Gmm Home Health Care, Inc.

“Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. 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 at home), failed to ensure Condition of Participation (COP, conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Reporting OASIS information (OASIS-Outcome and Assessment Information Set. Specific patient assessment information required by Medicare) was met as follows: Failed to ensure three of seven sampled patients (Patient 1, Patient 2, and Patient 5) OASIS (Outcome Assessment Information Set- a tool required by CMS for measuring home health quality and determining disbursement) accurately reflected the patient’s health status. The OASIS data transmitted to CMS that contained the inaccurate assessment or evaluation resulted to the continued provision of home health services or recertification of patients, and continued Medicare disbursements. Refer to G374. The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Reporting OASIS information to ensure home health care benefits are verified for eligibility to patients provided home health services.”

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home), failed to ensure Condition of Participation (COP, conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) failed to meet the Condition of Participation regarding Patient Rights as follows: 1. The HHA failed to investigate a formal complaint alleging potential neglect submitted by the Physical Therapist (PT) for one of seven sample patients (Patient 1). This failure interfered with the patient’s right to have concerns addressed in a timely and appropriate manner. (Refer to G478). 2. The HHA failed to log, track, document or resolve the formal complaint alleging potential neglect for one of seven sampled patients (Patient 1). This failure resulted in the HHA not logging the complaint, not completing an investigation, and not documenting findings or resolutions, preventing the HHA from identifying, tracking, or preventing recurrence of similar concerns. (Refer to G484). 3. The HHA failed to take action to prevent further potential violations during an open complaint alleging possible neglect for one of seven sampled patients (Patient 1). This failure resulted in the potential for continued neglect, malnutrition, dehydration, hypoglycemia, hospitalization or death, and exposed Patient 1 to ongoing risk of serious adverse outcomes while the complaint remained unaddressed. (Refer to G486). The cumulative effect of these systemic practices resulted in the failure of the HHA to implement, maintain, or operate an effective Patient Rights program by protecting Patient 1’s right to be free from neglect, have complaints investigated and resolved, and be safeguarded during the complaint process.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home), failed to ensure Condition of Participation (COP, conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to review and document all the medications and treatments the patient was currently using for two of seven sampled patients (Patient 2 and Patient 5). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. (Refer to G536). 2. The HHA failed to ensure a Registered Nurse updated the comprehensive assessment for the recertification period for two of seven sampled patients (Patient 2 and Patient 5). This deficient practice had the potential to result in decline in health status by not assessing the patient’s current needs. (Refer to G544). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Comprehensive Assessment of patients to ensure home health care benefits are verified for eligibility to patients provided home health services.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home), failed to ensure Condition of Participation (COP, conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) failed to ensure the Condition of Participation regarding Care Planning, Coordination, and Quality of Care was met as follows: 1. The HHA failed to ensure the Plan of Care (POC) was developed or followed for four of seven sampled patients (Patient 2, Patient 5, Patient 6, and Patient 7). This failure placed patients at risk for health status decline by not providing the services as indicated in the POC (Refer to G572). 2. The HHA failed to ensure the physician signed Occupational Therapy (OT) orders based on multiple OT evaluations for one of seven sampled patients (Patient 1). This failure had the potential to result in patients receiving unauthorized OT services, placing patients at risk for inappropriate or unapproved care. (Refer G580). 3. The HHA failed to ensure physician verbal patient orders were received by a qualified licensed individual for two of seven sample patients (Patient 2 and Patient 7b). This failure place patients at risk for health status decline by not receiving the appropriate physician orders to be able to take care of them properly. (Refer to G584). 4. The HHA failed to provide written information regarding the plan of care and medication list for two of seven patients (Patient 2, Patient 5). This deficient practice resulted in patients and their representatives not knowing their care team or their treatment course. (Refer to G612). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to ensure Condition of Participation (COP, conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding Organization and administration of services was met as follows: Based on observation, interview, and record review the Home Health Agency (HHA) failed to ensure the administrator has the responsibility to maintain all day operations of the HHA, oversight, and active involvement in running the HHA for seven of seven sampled selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). Refer to G948. This failure resulted in the non-compliance of six (6) Conditions of Participation that could negatively impact the health and safety of all certified patients of the home health agency. The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Organization and administration of services to ensure highest quality health care is provided to patients assessed to receive home health services.”

“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 observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home), failed to ensure Condition of Participation (COP, conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Clinical Records was met as follows: The HHA failed to ensure clinical records (is a detailed, official document of a patient’s health history, medical signs, diagnoses, and treatments), were safeguarded against unauthorized (without official approval, consent, or permission), use for 7 of 7 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5 Patient 6, and Patient 7), when: 1. Unknown staff used an auto-populated (filled in automatically by a computer system or software instead of requiring you to type the information by hand), username and password in the electronic medical record (EMR, a digital version of a patient’s paper chart used by doctors and clinic staff), to enter doctor orders for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7. 2. The agency’s office staff usernames do not clearly indicate the first and last name of staff accessing the patient clinical records. (Refer to G1024). The cumulative effect of these systemic practices resulted in unknown staff used, accessed, and entered doctor’s orders in the patients’ medical records, which increased the risk for inappropriate treatment, delayed or incorrect diagnoses, and medical errors, that could lead to serious injury, harm, impairment, or death.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home), failed to ensure three of seven sampled patients (Patient 1, Patient 2, and Patient 5) OASIS (Outcome Assessment Information Set- a tool required by CMS for measuring home health quality and determining disbursement) accurately reflected the patient’s health status. The OASIS data transmitted to CMS that contained the inaccurate assessment or evaluation resulted to the continued provision of home health services or recertification of patients, and continued Medicare disbursements. 1. During a record review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/20/2026 to 8/18/2026, with a SOC of 4/21/2026, and a primary diagnosis of type 2 diabetes mellitus (high blood sugar). During a concurrent interview and record review on 8/19/2026, at 11:59 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 1’s records for certification period 6/20/2026 to 8/18/2026 titled, “OASIS Report”, dated 6/15/2026 and “Recertification/Follow-Up Assessment”, dated 6/15/2026, were reviewed. Patient 1’s Recertification/Follow-Up Assessment indicated in section GG0170Q4 Q. Does Patient use Wheelchair and/or scooter?: “1 - Yes”. The OASIS report indicated a “0 – No.” The ADM/DPCS stated “there are discrepancies between the assessments and OASIS. I don’t know if Patient 1 has a scooter or not. When there are discrepancies there is risk of harm to the patient if they are not receiving the care that they need. 2.During a record review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/08/2026-8/06/2026, indicated a SOC (Start of Care) of 4/09/2026, with a primary diagnosis of hypertensive heart failure (heart not pumping blood effectively to the body). During an observation of the home visit on 8/18/2026, at 10:05 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 provided a home visit. Patient 2 was alert and oriented to person, place time and purpose. Patient 2 was observed to be walking without the use of an assistive device (in example, cane and/or walker) and without difficulty. During an interview at the home visit on 8/18/2026, at 10:46 a.m., with Patient 2, Patient 2 stated he walks about four (4) to five (5) blocks a day, enjoys going shopping with his wife and daughter. Patient 2 stated he was planning on meeting his daughters for lunch at a restaurant, after the home visit. Patient 2 stated he did not use a cane or walker because he felt he did not need it. Patient 2 did not feel unbalanced or uneasy to say he needed an assistive device to walk. During a concurrent interview and record review on 8/19/2026, at 9:48 a.m., with the Administrator and Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 2’s medical records and stated there was no recertification assessment in the medical record for the current certification period beginning 8/7/2026. The ADM/DPCS stated Patient 2 was seen Registered Nurse 1 (RN 1) for the recertification assessment on 8/5/2026, but RN 1 had not submitted the assessment. The ADM/DPCS provided Patient 2’s “OASIS Report”, dated 8/5/2026. The record indicated its purpose was for recertification reassessment. Further review of the record indicated, “M1860 Ambulation/Locomotion: 01-With the use of one-handed device (for example, cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.” “M1850 Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast 01-Able to transfer with minimal human assistance or with use of an assistive device.” The ADM/DPCS stated the Quality Assurance (QA) staff was the one who had documented the OASIS Report. During a concurrent interview and record review on 8/19/2026, with the Quality Assurance (QA) staff, the QA staff reviewed Patient 2’s record titled, “OASIS Report”, dated 8/5/2026. The QA staff was asked how the information was obtained if there was no recertification assessment for the period beginning 8/7/2026, in Patient 2’s medical records. The QA staff stated the information was obtained from the ADM/DPCS. The QA staff stated it was the ADM/DPCS who put the information in the OASIS assessment, then the QA staff lock the assessment and send it to the claims department. The QA staff stated the ADM/DPCS reviews the OASIS assessment and corrects it if needed. During an interview on 8/19/2026, at 9:51 a.m., with the ADM/DPCS, the ADM/DPCS was informed about the QA’s interview regarding Patient 2’s record titled, “OASIS Report”, dated 8/5/2026. The ADM/DPCS stated, “I have no answer for that. There is nothing in the patient record as far as a recertification assessment”, for current certification period beginning on 8/7/2026. The ADM/DPCS stated the recertification assessment was supposed to be turned in within 1 (one) week of the recertification period, so the HHA is aware of the condition of the patient. The purpose of the recertification assessment was to ensure the patient qualified for another home health period. During an interview on 8/19/2026, at 10:06 a.m., with the ADM/DPCS, the ADM/DPCS stated the process of OASIS documentation was as follows: A nurse completes the assessment. The assessment is a paper process that the nurse needs to fill out. The nurse brings the assessment to the office. The QA staff or the ADM/DPCS enter in the assessment information into the electronic OASIS format. The ADM/DPCS stated the information entered in the OASIS format needed to match the assessment from the nurse. RN 1 assessed Patient 2. The nurse assessment describes the patient’s condition. If the OASIS is not accurate, it does not reflect the condition of the patient. The OASIS goes to Medicare for reimbursement and Medicare follows up on the condition of the patient: whether the patient is improving or not. During a concurrent interview and record review on 8/19/2026, at 10:20 a.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 2’s previous recertification period. The ADM/DPCS reviewed Patient 2’s record titled, “OASIS Report”, dated 6/3/2026 and stated the assessment was for certification period 6/8/2026 to 8/6/2026. The ADM/DPCS also reviewed Patient 2’s record titled, “Recertification/Follow-Up Assessment”, dated 6/3/2026, and stated the information in the document was the recertification assessment obtained from RN 1, for certification period 6/8/2026 to 8/6/2026. The ADM/DPCS stated he had entered the information in Patient 2’s document titled, “OASIS Report”, dated 6/3/2026. The ADM/DPCS reviewed the records and stated discrepancies in the OASIS Report, dated 6/3/2026 as follows: The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated in section M1820: “1” able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient. The OASIS Report dated 6/3/2026 indicated a “2” Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes. The ADM/DPCS stated the information on the OASIS Report, dated 6/3/2026 was incorrect. That is not what was documented on the Recertification/Follow-Up Assessment, dated 6/3/2026. The ADM/DPCS stated he did not know why the information was incorrect on the OASIS Report, dated 6/3/2026. The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated in section M1830 Bathing: Current ability to wash entire body safely “2” able to bathe in shower or tub with the intermittent assistance of another person. The OASIS Report dated 6/3/2026 indicated a “4”-Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode. The ADM/DPCS stated he did not know what happened and maybe it was a typing mistake. The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated in section M1860 Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces- “1” With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings. The OASIS Report dated 6/3/2026 indicated a “2”-Requires use of a two-handed device (for example, walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces. The ADM/DPCS stated the discrepancy was a typing mistake. The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated in section GG0130 Self-care: Eating - “6” patient completes the activity by themself with no assistance from a helper. The OASIS Report dated 6/3/2026 indicated a “5”-Setup or clean-up assistance. The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated in section GG0130 Self-care: Oral Hygiene- “6” patient completes the activity by themself with no assistance from a helper. The OASIS Report dated 6/3/2026 indicated a “5”-Setup or clean-up assistance. The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated in section GG0170 Mobility: Roll left and right- “6” patient completes the activity by themself with no assistance from a helper. The OASIS Report dated 6/3/2026 indicated a “5”-Setup or clean-up assistance. The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated in section GG0170 Mobility: Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space- “5” -Setup or clean-up assistance. The OASIS Report dated 6/3/2026 indicated a “4”-Supervision or touching assistance. The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated in section GG0170 Mobility: Walk 50 feet: Once standing, the ability to walk 50 feet and make two turns- “5” -Setup or clean-up assistance. The OASIS Report dated 6/3/2026 indicated a “3”-Partial/moderate assistance. The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated in section GG0170 Mobility: Walk 10 feet on uneven surfaces: the ability to walk 10 feet on uneven or sloping surfaces: “5” -Setup or clean-up assistance. The OASIS Report dated 6/3/2026 indicated a “3”-Partial/moderate assistance. The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated in section GG0170 Mobility: Walk 10 feet on uneven surfaces: the ability to walk 10 feet on uneven or sloping surfaces: “5” -Setup or clean-up assistance. The OASIS Report dated 6/3/2026 indicated a “3”-Partial/moderate assistance. The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated in section GG0170 Mobility: 1 step (curb): The ability to go up and down a curb or up and down one step: “5” -Setup or clean-up assistance. The OASIS Report dated 6/3/2026 indicated a “3”-Partial/moderate assistance. The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated in section GG0170 Mobility: 4 steps: The ability to go up and down four steps with or without a rail: “5” -Setup or clean-up assistance. The OASIS Report dated 6/3/2026 indicated a “3”-Partial/moderate assistance. The Recertification/Follow-Up Assessment, dated 6/3/2026, indicated Patient 2 was not confined to the home. The ADM/DPCS stated that the criteria for home health services required for the patient to be confined to the home. When the ADM/DPCS was asked why Patient 2 was recertified for home health services if Patient 2 was not confined to the home, the ADM/DPCS stated, “I don’t know the answer to that”. The ADM/DPCS stated that if a patient was not homebound, the patient could go to an outpatient clinic for services. The ADM/DPCS stated Patient 2 was receiving HHA services for vital sign monitoring and medication management. Since Patient 2 was not homebound, according to the recertification assessment, Patient 2 could have received vital sign monitoring and medication management from the primary doctor. If Patient 2 uses the home health benefits while not homebound, the benefits can run out, and Patient 2 might not have the benefit available when Patient 2 really needs it. 3.During a record review of Patient 5’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/08/2026-8/06/2026, with a SOC of 4/09/2026, and a primary diagnosis of primary generalized osteo arthritis (joint stiffness). During a record review of Patient 5’s medical record form titled “Recertification/Follow up Assessment” dated 6/3/2026, indicated in section M1840 that Patient 5 was unable to get to and from the toilet. During a record review of Patient 5’s medical record from titled “OASIS Report” dated 6/3/2026, indicated in section M1840 that Patient 5 was able to get to and from the toilet when reminded. During a record review of Patient 5’s medical record form titled “Recertification/Follow up Assessment” dated 6/3/2026, indicated in section GG0130A4 A that Patient 5 ate independently. During a record review of Patient 5’s medical record from titled “OASIS Report” dated 6/3/2026, indicated in section GG0130A4 A that Patient 5 needed assistance with setting up and cleaning to eat. During a record review of Patient 5’s medical record form titled “Recertification/Follow up Assessment” dated 6/3/2026, indicated in section GG0130B4 B that Patient 5 independently performed oral hygiene. During a record review of Patient 5’s medical record from titled “OASIS Report” dated 6/3/2026, indicated in section GG0130B4 B that Patient 5 needed assistance with performing oral hygiene. During a record review of Patient 5’s medical record form titled “Recertification/Follow up Assessment” dated 6/3/2026, indicated in section GG0170A4 A that Patient 5 rolled left and right independently. During a record review of Patient 5’s medical record from titled “OASIS Report” dated 6/3/2026, indicated in section GG0170A4 A that Patient 5 needed assistance with rolling from left to right. During a concurrent interview and record review on 8/19/2026 at 1:43 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 5’s medical record, the ADM/DPCS stated that there were some differences between Patient 5’s Recertification/Follow up Assessment and OASIS report both dated 6/3/2026. The ADM/DPCS stated, “Differences like that can potentially cause the patient not to receive the care ordered.” During a record review of the HHA’s undated document titled, “OASIS”, indicated, “The encoded OASIS data must accurately reflect the patient’s status at the time of assessment...The organization must electronically transmit accurate, complete and encoded OASIS for each patient...”.”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the comprehensive assessment of patients are updated or revised by the Registered Nurse during re-certification period for two of seven sampled patients (Patient 2 and Patient 5). This deficient practice has the potential to result in the inability of the HHA staff to determine any major decline or improvement of the patients’ health status to in order to develop the recertification plans of care. 1. During a record review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/08/2026-8/06/2026, indicated a SOC (Start of Care) of 4/09/2026, with a primary diagnosis of hypertensive heart failure (heart not pumping blood effectively to the body). During a concurrent interview and record review on 8/19/2026, at 9:48 a.m., with the Administrator and Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 2’s medical records and stated there was no recertification assessment in the medical record for the current certification period beginning 8/7/2026. During an interview on 8/19/2026, at 9:56 a.m., with the ADM/DPCS, the ADM/DPCS stated the purpose of a recertification assessment was to ensure the patient qualified for another home health care period, to see what changes were made and to be aware of the patient condition. The recertification assessment was used to create the plan of care. The ADM/DPCS stated the risk of not having an assessment was as follow: The HHA cannot establish a correct plan of care, because the condition of the patient was unknown. Without the assessment the HHA is not aware of any changes that happened and are not able to provide correct care for the patient, which places the patient at risk for hospitalization. 2. During a record review of Patient 5’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/08/2026-8/06/2026, with a SOC of 4/09/2026, and a primary diagnosis of primary generalized osteo arthritis (joint stiffness). During a concurrent interview and record review on 8/19/2026 at 1:43 p.m. with the ADM/DPCS of Patient 5’s medical record, the ADM/DPCS stated that Patient 5’s medical record did not contain a current recertification assessment that was due on 8/5/2026. The ADM/DPCS stated that the importance of a recertification assessment was to know a patient’s current condition, to be able to formulate a plan of care (POC – personalized care planed) for the nurses to follow. The ADM/DPCS stated that due to Patient 5 not having a current recertification assessment, possible outcomes include nursing staff do not follow specific patient care, the patient might not meet the criteria to continue receiving home health services, and the physician not aware or approve of continuance of receiving home health services. During a record review of the HHA’s document titled, Reassessments/Recertification, dated 11/2025, indicated, “For each new episode of care, a comprehensive assessment will be completed no earlier than five (5) days before and no later than one (1) day before the calendar day on which the new episode of care began.””

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to ensure the Plan of Care (POC) was developed or followed for four of seven sampled patients (Patient 2, Patient 5, Patient 6, and Patient 7). This failure placed patients at risk for health status decline by not providing the services as indicated in the POC. 1. During a record review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/08/2026-8/06/2026, indicated a SOC (Start of Care) of 4/09/2026, with a primary diagnosis of hypertensive heart failure (heart not pumping blood effectively to the body). During a concurrent interview and record review on 8/19/2026, at 10:00 a.m., with the Administrator and Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 2’s medical records and stated there was no POC developed for Patient 2’s current certification period beginning on 8/7/2026. The ADM/DPCS stated the POC was supposed to be completed by 8/14/2026, with the purpose of the staff to follow the updated POC, to make sure what to do exactly for the patient. The risk of not having a POC is that the patient doesn’t receive the appropriate care based on their needs. If patient does not get the care they need, patient can decompensate. The HHA can miss a change of condition. 2. During a record review of Patient 5’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/08/2026-8/06/2026, with a SOC of 4/09/2026, and a primary diagnosis of primary generalized osteo arthritis (joint stiffness). During a concurrent interview and record review on 8/19/2026 at 1:43 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 5’s medical record, the ADM/DPCS stated that Patient 5’s medical record did not contain a current recertification assessment that was due on 8/5/2026. The ADM/DPCS stated that the importance of a recertification assessment was to know a patient’s current condition, to be able to formulate a plan of care (POC – personalized care planed) for the nurses to follow. The ADM/DPCS stated that the importance of a patients POC was for visiting nursing know the patient’s current health condition and are aware of changes. 3. During a record review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 5/08/2026-7/06/2026, with a SOC of 9/10/2025, with a primary diagnosis of other specific arthropathies (stiffness). During a concurrent interview and record review on 8/17/2026 at 12:30 p.m. with the ADM/DPCS of Patient 6’s medical record, the ADM/DPCS stated that Patient 6’s medical record does not have a current plan of care documented. The ADM/DPCS stated that he (ADM/DPCS) completed a recertification assessment for Patient 6 on 7/2/2026 but did not document the current plan of care. The ADM/DPCS stated that he (ADM/DPCS) was responsible for completing Patient 6’s plan of care. The ADM/DPCS stated that a patients POC contained their needs, goals and what care needs be provided by the HHA nurses. The ADM/DPCS stated, “I have no answer for that”, when asked what services were being provided to Patient 6 by the HHA nurses. The ADM/DPCS stated that nurses might not be able to provide the care needed because they did not have a POC to follow. The ADM/DPCS stated that Patient 6 might not be receiving the care needed which may cause hospitalization, longer home health services, and medication errors. 4. During a record review of Patient 7b’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 5/21/2026-7/19/2026, with a SOC of 1/21/2026 and an end of care date of 8/13/2026, with a primary diagnosis of type 2 diabetes (high blood sugar). During a concurrent interview and record review on 8/19/2026 at 3 p.m. with the ADM/DPCS of Patient 7b’s medical record, the ADM/DPCS stated that Patient 7b’s medical record did not contain a current plan of care which covered from 7/20/2026 till she (Patient 7b) was discharged on 8/13/2026. The ADM/DPCS stated that he (ADM/DPCS) was responsible for documenting Patient 7b’s plan of care. The ADM/DPCS stated, “We wouldn’t know what services, needs, or interventions the patient was having because there is no plan of care.””

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to provide the written information regarding the plan of care POC) and medication list for two of seven patients (Patient 2 and Patient 5). This deficient practice resulted in patients and their representatives not knowing their care team or their treatment course. 1. During a record review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/08/2026-8/06/2026, indicated a SOC (Start of Care) of 4/09/2026, with a primary diagnosis of hypertensive heart failure (heart not pumping blood effectively to the body). During a concurrent observation, interview and record review on the home visit, on 8/18/2026 at 10:34 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 reviewed Patient 2’s patient information folder provided to Patient 2 by the HHA. LVN 2 stated the folder did not include a copy of Patient 2’s POC. Patient 2 was asked if the HHA had provided a document outlining the services and treatments he was receiving. Patient 2 was also shown an example of a POC. Patient 2 stated the document shown (POC) did not look familiar nor had received the document. LVN 2 stated the importance of Patient 2 receiving a copy of the POC was so that Patient 2 knows what services should be expected. 2. During a record review of Patient 5’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/08/2026-8/06/2026, with a SOC of 4/09/2026, and a primary diagnosis of primary generalized osteo arthritis (joint stiffness). During a concurrent observation, interview, and record review on 8/18/2026 at 10 a.m. with License Vocational Nurse 3 (LVN 3) at Patient 5’s residence, LVN3 stated that Patient 5’s home health folder did not contain her (Patient 5) plan of care. LVN3 stated that Patient 5 and her (Patient 5) family need to be aware of Patient 5’s goals, interventions, and what discipline will be providing care. LVN3 stated that HHA nurses, who conduct the home visits, need to know what is on Patient 5’s plan of care to be able to coordinate care and provide the required teachings. Lastly, LVN3 also stated that the HHA nurses need to be aware of any parameters that are required to be reported to the MD. During a review of the HHA’s undated document titled, Plan of Care Policy, indicated, “At the time of initial assessment, the clinician, along with the physician and other involved disciplines, will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family/caregiver.””

“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 observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home), failed to ensure clinical records (a detailed, official document of a patient’s health history, medical signs, diagnoses, and treatments), were safeguarded against unauthorized (without official approval, consent, or permission) use for 7 of 7 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5 Patient 6, and Patient 7), when: 1. Unknown staff used an auto-populated (filled in automatically by a computer system or software instead of requiring you to type the information by hand), username and password in the electronic medical record (EMR, a digital version of a patient’s paper chart used by doctors and clinic staff), to enter doctor orders for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7. 2. The agency’s office staff’s usernames do not clearly indicate the first and last name of staff accessing patient records. The non-compliance, resulted in unknown staff accessed and entered doctor’s orders in the patients’ clinical records, which increased the risk for inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/20/2026, at 10:20 a.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider’s non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Administrator (ADM) / Director of Patient Care Services (DPCS) related to the Home Health Agency’s (HHA’s) failure to ensure clinical records were safeguarded against unauthorized use for 7 of 7 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5 Patient 6, and Patient 7. On 8/20/2026 at 1:42 p.m. the HHA Administrator/Director of Patient Care Services (DPCS) submitted the HHA’s first Immediate Jeopardy Removal Plan (IJRP- includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) which was reviewed and was not unaccepted. On 8/20/2026 at 2 p.m., the HHA was unable to submit an acceptable IJ. The survey team completed the survey task and conducted an exit conference in the presence of the DPCS with the IJ not removed. Findings: During a concurrent interview and review of undated document titled, “List of users” on 8/19/2026, at 12:52 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS provided an undated document titled, “List of users”. The “List of users” indicated that the usernames have to be the first name of staff. The “List of users” record indicated three (3) of eleven (11) users, used the username as first and last name. One (1) of eleven (11) staff used the agency’s name of “GMM” as last name, while another one (1) of eleven (11) used the name EMR as the last name, with an employee ID of “ONBOARDING”. During continued review of the “List of users” indicated zero (0) of the eleven (11) users had a title or employee identification associated with the username. The ADM/DPCS stated the importance of the usernames to have first and last name, was to have information on who exactly entered the information on the patient records. The ADM/DPCS stated that there would be no mis communication on who documented it and to identify who was the responsible party for the documentation. During an interview on 8/19/2026 at 1:45 p.m., with the ADM/DPCS, the ADM/DPCS stated that the Quality Assurance (QA, involves the systematic collection and evaluation of data to monitor the outcomes of care processes) Staff, was responsible for creating EMR access to the HHA employees. During an interview on 8/19/2026 at 2:30 p.m., with the Quality Assurance staff (QA), the QA stated that she (QA) was responsible for creating staff access to their EMR system. The QA stated that the HHA’s EMR was software used to create patients’ medical records, including physician orders. The QA stated when the HHA was purchased by the current owner, the EMR system was already in use and had unknown active users. The QA stated there were two unknown employees (UE1 and UE2) listed and active on the HHA’s EMR system. The QA stated the Office Manager Assistant (OMA) was nonclinical and did not have a clinical license or certificate. During an interview on 8/20/2026 at 9:10 a.m., with the ADM/DPCS, the ADM/DPCS stated that HHA had computer based electronic documentation system. The ADM/DPCS stated that an electronic signature verifies the person completing the document. The ADM/DPCS stated the HHA did not use the electronic signature function and would not know why it was not used on the patients’ EMR. The ADM/DPCS stated there is no way of knowing who completed patient’s (in general) documents. 1. During a review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” (POC, a highly individualized, physician-certified roadmap outlining your medical needs, treatments, and expected outcomes), dated from 6/20/2026-8/18/2026, indicated a start of care (SOC) of 4/21/2026, with a primary diagnosis of type 2 diabetes (too much sugar in the blood). During a concurrent interview and review of Patient 1’s clinical record form titled “Communication” on 8/19/2026 at 2:49 p.m., with QA, Patient 1’s clinical record form titled “Communication” dated 6/16/2026, was reviewed. The “Communication indicated Patient 1’s recertification order dated 6/15/2026, was created by UE2. QA stated it was unknown who “entered the order because when accessing the patient’s medical record, the staff picked which ever username comes first, not necessarily their own name (staff entering the document), when entering physician orders into EMR platform.” 2. During a review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/08/2026-8/06/2026, indicated a SOC of 4/09/2026, with a primary diagnosis of hypertensive heart failure (heart not pumping blood effectively to the body). During a concurrent observation, interview, and review of Patient 2’s medical record (in general), on 8/19/2026, at 11:41 a.m., with the ADM/DPCS, the ADM/DPCS observed looking through a pile of documents in the office. The ADM/DPCS located Patient 2’s record titled, “Physician Order 8/5/2026 Recertification”. During a review of the “Physician Order 8/5/2026 Recertification”, indicate the physician order was not signed. The ADM/DPCS stated the order was not signed because he (ADM/DPCS) did not have time to sign. During a concurrent observation and interview on 8/19/2026, at 11:50 a.m., with the ADM/DPCS, the ADM/DPCS logged into the EMR to retrieve the recertification order for Patient 2. The ADM/DPCS was observed to have logged into the EMR, using the access of the intake coordinator (IC). The ADM/DPCS logged into EMR and the usernames was auto populating in the drop-down menu, when a name was selected, the password was saved in the EMR, and immediate access to the EMR was granted. The ADM/DPCS was asked to log out the IC and to log in using the ADM/DPCS access information. The ADM/DPCS stated he (ADM/DPCS) did not have a username or password, and he (ADM/DPCS) usually logged into the EMR using the log-in information of whoever was in the office. The ADM/DPCS stated he enters doctor’s (physician) orders himself, using another person’s log-in information. The ADM/DPCS stated he prints the document and signs it, and this is how he validates the information entered. When asked who enters the doctor’s orders into the EMR, the ADM/DPCS stated either himself or the QA. During a concurrent observation and interview on 8/19/2026, at 11:50 a.m., with the IC, the IC stated the ADM/DPCS used her (IC) log-in information to access the medical record (in general), and document doctor’s orders. The IC stated she (IC) was not a licensed nurse/clinician. During an interview on 8/19/2026, at 12:05 p.m., with the ADM/DPCS, the ADM/DPCS stated log-in information to the EMR should not be shared. The reason why log-in information should not be shared is due to conflict of interest. Office staff were not licensed nurses/clinicians, and staff could make changes to the order. The ADM/DPCS stated the office staff (in general) have access to patient information and that office staff should not have. The ADM/DPCS stated staff should not document under another username because it does not accurately reflect who entered the order. The ADM/DPCS stated that for medication errors and other orders entered, it would not indicate who took the order. The ADM/DPCS stated patients (in general) could be harmed if the incorrect order is placed because the order would not validate that a licensed nurse took the order and that medication errors could harm patients, placing them at risk of hospitalization and death. During a concurrent interview, and review of Patient 2’s document titled, “Communication “on 8/19/2026, at 12:38 p.m., with the ADM/DPCS, the ADM/DPCS presented Patient 2’s document titled, “Communication” for the action of recertification physician order, dated 8/5/2026. The document indicated the order was created by unknown employee (UE2). The ADM/DPCS stated the username for UE2 was probably access from the previous owner. The ADM/DPCS stated the username for UE2 was a generic username used by “everyone”. 3. During a review of Patient 3’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/18/2026-8/16/2026, indicated a SOC of 8/22/2025, with a primary diagnosis of Vitamin B12 (an essential vitamin) deficiency anemia (not enough in the blood). During a concurrent interview and review of Patient 3’s record titled, “Communication Info 387” on 8/19/2026, at 1:43 p.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 3’s record titled, “Communication Info 387”, for Recertification Physician Order, dated 6/16/2026 and “Physician Order: 06/16/2026 Recertification”. The “Communication Info 387” indicated UE 2 accessed and created the order. The ADM/DPCS stated did not know who UE2 was. Patient 3’s record titled, “Physician Order: 06/16/2026 Recertification”, indicated the ADM/DPCS signature. The ADM/DPCS stated he (ADM/DPCS) had signed the document using a wet signature (manual signature done with a pen). The ADM/DPCS stated UE2’s username automatically populated in the list of users in the EMR. UE2’s password was saved so all that needed to be done was click on UE2’s name to enter and document in the EMR. 4. During a review of Patient 4’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/09/2026-8/07/2026, with a SOC of 8/13/2025, with a primary diagnosis of hypertensive heart failure (heart not pumping blood effectively to the body). During a concurrent observation, interview, and review of Patient 4’s medical record (in general), on 8/17/2026, at 12:32 p.m., with the Quality Assurance staff (QA), the QA was observed with stack of patients (multiple) documents and was signing one after the other using a pen. One of the documents observed belonged to Patient 4 and was titled, “Care Coordination: 6/8/2026 Physician Order”. The record indicated “Clinician Name” and had the name of the ADM/DPCS listed. During a review of the “Care Coordination: 6/8/2026 Physician Order” indicated a signature, with a date of 6/8/26. The QA stated was signing Patient 4’s document at the time of the interview. The QA stated she (QA) had not taken the order written on Patient 4’s Physician order. During a concurrent interview and review of Patient 4’s record titled, “Care Coordination: 6/8/2026 Physician Order” on 8/17/2026, at 12:44 p.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 4’s record titled, “Care Coordination: 6/8/2026 Physician Order”. The “Care Coordination: 6/8/2026 Physician Order” indicated, “Date and Time of Orders: 6/8/2026 10:17 a.m... ORDERS READ BACK/CONFIRMED”. The ADM/DPCS stated he (ADM/DPCS) had taken the order from the doctor as the ADM/DPCS’ name was indicated in the section “Clinician Name”. The ADM/DPCS reviewed the signature on the record and stated “No, this is not my signature”. The ADM/DPCS stated the QA had signed the document. The ADM/DPCS stated he did not sign the document because he (ADM/DPCS) was not available at that time. The ADM/DPCS stated the date next to the signature of 6/8/2026, indicated when the order was taken and signed. The ADM/DPCS stated he (ADM/DPCS) should have verified the order and signed it. The signature validated and the order was correct. When asked about the risk of having another staff sign the order when the staff did not take the order, the ADM/DPCS stated the order could be wrong. Whoever took the order is the staff who had to write it and sign it, otherwise the order was invalid. Moreover, the ADM/DPCS was informed of the QA’s actions of signing and dating the order 6/8/2026, when the surveyor observed the action on 8/17/2026, at 12:32 p.m. The ADM/DPCS stated the QA’s actions were an obvious problem because the record was signed on 8/17/2026, not 6/8/2026, making the document incorrect/false. During a review of Patient 4’s “Communication Info 233”, for the action of Recertification Physician Order, dated 6/4/2026, indicated UE 2 had created the order. 5. During a review of Patient 5’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/08/2026-8/06/2026, with a SOC of 4/09/2026, and a primary diagnosis of primary generalized osteo arthritis (joint stiffness). During a review of Patient 5’s medical record form titled “Communication” dated 8/5/2026, indicated Patient 5’s physicians recertification order was created by the Unknown Employee 2 (UE2). During a concurrent interview and review of Patient 5’s medical record (in general), on 8/19/2026, at 1:45 p.m. with the ADM/DPCS, Patient 5’s medical record form titled “Communication” dated 8/5/2026 was reviewed, the ADM/DPCS stated that the HHA’s EMR system UE2 created Patient 5’s recertification physician order dated 8/5/2026. The ADM/DPCS stated he (ADM/DPCS) did not know when it was written or by whom. The ADM/DPCS stated, “I have no idea who (UE2) is, I don’t know if (UE2) is clinical.” 6. During a review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 5/08/2026-7/06/2026, with a SOC of 9/10/2025, with a primary diagnosis of other specific arthropathies (stiffness). During a record review of Patient 6’s medical record form titled “Communication” dated 7/2/2026, indicated Patient 6’s physicians recertification order was created by the Unknown Employee 2 (UE2). During a concurrent interview and record review on 8/19/2026, at 2:10 p.m. with the ADM/DPCS of Patient 6’s medical record form titled “Communication” dated 7/2/2026 was reviewed, the ADM/DPCS stated that the HHA’s EMR system UE2 created Patient 6’s recertification physician order dated 7/2/2026. The ADM/DPCS stated that he (ADM/DPCS) did not know who UE2 was. 7. During a review of Patient 7b’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 5/08/2026-7/06/2026, with a SOC of 9/10/2025, with a primary diagnosis of other specific arthropathies (joint abnormality) NEC (not elsewhere classified). During a record review of Patient 7b’s medical record form titled “Communication” dated 8/13/2026, indicated the Office Manager Assistant (OMA) created Patient 7b’s discharge physician order. During a concurrent interview and review of Patient 7b’s medical record (in general), on 8/19/2026 at 2:40 p.m., with the Quality Assurance (QA) of Patient 7b’s medical record form titled “Communication”, the QA stated that according to Patient 7b’s form the OMA entered the discharge physician order dated 7/2/2026. The QA stated that OMA is a non-clinical staff and could not take and document physician orders. The QA stated the HHA’s computers have the employees’ names and EMR log in information saved. The QA stated that when staff open the HHA’s EMR system the first name that comes up is used. During a record review of the HHAs form titled “Access to Information” revised 11/2022, indicated “Access to patient information files will be limited to organization personnel involved in the care of the patient… Personnel will only have access to information on those patients to which they are actively providing care and services…” During a record review of the HHAs form titled “Computer Access to Information” revised 11/2022, indicated “Authorized personnel will be assigned passwords and/or access codes and complete a signed statement that no one else will be allowed to use his/her computer key. Data will be protected by safeguards that prevent unauthorized access to information and/or modification of existing data. A system for validation will be in place.” During a record review of the HHAs form titled “Safeguarding/Retrieval of Clinical/Services Record” revised 11/2022, indicated “The organization will safeguard the clinical/service record against…unauthorize use… Safeguard procedures assure current acceptable professional standards and follow state laws that may be more prescriptive and: B. Passwords will not be taped on computer. C. Passwords will not be shared with other persons.” During a record review of the HHAs form titled “Minimum Necessary Uses of PHI” revised 11/2022, indicated “(HHA) will not permit personnel or classes of personnel to access an entire clinical record, except when the entire clinical record is specifically justified as the amount that is reasonably necessary to carry out their duties.””

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home), failed to investigate a formal complaint alleging potential neglect submitted by the Physical Therapist (PT) for one of seven sampled patients (Patient 1). This failure violated the patient’s right to have concerns addressed and be investigated in a timely manner. During an interview on 8/19/2026 at 12:46 p.m., with the Physical Therapist (PT), the PT stated Patient 1’s caregiver “was not attentive, not involved in patient care, and on his phone the entire time.” The PT stated that Patient 1 nodded yes when asked if assistance with feeding was needed. The PT stated Patient 1 reported “He doesn’t do anything. How can I get rid of him?” The PT stated this concern was submitted to the HHA as a formal complaint and that the PT filed Adult Protective Services (APS) report #1251815. During a concurrent interview and record review on 8/19/2026 at 12:02 p.m., with Administrator and Director of Patient Care Services (ADM/DPCS), the “MSW Order, Physician Order” dated 6/29/2026 was reviewed. The order indicated the PT contacted the HHA regarding suspected neglect for Patient 1 and the physician ordered a Medical Social Worker (MSW) evaluation. The ADM/DPCS stated there was “no documentation of any follow-up with the social worker or APS” and the complaint “should have investigated and followed up with the complaint, but it did not.” During a review of the HHA’s policy and procedures procedure (P&P - a policy is an official rule or standard that a HHA must follow, while a procedure is the exact step-by-step method staff use to carry that rule out) titled “Assessment of Possible Abuse/Neglect, Policy No. 2‑037.1,” dated November 2025, the policy indicated the organization will “investigate complaints regarding treatment or care, mistreatment, neglect…” There was no documentation showing the complaint submitted on 6/29/2026 was investigated as required. During a review of the HHA’s P&P titled, “Patient Bill of Rights Policy No. 2-002.1,” undated, the P&P indicated the patient has the right to “receive an investigation by the organization of complaints ….. regarding treatment or care that is (or fails to be) furnished.” No documentation was found showing the complaint involving suspected neglect of Patient 1 was investigated as required.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home), failed to log, track, document, or resolve the formal complaint alleging potential neglect for one of seven sampled patients (Patient 1). This failure resulted in the patient’s documented concern was not investigated immediately and no documented evidence it was resolved. During a concurrent interview and record review on 8/18/2026 at 12:46 p.m. with Physical Therapist (PT), the “MSW Order Physician Order” dated 6/29/2026 was reviewed. The order indicated that the PT reported to the HHA that Patient 1 stated he had not eaten for two days and that the caregiver was not providing adequate assistance. The PT stated the PT submitted a concern of suspected caregiver neglect to HHA as a formal complaint and filed a report with Adult Protective Services (APS). During a concurrent interview and record review on 8/19/2026 at 12:02 p.m., with Administrator/Director of Patient Care Services (ADM/DPCS), the “Complaint Log,” undated, was reviewed. The “Complaint Log” contained no entry for the PT complaint reported on 6/29/2026. The ADM/DPCS stated the complaint “should have been logged in the “Complaint Log” and was not,” the HHA “did not follow up with the social worker,” the complaint “was not fully investigated and resolved,” and that “logging complaints helps the HHA resolve complaints to prevent patient harm while not logging complaints risks repeating the same mistakes with other patients.” During a concurrent interview and record review on 8/19/2026 at 12:02 p.m., with ADM/DPCS, stated I was “not aware of this complaint and the complaint should have been followed up on and resolved but was not.” HHA’s policy and procedure (P&P - a policy is an official rule or standard that a HHA must follow, while a procedure is the exact step-by-step method staff use to carry that rule out) titled, “Assessment of Possible Abuse/Neglect Policy No. 2-037.1,” dated November 2025, was reviewed. The P&P indicated, “The suspected abuse/neglect investigation report with specific information relating to the occurrence forward to the Clinical Supervisor, who will forward the information to the Executive Director/Administrator within 24 hours of the report” and “The Executive Director/Administrator will Review all reports (incident report and follow-up investigation).””

“Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. 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 at home), failed to take actions to prevent further potential violations during an open complaint alleging possible neglect for one of seven sampled patients (Patient 1). This failure resulted to the unmonitored patient’s weight loss that could lead to malnutrition, dehydration, and hospitalization or death. During a concurrent interview and record review on 8/19/2026 at 12:02 p.m. with Administrator/Director of Patient Care Services (ADM/DPCS), the “MSW Order, Physician Order” dated 6/29/2026 was reviewed. The order indicated that the Physical Therapist (PT) reported that Patient 1 had not eaten for two days. The ADM/DPCS stated “there is no documentation of any follow-up, no MSW assessment findings,” and no protective actions were initiated. During a concurrent interview and record review on 8/19/2026 at 12:02 p.m. with ADM/DPCS, Patient 1’s clinical records were reviewed. The clinical records contained no documentation indicating the HHA verified Patient 1’s safety or caregiving following the complaint. The ADM/DPCS stated the HHA took no actions because “I was not aware of this complaint,” and stated the complaint “should have been investigated and followed up with but was not.” During a review of the Complaint Log, undated, the Complaint Log indicated no entry, preventing supervisory review or protective follow-up. During a concurrent interview and review on 8/19/2026 at 1:07 p.m., with Licensed Clinical Social Worker (LCSW), “MSW Communication Notes” dated 7/1/2026, 7/2/2026, and 7/7/2026, were reviewed. The notes indicated that the Medical Social Worker (MSW) made repeated unsuccessful attempts to contact Patient 1. The HHA did not verify the patient’s safety, did not provide additional contact information, and did not escalate the concern to the AMD/DPCS, leaving Patient 1 without protective interventions. During a review of Patient 1’s Sherman Oaks Admission record dated 4/16/2026, the record indicated Patient 1 weighed 161 pounds on 4/12/0026. During a review of Patient 1’s JEK Admission record, dated 8/17/2026, the record indicated Patient 1 weighed 147 pounds on 8/17/2026. These records indicate a 14-pound (8.7%) weight loss over 4 months. No documentation indicated the HHA evaluated this weight loss or implemented safety measures following the complaint alleging neglect.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to review and document all the medications and treatments the patient was currently using for two of seven sampled patients (Patient 2 and Patient 5). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. During an interview on 8/19/2026 at 2:30 p.m., with License Vocational Nurse/Quality Assurance (QA), the QA stated that she (QA) sometimes takes nurses report of medication changes. During an interview on 8/19/2026 at 1:43 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated patients’ medications are to be reconciliated at every nurse home visit. The ADM/DPCS stated that medication reconciliation prevents medication errors and provides current medication list for patients. 1. During a record review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/08/2026-8/06/2026, indicated a SOC (Start of Care) of 4/09/2026, with a primary diagnosis of hypertensive heart failure (heart not pumping blood effectively to the body). During a concurrent observation, interview and record review on the home visit, on 8/18/2026 at 10:28 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 reviewed Patient 2’s medications, using Patient 2’s record titled, Drug Regimen Review, dated 8/5/2026. LVN 2 stated the following listed medications on the Drug Regimen Review were not updated to reflect the medication Patient 2 was taking: Docusate Sodium (stool softener) 200 mg (mg-milligrams, unit of measurement) 2 capsules by mouth 2 twice a day. The dose 100 mg once a day was listed. LVN 2 stated the medication profile should have been accurate. LVN2 stated this medication was filled by the pharmacy on 7/27/2026. Tamsulosin (makes urinating easier for men) 0.4 mg 2 capsules a day. 1 capsule a day was listed. Rosuvastatin (lowers cholesterol in the blood) 20 mg at bedtime. LVN 2 stated the Drug Regimen Review did not indicate taking it at bedtime. The Drug Regimen Review indicated list 1 tablet, once a day. Clonidine (high blood pressure) 0.1 mg 1 tablet “thrice” a day. LVN 2 stated “thrice” is not an acceptable medication term. It should say “three”. During an interview on 8/18/2026 at 10:55 a.m., with LVN 2, LVN 2 stated the medication profile needed to be accurate because the patient needed to know how to correctly take the medication. A copy of the medication profile (Drug Regimen Review) is given to the patient, so it needed to be accurate. LVN 2 stated the risks of not having an accurate medication profile was bad things can happen; medical conditions will worsen. Patient will not get adequate treatment and could end up in the hospital. Patients can die of heart complications. 2. During a record review of Patient 5’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/08/2026-8/06/2026, with a SOC of 4/09/2026, and a primary diagnosis of primary generalized osteo arthritis (joint stiffness). During a concurrent observation, interview, and record review on 8/18/2026 at 10 a.m. with License Vocational Nurse 3 (LVN 3) at Patient 5’s residence, LVN3 stated that it was important to reconcile patients’ medications to prevent medication errors. LVN3 reconciled Patient 5’s medications. LVN3 stated that there were three findings in Patient 5’s medication labels and Patient 5’s HHA medication list. Patient 5’s HHA medication list included Lisinopril (treats high blood pressure) 10mg one table everyday hold if SBP During a record review of the HHA’s undated document titled, Medication Reconciliation, indicated, “Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.””

“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 - a public or private organization that provides skilled nursing care and other therapeutic services to patients in their own homes) failed to ensure the physician signed the Occupational Therapy (OT, a healthcare profession that helps people do everyday tasks and activities – known as “occupations” – safely and independently) orders based on multiple OT evaluations for one of seven sampled patients (Patient 1). This failure had the potential to result in patients receiving unauthorized OT services and placing patients at risk for inappropriate or unapproved care. During a record review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/20/2026 to 8/18/2026, with Start of Care (SOC, date of the first billable, in-person clinical visit when a patient officially begins receiving home health services) of 4/21/2026, and a primary diagnosis of type 2 diabetes mellitus (high blood sugar). During a concurrent interview and record review on 8/14/2026, at 12:36 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS - licensed clinical leader responsible for overseeing all nursing and clinical operations, patient care quality, and regulatory compliance), “Occupational Therapy Evaluation,” dated 4/29/2026, 5/28/2026, and 7/3/2026 were reviewed. All three “Occupational Therapy Evaluations” indicated no physician signatures, that were required. The ADM/DPCS stated, “The physician’s signature is required to certify that the physician ordered OT for Patient 1. The physician did not sign these OT evaluations, so there are no physician orders for OT. I will make a note of this and have the physician sign them .” During a review of the facility’s policy and procedure (P&P - the core operational blueprints and rules that dictate how clinical care, safety, and administrative tasks are performed) titled, “Verification of Physician Orders Policy No. 4-003.1,” undated, the P&P indicated, “POLICY Orders will be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services to be provided to home health patients” and “8. Signed orders will be in the clinical record within 30 days of initiation of care or interim order, unless otherwise specified by applicable state law and regulation.””

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure physician verbal patient orders were received by a qualified licensed individual for two of seven sample patients (Patient 2 and Patient 7). This failure place patients at risk for health status decline by not receiving the appropriate physician orders to be able to take care of them properly. 1. During a record review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/08/2026-8/06/2026, indicated a SOC of 4/09/2026, with a primary diagnosis of hypertensive heart failure (heart not pumping blood effectively to the body). During a concurrent observation and interview on 8/19/2026 at 11:50 a.m., the ADM/DPCS was asked to log into the EMR to retrieve the recertification order for Patient 2. The ADM/DPCS was observed to have logged into the EMR, using the access of the intake coordinator (IC). Continued observation of the EMR indicated usernames auto populating in the drop-down menu. Once a name was selected, the password was saved in the EMR, and immediate access to the EMR was granted. The ADM/DPCS was asked to log out the IC and to log in using the ADM/DPCS access information. The ADM/DPCS stated he (ADM/DPCS) did not have a username or password, and he (ADM/DPCS) usually logged into the EMR using the log-in information of whoever was in the office. The ADM/DPCS stated he enters doctor’s (physician) orders himself, using another person’s log-in information. The ADM/DPCS stated he prints the document and signs it, and this is how he validates the information entered. When asked who enters the doctor’s orders into the EMR, the ADM/DPCS stated either himself or the QA. During an interview on 8/19/2026 at 11:50 a.m., with the Intake Coordinator (IC), the IC stated the ADM/DPCS uses her (IC) log-in information to access the medical record and document doctor’s orders. The IC stated the IC was not a licensed nurse/clinician. During an interview on 8/19/2026, at 12:05 p.m., with the ADM/DPCS, the ADM/DPCS stated log-in information to the EMR should not be shared. The reason why log-in information should not be shared is due to conflict of interest. Office staff are not licensed nurses/clinicians. The staff can make changes to the order. The office staff have access to patient information that office staff should not have. Staff should not document under another username because it does not accurately reflect who entered the order. Medication errors and other orders entered would not indicate who took the order. Patients could be harmed if the incorrect order is placed because the order does not validate that a licensed nurse took the order. Medication errors can harm patients, placing them at risk of hospitalization and death. 2. During a record review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 5/21/2026-7/19/2026, with a SOC of 1/21/2026 and an end of care date of 8/13/2026, with a primary diagnosis of type 2 diabetes (high blood sugar). During a record review of Patient 7’s medical record form titled “Physician Order” dated 8/13/2026, indicated under “Physician Orders: discharge patient from (HHA) services due to patient centered goals were achieved. ORDERS READ BACK/CONFIRMED.” The form also indicated it was not signed by HHA staff or the physician. During a concurrent interview and record review on 8/19/2026 at 2:30 p.m. with License Vocational Nurse/Quality Assurance (QA) of Patient 7’s medical record form titled “Communication” dated 8/13/2026, indicated the Office Manager Assistant (OMA) created Patient 7’s discharge physician order. The QA stated that the OMA was a non-clinical staff, she (OMA) was not a licensed or registered nurse. During a record review of the HHA’s undated document titled, Verification of Physician Orders, indicated, “POLICY Orders will be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services to be provided to home health patients”.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to ensure the administrator has the responsibility to maintain all day operations of the HHA, oversight, and active involvement in running the HHA for seven of seven sampled selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). This failure resulted in the non-compliance of six (6) Conditions of Participation that could negatively impact the health and safety of all certified patients of the home health agency. During an interview on 8/20/2026 at 9:10 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that he (ADM/DPCS) had been the Administrator for the HHA for over two years, which had been his (ADM/DPCS) first time being an administrator. The ADM/DPCS also stated that he (ADM/DPCS) was currently a DPCS at another HHA fulltime. The ADM/DPCS stated that he (ADM/DPCS) oversees training, conducts in services, and human resources by ensuring staff credentials are up to date. The ADM/DPCS stated that as an administrator “I don’t know what my day-to-day responsibilities are. There’s not much to do.” The ADM/DPCS stated that the office staff ensure patients are being seen as ordered. The ADM/DPCS stated that he (ADM/DPCS) is at the HHA 2-3 times per week to ensure “everything is ok”. The ADM/DPCS stated that the License Vocational Nurse/Quality Assurance (QA) is responsible for the HHA’s billing and quality assurance. During an interview on 8/20/2026 at 9:14 a.m., with the ADM/DPCS, the ADM/DPCS stated that the role of DPCS included to make sure the OASIS were done, the plan of care was completed, write communication notes, follow up with the nurses, and sign doctor’s orders. When asked about the Quality Assurance program (QA program) and what projects the HHA was currently working on, the ADM/DPCS stated “I don’t know what that means. There are no specific things we are monitoring. We review as needed, as the issues come in.” When asked who the Governing Body of the HHA was, the ADM/DPCS stated, “I am blanking out. I don’t remember”. The non-compliance resulted to the following Conditions of Participation (COP) not met: 1.During a record review of two of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 4/21/2026 – 6/19/2026 and 6/20/2026 – 8/18/2026, with a SOC of 4/21/2026, with a primary diagnosis of type 2 diabetes mellitus (high blood sugar). The ADM/DPCS failed to ensure Patient 1’s Patient’s Rights were adhered to. (Refer to COP: G 406). 2. During a record review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/08/2026-8/06/2026, indicated a SOC (Start of Care) of 4/09/2026, with a primary diagnosis of hypertensive heart failure (heart not pumping blood effectively to the body). The ADM/DPCS failed to ensure Patient 2’s OASIS accurately reflected Patient 2’s condition. (Refer to COP: G 370). 3. The ADM/DPCS failed to ensure Patient 2’s medication profile was updated, and a recertification assessment was completed. (Refer to COP: G 510). 4. The ADM/DPCS failed to ensure Patient 2 had a plan of care developed, recertification orders were taken by a licensed nurse, and Patient 2 was provided with a plan of care. (Refer to COP: G 570). 5(a) The ADM/DPCS failed to ensure Patient 2’s records were properly authenticated and clinical records were complete. (Refer to COP: G 1008). 5(b) During a record review of Patient 3’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/18/2026-8/16/2026, indicated a SOC of 8/22/2025, with a primary diagnosis of Vitamin B12 (an essential vitamin) deficiency anemia (not enough in the blood). 5(c) The ADM/DPCS failed to ensure Patient 3’s records were properly authenticated, and clinical records were complete. (Refer to COP: G1008). During a record review of Patient 4’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/09/2026-8/07/2026, with a SOC of 8/13/2025, with a primary diagnosis of hypertensive heart failure (heart not pumping blood effectively to the body). 5(d) The ADM/DPCS failed to ensure Patient 4’s records were properly authenticated. (Refer to COP 1008). 5(e) During a record review of Patient 5’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/08/2026-8/06/2026, with a SOC of 4/09/2026, and a primary diagnosis of primary generalized osteo arthritis (joint stiffness). The ADM/DPCS failed to ensure Patient 5’s records were properly authenticated. (Refer to COP 1008). 5(f) During a record review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 5/08/2026-7/06/2026, with a SOC of 9/10/2025, with a primary diagnosis of other specific arthropathies (stiffness). The ADM/DPCS failed to ensure Patient 6’s records were properly authenticated. (Refer to COP 1008). 5(g) During a record review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 5/08/2026-7/06/2026, with a SOC of 9/10/2025, with a primary diagnosis of other specific arthropathies (joint abnormality) NEC (not elsewhere classified). The ADM/DPCS failed to ensure Patient 7’s records were properly authenticated. (Refer to COP 1008). 6 (a)The HHA failed to ensure the Plan of Care (POC) was developed or followed for four of seven sampled patients (Patient 2, Patient 5, Patient 6, and Patient 7). This failure placed patients at risk for health status decline by not providing the services as indicated in the POC (Refer to COP: G570). 6 (b) Ensure the physician signed Occupational Therapy (OT) orders based on multiple OT evaluations for one of seven sampled patients (Patient 1). This failure had the potential to result in patients receiving unauthorized OT services, placing patients at risk for inappropriate or unapproved care. (COP: G570). 6 (c) Physician’s verbal patient orders were received by a qualified licensed individual for two of seven sample patients (Patient 2 and Patient 7). This failure place patients at risk for health status decline by not receiving the appropriate physician orders to be able to take care of them properly. (COP: G570). 4. Provide written information regarding the plan of care and medication list for two of seven patients (Patient 2, Patient 5). This deficient practice resulted in patients and their representatives not knowing their care team or their treatment course. (COP: 570). During a record review of the HHA’s document titled, Job Title/Position: Executive Director/Administrator, dated 6/1/2023, indicated this was a job description document and had been signed by the ADM/DPCS. Further review of the record indicated the essential job functions included “Planning and directing operations to ensure the provision of adequate and appropriate care and services...Ensuring organizational compliance with legal, regulatory and accreditation standards...Ensuring program personnel have current clinical information and current practices...Ensuring ongoing oversight of the agency’s quality management system...Directing personnel in performance of their duties including admission, discharge and provision of service to patients...Is responsible for all day-to-day operations of the HHA.” During a record review of the HHA’s document titled, Job Title/Position: Clinical Director/Director of Patient Care Services, dated 6/1/2023, indicated this was a job description document and had been signed by the ADM/DPCS. Further review of the record indicated the essential job functions included “Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel...Oversees the maintenance of patient clinical records, statistics, reports and records for purposes of evaluation and reporting of organization activities...Assures proper maintenance of clinical records in compliance with local, state, and federal laws...The clinical manager’s oversight must include the following: Making patient and personnel assignments, Coordinating patient care, Coordinating patient referrals, Assuring that patient needs are continually assessed, Assuring the development, implementation, and updates of the individualized plan of care.””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interviews and record reviews, the Home Health Agency (HHA) failed to ensure the clinical record contained completed nursing notes, visit notes, current plan of care, and updated certification/recertification assessments for six of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6 and Patient 7). This failure resulted in an incomplete clinical record leading to misinformation and non-continuity of care provided to these certified patients. During an interview on 8/17/2026 at 12:06 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS - high-level clinical leader who oversees nursing and patient care operations in healthcare facilities like home health agencies, hospices, and hospitals), the ADM/DPCS stated that visiting nurses are to complete their nursing visit note in the HHA. The ADM/DPCS stated that there are nursing note templates in the HHA computers. The ADM/DPCS stated that nurses physically go into the HHA to type their patients’ visit notes, print them, sign them, then file the notes in the patient’s medical record. The ADM/DPCS stated that nursing visit notes are to be in the patients’ medical record within 7 days from the date of the visit. The ADM/DPCS stated that it was important for the nurses to submit their visit notes within 7 days to keep the patients’ medical record updated. 1.During a record review of two of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 4/21/2026 – 6/19/2026 and 6/20/2026 – 8/18/2026, with a SOC of 4/21/2026, with a primary diagnosis of type 2 diabetes mellitus (high blood sugar). During a concurrent interview and record review on 8/17/2026 at 12:18 p.m. with the ADM/DPCS, Patient 1’s POC dated from 4/21/2026 – 6/19/2026 and 6/20/2026 – 8/18/2026, was reviewed. Patient 1’s POCs indicated no nursing notes. The ADM/DPCS stated that “There are no nursing notes for both POCs dated 4/21/2026 – 6/19/2026 and 6/20/2026 – 8/18/2026, there should be, and the ADM/DPCS does not know Patient 1’s current medical condition because there were no nursing notes to review.” 2.During a record review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/08/2026-8/06/2026, indicated a SOC (Start of Care) of 4/09/2026, with a primary diagnosis of hypertensive heart failure (heart not pumping blood effectively to the body). During an interview on 8/17/2026, at 12:20 p.m., with the ADM/DPCS, the ADM/DPCS stated the last visit note in Patient 2’s record was dated 5/28/2026. The ADM/DPCS stated the nursing notes were supposed to be documented and in Patient 2’s records 1 week following the care. The ADM/DPCS stated he was not aware of the status of Patient 2 because there were no nursing visit notes in the medical record. During a concurrent interview and record review on 8/19/2026, at 9:48 a.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 2’s medical records and stated there was no recertification assessment in the medical record for the current certification period beginning 8/7/2026. During an interview on 8/19/2026, at 9:56 a.m., with the ADM/DPCS, the ADM/DPCS stated the purpose of a recertification assessment was to ensure the patient qualified for another home health care period, to see what changes were made and to be aware of the patient condition. The recertification assessment was used to create the plan of care. The ADM/DPCS stated the risk of not having an assessment was as follow: The HHA cannot establish a correct plan of care, because the condition of the patient was unknown. Without the assessment the HHA is not aware of any changes that happened and are not able to provide correct care for the patient, which places the patient at risk for hospitalization. During a concurrent interview and record review on 8/19/2026, at 10 a.m., with the Administrator and Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 2’s medical records and stated there was no POC developed for Patient 2’s current certification period beginning on 8/7/2026. The ADM/DPCS stated the POC was supposed to be completed by 8/14/2026, with the purpose of the staff to follow the updated POC, to make sure what to do exactly for the patient. The risk of not having a POC is that the patient doesn’t receive the appropriate care based on their needs. If patient does not get the care they need, patient can decompensate. The HHA can miss a change of condition. During a concurrent interview and record review on 8/19/2026, at 11:40 a.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 2’s medical records. The ADM/DPCS stated there was no recertification order for the current period beginning on 8/7/2026. The ADM/DPCS stated he would need to look in the office for the recertification order. 3.During a record review of Patient 3’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 6/18/2026-8/16/2026, indicated a SOC of 8/22/2025, with a primary diagnosis of Vitamin B12 (an essential vitamin) deficiency anemia (not enough in the blood). During a concurrent interview and record review on 8/17/2026, at 12:15 p.m., with the ADM/DPCS, the ADM/DPCS stated the last visit note in Patient 3’s record was dated 6/9/2026. The ADM/DPCS stated the nursing notes were supposed to be documented and in Patient 3’s records 1 week following the care. The ADM/DPCS stated he was not aware of the status of Patient 3 because there were no nursing visit notes in the medical record. 4.During a record review of Patient 5’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/08/2026-8/06/2026, with a SOC of 4/09/2026, and a primary diagnosis of primary generalized osteo arthritis (joint stiffness). During a concurrent interview and record review on 8/17/2026 at 12:20 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 5’s medical record, the ADM/DPCS stated that the last documented nursing home visit note was dated 5/28/2026. The ADM/DPCS stated that Patient 5’s medical record was missing two and a half months of nursing notes. The ADM/DPCS stated that he (ADM/DPCS) did not know Patient 5’s current status or if Patient 5 had any change of condition. During a concurrent interview and record review on 8/19/2026 at 1:43 p.m. with the ADM/DPCS of Patient 5’s medical record, the ADM/DPCS stated that Patient 5’s medical record did not contain a current recertification assessment that was due on 8/5/2026. The ADM/DPCS stated that the importance of a recertification assessment was to know a patient’s current condition, to be able to formulate a plan of care (POC – personalized care planed) for the nurses to follow. The ADM/DPCS stated that due to Patient 5 not having a current recertification assessment, possible outcomes include nursing staff do not follow specific patient care, the patient might not meet the criteria to continue receiving home health services, and the physician not aware or approve of continuance of receiving home health services. Lastly, the ADM/DPCS stated that Patient 5’s medical record did not contain a physician recertification order. The ADM/DPCS stated that an order is required to recertify Patient 5 to be able to continue providing home health services. 5.During a record review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 5/08/2026-7/06/2026, with a SOC of 9/10/2025, with a primary diagnosis of other specific arthropathies (stiffness). During a concurrent interview and record review on 8/17/2026 at 12:30 p.m. with the ADM/DPCS of Patient 6’s medical record, the ADM/DPCS stated that the last documented nursing home visit note was dated 6/26/2026. The ADM/DPCS stated that he (ADM/DPCS) does not know Patient 6’s current medical condition because there were no nursing notes to review. 6. During a record review of Patient 7a’s medical record form titled “Home Health Certification and Plan of Care” (POC) dated from 5/09/2025-7/07/2025, with a SOC of 5/9/2025 and an end of care date of 8/13/2026, with a primary diagnosis of hypertensive heart disease (heart damage caused by long-term, unmanaged high blood pressure). During a concurrent interview and record review on 8/19/2026 at 3 p.m. with the ADM/DPCS of Patient 7a’s medical record, the ADM/DPCS stated that Patient 7a’s medical record did not contain a physician recertification order for recertification period starting on 7/20/2026. During a record review of the HHA’s undated document titled, Clinical Documentation/Service Data Collection, indicated, “Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided...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.””

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) staff failed to review all medications the patient is currently taking for one of seven sampled patients (Patient 3). The deficient practice had the potential to result in the delay to assess potential side effects, therapeutic effects, and drug interactions of the medications that could affect the patient’s health status and well-being. During a record review of Patient 3’s medication profile, revised 7/8/2024, indicated a medication order for Ferrous sulfate (Iron supplemental pills to replace low iron levels in the body) 325mg 1 tablet daily orally. During a concurrent observation and interview on 7/10/2024 at 1:20 pm, at Patient 3’s residence with Patient 3 the Ferrous sulfate pill container was empty. Patient 3 stated, “I have been out of my Iron pills for a few weeks. I have been calling the pharmacy to refill the medication. They were supposed to bring it yesterday, but they didn’t.” During an interview on 7/10/24 at 1:35 pm, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated, “I usually go over all the medications on every visit. I am not sure how the Iron container was missed for Patient 3. It must not have been in the room. I should have asked for all the medications listed in her medication profile, not just the ones Patient 3 put for me to check.” During an interview on 7/12/2024 at 11:10 am, with Director of Patient Care Services/Administrator (DPCS/ADMIN), DPCS/ADMIN stated l, “The nurses are supposed to do medication reconciliation (the process of comparing patient’s medication orders to all medications that the patient has been taking) every visit. If there is a need to fill a medication, our nurses can contact pharmacy and assist in the process. LVN 2 should have known the Iron pills were empty and should have assisted in this process for Patient 3. “ During record review of the HHA’s policy and procedure titled, “Medication Profile/Reconciliation”, undated, the policy and procedure indicated, “3. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, and when care is resumed after patient has been placed on hold. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy emissions and unclear information. 4. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but not limited to: A. using the medication profile in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the home health agency staff failed to document and complete the patient’s clinical record for one of 7 sampled patients (Patient 4). This deficient practice resulted in the inability of the agency staff to assess any documented evidence of the patient’s health status in order to provide continuity of care services as identified in the plan of care (POC). A complaint validation survey was conducted on 7/9/2024 to 7/12/2024, regarding Patient 4’s skilled nurse (LVN 1) not visiting the patient and Patient 4 being found by police during a wellness check on the floor unconscious ( when a person is unable to respond to people or activities), dehydrated (having loss a large amount of water from the body), transported to the general acute care hospital(GACH) where Patient 4 passed away two days later. A review of Patient 4’s electronic clinical records indicated a start of care date of 6/15/2023, for the certification period of 12/12/2023 to 2/9/2024, with diagnoses of hypertensive heart disease and age-related physical debility (general weakness and weight loss as a result of illness). The physician ordered the skilled nurse (SN) to visit 2 times a week for 2 weeks and 1 time a week for 7 weeks, to perform vital signs, check oxygen saturation levels and validate patient /patient caregivers understanding on diet restrictions and medication regimen. During a telephone interview on 7/10/2024, at 1:20 pm, with LVN 1, stated he tried to call Patient 4 multiple times to schedule a home visit and when LVN 1 did not hear back from her, LVN 1 contacted the patient’s sister who lives out of state. LVN 1 stated he did not document this in his notes. On 7/11/2024, at 2 PM, during a concurrent review of Patient 4’s electronic medical record, and interview with the Administrator/Director of Patient Care Service (ADM/DPCS), revealed there was no documentation that LVN 1 attempted to contact Patient 4 to schedule a home visit and Patient 4’s failed to response from the call, and that LVN 1 contacted the family member from out of state (FM 1). FM 1 then sent another family member (FM 2) to Patient 4’s residence who contacted local authorities to enter Patient 4’s residence who conducted a wellness check and found Patient 4 lying on the floor in her feces, unconscious, and dehydrated. During further interview with the ADM/DPCS stated, LVN 1 did not contact the office and, he should have documented the incident in his clinical notes. A review of the HHA’s policy and Procedure titled, “Contents of the Clinical Record”, undated stipulated, “Staff notes will be submitted within 7 days of the clinical visit date with the patient.””