Dina Sova Home Health Care, Inc.

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on interview, observation, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient’s personal residence) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Comprehensive Assessment of Patients was met as follows: 1. The HHA nursing staff failed to assess the patient’s pressure injuries (localized damage to the skin and underlying tissue, typically over a bony prominence) and failed to document the primary and secondary diagnosis for two of seven sampled patients (Patient 4 and Patient 6). This failure had the potential to result in undetected changes in wound condition, leading to delayed healing and an increased risk of infection, thereby prolonging the patient’s pain and discomfort, and by not providing current patient status. (Refer to G528). 2. The HHA nursing staff failed to assess the patient’s caregiver’s willingness and ability to provide wound care for one of seven sampled patients (Patient 4). This failure had the potential to result in delayed wound healing, increased risk of infection, and the patient’s home health goals not met. (Refer to G538). 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 Comprehensive Assessment of Patients to ensure the highest quality of care was being provided to patients certified to receive home health care and 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, an organization that delivers skilled nursing and other therapeutic services to a patient) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid Programs) regarding Care planning, Coordination, and Quality of care was met as follows: 1. The HHA failed to ensure all ordered disciplines with their frequency were written in the plan of care for one of seven sampled patients (Patients 6). This failure placed these patients at risk for health complications and no interventions for the skilled nurse to assess or follow up on. (Refer to G574). 2. The HHA failed to obtain a physician order for the administration of normal saline (a sterile mixture of salt and water that matches the body’s natural fluid balance; its primary purpose is to replenish body fluids, maintain blood volume, deliver intravenous medications, and safely cleanse bodily tissues without causing cell damage), Silvasorb (an antimicrobial hydrogel wound dressing), Triad paste (a zinc-oxide-based, medical-grade paste used for wound and skincare) to the peri wound (reddened areas), Calcium Alginate (a highly absorbent, non-woven wound dressing derived from brown seaweed), and Mepilex bordered foam dressing (a line of specialized, soft silicone foam wound dressings designed to absorb fluid and maintain a moist wound healing environment) for one of seven sampled patients (Patients 4). This failure had the potential to place the patient at risk for unmonitored treatment efficacy and adverse effects. (Refer to G580). 3. The HHA nursing staff failed to notify the physician regarding the change of condition for one of seven sampled patients (Patient 4). As a result of this failure, Patient 4’s physician did not give any wound care orders as the physician was never informed the patient had developed pressure injuries. (Refer to G590). 4. The HHA failed to update the Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for one of seven sampled patients (Patient 4) after the patient developed pressure injuries (localized damage to the skin and underlying tissue caused by prolonged, unrelieved pressure, friction, or shear force, usually over a bony prominence). This failure had the potential to result in improper treatment, worsening wounds, and delayed necessary interventions. (Refer to G592). 5. The HHA failed to integrate orders from all physicians involved into the plan of care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for one of seven sampled patients (Patient 4). This failure had the potential to result in a lack of coordination of services and interventions provided to Patient 4. (Refer to G604). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal (government) Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure the provision of highest quality health care is provided to patients assessed to receive home health services in a safe environment.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid Programs) regarding Skilled Professional Services was met as follows: 1. The HHA failed to conduct performance evaluation for one of two nursing staff (Licensed Vocational Nurse 3/LVN 3) and to provide training/orientation and to run background check for one of two nursing staff (Registered Nurse 2/RN 2). This failure might result in unaddressed clinical incompetence, jeopardized patient safety, and lack of supervision. (Refer to G702). 2. The HHA failed to perform supervisory visits for their License Vocational Nurse (LVN) services for two of seven sampled patients (Patient 6 and Patient 7). This failure had the potential to result in patients being taken care of by an unqualified staff. (Refer to G726). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal (government) Regulations for Skilled professional services to ensure the provision of highest quality health care is provided to patients assessed to receive home health services in a safe environment.”

“Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid Programs) regarding Home Health Aide Services was met as follows: 1. The HHA failed to ensure two of seven sample patients (Patient 4 and Patient 7) had written patient care instructions for the Certified Home Health Aide (CHHA) to follow. This failure had the potential to result in endangering patients’ health and wellbeing. (Refer to G798). 2. The HHA failed to ensure one of seven sample patients (Patient 7) Certified Home Health Aides (CHHA) were supervised for the care they were providing. This failure had the potential to result in endangering patients’ health and wellbeing. (Refer to G808). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal (government) Regulations for Home health aide services to ensure the provision of highest quality health care is provided to patients assessed to receive home health services in a safe environment.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid Programs) regarding Organization and Administration of Services was met as follows: 1. The HHA failed to ensure a Clinical Manager oversaw the nursing care provided to three of seven sampled patients (Patient 1, Patient 6, and Patient 7). This failure resulted in lack of nursing oversight, to ensure services were provided according to patients individualized care plan, accepted standards of care, and federal guidelines which 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 G958). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal (government) Regulations for Organization and administration of services to ensure the provision of highest quality health care is provided to patients assessed to receive home health services in a safe environment.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid Programs) 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, and Patient 7) clinical records contained completed skilled nursing clinical notes, physician’s orders for discharge, and completed physician’s discharge summaries. This failure resulted in an incomplete clinical record, lack of coordination in the continuity of patient care, uncoordinated patient’s decline or progress not identified, and physician’s assessment for clearance/orders of patient’s safe discharge from home health care. Refer to G1012. 2. The HHA failed to ensure a discharge summary was sent to the physician for two of seven sampled patients (Patient 2 and Patient 5). This failure resulted in a lack of continuity of care and safety post discharge. (Refer to G1022). 3. The HHA failed to ensure patient care records were properly authenticated for two of seven sample patients (Patient 6 and Patient 7). This failure resulted in patients’ medical records that contained entries without required signatures, which prevented verification of the individual responsible for the documentation and compromised the integrity and reliability of the clinical record. (Refer to G1024). 4. The HHA failed to ensure that two of seven sample patients (Patient 6 and Patient 7) clinical records were safeguarded. This failure had the potential to result in unauthorized use which could cause patients’ personal information to be used without consent. (Refer to G1028). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal (government) Regulations for Clinical records to ensure the provision of highest quality health care is provided to patients assessed to receive home health services in a safe environment.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to conduct performance evaluation for one of two licensed vocational nurse 3 (LVN 3) and to provide training/orientation, conduct background check for one of two registered nurse 2 (RN 2). This failure had the potential to result in lack of supervision, unaddressed clinical incompetence, and jeopardized patient safety. 1. During a review of RN 2’s employee file, there was no Employee Application form in RN 2’s employee file that indicated RN 2’s date of hire. There was no documentation of initial documentation, orientation and/or training for new hire, and background check completion. During a concurrent interview and record review with the Office Administrator (OA) on 5/29/2026 at 11:53 a.m., the OA reviewed RN 2’s employee file. The OA stated that RN 2’s employee file was incomplete. The OA stated, “RN 2 is a backup nurse and she was recently hired.” When asked for clarification on what backup nurse meant, the OA stated that a backup nurse was a nurse who would cover when the regular nurse was unavailable. The OA could not verify RN 2’s date of hire. The OA stated that RN 2 visited a patient for the first time on 5/27/2026. The OA stated that the HHA had not provided RN 2 with onboarding that includes orientation and training. The OA stated that the HHA had not done a background check for RN 2. The OA stated that it was the HHA’s due diligence to make sure that the nurse was competent, professional, and knowledgeable about the policies and procedures. The OA stated that background check should have been done to be upon hire, before RN 2 worked with a patient, to ensure the nurse did not have criminal background and not a threat to the patient and/or family. 2. During a review of LVN 3’s employee file, the Employee Application form in LVN 3’s employee file indicated that LVN 3’s date of hire was 9/1/2024. There was no documentation of performance evaluation (a formal, systematic process where a manager assesses an employee’s job performance, skills, and accomplishments over a specific period, typically annually or semi-annually) for LVN 3. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 5/29/2026 at 12:41 p.m., the DPCSD acknowledged there was no performance evaluation done for LVN 3 since LVN 3 was hired by the HHA. The DPCSD stated that LVNs, RNs, and CHHAs had to complete initial competency upon hire, where the Director of patient Care Services (DPCS) or DPCSD ensured they were competent to provide patient care. The DPCSD stated that LVNs, RNs, and CHHAs would be evaluated for their performance annually by the DPCS. The DPCSD stated that performance evaluation was important to evaluate the nurse’s or aide’s skills, ensuring they followed infection control and hand hygiene practices. The DPCSD stated, “Everything needs to be checked. If they don’t meet the standards, we provide teaching and in-services.” During a review of the HHA’s policy and procedure (P & P), titled “Development of Policies and Procedures,” revised December 2025, the P & P indicated that policies and procedures would be developed as necessary to provide guidance to organization personnel in providing care and service to patients. The P & P indicated the following policies and procedures will form the minimum framework for the HHA: Personnel: E. Employee orientation. I. Recruitment, retention, and performance evaluation of personnel.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure two of seven sample patients (Patient 4 and Patient 7) had written patient care instructions for the Certified Home Health Aide (CHHA) to follow. This failure had the potential to result in endangering patients’ health and wellbeing. 1. During a review of Patient 4’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 3/30/2026 to 5/28/2026, the POC indicated that Patient 4 was admitted to the HHA on 3/30/2026 with a primary diagnosis of primary generalized osteoarthritis (a widespread, age-associated degenerative condition affecting multiple joint groups). The POC indicated that Patient 4 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and then one SN visit per week for seven weeks. The POC indicated that Patient 4 was also to receive Certified Home Health Aide (CHHA, a trained healthcare professional who provides personal care and daily living assistance to patients in their homes under the supervision of a nurse) once a week for nine weeks. During a review of Weekly Activity Log for Patient 4, dated 5/19/2026, 5/15/2026, and 5/12/2026, the Weekly Activity Log indicated that on those dates, CHHA 2 provided bed bath and hygiene assistance (personal care, dressing, pressure care area, skin care/foot care, and dressing) for Patient 4. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 5/29/2026 at 12:15 p.m., the DPCSD stated that there was plan of care for CHHA 2 with instructions on what services to provide for Patient 4. The DPCSD stated that Patient 4’s plan of care should have included instructions for the CHHA since Patient 4 was receiving CHHA visit once a week. According to the DPCSD, the CHHA plan of care should serve as a guidance for the CHHA who provided care for the patient. 2. During a record review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/18/2026 to 6/16/2026, indicated a start of care date of 2/17/2026 with a primary diagnosis of hemiplegia (paralysis on one side of the body) following cerebral infarction (lack of blood supply to brain). Lastly, the form indicated Patient 7 had CHHA services for personal care needs with frequency of once a week for nine weeks. During a concurrent interview and record review on 5/29/2026 at 12:01 p.m. with the Director of Nurses Designee (DOND), of Patient 7’s medical record, the DOND stated that Patient 7 had CHHA services ordered once a week for nine weeks. The DOND stated that Patient 7’s assigned CHHA, Certified Home Health Aide 1 (CHHA1), did not have a care plan to follow, because it was not done. The DOND stated that a CHHA care plan derives from the patients’ plan of care and is required to instruct CHHA1 on what and how to care for Patient 7. During a review of the HHA’s policy and procedure (P & P), titled “Internal Control Systems/Accountabilities,” revised December 2025, the P & P indicated that Aide supervisory visits are performed and documented every 14 days.”

“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 interviews and record reviews, the Home Health Agency (HHA - an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure a Clinical Manager oversaw the nursing care provided to three of seven sampled patients (Patient 1, Patient 6, and Patient 7). This failure resulted in lack of nursing oversight, to ensure services were provided according to patients individualized care plan, accepted standards of care, and federal guidelines which 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. During an interview on 5/28/2026 at 9:35 a.m., with the Administrator/Director of Nurses (DON), the DON stated her responsibilities included oversight of the agency and its functions. The DON stated she was responsible for signing patients plans of care after they were received by the coding department. DON stated she worked onsite at agency every two weeks. During an interview on 5/28/2026 at 10 a.m., with the DON, stated that skilled nurses (SN) have 24-48 hours after their visit to submit their home visit documentation. The DON stated nurses do not document directly in their electronic medical record (EMR) system because they document on a hard copy. The DON stated nurses bring their documented hard copy notes to the office and either the Office Administrator (OA) or the Intake (IN) uploaded into their EMR system. The DON stated submitting nurses’ notes late can cause delays in care, and improper documentation. The DON stated patients could have a change of status that could cause hospitalization and/or death. During an interview on 5/28/2026 at 10:24 a.m., with the Administrator/Director of Nurses (DON) stated that Certified Home Health Aide (CHHA) supervisory visits were conducted every two weeks. The DON stated that Licensed Vocational Nurse (LVN) supervisory visits were conducted at patients’ start of care and during recertifications. During an interview on 5/28/2026 at 10:26 a.m., with the DON stated that supervisory visits were done to ensure the discipline is accurately doing the job, following policies and procedures, and aware of how things were done safely. 1. During a review of Patient 1’s medical record titled, SOC (Start of care) Worksheet, undated, it indicated Patient 1 had a start of care of 2/20/2026. During a review of Patient 1’s medical record titled, Home Health Certification and Plan of Care (POC, a document that outlines the patient’s treatments, goals and interventions), it indicated a primary diagnosis of generalized osteoarthritis (a joint condition that causes pain, swelling and stiffness) and chronic pain syndrome (pain lasting from 3 to 6 months and is accompanied by emotional and behavioral symptoms). During a concurrent interview and record review on 5/26/2026 at 2:32 p.m., with Office Administrator (OA), Patient 1’s Clinical Notes were reviewed. Patient 1 had clinical notes in the medical chart dated 2/22/2026, 2/26/2026, 3/1/2026, 3/5/2026, 3/12/2026, 3/17/2026, 3/23/2026, 3/30/2026, 4/6/2026, 4/21/2026, 4/25/2026, 4/29/2026, and 5/5/2026. OA stated there were no notes in the electronic medical record and all notes were in the patient’s physical chart. OA stated the nurses take their notes to the office once a week and the last notes in Patient 1’s chart were dated 5/5/2026. During an interview on 5/28/2026 at 1:15 p.m., with the DON stated it was important to have the nursing notes in the patient records so the agency can keep track of the up-to-date plan of care and to assure the skilled nursing care is being provided according to the plan of care. 2a. During a record review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” undated, indicated a start of care date of 3/12/2026 with a primary diagnosis of chronic pain syndrome. Patient 6 was provided skilled nurse (SN) visits twice a week for one week, then once a week for eight weeks. During a record review of Patient 6’s medical record form titled “Clinical Note” dated 3/15/2026, 3/23/2026, 3/28/2026, 4/3/2026, 4/16/2026, 4/23/2026, 4/26/2026, 5/11/2026, and 5/22/2026, indicated the same documentation and vital signs (clinical measurements used to assess the body’s basic function). The form also indicated they were all documented by License Vocational Nurse 1 (LVN1). During a record review of Patient 6’s medical record form titled “Clinical Note” dated 3/19/2026, 4/9/2026, and 5/15/2026, indicated they all had the same documentation and vital signs. The form also indicated they were all documented by LVN1. During a concurrent interview and record review on 5/28/2026 at 12:54 p.m. with the Administrator/Director of Nurses (DON) of Patient 6’s medical record, the DON stated that a thorough assessment was not being made by LVN1 during Patient 6’s skilled nursing visits. The DON stated that Patient 6 is not getting the care that the HHA needs to provide, which can cause deterioration, hospitalization, and/or death. 2b. During a record review of Patient 6’s medical record form titled “Supervisory visit of home health care staff” undated, indicated Registered Nurse 1 (RN1) was listed as the supervising nurse. The form did not contain the name of the License Vocational Nurse (LVN) being supervised. Lastly, the forms did not indicate if the LVN met or did not meet the requirements to safely provide services. During a concurrent interview and record review on 5/28/2026 at 10:26 a.m. with the Administrator/Director of Nurses (DON), of Patient 6’s medical record, the DON stated that Patient 6’s start of care date was on 3/12/2026. The DON stated that Patient 6’s medical record contained one incomplete LVN supervisory visit note dated 3/12/2026. The DON stated that the supervisory visit for should have been complete to evaluate whether the LVN exceeds or not with the requirements. 3a. During a record review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/18/2026 to 6/16/2026, indicated a start of care date of 2/17/2026 with a primary diagnosis of hemiplegia (paralysis on one side of the body) following cerebral infarction (lack of blood supply to brain). The form indicated Patient 7 had skilled nurse (SN) visits once a week for one week, then twice a week for one week, then once a week for seven weeks. Lastly, the form indicated Patient 7 had CHHA services for personal care needs with frequency of once a week for nine weeks. During a record review of Patient 7’s medical record form titled “Clinical Note” dated 2/21/2026, 3/3/2026, 3/24/2026, 4/18/2026, and5/17/2026, indicated they all had the same documentation and vital signs (clinical measurements used to assess the body’s basic function). The form also indicated they were all documented by License Vocational Nurse 1 (LVN1). During a record review of Patient ’s medical record form titled “Clinical Note” dated 2/24/2026, 3/17/2026, 4/7/2026, 4/26/2026, and5/10/2026, indicated they all had the same documentation and vital signs. The form also indicated they were all documented by LVN1. During a record review of Patient ’s medical record form titled “Clinical Note” dated 2/27/2026, 3/10/2026, 3/31/2026, 4/13/2026, and 5/3/2026, indicated they all had the same documentation and vital signs. The form also indicated they were all documented by LVN1. During a concurrent interview and record review on 5/28/2026 at 12:21 p.m. with the Administrator/Director of Nurses (DON) of Patient 7’s medical record, the DON stated that a thorough assessment was not being made by LVN1 during Patient 7’s skilled nursing visits. The DON stated that Patient 7 is not getting the care that the HHA needs to provide, which can cause deterioration, hospitalization, and/or death. 3b. During a concurrent interview and record review on 5/29/2026 at 12:01 p.m. with the Director of Nurses Designee (DOND), of Patient 7’s medical record, the DOND stated that Patient 7 had CHHA services ordered once a week for nine weeks. The DOND stated that Patient 7’s assigned CHHA, Certified Home Health Aide 1 (CHHA1), did not have a care plan to follow, because it was not done. The DOND stated that a CHHA care plan derives from the patients’ plan of care and is required to instruct CHHA1 on what and how to care for Patient 7. 3c. During a concurrent interview and record review on 5/29/2026 at 12:01 p.m. with the Director of Nurses Designee (DOND), of Patient 7’s medical record, the DOND stated that Patient 7 had CHHA services ordered once a week for nine weeks. The DOND stated that CHHA are to have supervisory visits every two weeks to ensure they are taking care of the patient properly. The DOND stated the CHHA need to be assessed to ensure they are following infection control and are able to transfer the patients properly. The DOND stated that Certified Home Health Aide 1 (CHHA1), assigned to Patient 7, has not been supervised. The DOND stated that she (DOND) does not know how CHHA1 is taking care of Patient 7 3d. During a record review of Patient 7’s medical record form titled “Supervisory visit of home health care staff” undated, indicated Registered Nurse 1 (RN1) was listed as the supervising nurse. The form did not contain the name of the License Vocational Nurse (LVN) being supervised. During a concurrent interview and record review on 5/28/2026 at 10:30 a.m. with the Administrator/Director of Nurses (DON), of Patient 7’s medical record, the DON stated that Patient 7’s start of care date was on 2/17/2026. The DON stated that RN1 completed an LVN supervisory visit on 2/17/2026 but did not document the name of the LVN being supervised. The DON stated that without an LVNs name the HHA would not know who was being supervised to be able to provide corrective action if required.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA - an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure patient care records were appropriately authenticated for two of seven sample patients (Patient 6 and Patient 7). This failure resulted in patients’ clinical records contained entries without required signatures, which prevented verification of the individual responsible for the documentation and compromised the integrity and reliability of the clinical record. During an interview on 5/26/2026 at 2:18 p.m. with the Office Administrator (OA), the OA stated that once the HHA receives patients plan of care (485/POC) from their Coder (CD), a Registered Nurse (RN) reviews and signs it. Once it is signed by the RN, the patients POC are sent to the physician to sign. When received from the physician the POC is then archived in the patient’s MR. During an interview on 5/26/2026 at 2:31 p.m. with the OA, the OA stated that Registered Nurses (RN), License Vocational Nurses (LVN), and Certified Home Health Aides (CHHA) do not document directly on the HHAs Electronic Medical Record (EMR) system. The OA stated that all nurses take their hard copy visit documentation to the office or email them once a week. During an interview on 5/28/2026 at 9:35 a.m. with the Administrator/Director of Nurses (DON), the DON stated that after the RN completes a patient’s comprehensive assessment, the RN brings the assessment to the HHA. The RN hands the comprehensive assessment to either the OA or Intake (IN) for review and to be sent to the Coders (CD). The CD formulates the patient POC then emails it back to the HHA. Once the HHA receives the patients POC, I review and sign it so that the OA or IN could email it to the physician for review and signature. During an interview on 5/28/2026 at 10 a.m. with the DON, the DON stated that skilled nurses have 24-48 hours after their home visit to submit their nursing notes. The DON stated that skilled nurses visit notes are uploaded into the HHAs computer as a PDF (portable document format) file and not in the HHAs EMR. The DON stated that the HHAs EMR system does not have a section for nursing notes. The DON stated that the patient’s hard copy visit notes are filed in the patient’s physical medical record. During an interview on 5/28/2026 at 12:17 p.m. with Registered Nurse 1 (RN1), RN1 stated that she (RN1) is contracted with the HHA and receives calls or text from the HHA when there is a patient that needs an assessment. RN1 stated that she (RN1) emails or drops off her nursing documentation every week at the office. RN1 stated that she types her (RN1) visit notes on her personal computer on a PDF template form. RN1 stated that she (RN1) types in her (RN1) signature to verify it is hers (RN1). RN1 emailed the recertification nursing assessment template. During an interview on 5/29/2026 at 11:25 a.m. with Office Administrator (OA), OA stated that the nurses fill out and submit the patients comprehensive nursing assessment, which then gets emailed to the HHAs Coders. The Coders then use the comprehensive nursing assessment patient information to formulate patients’ POC. Once completed, the Coders email the completed patients POC back to the HHA for review and signatures from the RN. Once the RN reviews and signs the patient POC it is emailed to the Medical Group (MG) for physician review and signature. Lastly, once the physician signs the patient’s POC, the physician emails the signed POC back to HHA to be followed and placed in the patients’ medical record. 1a. During a record review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” undated, indicated a start of care date of 3/12/2026 with a primary diagnosis of chronic pain syndrome. During a record review of Patient 6’s medical record form titled “Recertification /Follow up Assessment” dated 5/6/2026, did not indicate Patient 6’s home health primary or secondary diagnosis. Lastly, the form indicated RN1’s name was typed under “Person Completing this form (signature/title)”. During a concurrent interview and record review on 5/29/2026 at 10:15 a.m. with the Director of Nurses Designee (DOND) of Patient 6’s medical record, the DOND stated that Patient 6’s recertification nursing assessment dated 5/6/2026 was not authenticated by RN1 because it did not contain a wet signature. The DOND stated that an author’s signature indicates that she/he documented the home visit findings. 1b. During a concurrent interview and record review on 5/29/2026 at 11:25 a.m. with the OA, of “Gmail – CODING DONE” form dated 5/11/2026, was reviewed. The OA stated that Patient 6’s comprehensive nursing assessment dated 5/6/2026 was sent to the Coders (CD) to formulate Patient 6’s POC. The OA stated that Patient 6’s POC dated 5/11/2026 to 7/9/2026, was received from the CD on 5/11/2026 for RN review. During a concurrent interview and record review on 5/29/2026 at 11:25 a.m. with the OA, of “Gmail – Signature Needed” form dated 5/19/2026, was reviewed. The OA stated that Patient 6’s POC was emailed to the Medical Group (MG) to review and sign on 5/19/2026. During a concurrent interview and record review on 5/29/2026 at 11:30 a.m. with OA of Patient 6’s medical record form titled “Home Health Certificate and Plan of Care” dated from 5/11/2026 to 7/9/2026, was reviewed. The OA stated that they received the POC from the CD on 5/11/2026 and was signed by the DON on 5/6/2026 and the physician on 5/13/2026. The OA stated that the HHA does not generate the date next to the nurses or physician signatures. The OA stated that both the DON and the physician should have indicated the date they signed Patient 6’s POC. 1c. During a record review of Patient 6’s medical record form titled “Recertification Follow-Up Assessment” dated 5/6/2026, provided electronically by the Office Administrator (OA), indicated the documentation on the form was able to be altered by this writer. Documentation was not altered by this writer. 2a. During a record review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/18/2026 to 6/16/2026, indicated a start of care date of 2/17/2026 with a primary diagnosis of hemiplegia (paralysis on one side of the body) following cerebral infarction (lack of blood supply to brain). During a record review of Patient 7’s medical record form titled “Recertification /Follow up Assessment” dated 4/15/2026, indicated RN1’s name was typed under “Person Completing this form (signature/title)”. 2b. During a concurrent interview and record review on 5/29/2026 at 11:33 a.m. with the OA, of “Gmail – CODING DONE” form dated 4/22/2026, was reviewed. The OA stated that Patient 7’s comprehensive nursing assessment dated 4/15/2026 was sent to the Coders (CD) to formulate Patient 7’s POC. The OA stated that Patient 7’s POC dated 4/18/2026 to 6/16/2026, was received from the CD on 4/22/2026 for RN review. During a concurrent interview and record review on 5/29/2026 at 11:33 a.m. with OA of Patient 7’s medical record form titled “Home Health Certificate and Plan of Care” dated from 4/18/2026 to 6/16/2026, was reviewed. The OA stated that they received the POC from the CD on 4/22/2026 and was signed by the Administrator/Director of Nurses (DON) on 4/15/2026. The OA stated that the HHA does not generate the date next to the nurses or physician signatures. The OA stated that the DON should have indicated the date she (DON) signed Patient 7’s POC. 2c. During a record review of Patient 7’s medical record form titled “Recertification Follow-Up Assessment” dated 4/15/2026, provided electronically by the Office Administrator (OA), indicated the documentation on the form was able to be altered by this writer. Documentation was not altered by this writer. During a record review of the HHA’s form titled “Clinical/Service Data Collection” revised 12/2025, indicated “Entries into the clinical/service record will be clear, concise, and specific statements of fact.” The form also indicated “Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday.” ””

“Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This Standard is not met as evidenced by: Based on interviews and record review the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that two of seven sample patients (Patient 6 and Patient 7) clinical records were secured and confidential information are protected. This failure had the potential to result in an unauthorized use which could cause patients personal/medical information to be used without consent. During an interview on 5/26/2026 at 2:31 p.m., with the Office Administrator (OA), the OA stated that Registered Nurses (RN), License Vocational Nurses (LVN), and Certified Home Health Aides (CHHA) do not document directly on the HHAs Electronic Medical Record (EMR) system. The OA stated that all nurses take their hard copy visit documentation to the office or email them once a week. During an interview on 5/28/2026 at 10 a.m., with the Administrator/Director of Nurses (DON), the DON stated that skilled nurses have 24-48 hours after their home visit to submit their nursing notes. The DON stated that skilled nurses visit notes are uploaded into the HHAs computer as a PDF (portable document format) file and not in the HHAs EMR. The DON stated that the HHAs EMR system does not have a section for nursing notes. The DON stated that the patient’s hard copy visit notes are filed in the patient’s physical medical record. During an interview on 5/28/2026 at 12:17 p.m., with Registered Nurse 1 (RN1), RN1 stated that she (RN1) is contracted with the HHA and receives calls or text from the HHA when there is a patient that needs an assessment. RN1 stated that she (RN1) emails or drops off her nursing documentation every week at the office. RN1 stated that she types her (RN1) visit notes on her personal computer on a PDF template form. RN1 stated that she (RN1) types in her (RN1) signature to verify it is hers (RN1). RN1 emailed the recertification nursing assessment template. During an interview on 5/29/2026 at 10:15 a.m., with the Director of Nurses Designee (DOND), the DOND stated that the HHA nurses had to use their personal computer to document the patient’s OASIS (Outcome and Assessment Information Set – standardized Medicare mandated assessment tool). The DOND stated that she (DOND) did not know if Registered Nurse 1 (RN1)’s personal computer was HIPPA (Health Insurance Portability and Accountability – law designed to keep patients personal medical record information private and secure) protected. During an interview on 5/29/2026 at 10:44 a.m., with the Office Administrator (OA), the OA stated that she (OA) was not sure if RN1s personal computer was HIPPA protected. The OA stated that “As a nurse, it is her (RN1) responsibility to have her computer HIPPA protected. 1. During a record review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” undated, indicated a start of care date of 3/12/2026 with a primary diagnosis of chronic pain syndrome. During a record review of Patient 6’s medical record form titled “Recertification /Follow up Assessment” dated 5/6/2026, did not indicate Patient 6’s home health primary or secondary diagnosis. Lastly, the form indicated RN1’s name was typed under “Person Completing this form (signature/title)”. The form did not indicate it had RN1’s electronic signature under section “Person Completing this form (signature/title)”. During a record review of Patient 6’s medical record form titled “Recertification Follow-Up Assessment” dated 5/6/2026, provided electronically by the Office Administrator (OA), indicated the documentation on the form was able to be altered by this writer. Documentation was not altered by this writer. 2. During a record review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/18/2026 to 6/16/2026, indicated a start of care date of 2/17/2026 with a primary diagnosis of hemiplegia (paralysis on one side of the body) following cerebral infarction (lack of blood supply to brain). During a record review of Patient 7’s medical record form titled “Recertification /Follow up Assessment” dated 4/15/2026, indicated RN1’s name was typed under “Person Completing this form (signature/title)”. The form did not indicate it had RN1’s electronic signature under section “Person Completing this form (signature/title)”. During a record review of Patient 7’s medical record form titled “Recertification Follow-Up Assessment” dated 4/15/2026, provided electronically by the Office Administrator (OA), indicated the documentation on the form was able to be altered by this writer. Documentation was not altered by this writer. During a record review of HHA’s form titled “Safeguarding/Retrieval of Clinical/Services Record” revised 12/2025, indicated “The organization will safeguard the clinical/service record against loss, destruction, tampering, or unauthorized use through the development of processes, policies and procedures. The clinical/service record will be safeguarded in compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements.””

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to assess the patient’s pressure injuries (localized damage to the skin and underlying tissue, typically over a bony prominence) and failed to document the primary and secondary diagnosis for two of seven sampled patients (Patient 4 and Patient 6). This failure had the potential to result in undetected changes in wound condition, leading to delayed healing and an increased risk of infection, thereby prolonging the patient’s pain and discomfort, and by not providing current patient status. 1. During a review of Patient 4’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 3/30/2026 to 5/28/2026, the POC indicated that Patient 4 was admitted to the HHA on 3/30/2026 with a primary diagnosis of primary generalized osteoarthritis (a widespread, age-associated degenerative condition affecting multiple joint groups). The POC indicated that Patient 4 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and then one SN visit per week for seven weeks. The POC indicated that Patient 4 was also to receive Certified Home Health Aide (CHHA, a trained healthcare professional who provides personal care and daily living assistance to patients in their homes under the supervision of a nurse) once a week for nine weeks. The POC indicated the SN was to assess all body systems with emphasis that included the integumentary (skin) status: Monitor for skin breakdown. During a review of Patient 4’s Comprehensive Adult Nursing Assessment, dated 3/30/2026, the Comprehensive Adult Nursing Assessment indicated that Patient 4 was unable to ambulate (walk) and was unable to wheel himself (when put in a wheelchair). The Comprehensive Adult Nursing Assessment indicated that Patient 4 had bladder incontinence (loss of bladder control). The Skin Conditions section of the Comprehensive Adult Nursing Assessment indicated that Patient 4’s skin was intact. During a review of Patient 4’s Comprehensive Adult Nursing Assessment, dated 4/21/2026, the Skin Conditions section of the Comprehensive Adult Nursing Assessment indicated that Patient 4’s skin was intact. During a review of Clinical Note, dated 5/5/2026, the Integumentary assessment section of the Clinical Note was blank. The Clinical Note was completed by Licensed Vocational Nurse 3 (LVN 3). During a review of Clinical Note, dated 5/12/2026, the Integumentary assessment section of the Clinical Note indicated there were no issues with Patient 4’s skin. During a review of Visit Report from Wound Clinic 1 (WC 1), dated 5/19/2026, the Visit Report indicated that on 5/12/2026, an initial wound care evaluation was completed for Patient 4 by the wound specialist from WC 1. The Visit Report indicated that on 5/12/2026, Patient 4 had an acute unstageable pressure injury (a severe, full-thickness wound where the true depth and severity are hidden by a layer of dead tissue) in the coccyx (tailbone), measuring 5 centimeters (cm, a measurement unit) in length and 6 cm in depth, with no measurable depth; Patient 4 also had a stage 1 pressure injury (the earliest stage of pressure injury; it presents as intact skin with a localized area of persistent redness) on the left lateral hip and moisture-associated skin damage (MASD, an inflammatory condition and skin erosion caused by prolonged exposure to bodily fluids like sweat, urine, feces, or wound discharge) on bilateral groin. During a joint visit observation with Registered Nurse 2 (RN 2) on 5/27/2026 at 11:15 a.m., at Patient 4’s home, observed Patient 4 lying down in a hospital bed. Observed Patient 4 awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 4 lives with a family member (Patient 3), who stated that she was the primary caregiver. During the joint home visit, observed RN 2 assess Patient 4’s skin. Observed an unstageable pressure injury in the coccyx, a stage 1 pressure injury on the left lateral hip, and MASD on the groin. During an interview with Patient 3, who was also the primary caregiver for Patient 4 on 5/27/2026 at 11:48 a.m., Patient 3 stated that a wound specialist had visited Patient 4 and treated the pressure injuries about 2 or 3 times. Patient 3 stated, “The wound specialist comes once a week, I think she started coming 2 weeks ago. The wound specialist was here yesterday.” Patient 3 stated that Patient 4 developed the pressure injury on the coccyx a few weeks ago. Patient 3 stated that LVN 3 was Patient 4’s regular nurse, and LVN 3 knew about the wounds. Patient 3 stated that the wound treatment was being done twice a week, once by the wound specialist and once by LVN 3. When Patient 3 was asked if she did the wound treatment on the days the wound specialist and the home health nurse did not visit, Patient 3 stated, “No. I’m scared to touch the wound. I just wait until the nurses come and do it.” During a phone interview with LVN 3 on 5/27/2026 at 4 p.m., LVN 3 stated that she had been visiting Patient 4 once a week for a couple months. LVN 3 stated that on one of her visits, Patient 3 reported that Patient 4 had an open wound on the coccyx; LVN 3 stated that she did not remember the exact date. LVN 3 stated that she notified the HHA office immediately after she observed the wound during the visit. When LVN 3 was asked during the interview if she had access to her Clinical Notes so that she could review it with the surveyor, LVN 3 stated she did not have access to a computer at that time. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 5/28/2026 at 11:15 a.m., the DPCS reviewed Patient 4’s Comprehensive Adult Nursing Assessments, dated 3/30/2026 and 4/21/2026, Home Health Certification and Plan of Care for the certification period of 3/30/2026 to 5/28/2025, Clinical Notes, dated 5/5/2026 and 5/12/2026, and Visit Report from WC 1, dated 5/12/2026. The DPCS stated that skin assessment needed to be done on every visit. The DPCS confirmed that there was no skin assessment documented on 5/5/2026. The DPCS stated that without documentation, there was no evidence that skin assessment was done. The DPCS stated that based on the Visit Report from WC 1, dated 5/12/2026, Patient 4 had already had the pressure injuries on 5/12/2026. The DPCS stated, “On 5/12/2026, the patient refused the nurse to take a look at the wound, so she documented it as no issues.” When the DPCS was asked for documentation regarding Patient 4’s refusal for wound assessment on 5/12/2026, the DPCS could not provide it. The DPCS stated that LVN 3 did not document the refusal in her Clinical Note on 5/12/2026. During a phone interview with LVN 3 on 5/29/2026 at 10:57 a.m., LVN 3 stated that after she had a chance to go through her notes for Patient 4, she recalled that she learned about Patient 4’s open wound on the coccyx on 5/5/2026. LVN 3 stated, “I was visiting the patient and the wife told me about the wound. I saw that he had an open pressure ulcer on the coccyx, so I called the office immediately. I spoke to the Office Administrator (OA).” LVN 3 stated that she left the Integumentary assessment section of the 5/5/2026 Clinical Note because she was waiting for instructions from the wound clinic. LVN 3 stated, “When I called the office, the OA said she was going to order a wound consult for Patient 4, so I wanted to wait for the wound clinic’s instruction.” When LVN 3 was asked if Patient 4 refused wound assessment on 5/5/2026, LVN 3 stated that Patient 4 had never refused assessment. LVN 3 stated, “I did see the wound, he let me look at it.” LVN 3 stated that she should not have left the Integumentary assessment on 5/5/2026 blank. LVN 3 stated that the lack of skin assessment documentation on 5/5/2026 could make it hard to determine when Patient 4 got the wound. Regarding the Clinical Note that she completed for the visit on 5/12/2026, LVN 3 stated that she marked the Integumentary assessment as “no issues” because the wound specialist came and assessed Patient 4 that day. When LVN 3 was asked if she still needed to assess Patient 4’s skin despite the wound specialist’s assessment, LVN 3 stated, “Yes.” LVN 3 stated that skin assessment had to be done on every visit. 2. During a record review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” dated from 5/11/2026 to 7/9/2026, indicated a start of care date of 3/12/2026 with a primary diagnosis of chronic pain syndrome. During a record review of Patient 6’s medical record form titled “Recertification Follow-Up Assessment” dated 5/6/2026, provided electronically by the Office Administrator (OA) did not indicate Patient 6’s primary or secondary diagnosis. The form indicated Registered Nurse 1 (RN1) name was typed and not signed in section “Person Completing this form (signature/Title)”. Lastly, the documentation on the form was able to be altered by this writer. Documentation was not altered by this writer. During a review of the HHA’s Policy and Procedure (P & P), titled “Ongoing Assessment,” revised December 2025, the P & P indicated the following: During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter.Using the standards of care identified by the organization, the clinician will reassess the patient for: E. Skin integrity.”

“Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient’s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) nursing staff failed to assess the patient’s caregiver’s willingness and ability to provide wound care for one of seven sampled patients (Patient 4). This failure had the potential result in delayed wound healing, increased risk of infection, and the patient’s home health goals not met. During a review of Patient 4’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 3/30/2026 to 5/28/2026, the POC indicated that Patient 4 was admitted to the HHA on 3/30/2026 with a primary diagnosis of primary generalized osteoarthritis (a widespread, age-associated degenerative condition affecting multiple joint groups). The POC indicated that Patient 4 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and then one SN visit per week for seven weeks. The POC indicated that Patient 4 was also to receive Certified Home Health Aide (CHHA, a trained healthcare professional who provides personal care and daily living assistance to patients in their homes under the supervision of a nurse) once a week for nine weeks. The POC indicated the SN was to assess all body systems with emphasis that included patient/caregiver response to teaching. During a review of Patient 4’s Comprehensive Adult Nursing Assessment, dated 3/30/2026, the Comprehensive Adult Nursing Assessment indicated that Patient 4 lived with other person around the clock and that non-agency caregiver(s) needed training/supportive services to provide assistance. During a joint visit observation with Registered Nurse 2 (RN 2) on 5/27/2026 at 11:15 a.m. at Patient 4’s home, observed Patient 4 lying down in a hospital bed. Observed Patient 4 awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 4 lives with a family member (Patient 3), who stated that she was Patient 4’s primary caregiver. During the joint home visit, observed RN 2 assess Patient 4’s skin. Observed an unstageable wound in the coccyx, a stage 1 pressure injury on the left lateral hip, and MASD on the groin. During an interview with Patient 3 on 5/27/2026 at 11:48 a.m., Patient 3 stated that a wound specialist had visited Patient 4 and treated the pressure injuries about 2 or 3 times. Patient 3 stated, “The wound specialist comes once a week, I think she started coming 2 weeks ago. The wound specialist was here yesterday.” Patient 3 stated that Patient 4 developed the pressure injury on the coccyx a few weeks ago. Patient 3 stated that LVN 3 was Patient 4’s regular nurse, and LVN 3 knew about the wounds. Patient 3 stated that the wound treatment was being done twice a week, once by the wound specialist and once by LVN 3. When Patient 3 was asked if she did the wound treatment on the days the wound specialist and the home health nurse did not visit, Patient 3 stated, “No. I’m scared to touch the wound. I just wait until the nurses come and do it.” During a review of Visit Report from Wound Clinic 1 (WC 1), dated 5/12/2026, the Visit Report indicated that on 5/12/2026, an initial wound care evaluation was completed for Patient 4 by the wound specialist from WC 1. The Visit Report indicated that on 5/12/2026, Patient 4 had an acute unstageable pressure injury (a severe, full-thickness wound where the true depth and severity are hidden by a layer of dead tissue) in the coccyx (tailbone), measuring 5 centimeters (cm, a measurement unit) in length and 6 cm in depth, with no measurable depth; Patient 4 also had a stage 1 pressure injury (the earliest stage of pressure injury; it presents as intact skin with a localized area of persistent redness) on the left lateral hip and moisture-associated skin damage (MASD, an inflammatory condition and skin erosion caused by prolonged exposure to bodily fluids like sweat, urine, feces, or wound discharge) on bilateral groin. The Visit Report indicated that wound treatment for the unstageable pressure injury on the coccyx was to be done 3 times a week or as needed if loose or soiled. During a phone interview with LVN 3 on 5/27/2026 at 4 p.m., LVN 3 stated that she had been visiting Patient 4 once a week for a couple months. LVN 3 stated that on one of her visits, Patient 3 reported that Patient 4 had an open wound on the coccyx; LVN 3 stated that she did not remember the exact date. LVN 3 stated that she notified the HHA office immediately after she observed the wound during the visit. LVN 3 stated that a wound specialist had been visiting Patient 4 weekly to do wound treatment. LVN 3 stated that she was aware the wound specialist recommended wound treatment to be done 3 times a week. LVN 3 stated that she was not aware that Patient 3 did not feel comfortable doing the wound care because each time LVN 3 did the wound care, Patient 3 would observe. LVN 3 stated that Patient 3 never informed her that she (Patient 3) was “scared to touch the wound.” LVN 3 stated that she never asked Patient 3 if Patient 3 did the wound treatment on the days the wound specialist or the HHA nurse did not come. LVN 3 stated, “Patient 3 must have done the wound treatment because every time I went there the dressing is intact. The wound is always covered.” When LVN 3 was asked if she (LVN 3) had observed Patient 3 do a return demonstration on the wound care, LVN 3 stated, “No, but Patient 3 was always there when I did it. She watched me do it. She knows how to do it.” During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 5/28/2026 at 11:15 a.m., the DPCS reviewed Patient 4’s Comprehensive Adult Nursing Assessments, dated 3/30/2026, Home Health Certification and Plan of Care for the certification period of 3/30/2026 to 5/28/2026, Clinical Note dated 5/22/2026, and Visit Report from WC 1, dated 5/12/2026. The DPCS stated, “On 5/22/2026, per Clinical Note, LVN 3 provided wound care teaching to the caregiver. LVN 3 also documented that the caregiver would do wound care when the home health nurse doesn’t come. How do we know if she actually does it or not?” The DPCS stated that during teaching the nurse should have assessed for the caregiver’s competence, willingness, and compliance to provide wound care for the patient. During a review of the HHA’s Policy and Procedure (P & P), titled “Patient Education Process,” revised December 2025, the P & P indicated the clinician would assess, plan, implement, and evaluate the following on each patient and family/caregiver, as appropriate: C. The level of knowledge of the patient and family/caregiver in relation to the diagnoses, plan of care, required activities by patient and family/caregiver, lifestyle changes, etc. D. The ability and readiness of the patient and family/caregiver to learn”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA - an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure all ordered disciplines’ visit frequencies were written in the plan of care (POC) for one of seven sampled patients (Patients 6). This failure placed these patients at risk for health complications and no interventions for the skilled nurse to assess or follow up on. During a record review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” dated from 5/11/2026 to 7/9/2026, indicated a start of care date of 3/12/2026 with a primary diagnosis of chronic pain syndrome. Lastly, the form indicated Patient 6 was ordered to have Physical Therapy (PT) to evaluate and treat. During a record review of Patient 6’s medical record indicated Patient 6 was evaluated by PT and ordered a frequency of twice a week for one week then once a week for three weeks signed by a physician on 5/20/2026. During an interview on 5/27/2026 at 12:30 p.m., with Patient 6, stated that he was seen by PT twice a week. During a concurrent interview and record review on 5/28/2026 at 12:54 p.m., with the Administrator/Director of Nurses (DON) of Patient 6’s medical record, the DON stated Patient 6 was receiving physical therapy (PT) services. The DON stated that Patient 6’s plan of care (POC) was not updated to reflect the PT visit frequency. The DON stated that the PT orders should have been inputted on Patient 6’s POC. The DON stated that the HHA does not revise or update patients POCs. The DON stated that patients POC need to be updated to reflect the most current orders to ensure the orders are followed and carried out.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to obtain a physician’s order for the administration of normal saline (a sterile mixture of salt and water that matches the body’s natural fluid balance; its primary purpose is to replenish body fluids, maintain blood volume, deliver intravenous medications, and safely cleanse bodily tissues without causing cell damage), Silvasorb (an antimicrobial hydrogel wound dressing), Triad paste (a zinc-oxide-based, medical-grade paste used for wound and skincare) to the peri wound (reddened areas), Calcium Alginate (a highly absorbent, non-woven wound dressing derived from brown seaweed), and Mepilex bordered foam dressing (a line of specialized, soft silicone foam wound dressings designed to absorb fluid and maintain a moist wound healing environment) for one of seven sampled patients (Patients 4). This failure had the potential to place the patient at risk for unmonitored treatment efficacy and adverse effects. During a review of Patient 4’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 3/30/2026 to 5/28/2026, the POC indicated that Patient 4 was admitted to the HHA on 3/30/2026 with a primary diagnosis of primary generalized osteoarthritis (a widespread, age-associated degenerative condition affecting multiple joint groups). The POC indicated that Patient 4 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and then one SN visit per week for seven weeks. The POC indicated that Patient 4 was also to receive Certified Home Health Aide (CHHA, a trained healthcare professional who provides personal care and daily living assistance to patients in their homes under the supervision of a nurse) once a week for nine weeks. The POC indicated the SN was to assess all body systems with emphasis that included the integumentary (skin) status: Monitor for skin breakdown. The POC indicated the SN was to notify the physician of any abnormal findings, including skin breakdown. During a review of Visit Report from Wound Clinic 1 (WC 1), dated 5/19/2026, the Visit Report indicated that on 5/12/2026, an initial wound care evaluation was completed for Patient 4 by the wound specialist from WC 1. The Visit Report indicated that on 5/12/2026, Patient 4 had an acute unstageable pressure injury (a severe, full-thickness wound where the true depth and severity are hidden by a layer of dead tissue) in the coccyx (tailbone), measuring 5 centimeters (cm, a measurement unit) in length and 6 cm in depth, with no measurable depth; Patient 4 also had a stage 1 pressure injury (the earliest stage of pressure injury; it presents as intact skin with a localized area of persistent redness) on the left lateral hip and moisture-associated skin damage (MASD, an inflammatory condition and skin erosion caused by prolonged exposure to bodily fluids like sweat, urine, feces, or wound discharge) on bilateral groin. The Visit Report indicated that for the unstageable pressure injury on the coccyx, the wound specialist recommended the following: Cleanse with normal saline, pat dry, treated with Silvasorb gel to the wound bed, followed by application of Triad paste to the peri wound (reddened areas), then Calcium Alginate, and cover with Mepilex sacral bordered foam dressing. The Visit Report indicated that wound treatment for the unstageable pressure injury on the coccyx was to be done 3 times a week or as needed if loose or soiled. For the stage 1 pressure injury on the left lateral hip, the recommendation was to apply Mepilex bordered foam dressing; dressing to be changed every 2-3 days or as needed if loose or soiled. For the bilateral groin MASD, the recommendation was to clean with normal saline, pat dry, and apply Clotrimazole cream 1% (antifungal medication) twice daily until resolved. During a review of Clinical Note, dated 5/22/2026, the Interventions section of the Clinical Note indicated that LVN 3 performed the following on the pressure ulcer on Patient 4’s coccyx: Cleansed with normal saline, applied a combination of Silvasorb, Triad paste, and Calcium Alginate, and covered with bordered Mepilex. During a joint visit observation with Registered Nurse 2 (RN 2) on 5/27/2026 at 11:15 a.m. at Patient 4’s home, observed Patient 4 lying down in a hospital bed. Observed Patient 4 was awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 4 lives with a family member (Patient 3), who stated that she was his primary caregiver. During the joint home visit, observed RN 2 assess Patient 4’s skin. Observed an unstageable wound in the coccyx, a stage 1 pressure injury on the left lateral hip, and MASD on the groin. During the joint home visit, after reviewing the Visit Report dated 5/19/2026 from WC 1, RN 2 stated that she would not treat Patient 4’s wounds. RN 2 stated, “This Visit Report is not a physician order. It says, “Progress Note Details” on top, to explain what the Nurse Practitioner (NP) did.” RN 2 stated the Visit Report dated 5/19/2026 indicated the NP made recommendations on how to treat Patient 4’s wounds, but it was not considered a physician order. RN 2 stated, “I don’t have a wound care order. I’ll call the home health office so they can call the doctor and get an order.” RN 2 stated that she had never seen Patient 4 before. During a phone interview with LVN 3 on 5/27/2026 at 4 p.m., LVN 3 stated that she had been visiting Patient 4 once a week for a couple months. LVN 3 stated that on one of her visits, Patient 3 reported that Patient 4 had an open wound on the coccyx; LVN 3 stated that she did not remember the exact date. LVN 3 stated that she notified the OA from the HHA office immediately after she observed the wound during the visit. LVN 3 stated that she did not notify Patient 4’s physician regarding the wound. LVN 3 stated, “Whenever a patient has a change of condition, or a new wound, I just call the office. They take care of everything.” According to LVN 3, that was the procedure that she was trained by the HHA to follow. When LVN 3 was asked about which physician order she followed when doing the wound care for Patient 4, LVN 3 stated that she referred to the instruction in the Visit Report from WC 1. LVN 3 stated that she was told by the OA that the Visit Report had the wound care order. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 5/29/2026 at 12:15 p.m., the DPCSD reviewed Patient 4’s active physician orders, Home Health Certification and Plan of Care for the certification period of 3/30/2026 to 5/28/2026, Visit Report from WC 1, dated 5/19/2026, and Clinical Note, dated 5/22/2026. The DPCSD stated that the Visit Report was not a physician order. According to the DPCSD if the patient was seen by a wound specialist and the wound specialist had treatment recommendation, the PCP needed to be informed and if the PCP agreed with the recommendation then the PCP would give an order for the HHA to follow the recommendation. The DPCSD stated that normal saline, Silvasorb gel, Triad paste, calcium Alginate, and Mepilex were considered treatment and must be ordered by a doctor. The DPCSD stated that treatments were also considered medications and needed to be listed in the patient’s medication profile or drug regimen. The DPCSD stated if treatment was being administered without a physician’s order, it would not be included in the patient’s plan of care, and as a result it would be hard to monitor if the treatment worked, or if the patient experienced adverse effects. During a review of the HHA’s Policy and Procedure (P & P), titled “Identification of Medication for Administration,” revised December 2025, the P & P indicated that orders for the administration of medications must be given by a physician (or allowed practitioner) and include patient name, patient identifier, the name of the medication, dosage, dilution, route, frequency of administration, and rate of infusion, if applicable, as well as orders for anaphylaxis and laboratory work, when appropriate. The P & P also indicated that the nurse would review the written physician (or allowed practitioner) orders prior to medication administration.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) nursing staff failed to notify the physician regarding the patient’s change of condition for one of seven sampled patients (Patient 4). The deficient practice resulted in Patient 4’s physician was not informed promptly of the existing wound for treatment orders and further intervention. During a review of Patient 4’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 3/30/2026 to 5/28/2026, the POC indicated that Patient 4 was admitted to the HHA on 3/30/2026 with a primary diagnosis of primary generalized osteoarthritis (a widespread, age-associated degenerative condition affecting multiple joint groups). The POC indicated that Patient 4 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and then one SN visit per week for seven weeks. The POC indicated that Patient 4 was also to receive Certified Home Health Aide (CHHA, a trained healthcare professional who provides personal care and daily living assistance to patients in their homes under the supervision of a nurse) once a week for nine weeks. The POC indicated the SN was to assess all body systems with emphasis that included the integumentary (skin) status: Monitor for skin breakdown. Per POC, the SN was to notify the physician of any abnormal findings, including skin breakdown. During a review of Patient 4’s Comprehensive Adult Nursing Assessment, dated 3/30/2026, the Comprehensive Adult Nursing Assessment indicated that Patient 4 was unable to ambulate (walk) and was unable to wheel himself (when put in a wheelchair). The Comprehensive Adult Nursing Assessment indicated that Patient 4 had bladder incontinence (loss of bladder control). The Skin Conditions section of the Comprehensive Adult Nursing Assessment indicated that Patient 4’s skin was intact. During a review of Patient 4’s Comprehensive Adult Nursing Assessment, dated 4/21/2026, the Skin Conditions section of the Comprehensive Adult Nursing Assessment indicated that Patient 4’s skin was intact. During a review of Visit Report from Wound Clinic 1 (WC 1), dated 5/19/2026, the Visit Report indicated that on 5/12/2026, an initial wound care evaluation was completed for Patient 4 by the wound specialist from WC 1. The Visit Report indicated that on 5/12/2026, Patient 4 had an acute unstageable pressure injury (a severe, full-thickness wound where the true depth and severity are hidden by a layer of dead tissue) in the coccyx (tailbone), measuring 5 centimeters (cm, a measurement unit) in length and 6 cm in depth, with no measurable depth; Patient 4 also had a stage 1 pressure injury (the earliest stage of pressure injury; it presents as intact skin with a localized area of persistent redness) on the left lateral hip and moisture-associated skin damage (MASD, an inflammatory condition and skin erosion caused by prolonged exposure to bodily fluids like sweat, urine, feces, or wound discharge) on bilateral groin. During a joint visit observation with Registered Nurse 2 (RN 2) on 5/27/2026 at 11:15 a.m. at Patient 4’s home, observed Patient 4 lying down in a hospital bed. Observed Patient 4 awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 4 lives with a family member (Patient 3), who stated that she (Patient 3) was his (Patient 4) primary caregiver. During the joint home visit, observed RN 2 assess Patient 4’s skin. Observed an unstageable pressure injury in the coccyx, a stage 1 pressure injury on the left lateral hip, and MASDon the groin. RN 2 stated that she had never seen Patient 4 before. During an interview with Patient 3 on 5/27/2026 at 11:48 a.m., Patient 3 stated that Patient 4 developed the pressure injury on the coccyx a few weeks ago. Patient 3 stated that Licensed Vocational Nurse 3 (LVN 3) was Patient 4’s regular nurse, and LVN 3 knew about the wounds. During a phone interview with LVN 3 on 5/27/2026 at 4 p.m., LVN 3 stated that she had been visiting Patient 4 once a week for a couple months. LVN 3 stated that on one of her visits, Patient 3 reported that Patient 4 had an open wound on the coccyx; LVN 3 stated that she did not remember the exact date. LVN 3 stated that she notified the Office Administrator (OA) from the HHA office immediately after she observed the wound during the visit. LVN 3 stated that she did not notify Patient 4’s physician regarding the wound. LVN 3 stated, “Whenever a patient has a change of condition, or a new wound, I just call the office. They take care of everything.” According to LVN 3, that was the procedure that she was trained by the HHA to follow. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 5/28/2026 at 11:15 a.m., the DPCS reviewed Patient 4’s Comprehensive Nursing Assessments, dated 3/30/2026 and 4/21/2026, Clinical Notes, dated 5/5/2026, 5/12/2026, and 5/22/2026. When the DPCS was asked if the physician was aware that Patient 4 had developed pressure injuries, the DPCS stated that she was not sure. The DPCS stated she did not notify Patient 4’s physician about the pressure injuries. The DPCS stated that she was not sure because even though she and LVN 3 never notified the physician, “Someone else might have.” When asked for clarification who that “someone else” was and the role of that individual in the HHA, the DPCS could not answer. The DPCS stated there was no evidence that Patient 4’s physician was notified about the pressure injuries. During an interview with the OA on 5/28/2026 at 12:05 p.m., the OA stated she received report from LVN 3 about Patient 4’s pressure injuries. The OA stated she did not remember the exact date when LVN 3 notified her because she did not document it. The OA stated that she was not a licensed clinician. The OA stated she did not notify Patient 4’s physician about the wounds. The OA stated, “I don’t believe anyone notified the primary physician.” The OA stated that upon receiving LVN 3’s report, she immediately contacted the wound clinic that the HHA had a contract with and requested a wound consultation for Patient 4. When the OA was asked who gave her the order to contact the wound clinic, the OA said that there was no physician order for a wound consultation. During a review of the HHA’s Policy and Procedure (P & P), titled “Monitoring Patient Response/Reporting to Physician,” revised December 2025, the P & P indicated that the patient’s physician (or allowed practitioner) would be contacted on the same day when any of the following occur: A. Significant changes in the patient’s condition”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to update the Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) failed to ensure the POC contained an updated comprehensive assessment of the patient’s pressure injuries (localized damage to the skin and underlying tissue caused by prolonged, unrelieved pressure, friction, or shear force, usually over a bony prominence) to the coccyx (tailbone) and left hip for one of seven sampled patients (Patient 4). This failure had the potential to result in improper treatment, worsening wounds, and delayed necessary interventions. During a review of Patient 4’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 3/30/2026 to 5/28/2026, the POC indicated that Patient 4 was admitted to the HHA on 3/30/2026 with a primary diagnosis of primary generalized osteoarthritis (a widespread, age-associated degenerative condition affecting multiple joint groups). The POC indicated that Patient 4 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and then one SN visit per week for seven weeks. The POC indicated that Patient 4 was also to receive Certified Home Health Aide (CHHA, a trained healthcare professional who provides personal care and daily living assistance to patients in their homes under the supervision of a nurse) once a week for nine weeks. During a review of Patient 4’s Comprehensive Adult Nursing Assessment, dated 3/30/2026, indicated Patient 4 was unable to ambulate (walk) and was unable to wheel himself (when put in a wheelchair), and indicated Patient 4 had bladder incontinence (loss of bladder control). The Skin Conditions section of the Comprehensive Adult Nursing Assessment indicated Patient 4’s skin was intact. During a review of Patient 4’s Comprehensive Adult Nursing Assessment, dated 4/21/2026, the Skin Conditions section of the Comprehensive Adult Nursing Assessment indicated that Patient 4’s skin was intact. During a review of Visit Report from Wound Clinic 1 (WC 1), dated 5/19/2026, the Visit Report indicated that on 5/12/2026, an initial wound care evaluation was completed for Patient 4 by the wound specialist from WC 1. The Visit Report indicated that on 5/12/2026, Patient 4 had an acute unstageable pressure injury (a severe, full-thickness wound where the true depth and severity are hidden by a layer of dead tissue) in the coccyx (tailbone), measuring 5 centimeters (cm, a measurement unit) in length and 6 cm in depth, with no measurable depth; Patient 4 also had a stage 1 pressure injury (the earliest stage of pressure injury; it presents as intact skin with a localized area of persistent redness) on the left lateral hip and moisture-associated skin damage (MASD, an inflammatory condition and skin erosion caused by prolonged exposure to bodily fluids like sweat, urine, feces, or wound discharge) on bilateral groin. During a joint visit observation with Registered Nurse 2 (RN 2) on 5/27/2026 at 11:15 a.m. at Patient 4’s home, observed the patient was lying down in a hospital bed. It was observed Patient 4 was awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 4 lives with a family member (Patient 3). Patient 4 stated that Patient 3 was his primary caregiver. During the joint home visit, observed RN 2 assess Patient 4’s skin. Observed an unstageable pressure injury in the coccyx, a stage 1 pressure injury on the left lateral hip, and MASDon the groin. RN 2 stated that she had never seen Patient 4 before. During an interview with Patient 3 (Patient 4’s caregiver) on 5/27/2026 at 11:48 a.m., stated that Patient 4 developed the pressure injury on the coccyx a few weeks ago. Patient 3 stated that Licensed Vocational Nurse 3 (LVN 3) was Patient 4’s regular nurse, and LVN 3 knew about the wounds. During a phone interview with LVN 3 on 5/27/2026 at 4 p.m., LVN 3 stated that she had been visiting Patient 4 once a week for a couple months. LVN 3 stated that on one of her visits, Patient 3 reported that Patient 4 had an open wound on the coccyx; LVN 3 stated that she did not remember the exact date. LVN 3 stated that she notified the Office Administrator (OA) from the HHA office immediately after she observed the wound during the visit. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 5/28/2026 at 11:15 a.m., the DPCS reviewed Patient 4’s Comprehensive Nursing Assessments, dated 3/30/2026 and 4/21/2026, Home Health Certification and Plan of Care for the certification period of 3/30/2026 to 5/28/2026, and Supplemental Plan of Treatment from 4/21-2026 to 5/28/2026. The DPCS stated there were no pressure injuries or wound care orders documented on those records because Patient 4 did not have skin issues then. The DPCS also reviewed the Visit Report from WC 1, dated 5/19/2026. The DPCS stated that per the Visit Report, Patient 4 had developed pressure injuries on 5/12/2026, and the wound specialist made treatment recommendations. The DPCS stated that the HHA’s Registered Nurse should have notified the patient’s primary care physician, obtained a wound care order, and updated the patient’s Plan of Care. The DPCS stated the purpose of updating the Plan of Care was to give the most up-to-date care based on the patient’s condition; if patient has new wound, the Plan of Care needed to reflect that to make sure the HHA was providing wound care. During a review of the HHA’s policy and procedure (P & P), titled “Continuity of Care,” revised December 2025, the P & P indicated the following: The clinician will be responsible for: A. Communicating with all personnel caring for the patient including the physician (or allowed practitioner). B. Updating physicians’ (or allowed practitioner’s) orders and obtaining lab test results as needed. C. Updating the plan of care.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to integrate orders from all physicians involved into the plan of care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for one of seven sampled patients (Patient 4). This failure had the potential to result in the lack of coordination among designated HHA staff to implement care and services, intervention and treatment ordered for the patient. During a review of Patient 4’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 3/30/2026 to 5/28/2026, the POC indicated Patient 4 was admitted to the HHA on 3/30/2026 with a primary diagnosis of primary generalized osteoarthritis (a widespread, age-associated degenerative condition affecting multiple joint groups). The POC indicated that Patient 4 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and then one SN visit per week for seven weeks. The POC indicated that Patient 4 was also to receive Certified Home Health Aide (CHHA, a trained healthcare professional who provides personal care and daily living assistance to patients in their homes under the supervision of a nurse) once a week for nine weeks. During a review of Patient 4’s Comprehensive Adult Nursing Assessment, dated 3/30/2026, the Comprehensive Adult Nursing Assessment indicated that Patient 4 was unable to ambulate (walk) and was unable to wheel himself (when put in a wheelchair). The Comprehensive Adult Nursing Assessment indicated that Patient 4 had bladder incontinence (loss of bladder control). The Skin Conditions section of the Comprehensive Adult Nursing Assessment indicated that Patient 4’s skin was intact. During a review of Patient 4’s Comprehensive Adult Nursing Assessment, dated 4/21/2026, the Skin Conditions section of the Comprehensive Adult Nursing Assessment indicated that Patient 4’s skin was intact. On 5/26/2026, the HHA’s Office Administrator (OA) provided a document titled “Visit Report for 5/19/2026” from Wound Clinic 1 (WC 1). The OA stated the documents contained wound care orders for Patient 4. During a review of Visit Report from Wound Clinic 1 (WC 1), dated 5/19/2026, the Visit Report indicated that on 5/12/2026, an initial wound care evaluation was completed for Patient 4 by the wound specialist from WC 1. The Visit Report indicated that on 5/12/2026, Patient 4 had an acute unstageable pressure injury (a severe, full-thickness wound where the true depth and severity are hidden by a layer of dead tissue) in the coccyx (tailbone), measuring 5 centimeters (cm, a measurement unit) in length and 6 cm in depth, with no measurable depth; Patient 4 also had a stage 1 pressure injury (the earliest stage of pressure injury; it presents as intact skin with a localized area of persistent redness) on the left lateral hip and moisture-associated skin damage (MASD, an inflammatory condition and skin erosion caused by prolonged exposure to bodily fluids like sweat, urine, feces, or wound discharge) on bilateral groin. The Visit Report indicated that for the unstageable pressure injury on the coccyx, the wound specialist recommended the following: Cleanse with normal saline (a sterile mixture of salt and water that matches the body’s natural fluid balance; its primary purpose is to replenish body fluids, maintain blood volume, deliver intravenous medications, and safely cleanse bodily tissues without causing cell damage), pat dry, treated with Silvasorb gel (an antimicrobial hydrogel wound dressing) to the wound bed, followed by application of Triad paste (a zinc-oxide-based, medical-grade paste used for wound and skincare) to the peri wound (reddened areas), then Calcium Alginate (a highly absorbent, non-woven wound dressing derived from brown seaweed) was applied for moisture management, and cover with Mepilex sacral bordered foam dressing (a line of specialized, soft silicone foam wound dressings designed to absorb fluid and maintain a moist wound healing environment). The Visit Report indicated that wound treatment for the unstageable pressure injury on the coccyx was to be done 3 times a week or as needed if loose or soiled. For the stage 1 pressure injury on the left lateral hip, the recommendation was to apply Mepilex bordered foam dressing; dressing to be changed every 2-3 days or as needed if loose or soiled. For the bilateral groin MASD, the recommendation was to clean with normal saline, pat dry, and apply Clotrimazole cream 1% (antifungal medication) twice daily until resolved. During a joint visit observation with Registered Nurse 2 (RN 2) on 5/27/2026 at 11:15 a.m. at Patient 4’s home, observed Patient 4 lying down in a hospital bed. Observed Patient 4 awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 4 lives with a family member (Patient 3), who stated that she (Patient 3) was his (Patient 4) primary caregiver. During the joint home visit, observed RN 2 assess Patient 4’s skin. Observed an unstageable wound in the coccyx, a stage 1 pressure injury on the left lateral hip, and MASD on the groin. During an interview with Patient 3 (Patient 4’s caregiver) on 5/27/2026 at 11:48 a.m., Patient 3 stated that a wound specialist had visited Patient 4 and treated the pressure injuries about 2 or 3 times. Patient 3 stated, “The wound specialist comes once a week, I think she started coming 2 weeks ago. The wound specialist was here yesterday.” Patient 3 stated that Patient 4 developed the pressure injury on the coccyx a few weeks ago. Patient 3 stated that Licensed Vocational Nurse 3 (LVN 3) was Patient 4’s regular nurse, and LVN 3 knew about the wounds. Patient 3 stated that the wound treatment was being done twice a week, once by the wound specialist and once by LVN 3. During the joint home visit, after reviewing the Visit Report dated 5/19/2026 from WC 1, RN 2 stated that she would not treat Patient 4’s wounds. RN 2 stated, “This Visit Report is not a physician order. It says, “Progress Note Details” on top, to explain what the Nurse Practitioner (NP) did.” RN 2 stated the Visit Report dated 5/19/2026 indicated the NP made recommendations on how to treat Patient 4’s wounds, but it was not considered a physician order. RN 2 stated, “I don’t have a wound care order. I’ll call the home health office so they can call the doctor and get an order.” RN 2 stated that she had never seen Patient 4 before. During a phone interview with LVN 3 on 5/27/2026 at 4 p.m., LVN 3 stated that she had been visiting Patient 4 once a week for a couple months. LVN 3 stated that on one of her visits, Patient 3 reported that Patient 4 had an open wound on the coccyx; LVN 3 stated that she did not remember the exact date. LVN 3 stated that she notified the OA from the HHA office immediately after she observed the wound during the visit. LVN 3 stated that she did not notify Patient 4’s physician regarding the wound. LVN 3 stated, “Whenever a patient has a change of condition, or a new wound, I just call the office. They take care of everything.” According to LVN 3, that was the procedure that she was trained by the HHA to follow. When LVN 3 was asked about which physician order she followed when doing the wound care for Patient 4, LVN 3 stated that she referred to the instruction in the Visit Report from WC 1. LVN 3 stated that she was told by the OA that the Visit Report had the wound care order. During a review of Clinical Note, dated 5/22/2026, the Interventions section of the Clinical Note indicated that LVN 3 performed the following on the pressure ulcer on Patient 4’s coccyx: Cleansed with normal saline, applied a combination of Silvasorb, Triad paste, and Calcium Alginate, and covered with bordered Mepilex. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 5/28/2026 at 11:15 a.m., the DPCS reviewed Patient 4’s Comprehensive Adult Nursing Assessments, dated 3/30/2026 and 4/21/2026, Home Health Certification and Plan of Care for the certification period of 3/30/2026 to 5/28/2026, Visit Report from WC 1, dated 5/19/2026, and Clinical Note, dated 5/22/2026. The DPCS stated that the Visit Report, dated 5/19/2026, was considered a physician order for Patient 4. When the DPCS was asked if the wound specialist who assessed Patient 4 and made treatment recommendation for the wound on 5/12/2026 was Patient 4’s primary physician or the referring physician for Patient 4, the DPCS stated, “No. The wound specialist works for WC 1. It’s still an order because it’s part of the continuity of care.” The DPCS stated there was no wound order on Patient 4’s POC because Patient 4 did not have a wound upon admission. The DPCS stated that all orders needed to be included in the POC, and if a patient had a change of condition such as a new wound then the POC needed to be updated. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 5/29/2026 at 12:15 p.m., the DPCSD reviewed Patient 4’s Home Health Certification and Plan of Care for the certification period of 3/30/2026 to 5/28/2026, and Visit Report from WC 1, dated 5/19/2026. The DPCSD stated that the Visit Report was not a physician order. The DPCSD stated, “It’s an order for the wound nurse from WC 1, not for our nurses.” The DPCSD pointed out that there was no physician signature with the physician title on it. The DPCSD stated that LVN 3 or a Registered Nurse (RN) from the HHA should have notified Patient 4’s primary care physician (PCP) and notified him or her about the wound. According to the DPCSD if the patient was seen by a wound specialist and the wound specialist had treatment recommendation, the PCP needed to be informed and if the PCP agreed with the recommendation then the PCP would give an order for the HHA to follow the recommendation. The DPCSD stated, “The order from the PCP would then be added to the patient’s existing plan of care.” During a review of an undated form titled “Policy No. 4-001.1,” the form indicated that all clinicians would consider the conclusions of initial and ongoing assessments in their care planning process, including but not limited to: B. Changes in patients’ condition The form indicated that based on the assessment and conclusions, the plan of care would include, but not be limited to: A. Patient specific interventions and education D. Specific services and treatments to be provided including services furnished via telecommunication systems (if appropriate) K. All medications During a review of an undated, untitled form provided by the HHA on 5/29/2026, the untitled form indicated the following: Obtain and follow physician-ordered wound care treatmentsClarify incomplete or unclear orders prior to implementationReport significant changes promptly During a review of the HHA’s policy and procedure (P & P), titled “Continuity of Care,” revised December 2025, the P & P indicated the following: The clinician will be responsible for: Communicating with all personnel caring for the patient including the physician (or allowed practitioner).Updating physicians’ (or allowed practitioner’s) orders and obtaining lab test results as needed.Updating the plan of care.”

“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 – an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) performed registered nurse (RN) supervisory visits for their License Vocational Nurse (LVN) services for two of seven sampled patients (Patient 6 and Patient 7) provided LVN services. This failure had the potential to result in patients being taken care of by an unqualified staff. During an interview on 5/28/2026 at 10:24 a.m., with the Administrator/Director of Nurses (DON) stated that LVN supervisory visits were conducted for patients during start of care and recertification. During an interview on 5/28/2026 at 10:26 a.m., with the DON, supervisory visits were done to ensure the nursing disciplines were accurately doing the job, following policies and procedures, and were aware of how things were done safely. 1. During a record review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” undated, indicated a start of care date of 3/12/2026 with a primary diagnosis of chronic pain syndrome. Lastly, the form indicated Patient 6 had skilled nurse (SN) visits twice a week for one week, then once a week for eight weeks. During a record review of Patient 6’s medical record form titled “Supervisory visit of home health care staff” undated, indicated Registered Nurse 1 (RN1) was listed as the supervising nurse. The form did not contain the name of the License Vocational Nurse (LVN) being supervised and did not indicate if the LVN met or did not meet the requirements to safely provide services. During a concurrent interview and record review on 5/28/2026 at 10:26 a.m. with the Administrator/Director of Nurses (DON), of Patient 6’s medical record, the DON stated that Patient 6’s start of care date was on 3/12/2026. The DON stated that Patient 6’s medical record contained one incomplete LVN supervisory visit note dated 3/12/2026. The DON stated that the supervisory visit for should have been complete to evaluate whether the LVN exceeds or not with the requirements. 2. During a record review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/18/2026 to 6/16/2026, indicated a start of care date of 2/17/2026 with a primary diagnosis of hemiplegia (paralysis on one side of the body) following cerebral infarction (lack of blood supply to brain). Lastly, the form indicated Patient 7 had skilled nurse (SN) visits once a week for one week, then twice a week for one week, then once a week for seven weeks. During a record review of Patient 7’s medical record form titled “Supervisory visit of home health care staff” undated, indicated Registered Nurse 1 (RN1) was listed as the supervising nurse. The form did not contain the name of the License Vocational Nurse (LVN) being supervised. During a concurrent interview and record review on 5/28/2026 at 10:30 a.m. with the Administrator/Director of Nurses (DON), of Patient 7’s medical record, the DON stated that Patient 7’s start of care date was on 2/17/2026. The DON stated that RN1 completed an LVN supervisory visit on 2/17/2026 but did not document the name of the LVN being supervised. The DON stated that without an LVNs name the HHA would not know who was being supervised to be able to provide corrective action if required.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure two of seven sample patients (Patient 4 and Patient 7) provided Certified Home Health Aide (CHHA) services conducted supervisory visit/assessment every 14 days. This failure had the potential to result in endangering patients’ health and wellbeing. During an interview on 5/28/2026 at 10:24 a.m., with the Administrator/Director of Nurses (DON), the DON stated that CHHA supervisory visits are conducted every two weeks. During an interview on 5/28/2026 at 10:26 a.m., with the DON, the DON stated that supervisory visits are done to ensure the discipline is accurately doing the job, following policies and procedures, and is aware of how things are done safely. 1. During a review of Patient 4’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 3/30/2026 to 5/28/2026, the POC indicated that Patient 4 was admitted to the HHA on 3/30/2026 with a primary diagnosis of primary generalized osteoarthritis (a widespread, age-associated degenerative condition affecting multiple joint groups). The POC indicated that Patient 4 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and then one SN visit per week for seven weeks. The POC indicated that Patient 4 was also to receive Certified Home Health Aide (CHHA, a trained healthcare professional who provides personal care and daily living assistance to patients in their homes under the supervision of a nurse) once a week for nine weeks. During a review of Weekly Activity Log for Patient 4, dated 5/19/2026, 5/15/2026, and 5/12/2026, the Weekly Activity Log indicated that on those dates, CHHA 2 provided bed bath and hygiene assistance (personal care, dressing, pressure care area, skin care/foot care, and dressing) for Patient 4. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 5/29/2026 at 12:15 p.m., the DPCSD stated there were no supervisory visits done for CHHA 2. The DPCSD stated that supervisory visits for CHHA needed to be done to ensure the CHHA was doing patient care properly, such as bathing, transferring technique, cutting nails, especially if the patient had wounds, fractures, or catheters. The DPCSD stated that without supervisory visits, the RN did not know if the CHHA was providing the patient care safely and properly. 2. During a record review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/18/2026 to 6/16/2026, indicated a start of care date of 2/17/2026 with a primary diagnosis of hemiplegia (paralysis on one side of the body) following cerebral infarction (lack of blood supply to brain). Lastly, the form indicated Patient 7 had CHHA services for personal care needs with frequency of once a week for nine weeks. During a concurrent interview and record review on 5/29/2026 at 12:01 p.m. with the Director of Nurses Designee (DOND), of Patient 7’s medical record, the DOND stated that Patient 7 had CHHA services ordered once a week for nine weeks. The DOND stated that CHHA are to have supervisory visits every two weeks to ensure they are taking care of the patient properly. The DOND stated the CHHA need to be assessed to ensure they are following infection control and are able to transfer the patients properly. The DOND stated that Certified Home Health Aide 1 (CHHA1), assigned to Patient 7, has not been supervised. The DOND stated that she (DOND) does not know how CHHA1 is taking care of Patient 7. During a review of the HHA’s policy and procedure (P & P), titled “Internal Control Systems/Accountabilities,” revised December 2025, the P & P indicated that Aide supervisory visits are performed and documented every 14 days.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7) clinical records contained completed skilled nursing clinical notes, physician’s orders for discharge, and completed physician’s discharge summaries. This failure resulted in an incomplete clinical record, lack of coordination in the continuity of patient care, uncoordinated patient’s decline or progress not identified, and physician’s assessment for clearance/orders of patient’s safe discharge from home health care. During an interview on 5/28/2026 at 10 a.m., with the Administrator/Director of Nurses (DON), the DON stated that skilled nurses (SN) have 24-48 hours after their visit to submit their home visit documentation. The DON stated that nurses do not document directly in their electronic medical record (EMR) system because they document on a hard copy. The DON stated that nurses bring their documented hard copy notes to the office and either the Office Administrator (OA) or the Intake (IN) uploaded into their EMR system. The DON stated that submitting nurses’ notes late can cause delays in care, and improper documentation. The DON stated that patients can have a change of status that can cause hospitalization and/or death. 1. During a review of Patient 1’s medical record titled, SOC (Start of care) Worksheet, undated, it indicated Patient 1 had a start of care of 2/20/2026. During a review of Patient 1’s medical record titled, Home Health Certification and Plan of Care (POC, a document that outlines the patient’s treatments, goals and interventions), it indicated a primary diagnosis of generalized osteoarthritis (a joint condition that causes pain, swelling and stiffness) and chronic pain syndrome (pain lasting from 3 to 6 months and is accompanied by emotional and behavioral symptoms). During a concurrent interview and record review on 5/26/2026 at 2:32 p.m., with Office Administrator (OA), Patient 1’s clinical notes were reviewed. Patient 1 had clinical notes in the medical chart dated 2/22/2026, 2/26/2026, 3/1/2026, 3/5/2026, 3/12/2026, 3/17/2026, 3/23/2026, 3/30/2026, 4/6/2026, 4/21/2026, 4/25/2026, 4/29/2026, and 5/5/2026. OA stated there were no notes in the electronic medical record and all notes were in the patient’s physical chart. OA stated the nurses take their notes to the office once a week and the last notes in Patient 1’s chart were dated 5/5/2026. During an interview on 5/28/2026 at 1:15 p.m., with the Director of Nursing (DON), the DON stated it was important to have the nursing notes in the patient records so the agency can keep track of the up-to-date plan of care and to assure the skilled nursing care was being provided according to the plan of care. 2. During a review of Patient 2’s medical record titled, SOC Worksheet, undated, it indicated Patient 2 had a start of care of 4/24/2025 and a discharge date of 8/18/2025. During a review of Patient 2’s medical record titled, Discharge Summary, dated 8/18/2025, it indicated under “Summary of Care Provided: Goals are met”. During a concurrent interview and record review on 5/29/2026 at 10:45 a.m., with Director of Nursing Designee (DOND), Patient 2’s physical medical chart was reviewed. The medical chart did not include a physician’s discharge order. DOND stated the process for patient discharge includes the nurse visiting the patient, providing patient teaching and notifying the physician that the patient no longer requires further visits. DOND stated there should be a physician’s discharge order to ensure all paper works are in the chart and signed within 30 days. DOND stated the importance of having a discharge order was for the physician to be aware the patient was no longer under the home health agency care, notify the physician of any changes, communication between all disciplines, and ensure patient safety. 3. During a review of Patient 3’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 5/3/2026 to7/1/2026, the POC indicated that Patient 3 was admitted to the HHA on 5/3/2026 with a primary diagnosis of chronic pain syndrome (a condition where persistent pain lasts beyond 3 to 6 months and causes secondary physical and emotional symptoms, such as depression, anxiety, and sleep disturbances). The POC indicated that Patient 3 was to receive two Skilled Nurse (SN, a licensed nurse in general) visits twice a week for two weeks, and then one SN visit per week for seven weeks. On 5/26/2026, during a review of Patient 3’s clinical record revealed there were no SN visit notes since the patient’s start of care (SOC) date on 5/3/2026. 4. During a review of Patient 4’s Home Health Certification and Plan of Care for the certification period of 3/30/2026 to 5/28/2026, the POC indicated that Patient 4 was admitted to the HHA on 3/30/2026, with a primary diagnosis of primary generalized osteoarthritis (a widespread, age-associated degenerative condition affecting multiple joint groups). The POC indicated that Patient 4 was to receive two Skilled Nurse visits twice a week for two weeks, and then one SN visit per week for seven weeks. On 5/26/2026, during a review of Patient 4’s clinical record, revealed there were no SN visit notes for May 2026. During a phone interview with LVN 3 on 5/27/2026 at 4 p.m., LVN 3 stated that she had been visiting Patient 4 once a week for a couple months. LVN 3 stated she had also been visiting Patient 3 once a week since Patient 3 was admitted to the HHA in early May 2026. LVN 3 stated that she usually submitted her visit notes to the HHA office every two weeks. LVN 3 stated that she understood that visit notes should have been submitted every week so the RN and the doctor would know the patient’s condition, what treatment had been done, and if patient was getting better. LVN 3 stated, “It’s my mistake, I didn’t submit my notes.” 5. During a review of Patient 5’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 3/26/2026 to 5/24/2026, the POC indicated that Patient 5 was admitted to the HHA on 3/26/2026, with a primary diagnosis of primary generalized osteoarthritis (a widespread, age-associated degenerative condition affecting multiple joint groups). The POC indicated that Patient 5 was to receive one Skilled Nurse (SN, a licensed nurse in general) visits once a week for one week, and then two SN visits per week for two weeks, and then one SN visit per week for six weeks. During a review of a document provided by the HHA, titled Patient Transfer/Discharge Tracking, the document indicated that Patient 5 was discharged home on 5/21/2026. The document indicated that there were no further home health care needs for Patient 5. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 5/29/2026 at 1:26 p.m., the DPCSD reviewed Patient 5’s clinical records. The DPCSD confirmed that Patient 5 was discharged on 5/21/2026. The DPCSD stated there was physician order for discharge and no discharge summary done for Patient 5. The DPCSD stated that physician order for discharge was necessary because the physician was the one referring the patient to the HHA and was involved in the patient care. The DPCSD stated the HHA needed to make sure the doctor was aware that the patient would no longer be under the HHA’s service. 6. During a record review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” undated, indicated a start of care date of 3/12/2026 with a primary diagnosis of chronic pain syndrome. Lastly, the form indicated Patient 6 had skilled nurse (SN) visits twice a week for one week, then once a week for eight weeks. During a concurrent interview and record review on 5/26/2026 at 2:33 p.m. with the Office Administrator (OA) of Patient 6’s medical record, the OA stated that the last SN visit note documented in Patient 6’s physical and electronic medical record was dated 4/26/2026. The OA stated that Patient 6 had three more nurse visits after 4/26/2026, one from a Registered Nurse (RN) and the other two from Licensed Vocational Nurse 1 (LVN1). The AO stated that the assigned LVN1 has not turned in her (LVN1) documentation yet for home visits conducted on 5/11/2026 and 5/15/2026. 7. During a record review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/18/2026 to 6/16/2026, indicated a start of care date of 2/17/2026 with a primary diagnosis of hemiplegia (paralysis on one side of the body) following cerebral infarction (lack of blood supply to brain). The POC indicated Patient 7 had skilled nurse (SN) visits once a week for one week, then twice a week for one week, then once a week for seven weeks. During a concurrent interview and record review on 5/26/2026 at 2:36 p.m., with the Office Administrator (OA) of Patient 7’s medical record, the OA stated that the last SN visit note documented in Patient 7’s physical and electronic medical record was dated 5/3/2026. The OA stated that Patient 7 had one visit on 5/10/2026, from Licensed Vocational Nurse 1 (LVN1). The AO stated that LVN1 has not turned in her (LVN1) documentation yet for home visit conducted on 5/10/2026. During a review of the facility’s policy and procedure (P&P) titled, “Discharge Criteria and Process”, undated, the P&P indicated “All discharge paperwork will be due in the office within 72 hours of the discharge date. This will include the discharge order…” During a record review of the HHA’s form titled “Clinical/Service Data Collection” revised 12/2025, indicated “Entries into the clinical/service record will be clear, concise, and specific statements of fact.” The form also indicated “The clinical/service note will include: A. What care/service was provided.””

“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 facility failed to ensure a discharge summary was sent to the physician for two of seven sampled patients (Patient 2 and Patient 5). This failure had the potential to result in lack of continuity of care and safety post discharge. 1. During a review of Patient 2’s medical record titled, SOC Worksheet, undated, it indicated Patient 2 had a start of care of 4/24/2025 and a discharge date of 8/18/2025. During a review of Patient 2’s medical record titled, Discharge Summary, dated 8/18/2025, it indicated under “Summary of Care Provided: Goals are met”. During a concurrent interview and record review on 5/29/2026 at 10:45 a.m., with the Director of Nursing Designee (DON), Patient 2’s physical medical chart was reviewed. The medical chart did not include confirmation that the discharge summary was sent to the physician. DOND stated confirmation of the discharge summary sent to the physician should be in the patient’s chart. DOND stated the office staff would send the physician the discharge summary on the same day the patient is discharged, the physician would sign the summary and return it to the agency, and the agency is supposed to have a fax confirmation. DOND stated the agency would have to follow up with the physician’s office to confirm if the fax was received and if it was not received then the agency would then have to re send the summary. DOND stated it was important for the physician to have a copy of the discharge summary, so the physician is aware the patient was discharged and no longer required care. 2. During a review of Patient 5’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period of 3/26/2026 to 5/24/2026, the POC indicated that Patient 5 was admitted to the HHA on 3/26/2026 with a primary diagnosis of primary generalized osteoarthritis (a widespread, age-associated degenerative condition affecting multiple joint groups). The POC indicated that Patient 5 was to receive one Skilled Nurse (SN, a licensed nurse in general) visits once a week for one week, and then two SN visits per week for two weeks, and then one SN visit per week for six weeks. During a review of a document provided by the HHA, titled Patient Transfer/Discharge Tracking, the document indicated that Patient 5 was discharged home on 5/21/2026. The document indicated that there were no further home health care needs for Patient 5. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 5/29/2026 at 1:26 p.m., the DPCSD reviewed Patient 5’s clinical records. The DPCSD confirmed that patient 5 was discharged on 5/21/2026. The DPCSD stated there was physician order for discharge and no discharge summary done for Patient 5. The DPCSD stated that physician order for discharge was necessary because the physician was the one referring the patient to the HHA and was involved in the patient care. The DPCSD stated the HHA needed to make sure the doctor was aware that the patient would no longer be under the HHA’s service. The DPCSD also stated that discharge summary had instructions for the patient such as to follow-up with the primary physician, any change of condition to report to the physician, medication teaching, and when to call 911. Per DPCSD, if discharge summary was not provided, the patient might not know what to do after discharge, which could affect their health. During a review of the facility’s P&P titled, “Discharge Summary”, undated, the P&P indicated “A copy of the discharge summary and any necessary medical information will be provided to the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five (5) business days of the patient’s discharge.” During a review of the facility’s policy and procedure (P&P) titled, “Discharge Criteria and Process”, undated, the P&P indicated “All discharge paperwork will be due in the office within 72 hours of discharge date. This will include the discharge order, discharge summary, plan of care, medication profile and OASIS.””