recertification (follow up) assessment” dated from 9/29/2025 to 11/27/2025, the Recertification (follow up) assessment form did not indicate it was completed or had a registered nurse signature or name. During a review of Patient 2’s medical record titled “Order / Telephone Order” dated 9/27/2025, the Order / Telephone Order did not indicate to readmit Patient 2 for home health services. The Order / Telephone Order form indicated the DPCS and MD1 were listed but there were no signatures of the DPCS and MD1. During a concurrent interview and record review on 10/8/2025 at 10 a.m., with the DPCS of Patient 2’s medical record, the DPCS stated that she (DPCS) did Patient 2’s recertification nursing assessment on 9/27/2025. During the review, the DPCS stated that Patient 2’s recertification nursing assessment dated 9/27/2025 was not completed or signed. The DPCS stated that Patient 2’s recertification comprehensive assessment was to be completed before the end of the first certification period. The DPCS stated her (DPCS) signature would validate and verify the form. The DPCS stated that it was important to conduct comprehensive nursing assessments to assess the patients’ needs and to determine continuation of home health services was needed. The DPCS stated, she (DPCS) did not know if Patient 2 requires home health services. During a concurrent interview and record review on 10/8/2025 at 10:22 a.m., with the DPCS, of Patient 2’s medical record, the DPCS stated that Patient 2 did not have a readmission order in her medical record. The DPCS stated there was no documentation that the readmit order was written or sent to MD1. A2. During a record review of Patient 2’s medical record titled “Home Health Certification and Plan of Care” dated from 9/29/2025 to 11/27/2025, the Home Health Certification and Plan of Care form did not indicate it was completed or had a registered nurse or a physician’s name or signature. During a concurrent interview and record review on 10/8/2025 at 10:14 a.m., with the DPCS, of Patient 2’s medical record, (POC), the DPCS stated a patient’s (in general) individual problems/issues, interventions and goals are documented on their plan of care. The DPCS stated plan of care (in general) identifies patients’ needs to navigate their care. The DPCS stated Patient 2’s plan of care dated 9/29/2025 to 11/27/2025 was incomplete, and that she (DPCS) did not know Patient 2’s diet, problems/issues, interventions, goals, or what type of care she (Patient 2) was receiving. The DPCS stated that it was important for Patient 2 to have a written plan of care to be able to identify her (Patient 2) needs. During a concurrent interview and record review on 10/8/2025 at 10:30 a.m. with the DPCS of Patient 2’s medical record (POC), the DPCS stated MD1 had seven days to sign patients POCs. The DPCS stated MD1s signature would indicate he (MD1) read, acknowledge, verified, and agreed to patients care. B. During a review of Patient 3’s medical record titled “Patient Demographics” indicated, Patient 3’s admission date of 5/10/2025 with an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. B1. During a record review of Patient 3’s medical record titled “Recertification (follow up) assessment” dated from 7/9/2025 to 9/6/2025, the Recertification (follow up) assessment did not indicate it was completed and has no registered nurse signature or name. During a record review of Patient 3’s medical record titled “Recertification (follow up) assessment” dated from 9/7/2025 to 11/5/2025, the Recertification (follow up) assessment did not indicate it was completed or had a registered nurse signature or name. During a review of Patient 3’s medical record titled “Order / Telephone Order” dated 7/4/2025, the Order/Telephone Order indicated Patient 3 required further skilled nursing visits for further monitoring. The Order/Telephone Order indicated the DPCS signed the “Order / Telephone Order” and indicated the order was verified and read back to the Medical Director (MD1) on 7/4/2025. The Order/Telephone Order did not indicate the order was signed by MD1. During a review of Patient 3’s medical record titled “Order/Telephone Order” dated 9/3/2025, the Order/Telephone Order indicated Patient 3 required further skilled nursing services. Patient 3’s Order/Telephone Order indicated that the DPCS signed the Order/Telephone Order and that the order was verified and read back to the Medical Doctor (MD2) on 9/3/2025. Patient 3’s Order/Telephone Order did not indicate it was signed by MD2. During a concurrent interview and record review on 10/8/2025 at 11:45 a.m., with the DPCS, of Patient 3’s electronic medical record (EMR), the DPCS stated Patient 3’s recertification comprehensive nursing assessments for dates 7/9/2025 to 9/6/2025 and 9/7/2025 to 11/5/2025 were not completed. The DPCS stated the information on both recertification comprehensive nursing assessments was auto populated from the initial comprehensive nursing assessment. The DPCS stated that a comprehensive nursing assessment (in general) is required to identify patients’ needs and to evaluate if the patient requires continued home health services. The DPCS stated the recertification assessment (in general) was to be completed at least a week before the recertification date by a registered nurse. During a concurrent interview and record review on 10/8/2025 at 12:05 p.m., with the DPCS of Patient 3’s EMR, the DPCS stated Patient 3’s recertification physician orders were not signed by a physician. The DPCS stated the orders need to be signed to make the admission valid. During an interview on 10/8/2025 at 12:30 p.m., with the Intake Coordinator (IC) of Patient 3’s EMR, the IC stated physician orders need to be in patients’ (in general) medical records 30 days after we (agency staff) fax them to the physician. The IC stated there were no signed physician orders in Patient 3’s medical record. B2. During a review of Patient 3’s medical record titled “Home Health Certification and Plan of Care” dated from 7/9/2025 to 9/6/2025, Patient 3’s Home Health Certification and Plan of Care did not indicate it was completed or had a registered nurse signature or name. During a review of Patient 3’s medical record “Home Health Certification and Plan of Care” dated from 9/7/2025 to 11/5/2025, Patient 3’s Home Health Certification and Plan of Care form did not indicate it was completed or had a registered nurse signature or name. During a concurrent interview and record review on 10/8/2025 at 11:50 a.m., with the DPCS of Patient 3’s EMR, the DPCS stated Patient 3’s plans of care dated from 7/9/2025 to 9/6/2025 and 9/7/2025 to 11/5/2025, were not completed or signed by a registered nurse and a physician. The DPCS stated the Intake Coordinator (IC) filled out the form and she (DPCS) needed to read, approve, and sign it. The DPCS stated her (DPCS) signature would indicate that she verified the forms. C. During a review of Patient 6’s Patient Profile indicated Patient 6’s start of care date was 6/6/2025, with a primary diagnosis of mechanical complication of other urinary catheter (a tube inserted in the body used to drain urine). C1. During an interview on 10/7/2025 at 1p.m., Patient 6’s caregiver (CG 1) stated Patient 6 was receiving nursing services every week. CG 1 stated the nurse checks Patient 6’s blood pressure, heart rate and temperature. CG 1 stated Patient 6 sometimes had her (Patient 6) dressings (a special kind of bandage) changed. During a concurrent interview and record review on 10/8/2025 at 9:58 a.m., with the Intake Coordinator (IC), the IC reviewed Patient 6’s record titled, “Recertification (follow-up) Assessment”, for certification period 10/4/2025 to 12/2/2025. Patient 6’s Recertification (follow-up) Assessment” record did not indicate documentation of an assessment and there was no signature on the record. The IC stated the HHA was unable to find a registered nurse (RN) for the recertification visit. The IC stated she did not notify the DPCS that an RN was not available for a recertification assessment visit. The IC stated she was not sure why she did not notify the DPCS about this. During a concurrent interview and record review on 10/8/2025, at 3:23 p.m., with the DPCS, the DPCS reviewed Patient 6’s record titled, “Recertification (follow-up) Assessment”, for certification period 10/4/2025 to 12/2/2025. The record did not indicate documentation of an assessment and there was no signature on the record. The DPCS stated the record was incomplete and was missing an assessment. The DPCS stated the assessment identified what the needs of the patient were. The DPCS stated that a recertification assessment was not done for the reason of communication issue with scheduling. The DPCS stated the HHA did not know what the current care and services needs of Patient 6. During a concurrent interview and record review on 10/8/2025, at 3:30 p.m., with the DPCS, the DPCS reviewed Patient 6’s record titled, “Recertification (follow-up) Assessment”, for certification period 8/5/2025 to 10/3/2025. The record did not indicate documentation of an assessment and there was no signature on the record. The DPCS stated there was no reassessment done for this certification period. The DPCS stated an RN should have done the recertification assessment. C2. During an interview on 10/7/2025 at 1p.m., Patient 6’s caregiver (CG 1) stated Patient 6 was receiving nursing services every week. CG 1 stated the nurse checked Patient 6’s blood pressure, heart rate and temperature. CG 1 stated Patient 6 had her dressings (a special kind of bandage) changed. During a concurrent interview and record review on 10/8/2025 at 9:58 a.m., with the IC, the IC reviewed Patient 6’s records titled “Home Health Certification and Plan of care”, for certification period 10/4/2025 to 12/2/2025. Patient 6’s Home Health Certification and Plan of care record was not filled out completely and there was no nursing interventions documented. The IC stated the POC was not completed because the recertification visit had just been made on 10/3/2025 and the HHA had 7 days to complete it. The IC was asked who the RN was who visited the patient. The IC continued to review Patient 6’s records then stated Licensed Vocational Nurse (LVN 1) had visited the patient. The IC stated the HHA was unable to find a registered nurse (RN) for the recertification visit. The IC stated an RN was supposed to visit Patient 6 to reassess the patient and develop the plan of care. During a concurrent interview and record review on 10/8/2025, at 3:23 p.m., with the DPCS, the DPCS reviewed Patient 6’s record titled, “Home Health Certification and Plan of Care,” for certification period 10/4/2025 to 12/2/2025. The DPCS stated the POC had not been done. Patient 6’s POC has no doctor’s orders and no interventions documented. The DPCS stated Patient 6’s POC was supposed to be completed by 10/4/2025. The DPCS stated the POC (in general) was important because it provided a guide and interventions needed to assure the care was done and followed thoroughly, so the HHA avoids any incidents such as falls, infections, hospitalization, complications and death. The DPCS stated there was no doctor order to recertify Patient 6 for certification period 10/4/2025 to 12/2/2025. When asked what services Patient 6 needed, the DPCS stated the services were based on the recertification assessment. The recertification assessment was used to develop the plan of care. Patient 6’s records did not have a recertification assessment for the certification period forementioned (Refer to 1C). During a concurrent interview and record review on 10/8/2025, at 3:30 p.m., with the DPCS, the DPCS reviewed Patient 6’s record titled, “Home Health Certification and Plan of Care,” for certification period 8/5/2025 to 10/3/2025. The DPCS stated the Patient 6’s Home Health Certification and Plan of Care, record was incomplete. Patient 6’s Home Health Certification and Plan of Care record did not have nursing interventions, functional, mental, prognosis, nutritional requirements, and DME (durable medical equipment), and was not signed. When asked how the nurse knew what services to provide during the visits, the DPCS stated, “I think the care given was based on what the patient reported needing at the time of the visit.” The DPCS stated this was not acceptable standards of care. During a review of Patient 6’s records indicated nursing visits were made on 8/14/2025, 8/21/2025, 8/26/2025, 9/9/2025, 9/16/2025, and 9/21/2025, without the POC on what care and services being provided. D. During a review of Patient 5’s Patient Profile indicated a start of care date on 8/28/2025, with a primary diagnosis of type 2 diabetes (too much sugar in the blood). Patient 5’s Patient Profile indicated Patient 5’s diagnoses included congestive heart failure (CHF, the heart unable to pump blood effectively). D1. During a review of Patient 5’s record titled, “Home Health Certification and Plan of Care”, dated 8/28/2025 to 10/26/2025 indicated, “Skilled nurse to perform/train/instruct/supervise, patient/pcg (primary caregiver), blood sugar monitoring via finger stick using glucometer machine (a machine that reads blood sugar levels). During a joint home visit and observation, on 10/7/2025, at 10:10 a.m., with the DPCS at Patient 5’s home, the DPCS provided care to Patient 5. There was no glucometer observed in Patient 5’s home. During an interview at the home visit on 10/7/2025, at 11:26 a.m., with Patient 5’s caregiver (CG 2), the CG 2 stated Patient 5 did not check her blood sugar because Patient 5 did not have a glucometer. During an interview on 10/8/2025, at 11:45 a.m., with the IC, the IC stated she was not told by the nurse to order a glucometer, and glucometer supplies for Patient 5. During an interview on 10/8/2025, at 1:15 p.m., with LVN 1, LVN 1 stated she was the visiting nurse for Patient 5. LVN 1 stated she did not know if Patient 5 had a glucometer. During a concurrent interview and record review on 10/8/2025, at 3:10 p.m., with the DPCS, the DPCS reviewed Patient 5’s medical records. The DPCS stated there was no documented evidence of teaching about checking blood sugar levels with a glucometer. The DPCS stated monitoring blood sugar levels with a glucometer was important so the HHA could see an actual blood sugar level, identify the blood sugar levels, so the HHA knows if the treatment is working or if the dosage of the diabetic medication needs to change. The DPCS stated this was important to prevent complication of diabetes such as coma, generalized weakness, kidney damage, or damage to other organs. D2. During an observation of the home visit on 10/7/2025, at 10:10 a.m., the DPCS provided care to Patient 5 and at the conclusion of the visit, the DPCS did not assess Patient 5’s blood glucose levels. During a concurrent interview and record review on 10/7/2025, at 11:35 a.m., with the DPCS, the DPCS stated she did not check Patient 5’s blood sugar during the visit because it was not ordered. Patient 5’s record titled, “Home Health Certification and Plan of Care”, dated 8/28/2025 to 10/26/2025 was then shown to the DPCS. The record indicated, “Skilled nurse to perform/train/instruct/supervise patient/pcg (primary caregiver) blood sugar monitoring via finger stick using glucometer machine (a machine that reads blood sugar levels) ...Endocrine: Skilled nurse to monitor blood glucose levels at each visit, assessing for signs and symptoms of hypo/hyperglycemia…” The DPCS stated the intervention that was supposed to be in the POC was to teach signs and symptoms of hypoglycemia (low blood sugar). The DPCS stated it was the wrong wording in the POC. During the review of Patient 5’s POC indicated that the DPCS had signed the POC. The DPCS stated she had signed the POC but had not thoroughly reviewed it. The DPCS stated the signature on the document validated the information written on the POC. During a concurrent interview and record review on 10/8/2025, at 2:58 p.m., with the DPCS, the DPCS reviewed Patient 5’s record titled Nursing Progress Note, dated 9/3/2025. The record did not indicate Patient 5’s blood sugar levels were assessed and monitored. The DPCS stated the POC was not followed because Patient 5’s blood sugar was not assessed and monitored during the visit. During an interview on 10/7/2025, at 11:45 a.m., with the DPCS, the DPCS stated the risks of not monitoring the blood sugar was an increase of sugar in the blood (hyperglycemia), which can cause ketoacidosis (a life-threatening complication) delayed healing, vision problems, risk of falls, which increases the chance of hospitalization. D3. During an observation of the home visit on 10/7/2025, at 10:10 a.m., the DPCS provided care to Patient 5 and at the conclusion of the visit, the DPCS did not assess and monitor Patient 5’s weight. During a concurrent interview and record review on 10/7/2025, at 11:40 p.m., with the DPCS, the DPCS reviewed Patient 5’s record titled, “Home Health Certification and Plan of Care, dated 8/28/2025 to 10/26/2025. The record indicated, “Cardiopulmonary: Skilled nurse to assess and monitor…weight at each visit, reporting abnormal findings…weight gain greater than 2 pounds in 24 hours...”. The DPCS stated the intervention meant that the nurse was to ask the patient for the weight to see if there was an increase in weight. The DPCS stated an increase in weight meant there was more fluids in the body, which can make congestive heart failure (CHF) worse such as shortness of breath and hospitalization. The DPCS stated she had not assessed Patient 5’s weight during the visit because she had forgotten. The DPCS stated the nurses (in general) were supposed to document the weight assessment every visit. During a concurrent interview and record review on 10/8/2025, at 3:00 p.m., with the DPCS, the DPCS reviewed Patient 5’s records titled, Nursing Progress Note, dated 8/28/2025, 9/18/2025, and 9/23/2025. The records did not indicate a weight was assessed and monitored. The DPCS stated the POC was not followed because the nursing progress notes did not have a weight documented, nor evidence the weight was assessed and monitored. D4. During a record review of Patient 5’s “Home Health Certification and Plan of Care, dated 8/28/2025 to 10/26/2025, indicated, “Skilled Nurse to report to PMD (primary doctor)…edema (fluid buildup in the tissues, causing swelling) greater than 2+ (plus, a measurement of how much is swelled) unrelieved by medication or management…”. During a concurrent interview and record review on 10/8/2025, at 3:00 p.m., with the DPCS, the DPCS reviewed Patient 5’s record titled, Nursing Progress Note, dated 8/28/2025. Patient 5’s Nursing Progress Note indicated 2+ pitting edema in the lower legs. The DPCS stated there was no documented evidence that the nurse notified the doctor of the edema. The DPCS stated the doctor needed to be notified so the doctor was aware Patient 5 was having a symptom of fluid retention. The DPCS stated doctor needed to know this information to determine if a change of medication or treatment was needed. The risk of 2+ edema in the lower legs for Patient 5 was worsening of CHF. Excess fluid can cause water in the lungs, making it difficult to breathe. The DCS stated the POC was not followed. During a concurrent interview and record review on 10/8/2025, at 3 p.m., with the DPCS, the DPCS reviewed Patient 5’s record titled, Nursing Progress Note, dated 9/18/2025 and 9/23/2025. Patient 5’s record titled, Nursing Progress Note indicated 2+ pitting edema in the lower legs. The DPCS stated there was no documented evidence the nurse notified the doctor as indicated in the POC, and therefore, the POC was not followed. D5. During a review of Patient 5’s “Home Health Certification and Plan of Care”, for certification period 8/28/2025 to 10/26/2025, indicated, “Skilled nurse to instruct/supervise patient/pcg on the disease process…disease management, medications…skilled nurse to assess patient’s understanding and adherence to prescribed diabetic medications…” Durning a concurrent observation, interview, and record review on 10/7/2025, at 10:55 a.m., with the DPCS, the DPCS reviewed the medications Patient 5 was taking using Patient 5’s Medication Profile, for episode 8/28/2025 to 10/26/2025. During the review, Patient 5’s diabetic medication Dapagliflozin propanediol (medication used to treat type 2 diabetes, heart failure, and chronic kidney disease) 10 mg tablet was not at home. Patient 5’s CG 1 stated Patient 5 was not taking the medication due to the insurance not covering the medication. CG 1 stated the doctor was supposed to change the order and talk to the pharmacy about the medication. CG 1 stated Patient 5 had not taken the medication since she left the rehabilitation center in August 2025. During an interview on 10/8/2025, at 3:17 p.m., with the DPCS, the DPCS stated there was a discrepancy in the coordination of care. The DPCS stated Patient 5’s family member did not notify the HHA that he (Patient 5’s family member) had spoken to Patient 5’s doctor and was waiting for a response. The DPCS stated if the visiting nurse (unknown) did not review Patient 5’s medications at home, and the nurse (unknown) did not notice the medication (Dapagliflozin propanediol) was not available for Patient 5. The DPCS stated the HHA would have notify the doctor and asked the doctor for an alternative medication for the patient. The DPCS stated the risk of not taking the diabetic medication placed Patient 5 at risk of hyperglycemia (high blood sugar levels) and she could have had diabetes related complications. Patient 5 was placed at risk of health decline. During a record review of the HHAs form titled “Reassessment/Recertification” revised 10/2019, indicated “The comprehensive assessment must be updated and revised every second calendar month, beginning with the start of care. A comprehensive assessment… must be performed to measure patient progress toward outcomes. The total plan of care must be renewed at least every 60 days, or more often as warranted by the condition of the patient… The recertification statement must indicate the patients continuing need for home health services.” During a record review of the HHAs form titled “Care Planning Process” revised 10/2019, indicated “The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient. All clinicians including the physician involved in the patients care, either directly or indirectly, will contribute to the plan of care.””

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure patient care records were complete and authenticated for five of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 7). This failure resulted in patients’ medical records being modified by people not involved in patients’ care. During a record review of Patient 1’s medical record form titled “Patient Demographics”, indicated an admission date of 4/26/2025 with a discharge date of 5/13/2025, with a primary diagnosis of pressure ulcer of sacral region stage 4 (severe deep wound that damaged the skin, fat, muscle, and bone in the tailbone area). During a record review of Patient 1’s medical record form titled “Case Conference” dated 4/26/2025, the Case Conference form indicated License Vocational Nurse 2 (LVN2) and License Vocational Nurse 3 (LVN3) participated in the conference, but the form lacked agency staff signature. During a record review of Patient 1’s medical record, the medical record indicated there was one entry made in section “Communication Note”. Patient 1’s form titled “Communication Note” dated 4/26/2025, indicated it was Patient 1’s “start of care initial report”. The Communication Note listed the Director of Patient Care Services (DPCS) name but did not have her (DPCS) signature. During a record review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/26/2025 to 6/24/2025, the Home Health Certification and Plan of Care form did not indicate it had a skilled nurse’s name or signature. During a record review of Patient 1’s medical record form titled “Discharge - OASIS” dated 5/13/2025, indicated the physician was notified of Patient 1’s discharge, but does not state the physician’s name. Lastly, the Discharge - OASIS form did not indicate who completed the documentation due to not listing an agency staffs name or signature. During a record review of Patient 1’s medical record form titled “Order/Telephone Order” dated 4/24/2025 (Referred for Admission), 4/26/2025 (Admission Order), 4/30/2025 (Others – wound Care Treatment), and 5/13/2025 (Discharge from Agency), all forms indicated there were not signed by a skilled nurse or a physician. During a concurrent interview and record review on 10/8/2025 at 1 p.m. with the DPCS, of Patient 1’s medical record, the DPCS stated she forgot to sign her name on Patient 1’s physician orders. During a concurrent interview and record review on 10/8/2025 at 1:20 p.m. with the DPCS, of Patient 1’s medical record, the DPCS stated that Patient 1’s Discharge – OASIS form had some information, but she (DPCS) does not know who wrote it despite having her (DPCS) name on the form. During a concurrent interview and record review on 10/8/2025 at 1:27 p.m. with the DPCS of Patient 1’s medical record, the DPCS stated that she (DPCS) filled out Patient 1’s plan of care but did not sign it. The DPCS stated that her (DPCS) signature validates the form. 2. During a record review of Patient 2’s medical record form titled “Patient Profile by Episode” indicated an admission date of 7/31/2025 with an admitting diagnosis of other specified disorder of brain. During a record review of Patient 2’s medical record form titled “Recertification (follow – up) assessment” dated from 9/29/2025 to 11/27/2025, the Recertification (follow – up) assessment form did not have a registered nurse signature or name. During a record review of Patient 2’s medical record form titled “Order / Telephone Order” dated 9/27/2025, the Order / Telephone Order indicated the DPCS and MD1 names were listed but there were no signatures. During a concurrent interview and record review on 10/8/2025 at 10 a.m. with the DPCS of Patient 2’s medical record, the DPCS stated that she (DPCS) documented Patient 2’s recertification nursing assessment on 9/27/2025. Upon further review, the DPCS stated that Patient 2’s recertification nursing assessment dated 9/27/2025 was not complete or signed. The DPCS stated her (DPCS) signature would validate and verify the form. During a record review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” dated from 9/29/2025 to 11/27/2025, the Home Health Certification and Plan of Care form did not indicate it was completed or had a registered nurse or a physician’s name or signature. During a concurrent interview and record review on 10/8/2025 at 10:30 a.m. with the DPCS of Patient 2’s medical record, the DPCS stated that MD1 had seven days to sign patients POCs. The DPCS stated that MD1s signature would indicate he (MD1) read, acknowledge, verified, and agreed to patients care. 3. During a record review of Patient 3’s medical record form titled “Patient Demographics” indicated an admission date of 5/10/2025 with an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. During a record review of Patient 3’s medical record form titled “Recertification (follow – up) assessment” dated from 7/9/2025 to 9/6/2025, the Recertification (follow – up) assessment form did not indicate it was completed, nor did it have a registered nurse signature or name. During a record review of Patient 3’s medical record form titled “Recertification (follow – up) assessment” dated from 9/7/2025 to 11/5/2025, the Recertification (follow – up) assessment form did not indicate it was completed or had a registered nurse signature or name. During a record review of Patient 3’s medical record form titled “Home Health Certification and Plan of Care” dated from 7/9/2025 to 9/6/2025, the Home Health Certification and Plan of Care form did not indicate it was completed or had a registered nurse signature or name. During a record review of Patient 3’s medical record form titled “Home Health Certification and Plan of Care” dated from 9/7/2025 to 11/5/2025, the Home Health Certification and Plan of Care form did not indicate it was completed or had a registered nurse signature or name. During a concurrent interview and record review on 10/8/2025 at 11:50 a.m. with the DPCS of Patient 3’s medical record, the DPCS stated Patient 3’s plans of care dated from 7/9/2025 to 9/6/2025 and 9/7/2025 to 11/5/2025, were not completed or signed by a registered nurse and a physician. The DPCS stated that her (DPCS) signature would indicate she verified the forms. 4. During a record review of Patient 4’s document titled, Patient Profile, indicated a start of care on 7/12/2025, with a diagnosis of essential hypertension (high blood pressure). The record also indicated Patient 4 was discharged from the HHA on 8/28/2025. 4a. During a concurrent interview and record review on 10/9/2025, at 10:33 a.m., with the DPCS, the DPCS reviewed Patient 4’s record titled, Home Health Certification and Plan of Care, for certification period 7/12/2025 to 9/9/2025. The record did not indicate a signature of the person completing it. 4b. During a concurrent interview and record review on 10/9/2025, at 11:15 a.m., with the DPCS, the DPCS reviewed Patient 4’s nursing visit notes dated 7/12/25, 7/14/25, 7/24/25, 7/28/25, and 8/5/25. The DPCS stated none of the notes forementioned were signed. The purpose of signing the notes was to verify the information documented and to indicate who did the assessment. During an interview on 10/9/2025, at 11:23 a.m., with the Administrator (ADM), the ADM stated the DPCS was the primary person responsible for ensuring the clinical notes were in the medical record. 5. During a record review of Patient 7’s document titled, Patient Profile, indicated a start of care on 8/29/2025, with a primary diagnosis of laceration (cut) without foreign body of right forearm. a. During a concurrent interview and record review on 10/9/2025, at 9:35 a.m., with the DPCS, the DPCS reviewed Patient 7’s record titled, Home Health Certification and Plan of Care, for certification period 8/29/2025 to 10/27/2025. The record did not indicate a signature of the person completing it. The DPCS stated the importance of signing the record is to validate the plan of care (POC) had been reviewed. The importance of reviewing the record was to assure that patients plan, goals, interventions, will be met and followed by the licensed nurses. To make sure the services are being offered based on the needs of the patient. b. During a concurrent interview and record review on 10/9/2025, at 3:11 p.m., with the DPCS, the DPCS reviewed Patient 7’s nursing visit notes dated 8/29/2025, 9/4/2025, and 9/11/2025. The DPCS stated the notes were not signed. A record review of the HHA’s document titled, Entries Into the Clinical Record, dated 10/2019, indicated, “The clinical note will include...signature of clinician and his/her credentials.””

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure one of seven sampled patients (Patient 1) discharged from home health services was conducted safely and appropriately to facilitate continuity of care for the patient certified to receive home health benefits. This failure had the potential to result in Patient 1 experiencing pain, discomfort and anxiety that could impact on the patient’s quality of care and well-being. During a record review of Patient 1’s medical record form titled “Patient Demographics”, indicated an admission date of 4/26/2025, with a primary diagnosis of pressure ulcer of sacral region stage 4 (severe deep wound that damaged the skin, fat, muscle, and bone in the tailbone area). The Patient Demographic form also indicated Patient 1 was discharge on 5/13/2025 for “Lack of progress”. During a record review of Patient 1’s medical record form titled “Start of Care” dated from 4/26/2025 to 6/24/2025, the Start of Care form indicated Patient 1’s husband was her caregiver (FM2). The Start of Care form also indicated that Patient 1’s had a Stage 4 wound on the sacral region, a Foley Catheter (soft hollow tube inserted into the bladder to facilitate draining), a tracheostomy, fully dependent on a ventilator (machine connected to the tracheostomy that pushes air into the lungs), and a PEG tube (soft hollow tube inserted into the stomach to facilitate nourishment). The Start of Care form also indicated Patient 1 was nonverbal, completely bed bound, and was fully dependent on “caregiver support which is critical for maintaining safety and preventing complications”. The Start of Care form indicated section “Verbal Order – Physician called to report comprehensive assessment findings… discharge planning needs” was left blank. During a record review of Patient 1’s medical record form titled “Nursing Progress Note” dated 4/26/2025, indicated that Patient 1’s husband/care giver/Power of attorney (POA) agreed with the plan of care for Patient 1 and was willing and able to learn to care for Patient 1. The Progress Note also indicated that discharge planning was discussed with FM2. During a record review of Patient 1’s medical record form titled “Discharge - OASIS” dated 5/13/2025, indicated the physician was notified of Patient 1’s discharge, but did not indicate the physician’s name. Section “Complete this section for discharge purposes” was left blank. The Discharge - OASIS form also indicated Patient 1’s care giver was notified of the pending discharge and was provided with the HHABN form, but it does not state the date this was done. Sections “Strengths/limitations, education/training, risk factors and refused cares – related to plan of care and Pain” was left blank. The Discharge OASIS form did not indicate who completed the documentation due to note listing an agency staff name or signature. During a record review of Patient 1’s medical record form titled “Order/Telephone Order” dated 5/13/2025 (Discharge from Agency), indicated it was not signed by a skilled nurse or a physician. During a concurrent interview and record review on 10/8/2025 at 1:11 p.m. with the Director of Patient Care services (DPCS) of Patient 1’s medical record, the DPCS stated there was no discharge order written for Patient 1. The DPCS stated that a discharge order notifies the physician and the agency team that the patient is no longer receiving services from the agency. During a concurrent interview and record review on 10/8/2025 at 1:20 p.m., with the DPCS, of Patient 1’s medical record, the DPCS stated Patient 1’s Discharge OASIS (OASIS [Outcome and Assessment Information Set] standardized electronic record used for Medicare/Medicaid patients to collect patient demographic, clinical, and functional status information) was not complete. The DPCS stated that Patient 1’s Discharge OASIS form had some information, but DPCS did not know who wrote it despite having the DPCS name on the form. The DPCS stated that the Discharge OASIS indicates the reason why a patient is discharged and their current health status. During a concurrent interview and record review on 10/8/2025 at 1:24 p.m., with the DPCS, of Patient 1’s medical record, the DPCS stated Patient 1 did not have a documented discharge summary. The DPCS stated that the discharge summary indicated who Patient 1 was endorsed to and if the physician was made aware. The DPCS stated that Patient 1’s husband/ caregiver (FM2) was not provided with the Home Health Advance Beneficiary Notice (HHABN - a notice used to inform Medicare beneficiaries of potential non-coverage for home health services). During a concurrent interview and record review on 10/8/2025 at 1:27 p.m. with the Intake Coordinator (IC) of Patient 1’s medical record, the IC stated that the Medical Doctor 4 (MD4) was her (Patient 1) primary provider. The IC stated that Patient 1’s husband/caregiver (FM2) was made aware of Patient 1’s discharge on 5/13/2025. The IC stated that she called FM2 three times but that he did not answer. The IC stated that she left a message for FM2 informing him that MD4 was made aware of Patient 1’s discharge. The IC stated Patient 1’s discharge instructions were not documented in Patient 1’s medical record. The IC stated that FM2 did not receive discharge instructions. The IC stated that discharge instructions were important to ensure Patient 1 receives the proper wound management. During an interview and record review on 10/7/2025 at 11:17 a.m. with the Administrator (ADM), of the HHAs Complaint and Grievance Log, the ADM stated that there were no complaints or grievances made since January 2025. During a concurrent interview and record review on 10/8/2025 at 2:04 p.m. with the Intake Coordinator (IC) of Patient 1’s medical record, the IC was requested to provide Patient 1’s signed physician orders. The IC stated that she (IC) did not fax Patient 1’s orders or the plan of care to the Medical Director 1 (MD1). The IC stated that she (IC) was responsible for faxing the physicians’ patients’ orders and plans of care within 30 days of when the order was written. The IC stated that Patient 1’s had the potential to have improper care due to not having a physician oversight. The IC stated “The patient can be at risk for injury or something negative that might not be approved by the doctor. We are out of scope of practice.” During an interview on 10/9/2025 at 3:20 p.m. with Patient 1’s husband/POC/Caregiver (FM2), FM2 stated Patient 1 was discharged abruptly. FM2 stated there were no notices provided to give time to look for another agency. FM2 stated he (FM2) did not know why Patient 1 was discharged. FM2 stated he (FM2) was disappointed with the HHA. A record review of the HHA’s document titled, Discharge Summary, dated 10/2019, indicated, “Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record...Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include as appropriate...The date of discharge, including the date the physician and the patient were informed of discharge...The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service”.”

“Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure one of seven sampled patients (Patient 7) has the right to refuse services and be discharged from home health services as requested. Patient 7/caregiver had requested to be discharged during the period of 9/17/2025. HHA failed to conduct the discharge assessment visit. Patient 7 was still listed as an active patient of the HHA. This failure resulted in confusion of Patient 7/caregiver and did not know the status if the Medicare home health benefits had been continued or terminated. During a record review of Patient 7’s document titled, Patient Profile, indicated a start of care on 8/29/2025, with a primary diagnosis of laceration (cut) without foreign body of right forearm. During an interview on 10/9/2025, at 2:25 p.m., with Patient 7’s caregiver (CG 3), the CG 3 stated she had requested to stop HH services about 3 to 4 weeks ago. CG 3 stated she had sent the HHA a text message because that was the HHA’s preferred method of communication. CG 3 stated it was always hard to get a hold of the HHA, to speak to someone. CG 3 stated no one responded to her request, assumed the message was received, and Patient 7 was discharged. When told that Patient 7 was listed as an active patient, CG 3 stated she was surprised and asked if Patient 7 would be billed for services until she was discharged. During an interview on 10/9/2025, at 2:45 p.m., with Patient 7, Patient 7 stated her last visit from the HHA was on 9/12/2025. Patient 7 stated she told the HH nurse on the visit of 9/12/2025, not to visit her anymore, because the services were no longer needed. During an interview on 10/9/2025, at 3:19 p.m., with the Administrator (ADM), the ADM stated Patient 7 had requested to be discharged a while ago, sometime around 9/17/2025. The ADM stated, “we missed this one”. The ADM stated the HHA was going to schedule a discharge visit. The ADM stated it was the ADM’s responsibility to schedule a discharge visit, as the ADM was the one responsible for the day-to-day operations of the HHA. A record review of the HHA’s document titled, Rights/Responsibilities, dated 10/2019, indicated, “Procedure: 1. The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient, of the following...The organization’s transfer and discharge policies” A record review of the HHA’s document titled, Discharge Planning, dated 10/2019, indicated, “Policy...Clinicians will assist patients regarding their discharge by...Consulting with the patient and family/caregiver regarding plans for discharge from the organization...Serving as a referral source for the patient and family/caregiver in obtaining follow-up support services...Consulting with the patient and family/caregiver regarding the provision of discharge information.””

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure one of seven sampled patients (Patients 1) representative/care giver was made aware Patient 1 was being considered for discharge. This failure had the potential to result in Patient 1’s representative/care giver experience grief, stress and uncertainty. During a record review of Patient 1’s medical record form titled “Patient Demographics”, indicated an admission date of 4/26/2025, with a primary diagnosis of pressure ulcer of sacral region stage 4 (severe deep wound that damaged the skin, fat, muscle, and bone in the tailbone area). The Patient Demographic form also indicated Patient 1 was discharged from home health services on 5/13/2025 for “Lack of progress”. During a record review of Patient 1’s medical record indicated there was one entry made in section “Communication Note”. Patient 1’s form titled “Communication Note” dated 4/26/2025 indicated Patient 1’s husband/caregiver (FM2) was the authorized Power of Attorney (POA). During a record review of Patient 1’s medical record form titled “Discharge - OASIS” dated 5/13/2025, indicated the physician was notified of Patient 1’s discharge, but did not indicate the name of the physician notified. Section “Complete this section for discharge purposes” was left blank. The Discharge - OASIS form also indicated Patient 1’s care giver was notified of the pending discharge and was provided with the HHABN (Home Health Advance Beneficiary Notice) form, but it failed to indicate the date it was done. Sections “Strengths/limitations, education/training, risk factors and refused cares – related to plan of care and Pain” was left blank. The Discharge - OASIS form did not indicate who completed the information in the Form . The agency’s staff name or signature was missing and not verified. During a record review of Patient 1’s medical record form titled “Order/Telephone Order” dated 5/13/2025 (Discharge from Agency), indicated it was not signed by the skilled nurse who took the order or physician who gave the order. During a concurrent interview and record review on 10/8/2025 at 1:20 p.m., with the Director of Patient Care services (DPCS), of Patient 1’s medical record stated Patient 1’s Discharge – OASIS was not completed. The DPCS stated Patient 1’s Discharge – OASIS form had information documented, however she did not know who wrote it despite having her name written on the form. The DPCS stated that the Discharge – OASIS states the reason why a patient was discharged and their current health status. During a concurrent interview and record review on 10/8/2025 at 1:24 p.m., with the DPCS, of Patient 1’s medical record stated Patient 1 did not have a documented discharge summary. The DPCS stated the discharge summary should indicate who Patient 1 was endorsed to and if the physician was made aware, there was a wound treatment, and continuation of medications and wound treatments. The DPCS stated that FM2 was not provided with the Home Health Advance Beneficiary Notice (HHABN - a notice used to inform Medicare beneficiaries of potential non-coverage for home health services). During a concurrent interview and record review on 10/8/2025 at 1:27 p.m., with the Intake Coordinator (IC) of Patient 1’s medical record IC stated, FM2 was made aware of Patient 1’s discharge on 5/13/2025. The IC stated she called FM2 three times but did not answer. The IC stated she left messages for FM2, informing him that MD4 was made aware of Patient 1’s discharge. The IC stated Patient 1’s discharge instructions were not documented in Patient 1’s medical record. The IC stated FM2 did not receive discharge instructions. The IC stated that discharge instructions were important to ensure Patient 1 gets the proper wound management. During an interview on 10/9/2025 at 3:20 p.m., with FM2 stated Patient 1 was discharged abruptly. FM2 stated there were no notices provided to give time to look for another agency. FM2 stated he did not know why Patient 1 was discharged. FM2 stated he was disappointed with the HHA. A record review of the HHA’s document titled, Discharge Planning, dated 10/2019, indicated, “Patient will not be discharged without appropriate preparation. The patient’s continuing care needs will be assessed on an ongoing basis, as well as at discharge. Information will be provided to assist the patient in planning his/her discharge, including referral and transfer...Clinicians will assist patients regarding their discharge by...Consulting with the patient and family/caregiver regarding plans for discharge from the organization...Serving as a referral source for the patient and family/caregiver in obtaining follow-up support services.””

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to provide one of seven sampled patients (Patient 1) representative/care giver information of providers that may be able to provide Patient 1 continued services. This failure had the potential to result in Patient 1 missing the required care and treatment, and care for tracheostomy (tube inserted into the trachea to facilitate breathing), gastrostomy (tube inserted into the stomach to provide nourishment), and Foley catheter (soft hollow tube inserted into the urinary bladder to facilitate draining) that could impact the patient’s health status and quality of care. During a record review of Patient 1’s medical record form titled “Patient Demographics”, indicated an admission date of 4/26/2025, with a primary diagnosis of pressure ulcer of sacral region stage 4 (severe deep wound that damaged the skin, fat, muscle, and bone in the tailbone area). The Patient Demographic form also indicated Patient 1 was discharged on 5/13/2025 for “Lack of progress”. During a record review of Patient 1’s medical record form titled “Start of Care” dated from 4/26/2025 to 6/24/2025 indicated Patient 1’s husband was the caregiver (FM2). The Start of Care form also indicated Patient 1 had a Stage 4 wound on her sacral region, Foley Catheter, a tracheostomy, fully dependent on a ventilator (machine connected to the tracheostomy that pushes air into the lungs), and a PEG tube (soft hollow tube inserted into the stomach to facilitate nourishment). Patient 1 was nonverbal, completely bed bound, and was fully dependent on “caregiver support which is critical for maintaining safety and preventing complications”. The Start of Care form indicated section “Verbal Order Physician called to report comprehensive assessment findings… discharge planning needs” was left blank. During a record review of Patient 1’s medical record form titled “Case Conference” dated 4/26/2025, indicated Patient 1’s primary diagnosis was essential (primary) hypertension (high blood pressure). The Case Conference also indicated License Vocational Nurse 2 (LVN2) and License Vocational Nurse 3 (LVN3) participated in the conference, but the form had no agency staff signature. During a record review of Patient 1’s medical record form titled “Case Conference” dated 5/25/2025 was left blank. During a record review of Patient 1’s medical record form titled “Case Conference” dated 6/24/2025 was left blank. During a record review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/26/2025 to 6/24/2025, the Home Health Certification and Plan of Care form did not indicate a physician signed the form. During a record review of Patient 1’s medical record form titled “Discharge - OASIS” dated 5/13/2025, indicated the physician was notified of Patient 1’s discharge, but did not state the physician’s name. During a record review of Patient 1’s medical record form titled “Order/Telephone Order” dated 5/13/2025 (Discharge from Agency), all forms indicated it was not signed by a skilled nurse or a physician. During a concurrent interview and record review on 10/8/2025 at 1:11 p.m. with the Director of Patient Care services (DPCS) stated there was no discharge order written for Patient 1. The DPCS stated that a discharge order notifies the physician and the agency team that the patient was no longer receiving services from the agency. The DPCS stated that Medical Doctor 3 (MD3) was Patient 1’s primary physician and has not seen Patient 1. The DPCS stated that Patient 1 had a face-to-face appointment with MD3 but was discharge before he (MD3) saw her (Patient 1). During a concurrent interview and record review on 10/8/2025 at 1:24 p.m. with the DPCS stated Patient 1 did not have a documented discharge summary. DPCS stated the discharge summary would indicate who Patient 1 was endorsed to and if the physician was made aware. During a concurrent interview and record review on 10/8/2025 at 1:27 p.m. with the Intake Coordinator (IC) stated that the Medical Doctor 4 (MD4) was Patient 1’s primary provider. IC stated Patient 1’s discharge instructions were not documented in patient’s medical record. IC stated that discharge instructions were important to ensure Patient 1 gets the proper wound management. During a concurrent interview and record review on 10/8/2025 at 2:04 p.m. with the Intake Coordinator (IC), documented evidence was requested to provide Patient 1’s signed physician orders. IC stated she did not fax Patient 1’s orders or the plan of care to the Medical Director 1 (MD1). IC stated that she was responsible for faxing the physicians’ patients’ orders and plans of care within 30 days of when the order was written. The IC stated that Patient 1’s had the potential to have improper care due to not having a physician oversight. IC stated “The patient can be at risk for injury or something negative that might not be approved by the doctor. We are out of scope of practice.” A record review of the HHA’s document titled, Discharge Planning, dated 10/2019, indicated, “Patient will not be discharged without appropriate preparation. The patient’s continuing care needs will be assessed on an ongoing basis, as well as at discharge. Information will be provided to assist the patient in planning his/her discharge, including referral and transfer...Clinicians will assist patients regarding their discharge by...Consulting with the patient and family/caregiver regarding plans for discharge from the organization...Serving as a referral source for the patient and family/caregiver in obtaining follow-up support services.””

“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 Home Health Agency (HHA) failed to ensure a comprehensive assessment was completed for one of seven sampled patients (Patient 4). This failure resulted in provision of HHA services without identifying the needs of the patient. During a record review of Patient 4’s document titled, Patient Profile, indicated a start of care on 7/12/2025, with a diagnosis of essential hypertension (high blood pressure). The record also indicated Patient 4 was discharged from the HHA on 8/28/2025. During a concurrent interview and record review on 10/9/2025, at 10:25 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 4’s record titled, OASIS admission assessment for certification period 7/12/2025 to 9/9/2025. The record indicated the admission assessment was on 7/10/2025. The DPCS stated the OASIS assessment was the comprehensive assessment, but it was not done. The DPCS stated the importance of a comprehensive assessment was to identify the needs of the patient. The assessment was a walk through from head-to-toe assessment, physical, psychological, and emotional status. The comprehensive assessment was used to document the physical assessment, navigate what the needs of the patient are, so the HHA knows what care plan was needed. The comprehensive assessment was used to formulate the plan of care. During a concurrent interview and record review on 10/9/2025, at 11:15 a.m., with the DPCS of Patient 4’s visit notes stated Patient 4 was visited by the skilled nurse on 7/12/25, 7/14/25, 7/24/25, 7/28/25, and 8/5/25. A record review of the HHA’s record titled, Admission Criteria and Process, dated 10/2019, indicated, “Procedure...The initial and comprehensive assessments must be conducted by a registered nurse...A comprehensive assessment must be completed within five (5) calendar days of the patient’s start of care...Each patient must receive a patient-specific, comprehensive assessment that identifies the need for home health care and that meets the patient’s medical, nursing, rehabilitative, social, and discharge needs.””

“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 review and document all the medications and treatments the patient was currently using for two of seven sampled patients (Patient 2, Patient 5). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. 1. During a record review of Patient 2’s medical record form titled “Patient Profile by Episode” indicated an admission date of 7/31/2025 with an admitting diagnosis of other specified disorder of brain. During a record review of Patient 2’s medical record form titled “Patient Medication Profile” dated from 7/31/2025 to 9/28/2025, the Patient Medication Profile indicated there were two medications listed, Prozac (antidepressant) and Seroquel (antidepressant). During a concurrent interview and record review on 10/8/2025 at 10 a.m., with the Director of Patient Care services (DPCS) of Patient 2’s medical record stated Patient 2’s recertification nursing assessment form dated 9/27/2025 was not completed or signed. The DPCS stated her signature would validate and verify the form. The DPCS stated that it was important to conduct comprehensive nursing assessments to assess the patients’ needs. The DPCS stated she does not know if Patient 2 requires home health services. During a concurrent interview and record review on 10/8/2025 at 10:14 a.m. with the DPCS of Patient 2’s medical record stated that plans of care identify patients’ needs to navigate their care. DPCS stated Patient 2’s plan of care dated 9/29/2025 to 11/27/2025 was incomplete, and she did not know Patient 2’s diet, problems/issues, interventions, goals, or what type of care she (Patient 2) was receiving. DPCS stated that it was important for Patient 2 to have a written plan of care to be able to identify her (Patient 2) needs. During an interview on 10/8/2025 at 9:10 a.m. with Patient 2 stated that she takes three different medications daily. Patient 2 stated that she currently is takins Prozac, Seroquel, and Claritin for “a number of years”. 2. During a record review of Patient 5’s Patient Profile indicated a start of care date on 8/28/2025, with a primary diagnosis of Type 2 diabetes (too much sugar in the blood). The record also indicated Patient 5’s diagnoses included Congestive Heart Failure (CHF-the heart unable to pump blood effectively). Durning a concurrent observation, interview, and record review on 10/7/2025, at 10:55 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed the medications Patient 5 was taking using the Medication Profile, for episode 8/28/2025 to 10/26/2025. During the review, Patient 5’s diabetic medication Dapagliflozin propanediol 10 mg (milligram, unit of measurement) tablet was not at home. Patient 5’s caregiver (CG 1) stated Patient 5 was not taking the medication due to the insurance not covering the medication. CG 1 stated the doctor was supposed to change the order and talk to the pharmacy about the medication. CG 1 stated Patient 5 had not taken the medication since she left the rehabilitation center in August 2025. Continued review of the medications indicated Docusate Sodium (a stool softener) had the wrong dose listed in the profile. The DPCS stated 250 mg was listed on the profile, but the medication at home was 240 mg. The DPCS stated medication Guaifenesin (helps with cough) was listed but patient reported not taking. The DPCS continued to review the medications and stated the following medications were at home, but were not listed on the medication profile: Allopurinol (for gout) 100 mg. 1 tablet by mouth daily. Atorvastatin (for cholesterol management) 20 mg. 1 tablet by mouth daily. Preservision (a supplement for eye health) 1 tablet daily, supplement. Vitamin B 12 (a supplement) 1 tablet daily as needed. Allegra (for allergies) 180 mg 1 tablet daily as needed. During an interview on 10/7/25 at 11:31 a.m., with the DPCS, the DPCS stated medications needed to be reviewed and the medication profile updated every visit. The importance of this was to assure patients health and safety: to make sure the medications are not going to jeopardize their health, make sure treatment is working, monitor their symptoms, to see if a change of dosage is needed, and to communicate to the doctor, by being a bridge between the patient and doctor. A record review of the HHA’s document titled, Medication Profile, dated 10/2019, indicated, “Policy...medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.””

“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 observation, interview and record review the Home Health Agency (HHA) failed to include information required in the Plan of Care (POC) for four of seven sampled patients (Patient 2, Patient 3, Patient 4, Patient 6). This failure had the potential to result in patients not receiving the identified care needs and services which could lead to the decline of their health status and wellbeing. During an interview on 10/8/2025 at 4:04 p.m. with the Director of Patient Care Services (DPCS), stated she was lacking at ensuring patients nursing comprehensive assessments and plans of care were completed. DPCS stated that patients’ initial and recertification comprehensive nursing assessments were conducted by one of the three HHAs registered nurses, depending on who was scheduled. During an interview on 10/9/2025 at 11:40 a.m. with the Administrator (ADM) stated the HHA has three registered nurses (RN) on staff, all of whom have the per diem (by the day) status. The ADM stated RNs do not have set hours, they are on call, and work based on their availability. The ADM stated that the DPCS has zero patients assigned to her at this time. The ADM stated that Registered Nurse 1 (RN1) and Registered Nurse 2 (RN2) have never been to the HHA in person and that RN1 has one patient assigned and RN2 has no patient assigned at this time. 1. During a record review of Patient 2’s medical record form titled “Patient Profile by Episode” indicated an admission date of 7/31/2025 with an admitting diagnosis of other specified disorder of brain. During a record review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” dated from 9/29/2025 to 11/27/2025, the Home Health Certification and Plan of Care form did not indicate it was completed or had a registered nurse or a physician’s name or signature. During a concurrent interview and record review on 10/8/2025 at 10:14 a.m. with the Director of Patient Care services (DPCS) of Patient 2’s medical record, the DPCS stated that a patient’s individual problems/issues, interventions and goals are documented on their plan of care. The DPCS stated that plans of care identify patients’ needs to navigate their care. The DPCS stated Patient 2’s plan of care dated 9/29/2025 to 11/27/2025 was incomplete, and that she (DPCS) did not know Patient 2’s diet, problems/issues, interventions, goals, or what type of care she (Patient 2) was receiving. DPCS stated that it was important for Patient 2 to have a written plan of care to be able to identify her (Patient 2) needs. During a concurrent interview and record review on 10/8/2025 at 10:30 a.m. with the DPCS of Patient 2’s medical record, stated that Medical Director 1 (MD1) had seven days to sign patients POCs. DPCS stated that MD1s signature would indicate he had read, acknowledged, verified, and agreed to patients care. 2. During a record review of Patient 3’s medical record form titled “Patient Demographics” indicated an admission date of 5/10/2025 with an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. During a record review of Patient 3’s medical record form titled “Home Health Certification and Plan of Care” dated from 7/9/2025 to 9/6/2025, the Home Health Certification and Plan of Care form did not indicate it was completed or had a registered nurse signature or name. During a record review of Patient 3’s medical record form titled “Home Health Certification and Plan of Care” dated from 9/7/2025 to 11/5/2025, the Home Health Certification and Plan of Care form did not indicate it was completed or had a registered nurse signature or name. During a concurrent interview and record review on 10/8/2025 at 11:50 a.m. with the DPCS of Patient 3’s medical record, stated Patient 3’s plans of care dated from 7/9/2025 to 9/6/2025 and 9/7/2025 to 11/5/2025, were not completed or signed by a registered nurse and a physician. DPCS stated that the Intake Coordinator (IC) usually fills the form out and she (DPCS) approves and sings it. DPCS stated that her (DPCS) signature would indicate she verified the forms. 3. During a record review of Patient 4’s document titled, Patient Profile, indicated a start of care on 7/12/2025, with a diagnosis of essential hypertension (high blood pressure). The record also indicated Patient 4 was discharged from the HHA on 8/28/2025. During a concurrent interview and record review on 10/9/2025, at 10:33 a.m., with the DPCS, the DPCS reviewed Patient 4’s record titled, Home Health Certification and Plan of Care, for certification period 7/12/2025 to 9/9/2025. The record indicated an incomplete POC. The DPCS stated the POC was not completed. The areas that were missing were nutritional status, mental status, prognosis, DME (durable medical equipment), functional limitations, nursing interventions, and goals. 4a. During a record review of Patient 6’s Patient Profile indicated a start of care date on 6/6/2025, with a primary diagnosis of mechanical complication of other urinary catheter (a tube inserted in the body used to drain urine). During an interview on 10/7/2025 at 1 p.m., Patient 6’s caregiver (CG 1) stated Patient 6 was receiving nursing services every week. CG 1 stated the nurse checked Patient 6’s blood pressure, heart rate and temperature. CG 1 stated Patient 6 had her dressings (a special kind of bandage) changed sometimes. During a concurrent interview and record review on 10/8/2025 at 9:58 a.m., with the IC, the IC reviewed Patient 6’s records titled “Home Health Certification and Plan of care”, for certification period 10/4/2025 to 12/2/2025. The record was not filled out completely. There was no nursing interventions documented. The IC stated an RN was supposed to visit Patient 6 to reassess the patient and develop the plan of care. During a concurrent interview and record review on 10/8/2025, at 3:23 p.m., with the DPCS, the DPCS reviewed Patient 6’s record titled, “Home Health Certification and Plan of Care,” for certification period 10/4/2025 to 12/2/2025. The DPCS stated the POC had not been done. There were no doctor’s orders, no interventions documented. The DPCS stated the POC was supposed to be done by 10/4/2025. The DPCS stated the POC was important because it provided a guide and interventions needed to assure the care was done and followed thoroughly, so the HHA avoids any incidents such as falls, infections, hospitalization, complications and death. During a concurrent interview and record review on 10/8/2025, at 3:30 p.m., with the DPCS, the DPCS reviewed Patient 6’s record titled, “Home Health Certification and Plan of Care,” for certification period 8/5/2025 to 10/3/2025. The DPCS stated the record was incomplete. The record did not have nursing interventions, functional, mental, prognosis, nutritional requirements, and DME (durable medical equipment), and the record was not signed. When asked how the nurse knew what services to provide during the visits, the DPCS stated, “I think the care given was based on what the patient reported needing at the time of the visit.” The DPCS stated this was not acceptable standards of care. A record review of Patient 6’s records indicated nursing visits were made on 8/14/2025, 8/21/2025, 8/26/2025, 9/9/2025, 9/16/2025, and 9/21/2025. 4b. During an interview on 10/7/2025, at 1:00 p.m., with CG 1, CG 1 stated she was concerned that Patient 6 had not received the nephrostomy (tubes that drain fluid from the kidneys) bags she had been requesting since August 2025. During a concurrent interview and record review on 10/8/2025, at 3:23 p.m., with the DPCS, the DPCS reviewed Patient 6’s record titled, “Home Health Certification and Plan of Care,” for certification period 10/4/2025 to 12/2/2025. The record did not indicate the DME (Durable Medical Equipment) and supplies needed for Patient 6. During a concurrent interview and record review on 10/8/2025, at 3:30 p.m., with the DPCS, the DPCS reviewed Patient 6’s record titled, “Home Health Certification and Plan of Care,” for certification period 8/5/2025 to 10/3/2025. The record did not indicate the DME and supplies needed for Patient 6. The DPCS stated the record was incomplete. During an interview on 10/8/2025, at 3:42 p.m., with the IC, the IC stated the last time Patient 6 was provided with nephrostomy bags was in August 2024. During an interview on 10/8/2025, at 3:44 p.m., with the DPCS stated nephrostomy bags needed to be changed to avoid infection and hospitalization. The DPCS stated the last time the HHA documented Patient 6’s bag was changed was on 8/14/2025. A record review of the HHA’s document titled, Care Planning Process, dated 10/2019, indicated, “Individualized Plan of Care: The patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plane. Documents include plan of treatment (485) and plans of care (all disciplines).”

“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 Home Health Agency (HHA) failed to ensure the physician reviewed and revised one of seven sample patients (Patient 1) individualized plan of care. This failure had the potential to result in Patient 1 receiving inappropriate or lacking appropriate services. During a record review of Patient 1’s medical record form titled “Patient Demographics”, indicated an admission date of 4/26/2025, with a primary diagnosis of pressure ulcer of sacral region stage 4 (severe deep wound that damaged the skin, fat, muscle, and bone in the tailbone area). During a record review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/26/2025 to 6/24/2025, the Home Health Certification and Plan of Care form did not indicate the skilled nurse who filled the form out. The Home Health Certification and Plan of Care form did not have a physician signature. During a concurrent interview and record review on 10/8/2025 at 2:04 p.m. with the Intake Coordinator (IC) of Patient 1’s medical record, the IC was requested to provide Patient 1’s signed physician orders. The IC stated that she (IC) did not fax Patient 1’s orders or the plan of care to the Medical Director 1 (MD1). The IC stated that she (IC) is responsible for faxing the physicians’ patients’ orders and plans of care within 30 days of when the order was written. The IC stated that Patient 1’s had the potential to have improper care due to not having a physician oversight. The IC stated “The patient can be at risk for injury or something negative that might not be approved by the doctor. We are out of scope of practice.” A record review of the HHA’s document titled, Care Planning Process, dated 10/2019, indicated, “Based on the assessment and conclusions, the plan of care will include, but not limited to...All patient care orders from all physicians involved in the plan of care, including verbal orders.” A record review of the HHA’s document titled, Verification of Physician Orders, dated 10/2019, indicated, “Procedure...signed orders will be place in the clinical record within 30 days of initiation of the order...”.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to perform supervisory visits for License Vocational Nurse (LVN) services for five of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 7). This deficient practice resulted in the LVN not being evaluated for patient care and services, which had the potential for patients being taken care of by an unqualified person. During an interview on 10/8/2025 at 4:04 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated she (DPCS) oversees nursing care and is responsible for License Vocational Nurse (LVN) supervision. The DPCS stated that she (DPCS) supervises LVNs by their skilled nursing visit documentation, asking the LVNs questions, and by reading the LVNs inputs on the HHAs electronic application (EA). The DPCS stated the last time she (DPCS) conducted an LVN home supervisory visit, was in 2024. 1. During a record review of Patient 1’s medical record form titled “Patient Demographics”, indicated an admission date of 4/26/2025 and a discharge date of 5/13/2025, with a primary diagnosis of pressure ulcer of sacral region stage 4 (severe deep wound that damaged the skin, fat, muscle, and bone in the tailbone area). During a record review of Patient 1’s medical record titled “LVN (License Vocational Nurse) Supervisory Visit” dated 5/25/2025, indicated the form was left blank. During a record review of Patient 1’s medical record titled “LVN Supervisory Visit” dated 6/24/2025, indicated the form was left blank. 2. During a record review of Patient 2’s medical record form titled “Patient Profile by Episode” indicated an admission date of 7/31/2025 with an admitting diagnosis of other specified disorder of brain. During a record review of Patient 2’s medical record titled “LVN (License Vocational Nurse) Supervisory Visit” dated 8/29/2025, indicated the form was left blank. During a record review of Patient 2’s medical record titled “LVN Supervisory Visit” dated 9/28/2025, indicated the form was left blank. 3. During a record review of Patient 3’s medical record form titled “Patient Demographics” indicated an admission date of 5/10/2025 with an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. During a record review of Patient 3’s medical record titled “LVN (License Vocational Nurse) Supervisory Visit” dated 7/8/2025, indicated the form was left blank. During a record review of Patient 3’s medical record titled “LVN Supervisory Visit” dated 8/7/2025, indicated the form was not complete. The LVN Supervisory Visit form also indicated section SN (Skilled Nurse) name was left blank. Lastly, the LVN Supervisory Visit form did not indicate it was signed by a Registered Nurse. During a record review of Patient 3’s medical record titled “LVN (License Vocational Nurse) Supervisory Visit” dated 9/6/2025, indicated the form was left blank. During a record review of Patient 3’s medical record titled “LVN Supervisory Visit” dated 10/6/2025, indicated the form was left blank. During a concurrent interview and record review on 10/8/2025 at 12:05 p.m. with the DPCS of Patient 3’s medical record, the DPCS stated LVN supervisory visits are to be conducted every two weeks by a registered nurse to supervise and verify the assigned LVN is providing proper care. The DPCS stated that an LVN supervisory visit assures patient safety, by not jeopardizing patient health. 4. During a record review of Patient 5’s Patient Profile indicated a start of care date on 8/28/2025, with a primary diagnosis of Type 2 diabetes (too much sugar in the blood). The record also indicated Patient 5’s diagnoses included Congestive Heart Failure (CHF-the heart unable to pump blood effectively). During an interview on 10/8/2025 at 2:00 p.m., with the DPCS, the DPCS stated Patient 5 was receiving nursing care from a Licensed Vocational Nurse. The DPCS stated the LVN needed to be supervised. The DPCS stated there were no supervisory visit notes for the LVN caring for Patient 5. The importance of supervising LVN’s, was to ensure the nurse was following the plan of care. 5. During a record review of Patient 7’s document titled, Patient Profile, indicated a start of care on 8/29/2025, with a primary diagnosis of laceration (cut) without foreign body of right forearm. During an interview on 10/9/2025 at 2:00 p.m., with the DPCS, the DPCS stated Patient 7 was receiving nursing care from a Licensed Vocational Nurse. The DPCS stated the LVN needed to be supervised. The DPCS stated there were no supervisory visit notes for the LVN caring for Patient 7. A record review of the HHA’s document titled, Licensed Vocational Nurse Supervisory Visit, dated 10/2025, indicated, “Policy: 1. A supervisory visit shall be conducted by a Registered Nurse (RN) for all patients receiving skilled nursing services from an LVN at least every 28 days, or more frequently as indicated by the patient’s condition or per physician’s orders.””

“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 interviews and record review the Home Health Agency (HHA) failed to ensure seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5), Patient 6, Patient 7) clinical records included all the medical records of the care provided. This failure resulted in an incomplete clinical record. During an interview on 10/6/2025 at 3:23 p.m. with the Administrator (ADM), the ADM stated that clinical notes are due every Friday at 5 p.m., seven days after the nursing home visit. The ADM stated that entry of the notes is to ensure other nurses are aware of the patients’ status. 1. During a record review of Patient 1’s medical record form titled “Patient Demographics”, indicated an admission date of 4/26/2025 and a discharge date of 5/13/2025, with a primary diagnosis of pressure ulcer of sacral region stage 4 (severe deep wound that damaged the skin, fat, muscle, and bone in the tailbone area). During a concurrent interview and record review on 10/8/2025 at 1:11 p.m. with the Director of Patient Care Services (DPCS), of Patient 1’s medical record, the DPCS stated there was no discharge order written for Patient 1. The DPCS stated that a discharge order notifies the physician and the agency team that the patient is no longer receiving services from the agency. During a concurrent interview and record review on 10/8/2025 at 1:24 p.m. with the DPCS, of Patient 1’s medical record, the DPCS stated Patient 1 did not have a documented discharge summary. The DPCS stated that the discharge summary indicates who Patient 1 was endorsed to and if the physician was made aware, there is a wound treatment. During a concurrent interview and record review on 10/8/2025 at 1:27 p.m. with the Intake Coordinator (IC) of Patient 1’s medical record, the IC stated Patient 1’s discharge instructions were not documented in her (Patient 1) medical record. The IC stated that FM2 did not receive discharge instructions. The IC stated that discharge instructions were important to ensure Patient 1 gets the proper wound management. During an interview on 10/9/2025 at 3:20 p.m. with Patient 1’s husband/POC/Caregiver (FM2), FM2 stated Patient 1 was discharged abruptly. FM2 stated there were no notices provided to give time to look for another agency. FM2 stated he (FM2) did not know why Patient 1 was discharged. FM2 stated he (FM2) was disappointed with the HHA. 2. During a record review of Patient 2’s medical record form titled “Patient Profile by Episode” indicated an admission date of 7/31/2025 with an admitting diagnosis of other specified disorder of brain. During a concurrent interview and record review on 10/8/2025 at 10:22 a.m. with the DPCS of Patient 2’s medical record, the DPCS stated that Patient 2 does not have a readmission order in her medical record. The DPCS stated that there was no documentation that the readmit order was written or sent to the Medical Director 1 (MD1). 3. During a record review of Patient 3’s medical record form titled “Patient Demographics” indicated an admission date of 5/10/2025 with an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. During an interview on 10/8/2025 at 12:30 p.m. with the Intake Coordinator (IC) of Patient 3’s medical record, the IC stated physician orders need to be in patients’ medical records 30 days after the HHA fax them to the physician. The IC stated there were no signed physician orders in Patient 3’s medical record. 4. During a record review of Patient 4’s document titled, Patient Profile, indicated a start of care on 7/12/2025, with a diagnosis of essential hypertension (high blood pressure). The record also indicated Patient 4 was discharged from the HHA on 8/28/2025. 4a. During a concurrent interview and record review on 10/9/2025, at 10:25 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 4’s record titled, OASIS admission assessment for certification period 7/12/2025 to 9/9/2025. The record indicated the admission assessment was on 7/10/2025. The DPCS stated the OASIS assessment was the comprehensive assessment, but it was not done. The DPCS stated the importance of a comprehensive assessment was to identify the needs of the patient. The assessment was a walk through from head-to-toe assessment, physical, psychological, and emotional status. The comprehensive assessment is used to document the physical assessment, navigate what the needs of the patient are, so the HHA knows what care plan is needed. The comprehensive assessment is used to formulate the plan of care. 4b. During a concurrent interview and record review on 10/9/2025, at 10:44 a.m., with the DPCS, the DPCS reviewed Patient 4’s record titled, DC Oasis, for certification period 7/12/2025 to 9/9/2025. The record indicated a discharge date of 8/28/2025. The DPCS stated the assessment had not been completed. 4c. During a concurrent interview and record review on 10/9/2025, at 10:51 a.m., with the DPCS, the DPCS reviewed Patient 4’s record titled, Admission Order, dated 7/12/2025. The record indicated, “PT (Physical therapy): Evaluation and treatment…refused by patient despite explanation of risks/benefits.”. The DPCS reviewed Patient 4’s medical records and indicated there was no note to explain the patients refusal of PT services and no documentation that Patient 4’s doctor was notified. The DPCS stated she had written the admission order. When asked why the DPCS documented Patient 4 had refused PT services, the DPCS stated it was a typographical error. The error was the documentation of refusal of PT services by Patient 4. During an interview on 10/9/2025, at 1:23 p.m., with Patient 4, Patient 4 stated she was not offered PT services. 5. During a record review of Patient 5’s Patient Profile indicated a start of care date on 8/28/2025, with a primary diagnosis of Type 2 diabetes (too much sugar in the blood). The record also indicated Patient 5’s diagnoses included Congestive Heart Failure (CHF-the heart unable to pump blood effectively). During an interview at the home visit on 10/7/2025, at 10:15 a.m., Patient 5 stated she was receiving PT (physical therapy) services. During a concurrent interview and record review on 10/8/2025, at 2:40 p.m., with the DPCS, the DPCS reviewed Patient 5’s medical record. The DPCS stated there was no PT visit notes in Patient 5’s medical record. The DPCS stated the PT notes were in another software system. The HHA was supposed to retrieve the notes and update them into the medical record. During a concurrent interview and record review on 10/8/2025, at 2:45 p.m., with the DPCS, the DPCS reviewed Patient 5’s record titled, Home Health Certification and Plan of Care, for certification period 8/28/2025 to 10/26/2025. The record indicated Patient 5 was to receive PT and Occupational Therapy (OT) services. Further review of the record indicated patient had refused these services. The DPCS stated this was incorrect documentation because Patient 5 had not refused PT services. During an interview on 10/8/2025, at 2:56 p.m., with the Intake Coordinator (IC), the IC stated Patient 5 had refused OT services. The IC stated she did not document the reason why Patient 5 had refused OT services. 6. During a record review of Patient 6’s Patient Profile indicated a start of care date on 6/6/2025, with a primary diagnosis of mechanical complication of other urinary catheter (a tube inserted in the body used to drain urine). During a concurrent interview and record review on 10/6/2025, at 3:33 p.m., with the Administrator (ADM), the ADM reviewed Patient 6’s medical records. The ADM stated the last visit note documented was for 9/21/2025. The ADM stated visit notes were due within 7 days of the visit. 7. During a record review of Patient 7’s document titled, Patient Profile, indicated a start of care on 8/29/2025, with a primary diagnosis of laceration (cut) without foreign body of right forearm. During a concurrent interview and record review on 10/9/2025, at 10:12 a.m., with the DPCS, the DPCS reviewed Patient 7’s visit notes. The DPCS stated the last visit note in Patient 7’s medical record was dated 9/11/2025. The DPCS stated Patient 7 had been visited, but the visit notes were not documented. The DPCS stated the nurses were supposed to document their visit notes within 7 days of the visit to assure that the patient quality of care was reviewed. So, everyone in the team can have access to review the patients care and see what has been done. Visit notes are also used to monitor the care. A record review of the HHA’s document titled, Contents of the Clinical Record, dated 10/2019, indicated, “Policy: A clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel.” A record review of the HHA’s document titled, Entries Into the Clinical Record, dated 10/2019, indicated, “Entries into the clinical record will be clear, concise, and specific statements of fact...Entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned in to the office at the end of the workday and clinical notes dictated or written will be incorporated into the patient’s health record at least every seven working days.””

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to send all necessary medical information to the primary care practitioner within 5 days of discharge for one of seven sampled patients (Patient 1). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. During a record review of Patient 1’s medical record form titled “Patient Demographics”, indicated an admission date of 4/26/2025 and a discharge date of 5/13/2025, with a primary diagnosis of pressure ulcer of sacral region stage 4 (severe deep wound that damaged the skin, fat, muscle, and bone in the tailbone area). During a concurrent interview and record review on 10/8/2025 at 1:20 p.m. with the Director of Patient Care Services (DPCS), of Patient 1’s medical record, the DPCS stated Patient 1’s Discharge – OASIS dated 5/13/2025 was not complete. The DPCS stated that Patient 1’s Discharge – OASIS form had some information, but she (DPCS) does not know who wrote it despite having her (DPCS) name on the form. The DPCS stated that the Discharge – OASIS states the reason why a patient is discharge and their current health status. The Discharge – OASIS indicated the physician was notified of Patient 1’s discharge but does not state the physician’s name. Section “Complete this section for discharge purposes” was left blank. Lastly, the Discharge - OASIS form did not indicate who completed the documentation due to note listing an agency staff name or signature. During a concurrent interview and record review on 10/8/2025 at 1:24 p.m. with the DPCS, of Patient 1’s medical record, the DPCS stated Patient 1 did not have a documented discharge summary. The DPCS stated that the discharge summary indicates who Patient 1 was endorsed to and if the physician was made aware, there is a wound treatment. During a concurrent interview and record review on 10/8/2025 at 1:27 p.m. with the Intake Coordinator (IC) of Patient 1’s medical record, the IC stated Patient 1’s discharge instructions were not documented in her (Patient 1) medical record. The IC stated that Patient 1’s husband/caregiver/power of attorney (FM2) did not receive discharge instructions. The IC stated that discharge instructions were important to ensure Patient 1 gets the proper wound management. A record review of the HHA’s document titled, Contents of the Clinical Record, dated 10/2019, indicated, “Procedure...The following information will be available in the clinical record, as applicable to care and services provided...Discharge summary and other summary reports sent to the physician, as required by law, regulation, and organization policy.””