Pure Heart Home Health Services, Inc.

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Condition of Participation regarding Patient’s Rights was met when: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Condition of Participation regarding Patient’s Rights was met when: 1. The HHA failed to ensure three of seven sampled patients (Patient 1, Patient 2, and Patient 5) received information regarding the State toll free home health complaint telephone hotline, its contact information, its hours of operation, and its purpose. This failure resulted in a violation of Patient 1, Patient 2 and Patient 5’s rights, due to not having the information necessary to voice a complaint regarding the agency’s care and services received. (Refer to G444). The cumulative effect of this systemic practice resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal regulations for Patient’s Rights to ensure that their rights and responsibilities, as well as the transfer and discharge policies of the HHA, were understandable and accessible.”

“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, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Condition of Participation regarding Care planning, coordination and quality of care was met when: 1. The Home Health Agency failed to develop an individualized plan of care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) that includes management of potential problems, interventions, and goals for safety precautions while on anti-platelet (blood thinner medication that can cause serious bleeding) medication for two of seven sampled patients (Patient 1 and Patient 5). This deficient practice resulted in Patient 1 and Patient 5 without a specific formulated POC for the current health status for management of symptoms that was likely to cause delayed care, undetected adverse signs and symptoms of medication. (Refer to G574). 2. The HHA failed to record the physician order for nursing frequency visits for two of seven sample patients (Patient 3, and Patient 5). This deficient practice had the potential to result in Patient 3 and Patient 5 not receiving the nursing care and services needed. (Refer to G576). 3. The HHA failed to follow physician orders for the frequency of skilled nursing visits for one of seven sampled patients (Patient 5). This deficient practice could have resulted in Patient 5 not receiving the needed care, attention and services needed for her well-being causing a delay in care and healing. (Refer to G580) 4. The Home Health Agency failed to ensure the physician was notified of the care and services that were not rendered for one of seven sample patients (Patient 5). This failure had the potential to result in Patient 5’s health status decline with no immediate interventions due to lack of physician notification by the HHA. (refer to G590). 5. The HHA failed to provide a copy of a recent, updated Plan of Care for three of seven sampled patients (Patient 1, Patient 2, and Patient 5). This deficient practice had the potential to cause the patient and/or the family/caregiver to not know their treatment plan, the services provided, and not being an active participant in their care planning process. (refer to G612) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal regulation for compliance with Care planning, coordination, and quality of care which are provided to the patients who are assessed to receive home health care 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 interview and record review the Home Health Agency (HHA, agency providing care to a patient in the comfort of their home) failed to ensure the Condition of Participation for Clinical Records was met as follows: The Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to ensure the clinical records for the Plan of Care were completed for three of seven sampled patients (Patient 4, Patient 5, and Patient 6). This failure resulted in incomplete clinical records leading to the validity of documentation of care and services to be provided to these patients certified to receive the Medicare home health benefits. (refer to G1012). 2. The HHA failed to ensure the skilled nurses submit nursing visit notes and pertinent clinical records in a timely manner, to reflect the care and assessment provided to the patients for one of seven sampled patients (Patient 5) This failure resulted in Patient 5’s incomplete medical record that could lead to misinformation and a break in continuity of care and services to be provided to the patient for optimal health and recuperation. (refer to G1014) 3. The HHA failed to ensure the clinical records included emergency contact information for six of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This failure had the potential to delay the HHA in facilitating rapid response and communication in case of unforeseen medical or other emergencies, ensuring timely notification and support for the patient and their family. (refer to G1018). The cumulative effect of these systemic practice resulted in the failure of the HHA to deliver statutorily (written) mandated compliance with maintaining clinical records that reflect the patients’ past and current information which can potentially affect the patients’ care and services that could lead to potential hospitalization.”

“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, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to provide a copy of a recent, updated plan of care for three of seven sampled patients (Patient 1, Patient 2 and Patient 5). This deficient practice had the potential to cause the patient and/or the family/caregiver to not know their treatment plan, the services provided, and not being an active participant in their care planning process. Findings: a. During a review of Patient 1’s clinical record titled Patient Information, undated, indicated a start of care (SOC) date of 5/9/2025. During a review of Patient 1’s clinical record titled, Home Health Certification and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), for the certification period from 5/9/2025 to 7/7/2025, indicated a primary diagnosis of osteoarthritis (is a joint disease, in which the tissues in the joint break down over time). During a review of Patient 1’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 5/9/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. During a joint home visit on 6/17/2025 at 10:00 a.m., with the Registered Nurse (RN1), at Patient 1’s residence, Patient 1 was observed resting in her sofa chair, alert, awake and oriented to her name, time, place and events. During a concurrent interview and record review on 6/17/2025 at 10:15am with RN1, Patient 1’s “Home Health Folder (compilation of pertinent medical documents provided to patient for record and reference at home),” was reviewed. Patient 1’s home health folder did not include a copy of the POC. RN 1 confirmed and stated that there was no POC copy provided and included in Patient 1’s home health folder. RN 1 stated that it is important for patients and their caregivers to have copies of medication lists and POC for their reference and as part of their involvement in care. RN 1 stated that she has the copy of the most recent medication list and POC and will include to Patient 1’s home health folder. b. During a review of Patient 2’s clinical record titled Patient Information, undated, indicated a start of care (SOC) date of 5/22/2025. During a review of Patient 2’s clinical record titled Home Health Certification and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for the certification period from 5/22/2025 to 7/20/2025, indicated a primary diagnosis of Type 2 diabetes mellitus (is a disease which high blood sugar levels are due to the body is not making enough of a hormone called insulin, or the insulin it makes not working properly, known as insulin resistance). The Home Health Certification and POC also indicated Skilled Nurse visit frequency of twice a week for two weeks, then once a week for seven weeks. During a joint home visit on 6/17/2025, at 11:23 a.m. with the Registered Nurse (RN1) at Patient 2’s residence, Patient 2 was observed resting in her chair, alert, awake and oriented to her name, time, place and events. During a concurrent interview and record review on 6/17/2025 at 11:35am with RN1, Patient 2’s “Home Health Folder (compilation of pertinent medical documents provided to patient for record and reference at home),” was reviewed. Patient 2’s home health folder did not include a copy of the POC. RN 1 confirmed and stated that there was no POC copy provided and included in Patient 2’s home health folder. RN 1 stated that it is important for patients and their caregivers to have copies of medication lists and POC for their reference and as part of their involvement in care. RN 1 stated that she has the copy of the most recent medication list and POC and will include to Patient 2’s home health folder. RN1 stated HHA does not provide a copy of POC to patients unless the patients/patients’ family or caregiver requested a copy of it. c. During a review of Patient 5’s clinical record titled Home Health and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for the certification period of 6/6/2025 to 8/4/2025 indicated a Start of Care (SOC) date of 6/6/2025 with a principal diagnosis of Osteoarthritis (condition when cartilage that cushions the ends of bones in the joints gradually wears away). During a joint home visit on 6/17/2025 at 10:25am with Registered Nurse 2 (RN2), at Patient 5’s residence, Patient 5 was observed awake, alert and oriented to self, time and place, and walking in slow pace with assistance of a cane. Patient 5 was observed speaking Armenian and able to communicate simple words in English. During a review of Patient 5’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 6/6/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. During a concurrent interview and record review on 6/17/2025 at 10:40am with RN2 at Patient 5’s residence, Patient 5’s HHA folder was reviewed. Patient 5’s HHA folder indicated there was no copy of the patient’s medication list or POC. RN2 stated and confirmed Patient 5’s HHA folder did not include the patient’s medication or the POC. RN2 stated that every patient admitted to the HHA, upon admission, should receive a copy of their active medication list and their POC. RN2 further stated at every home visit the skilled nurse should verify that the patient has the most updated medication list and POC available to them. During an interview on 6/18/2025 at 11:39am with the DPCSD, the DPCSD stated that the HHA does not provide patients with a copy of their POC, the patients upon admission just get a copy of their active medication list. The DPCSD stated a copy of the POC is provided if the patient asks for it. The DPCSD stated that upon admission the skilled nurses verbally educate the patients about their POC and at every home visit, weekly, the skilled nurses are to continue educating and reinforcing the POC. The DPCSD stated that patients and their family/caregivers should be involved in formulating an individualized care plan to address specific needs and providing them with an updated POC would be informative for patients. The DPCSD further stated the negative outcome of not providing the patients with a copy of their POC is that they stay unaware of what services and treatment they are to receive and what to expect next. During a review of the HHA’s policy and procedure (P&P), titled Care Planning Process, undated, the P&P indicated that the patient and family/caregiver will participate in decisions regarding the plan of care whenever possible.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on observation, interview and record review the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure three of seven sampled patients (Patient 1, Patient 2, and Patient 5) received information regarding the State toll free home health complaint telephone hotline, its contact information, hours of operation and its purpose. This failure of not providing Patient 1, Patient 2, and Patient 5 with the State toll free hotline information resulted in the violation of their rights to voice a complaint regarding the agency’s care and services provided. Findings: a. During a review of Patient 1’s clinical record titled Patient Information, undated, indicated a start of care (SOC) date of 5/9/2025. During a review of Patient 1’s clinical record titled, Home Health Certification and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), for the certification period from 5/9/2025 to 7/7/2025, indicated a primary diagnosis of osteoarthritis (a joint disease, in which the tissues in the joint break down over time). During a concurrent interview and record review on 6/17/2025 at 10:15 a.m. with Registered Nurse (RN) 1, Patient 1’s home health folder was reviewed. Patient 1’s home health folder did not indicate a copy of the state complaint form with the number and address. RN 1 and Patient 1 were not able to locate the state complaint and hotline telephone number information in Patient 1’s home health folder. RN 1 stated that she was unable to locate the state complaint hotline telephone number information, and it should have been in Patient 1’s home health folder. RN 1 stated that the importance of the patient having the state complaint hotline number available was to provide them with the right and option to voice any concerns or issues about their care or services they have that the agency was unable to resolve. Patient 1 stated that if she has any issues or concerns with her care or services, she knows to call the home health agency. b. During a review of Patient 2’s clinical record titled Patient Information, undated, indicated a start of care (SOC) date of 5/22/2025. During a review of Patient 2’s clinical record titled Home Health Certification and Plan of Care for the certification period from 5/22/2025 to 7/20/2025, indicated a primary diagnosis of Type 2 diabetes mellitus (is a disease which high blood sugar levels were due to the body not making enough of a hormone called insulin, or the insulin it makes not working properly, known as insulin resistance). During a joint home visit on 6/17/2025, at 11:23 a.m., with the RN 1 at Patient 2’s residence, Patient 2 was observed resting in her chair, alert, awake and oriented to her name, time, place and events. During a concurrent interview and record review on 6/17/2025 at 11:30 a.m. with RN 1, at Patient 2’s residence, Patient 2’s home health folder was reviewed. Patient 2’s home health folder did not indicate a copy of the state complaint form with the number and address. RN 1 and Patient 2 were not able to locate the state complaint and hotline telephone number information in Patient 2’s home health folder. RN 1 stated that she was unable to locate the state complaint hotline telephone number information, and it should have been in the home health folder. RN 1 stated that the importance of providing the patient with the state complaint hotline number was to give the patient’s the option and right to voice any concerns or issues they might have regarding their care or service, that the agency was unable to resolve, and file a complaint if needed. Patient 2 stated that if she has any issues or concerns with her care or services, she knows to call the home health agency. c. During a review of Patient 5’s clinical record titled Home Health and Plan of Care for the certification period of 6/6/2025 to 8/4/2025 indicated a Start of Care (SOC) date of 6/6/2025 with a principal diagnosis of osteoarthritis (condition when cartilage that cushions the ends of bones in the joints gradually wears away). During a concurrent interview and record review on 6/17/2025 at 10:40 a.m. with RN 2 at Patient 5’s residence, Patient 5’s HHA folder was reviewed. Patient 5’s HHA folder indicated there was no document of the state complaint telephone hotline number, address or hours of operation. RN2 stated and confirmed Patient 5’s HHA folder did not have the state complaint form that included the hotline number, the address and hours of operation. RN2 translated for Patient 5 and Patient 5 stated she was not aware of a form with the state complaint hotline number. RN 2 translated for Patient 5 and Patient 5 stated that if she had any problems or questions, she was educated to call the HHA and stated she also contacts RN2 for any questions. During an interview on 6/18/2025, at 11:57 a.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated that there should be a booklet included in all the patient’s home health folder, which provides the State complaint hotline information. The DPCSD stated that the importance of all patient’s having the state complaint hotline number is so that each patient can exercise his/her right to file a complaint if they have any concerns with their care, which the HHA was unable to resolve. During a review of the HHA’s policy and procedure (P&P), titled Patient Bill of Rights, undated, the P&P indicated to encourage awareness of patient rights and provide guidelines to assist patients in making decisions regarding care and for active participation in care planning. The P&P also indicated that patients are to receive in writing, prior to the start of care, the telephone numbers for the State Home Health Hotline, including hours of operation and the purpose of the hotline to receive complaints or questions about the organization.”

“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, a public or private organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to review all the medications and updated the medication profile with the currently used medications for one of seven sampled patient (Patient 2). This deficient practice had the potential to put Patient 2 at risk for medication errors and adverse drug reactions. During a review of Patient 2’s clinical record titled Patient Information, undated, indicated a start of care (SOC) date of 5/22/2025. During a review of Patient 2’s clinical record titled, Home Health Certification and Plan of Care for certification period from 5/22/2025 to 7/20/2025, indicated a primary diagnosis of Type 2 diabetes mellitus (is a disease which high blood sugar levels are due to the body is not making enough of a hormone called insulin, or the insulin it makes not working properly, known as insulin resistance). During a concurrent observation and interview on 6/17/2025 at 11:23 a.m., with the Registered Nurse (RN1), in Patient 2’s residence for a joint home visit, Patient 2 was observed resting in her chair, alert, awake and oriented to her name, time, place and events. During a concurrent interview and record review on 6/17/2025 at 11:30 a.m. with RN1, Patient 2’s medication list and medication bottles were reviewed. Patient 2’s medications list indicated the following medication, Vitamin B12 (OTC, over-the counter non prescribed supplement) 1000 mcg (microgram, unit of weight) tablet, was not listed in Patient 2’s current medication list. RN1 stated and confirmed that Vitamin B12 OTC medication was not listed in Patient 12’s current medication list but was available on hand. Patient 2 stated that she is currently taking the Vitamin B12 medication one tablet daily. Patient 2’s medication bottle of Baclofen 20 mg (milligram, unit of weight) oral (by mouth) tablet, one tablet once at bedtime as needed for pain, had an expiration date of 4/17/2025. RN 1 stated and confirmed that the Baclofen medication had expired already and needed to be disposed. Patient 2 stated that she does not use the medication anymore. RN1 stated that this is her first time visiting Patient 2 but the process of medication reconciliation review with patients needs to be conducted on each visit. RN 1stated that it is important that medication reconciliation is done on each visit to prevent confusion and mixed up of patients/caregivers of what medication to take or not and to determine the expiration dates of each medications patient is taking. During an interview on 6/18/2025, at 12:11 p.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated that nurses should conduct medication reconciliation on each visit and if patients have new medications, expired medications, or discontinued medications, nurses should coordinate with the agency or with the physician so it could also be updated to the current medication list and to avoid unnecessary discontinued medications and confusion among the healthcare team and patient. During a review of the HHA’s policy and procedure (P&P) titled, Medication Profile, undated, the P&P indicated to define the use of the medication profile in evaluating a patient’s medication regimen, including over the counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals. The P&P indicated that patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record, medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to develop an individualized plan of care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) that includes management of potential problems, interventions, and goals for safety precautions while on anti-platelet (blood thinner medication that can cause serious bleeding) medication for two of seven sampled patients (Patient 1 and Patient 5). This deficient practice resulted in Patient 1 and Patient 5 without a specific formulated POC for the current health status for management of symptoms that is likely to cause delayed care, undetected adverse signs and symptoms of medication. Findings: a. During a review of Patient 1’s clinical record titled Patient Information, undated, indicated a start of care (SOC) date of 5/9/2025. During a review of Patient 1’s clinical record titled, Home Health Certification and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), for the certification period from 5/9/2025 to 7/7/2025, indicated a primary diagnosis of osteoarthritis (is a joint disease, in which the tissues in the joint break down over time). During a review of Patient 1’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 5/9/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. During a joint home visit on 6/17/2025 at 10:00 a.m., with the Registered Nurse (RN) 1, at Patient 1’s residence, Patient 1 was observed resting in her sofa chair, alert, awake and oriented to her name, time, place and events. During a concurrent interview and record review on 6/17/2025, at 10:23 a.m., with Registered Nurse (RN1), Patient 1’s Medication Profile was reviewed. Patient 1’s medication profile indicated a medication order for: Aspirin (A medication that reduces pain, fever, inflammation, and blood clotting) EC (refers to a type of coating applied to oral medications, such as tablets and capsules, this coating prevents the medication from dissolving in the stomach acid and instead allows it to pass through the stomach and into the small intestine before dissolving and being absorbed) 81 milligrams (mg, unit of weight), 1 tablet once daily. RN1 stated that aspirin can cause gum bleeding, nose bleeding, blood in stool, urine, uncontrolled bleeding and unusual bruising. RN 1 stated that teachings provided to patient and was documented which include when to call for immediate medical care. During a concurrent interview and record review on 6/17/2025 at 12:55 p.m., with the Director of Patient Care Services Designee (DPCSD), Patient 1’s electronic medical record titled Home Health Certification and Plan of Care (POC, a detailed written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) for the certification period starting from 5/9/2025 to 7/7/2025 was reviewed. The DPCSD stated that the POC did not indicate bleeding precautions that specify goals, interventions and expected outcomes. The DPCSD stated that aspirin is an anti-platelet and a high-risk medication, and that a care plan must be formulated for patients that are currently taking the medication which includes bleeding precautions. The DPCSD stated that a care plan for bleeding precautions should include goals, interventions, expected outcomes and patient/caregiver’s education of what symptoms to look for like gum bleeding, nose bleeding, blood in stool, urine, uncontrolled bleeding and unusual bruising and when to call for immediate medical care. The DPCSD stated that visiting nurses should provide teachings and education to patient/patient’s caregivers regarding medications, its side effects and what to monitor for as specified in the POC. The DPCSD stated visiting nurses should reinforce patient teachings on each certification period to ensure patient/patient’s caregiver understand it. The DPCSD stated visiting nurses should document the teachings and education provided to patient/patient’s caregiver to validate that it was done. b. During a review of Patient 5’s clinical record titled Home Health and Plan of Care (POC ) for the certification period of 6/6/2025 to 8/4/2025 indicated a Start of Care (SOC) date of 6/6/2025 with a principal diagnosis of Osteoarthritis (condition when cartilage that cushions the ends of bones in the joints gradually wears away). During a review of Patient 5’s clinical record titled POC for the certification period of 6/6/2025 to 8/4/2025 indicated a medication order for aspirin (medication used to prevent heart attack and strokes) 81 milligrams (mg) oral tablet administered by mouth 1 tablet every day. During a review of Patient 5’s clinical record titled POC for the certification period of 6/6/2025 to 8/4/2025 indicated there was no documented evidence of a formulated care plan for Patient 5’s use of medication aspirin and for monitoring its signs and symptoms of bleeding. During a review of Patient 5’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 6/6/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. During a concurrent interview and record review on 6/18/2025 at 11:40am with the DPCSD, Patient 5’s clinical record titled POC for the certification period of 6/6/2025 to 8/4/2025 was reviewed. Patient 5’s POC for the certification period of 6/6/2025 to 8/4/2025 indicated there was no documented evidence of a formulated care plan for Patient 5’s use and management of the medication aspirin. The DPCSD stated the care plan was to include bleeding precautions that specify goals, interventions and expected outcomes. The DPCSD stated that aspirin is an anti-platelet and a high-risk medication, stated that a care plan must be formulated for patients that are currently taking the medication which includes bleeding precautions. The DPCSD stated and confirmed Patient 5’s POC for the certification period of 6/6/2025 to 8/4/2025 did not include a documented care plan for the use and management of the medication aspirin and monitoring for signs and symptoms of bleeding. The DPCSD stated if a patient is on the medication aspirin, the skilled nurses are to educate the patients at every home visit on bleeding precautions, like gum bleeding, nose bleeding, blood in stool, urine, uncontrolled bleeding and unusual bruising and when to call for immediate medical care. The DPCSD further stated that all education the skilled nurses provide to the patient’s is on the POC to follow, and what is reinforced to the patients should be documented in their visit to validate that it was done and monitor the patent’s progress towards understanding. During a review of the HHA’s policy and procedure (P&P), titled Care Planning Process, undated, the P&P indicated to provide clinical direction to the clinicians providing direct patient care. The P&P indicated that Plan of Care: The clinical plan of care includes: K. Safety Measures O. Instructions to patient and family V. Other appropriate items such as precautions and contraindications”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to record the physician order for skilled nursing frequency visits in the Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for two of seven sampled patients (Patients 3 and Patient 5). This deficient practice had the potential to result in Patient 3 and Patient 5 not receiving the nursing care and services needed. Findings: a. During a review of Patient 3’s clinical record titled Patient Information, undated, indicated a start of care (SOC) date of 6/6/2025. During a review of Patient 3’s clinical record titled, Home Health Certification and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), for the certification period from 6/6/2025 to 8/4/2025, indicated a primary diagnosis of spondylosis (a general term for age-related wear and tear on the spine, specifically the joints and discs between vertebrae). Upon further review, the Home Health Certification and POC of Patient 3 did not indicate the patient skilled nursing frequency visit order. During a review of Patient 3’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 6/6/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. b. During a review of Patient 5’s clinical record titled Home Health and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for the certification period of 6/6/2025 to 8/4/2025 indicated a Start of Care (SOC) date of 6/6/2025 with a principal diagnosis of Osteoarthritis (condition when cartilage that cushions the ends of bones in the joints gradually wears away). During a review of Patient 5’s POC for the certification period of 6/6/2025 to 8/4/2025 indicated there was no documented evidence of the frequency of skilled nurse visits as ordered by the physician. During a review of Patient 5’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 6/6/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. During a joint home visit on 6/17/2025 at 10:25am with Registered Nurse 2 (RN2), at Patient 5’s residence, Patient 5 was observed awake, alert and oriented to self, time and place, and walking in slow pace with assistance of a cane. Patient 5 was observed speaking Armenian and able to communicate simple words in English. During a concurrent interview and record review on 6/18/2025 at 11:35 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 5’s POC for the certification period of 6/6/2025 to 8/4/2025 was reviewed. Patient 5’s POC for the certification period of 6/6/2025 to 8/4/2025 indicated there was no documented evidence of the frequency of skilled nurse visits as ordered by the physician. The DPCSD stated and confirmed that Patient 5’s POC did not have documentation of the physician order for the frequency of skilled nurse visits and for how long. The DPCSD stated every patient’s POC should include the physician’s order for skilled nursing visit frequencies and any other discipline because it is important that all members of the care team are aware of the services the patient is to be receiving and for how often and how long. DPCSD stated all physician orders and transcribed onto the POC. During a concurrent record review and interview on 6/18/2025, at 12:37 p.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD confirmed that the skilled nursing frequency of visits orders were not included in Patient 3 and Patient 5’s Home Health Certification and POC. DPCSD stated that he was unsure why the skilled nursing frequency order was not included in patients’ Home Health Certification and POC. The DPCSD stated that skilled nursing frequency of visit orders should be stated in patient’s Home Health Certification and POC to ensure that the skilled nurses followed the required visits and to ensure that the coordination of services with other staffs involved are in place and directions are clear. During a review of the HHA’s policy and procedure (P&P), titled Care Planning Process, undated, the P&P indicated to provide clinical direction to the clinicians providing direct patient care. The P&P indicated that the Plan of Care: the clinical plan of care includes N. Orders for specific home health services and disciplines, treatments and procedures, including amount/frequency/duration. S. Frequency and duration of visits. 3. Based on the assessment and conclusions, the plan of care will include, but will not be limited to: D. Specific services and treatments to be involved.”

“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 HHA failed to follow physician orders for the frequency of skilled nursing visits for one of seven sampled patients (Patient 5). This deficient practice could have resulted in Patient 5 not receiving the needed care, attention and services needed for her well-being causing a delay in care and healing. During a review of Patient 5’s clinical record titled Home Health and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for the certification period of 6/6/2025 to 8/4/2025 indicated a Start of Care (SOC) date of 6/6/2025 with a principal diagnosis of Osteoarthritis (condition when cartilage that cushions the ends of bones in the joints gradually wears away). During a review of Patient 5’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 6/6/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. During a review of Patient 5’s June 2025 visit schedule calendar, Patient 5’s calendar indicated there were no scheduled or documented skilled nursing home visits for the week of 6/8/2025 to 6/14/2025. During a joint home visit on 6/17/2025 at 10:25am with Registered Nurse 2 (RN2), at Patient 5’s residence, Patient 5 was observed awake, alert and oriented to self, time and place, and walking in slow pace with assistance of a cane. Patient 5 was observed speaking Armenian and able to communicate simple words in English. During a concurrent interview and record review on 6/18/2025 at 11:48 a.m. with the DPCSD, Patient 5’s Electronic Medical Record (EMR) was reviewed. Patient 5’s EMR indicated there was no documented evidence of skilled nursing visit notes for the week of 6/8/2025 to 6/14/2025. The DPCSD stated and confirmed Patient 5’s EMR did not have any documentation of a skilled nurse visit being conducted on the week of 6/8/2025 to 6/14/2025, as ordered by the physician. The DPCSD stated and confirmed that Patient 5’s June 2025 visit calendar also did not have documentation of completed or attempted home visits for the week of 6/8/2025 to 6/14/2025. The DPCSD stated there was also no documented evidence of a communication note that the physician, who ordered the frequency of skilled nurse visits, was not informed of the missed visit. The DPCSD stated that he spoke with the skilled nurse who was supposed to do the home visit with Patient 5 that week and the skilled nurse stated Patient 5 stated she was not available for a home visit, for personal reasons, until the following week. The DPCSD stated by the HHA policy, the skilled nurse should have documented in the EMR about the missed visit, the reason for the missed visit and if an attempt to reschedule was done. The DPCSD stated the missed visit should have been documented in a communication note and the physician should have also been notified of the missed visit since it caused a change in visit frequency. DPCSD stated he notification of the physician should have also been documented in the communication note, along with any new orders the physician might have had. The DPCSD further stated that a negative outcome of a patient having a missed visit without rescheduling is that the patient does not receive the proper and needed care that was ordered by the physician. DPCSD also stated a missed visit is also not following the physician orders for nursing frequency visits. The survey team requested a policy and procedure regarding following physician orders, but the HHA was unable to provide it.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation, interview and record review the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the physician was notified of the care and services that were not rendered for one of seven sample patients (Patient 5). This failure had the potential to result in Patient 5’s health status decline with no immediate interventions due to lack of physician notification by the HHA. During a review of Patient 5’s clinical record titled Home Health and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for the certification period of 6/6/2025 to 8/4/2025 indicated a Start of Care (SOC) date of 6/6/2025 with a principal diagnosis of Osteoarthritis (condition when cartilage that cushions the ends of bones in the joints gradually wears away). During a review of Patient 5’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 6/6/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. During a review of Patient 5’s June 2025 visit schedule calendar, Patient 5’s calendar indicated there were no scheduled or documented skilled nursing home visits for the week of 6/8/2025 to 6/14/2025. During a joint home visit on 6/17/2025 at 10:25am with Registered Nurse 2 (RN2), at Patient 5’s residence, Patient 5 was observed awake, alert and oriented to self, time and place, and walking in slow pace with assistance of a cane. Patient 5 was observed speaking Armenian and able to communicate simple words in English. During a concurrent interview and record review on 6/18/2025 at 11:48 a.m. with the DPCSD, Patient 5’s Electronic Medical Record (EMR) was reviewed. Patient 5’s EMR indicated there was no documented evidence of skilled nursing visit notes for the week of 6/8/2025 to 6/14/2025. The DPCSD stated and confirmed Patient 5’s EMR did not have any documentation of a skilled nurse visit being conducted on the week of 6/8/2025 to 6/14/2025, as ordered by the physician. The DPCSD stated and confirmed that Patient 5’s June 2025 visit calendar also did not have documentation of completed or attempted home visits for the week of 6/8/2025 to 6/14/2025. The DPCSD stated there was also no documented evidence of a communication note that the physician, who ordered the frequency of skilled nurse visits, was not informed of the missed visit. The DPCSD stated that he spoke with the skilled nurse who was supposed to do the home visit with Patient 5 that week and the skilled nurse stated Patient 5 stated she was not available for a home visit, for personal reasons, until the following week. The DPCSD stated by the HHA policy, the skilled nurse should have documented in the EMR about the missed visit, the reason for the missed visit and if an attempt to reschedule was done. The DPCSD stated the missed visit should have been documented in a communication note and the physician should have also been notified of the missed visit since it caused a change in visit frequency. DPCSD stated he notification of the physician should have also been documented in the communication note, along with any new orders the physician might have had. The DPCSD further stated that a negative outcome of a patient having a missed visit without rescheduling is that the patient does not receive the proper and needed care that was ordered by the physician. DPCSD also stated a missed visit is also not following the physician orders for nursing frequency visits. During a review of the HHA’s Policy and Procedure (P&P) titled, Missed Visits, undated, indicated if a visit is missed and not rescheduled then the clinical will notify the physician and clinical supervisor of the missed visit and reason for the missed visit.”

“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 observation, interview, and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to ensure the clinical records for Plan of Care were completed for three of seven sampled patients (Patient 4, Patient 5, and Patient 6). This failure resulted in an incomplete clinical records leading to validity of documentation of care and services to be provided to these patients certified to receive the Medicare home health benefits. Findings: a. During a review of Patient 4’s clinical record titled Patient Information, undated, indicated a start of care (SOC) date of 2/13/2025. During a review of Patient 4’s clinical record titled, Home Health Certification and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), for the certification period from 4/14/2025 to 6/12/2025, indicated a primary diagnosis of hypertensive heart disease (refers to heart problems that arise from long-term, uncontrolled high blood pressure, a condition where the force of blood against the artery walls is consistently too high). Upon further review of Patient 4’s Home Health Certification and POC, the section 27. Attending Physician’s signature and date signed was left blank. During an interview with the Director of Patient Care Services Designee (DPCSD) on 6/18/2025, at 2:10 p.m., the DPSCD confirmed and stated that Patient 4’s Home Health Certification and POC for the certification period from 4/14/2025 to 6/12/2025 section 27 was left blank, with no attending physician’s signature and date. DPCSD stated that he was unsure why Patient 4’s POC for the period of 4/14/2025 to 6/12/2025 was not signed by the physician. DPCSD stated that the doctor’s office must have forgot to fax to the HHA the signed documents. DPCSD stated that patient’s clinical records including Home Health Certification and POC, should be signed by the clinician to validate its completion. DPCSD stated that if a patient’s clinical records were not signed by the specific clinician, the documentation is not valid, or it will not validate that a certain task was done. The DPCSD stated that Home Health Certification and POC should be signed by a clinician within seven days. b. During a review of Patient 5’s clinical record titled Home Health and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for the certification period of 6/6/2025 to 8/4/2025 indicated a Start of Care (SOC) date of 6/6/2025 with a principal diagnosis of Osteoarthritis (condition when cartilage that cushions the ends of bones in the joints gradually wears away). Patient 5’s POC also indicated the signature from the attending physician was dated 6/17/2025, 11 days after the patient’s SOC. During a review of Patient 5’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 6/6/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. During a joint home visit on 6/17/2025 at 10:25am with Registered Nurse 2 (RN2), at Patient 5’s residence, Patient 5 was observed awake, alert and oriented to self, time and place, and walking in slow pace with assistance of a cane. Patient 5 was observed speaking Armenian and able to communicate simple words in English. During a concurrent interview and record review on 6/18/2025 at 1:57 p.m. with the DPCSD, Patient 5’s POC for the certification period of 6/6/2025 to 8/4/2025 was reviewed. Patient 5’s POC for the certification period of 6/6/2025 to 8/4/2025 indicated it was 6/17/2025, 11 days after the patient’s SOC. The DPCSD stated and confirmed patient 5’s POC for certification period of 6/6/2025 to 8/4/20205 was signed and dated by the attending physician on 6/17/2025. The DPCSD stated when a patient gets admitted to the HHA, the POC is formulated based off the patient’s history and physical assessment and the physician orders and then faxed to the physician for review and to sign. The DPCSD stated the patient’s POC should be signed within 7 days from SOC and placed in the patient’s chart. The DPCSD further stated if the POC is not signed within 7 days from the patient’s SOC by the attending physician then the care orders are not verified and validated. c. During a review of Patient 6’s clinical record titled Home Health and Plan of Care (POC) for the certification period of 4/27/2025 to 6/25/2025 indicated a Start of Care (SOC) date of 2/26/2025 with a principal diagnosis of Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Patient 6’s POC for the certification period of 4/27/2025 to 6/25/2025 indicated an order for skilled nurse frequency visits for two times a week for two weeks and one time a week for seven weeks. The POC also indicated a signature from the attending physician dated 5/15/2025. During a concurrent interview and record review on 6/18/2025 at 2:00pm with the DPCSD, Patient 6’s POC for the certification period of 4/27/2025 to 6/25/2025 was reviewed. Patient 6’s POC for the certification period of 4/27/2025 to 6/25/2025 indicated a signature from the attending physician dated 5/15/2025,18 days after the patient’s recertification date. The DPCSD stated and confirmed Patient 6’s POC was signed and dated by the attending physician on 5/15/2025 which was 18 days after the patient’s recertification date. The DPCSD stated POC’s for recertification of care are reviewed and revised and faxed to the attending physician for their review and signature, and once they are sent back, the signed POC’s are placed into the patient’s chart. The DPCSD stated a patient’s POC should be signed within 7 days of their SOC or recertification, or it is not considered valid. During a review of the HHA’s policy and procedure (P&P), titled Contents of Clinical Record, undated, the P&P indicated that the following information will be available in the clinical record for patients receiving skilled care: R. Signed and dated progress notes for each discipline rendering service. Clinical notes shall be signed and incorporated into the patient’s health record at least every seven working days.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on interview and record review the HHA failed to ensure the skilled nurses submit nursing visit notes and pertinent clinical records in a timely manner, to reflect the care and assessment provided to the patients for one of seven sampled patients (Patient 5) This failure resulted in Patient 5’s incomplete medical record that could lead to misinformation and a break in continuity of care and services to be provided to the patient for optimal health and recuperation. Findings: During a review of Patient 5’s clinical record titled Home Health and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for the certification period of 6/6/2025 to 8/4/2025 indicated a Start of Care (SOC) date of 6/6/2025 with a principal diagnosis of Osteoarthritis (condition when cartilage that cushions the ends of bones in the joints gradually wears away). During a review of Patient 5’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 6/6/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. During a review of Patient 5’s June 2025 visit schedule calendar, Patient 5’s calendar indicated there were no scheduled or documented skilled nursing home visits for the week of 6/8/2025 to 6/14/2025. During a joint home visit on 6/17/2025 at 10:25am with Registered Nurse 2 (RN2), at Patient 5’s residence, Patient 5 was observed awake, alert and oriented to self, time and place, and walking in slow pace with assistance of a cane. Patient 5 was observed speaking Armenian and able to communicate simple words in English. During a concurrent interview and record review on 6/18/2025 at 11:48 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 5’s Electronic Medical Record (EMR) was reviewed. Patient 5’s EMR indicated there was no documented evidence of skilled nursing visit notes for the week of 6/8/2025 to 6/14/2025. The DPCSD stated and confirmed Patient 5’s EMR did not have any documentation of a skilled nurse visit being conducted on the week of 6/8/2025 to 6/14/2025, as ordered by the physician. The DPCSD stated and confirmed that Patient 5’s June 2025 visit calendar also did not have documentation of completed or attempted home visits for the week of 6/8/2025 to 6/14/2025. The DPCSD stated there was also no documented evidence of a communication note that the physician, who ordered the frequency of skilled nurse visits, was not informed of the missed visit. The DPCSD stated that he spoke with the skilled nurse who was supposed to do the home visit with Patient 5 that week and the skilled nurse stated Patient 5 stated she was not available for a home visit, for personal reasons, until the following week. The DPCSD stated by the HHA policy, the skilled nurse should have documented in the EMR about the missed visit, the reason for the missed visit and if an attempt to reschedule was done. The DPCSD stated the missed visit should have been documented in a communication note and the physician should have also been notified of the missed visit since it caused a change in visit frequency. DPCSD stated he notification of the physician should have also been documented in the communication note, along with any new orders the physician might have had. The DPCSD further stated that a negative outcome of a patient having a missed visit without rescheduling is that the patient does not receive the proper and needed care that was ordered by the physician. DPCSD also stated a missed visit is also not following the physician orders for nursing frequency visits. During a review of the HHA’s Policy and Procedure (P&P) titled, Missed Visits, undated, indicated if a visit is missed and not rescheduled then the clinical will notify the physician and clinical supervisor of the missed visit and reason for the missed visit. The P&P also indicated the clinician will document in the patient’s clinical record the following information: patients name, date and type of visit missed, reason for the missed visit, description of any unmet needs and how the patient’s needs were met, physician notification including date, time, physician name, method of notification and staff reporting the information, other person notified of the missed visit, any other follow up needed, and signature of the staff member reporting the information.”

“Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient’s representative (if any), and the patient’s primary caregiver(s); This Element is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the clinical records included emergency contact information for six of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This failure had the potential to delay the HHA in facilitating rapid response and communication in case of unforeseen medical or other emergencies, ensuring timely notification and support for the patient and their family. Findings: a. During a review of Patient 1’s clinical record titled Patient Information, undated, indicated a start of care (SOC) date of 5/9/2025. During a review of Patient 1’s clinical record titled, Home Health Certification and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), for the certification period from 5/9/2025 to 7/7/2025, indicated a primary diagnosis of osteoarthritis (is a joint disease, in which the tissues in the joint break down over time). During a review of Patient 1’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 5/9/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. During a concurrent record review and interview with the Director of Patient Care Services Designee (DPCSD) on 6/18/2025 at 2:15 p.m., the DPCSD confirmed and stated that Patient 1’s Patient Information indicated no emergency contact information. DPCS stated that he was unsure why Patient 1’s emergency contact information was not provided and should have been included in the Patient Information for quick reference and in case there will be circumstances that patient is unable to get hold of. b. During a review of Patient 2’s clinical record titled Patient Information, undated, indicated a start of care (SOC) date of 5/22/2025. During a review of Patient 2’s clinical record titled Home Health Certification and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for the certification period from 5/22/2025 to 7/20/2025, indicated a primary diagnosis of Type 2 diabetes mellitus (is a disease which high blood sugar levels are due to the body is not making enough of a hormone called insulin, or the insulin it makes not working properly, known as insulin resistance). The Home Health Certification and POC also indicated Skilled Nurse visit frequency of twice a week for two weeks, then once a week for seven weeks. During a concurrent record review and interview with the Director of Patient Care Services Designee (DPCSD) on 6/18/2025 at 2:20 p.m., the DPCSD confirmed and stated that Patient 2’s Patient Information indicated no emergency contact information. DPCS stated that he was unsure why Patient 2’s emergency contact information was not provided and should have been included in the Patient Information for quick reference and in case there will be circumstances that patient is unable to get hold of. c. During a review of Patient 3’s clinical record titled Patient Information, undated, indicated a start of care (SOC) date of 6/6/2025. During a review of Patient 3’s clinical record titled, Home Health Certification and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), for the certification period from 6/6/2025 to 8/4/2025, indicated a primary diagnosis of spondylosis (a general term for age-related wear and tear on the spine, specifically the joints and discs between vertebrae). During a review of Patient 3’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 6/6/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. During a concurrent record review and interview with the Director of Patient Care Services Designee (DPCSD) on 6/18/2025 at 2:27 p.m., the DPCSD confirmed and stated that Patient 3’s Patient Information indicated no emergency contact information. DPCS stated that he was unsure why Patient 3’s emergency contact information was not provided and should have been included in the Patient Information for quick reference and in case there will be circumstances that patient is unable to get hold of. d. During a review of Patient 4’s clinical record titled Patient Information, undated, indicated a start of care (SOC) date of 2/13/2025. During a review of Patient 4’s clinical record titled, Home Health Certification and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), for the certification period from 4/14/2025 to 6/12/2025, indicated a primary diagnosis of hypertensive heart disease (refers to heart problems that arise from long-term, uncontrolled high blood pressure, a condition where the force of blood against the artery walls is consistently too high). During a concurrent record review and interview with the Director of Patient Care Services Designee (DPCSD) on 6/18/2025 at 2:35 p.m., the DPCSD confirmed and stated that Patient 4’s Patient Information indicated no emergency contact information. DPCS stated that he was unsure why Patient 4’s emergency contact information was not provided and should have been included in the Patient Information for quick reference and in case there will be circumstances that patient is unable to get hold of. e. During a review of Patient 5’s clinical record titled Home Health and Plan of Care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for the certification period of 6/6/2025 to 8/4/2025 indicated a Start of Care (SOC) date of 6/6/2025 with a principal diagnosis of Osteoarthritis (condition when cartilage that cushions the ends of bones in the joints gradually wears away). During a review of Patient 5’s clinical record titled Outcome and Assessment Information Set (OASIS- the initial evaluation conducted at the beginning of a patient’s healthcare services) Start of Care Assessment dated 6/6/2025 indicated Skilled Nurse visit frequency of once a week for one week, then two times a week for two weeks, and then once a week for three weeks. The OASIS also indicated a Physical therapy visit frequency of once a week for eight weeks. During a review of Patient 5’s clinical record titled Patient Information, undated, did not indicate documentation of Patient 5’s emergency contact information. During a joint home visit on 6/17/2025 at 10:25am with Registered Nurse 2 (RN2), at Patient 5’s residence, Patient 5 was observed awake, alert and oriented to self, time and place, and walking in slow pace with assistance of a cane. Patient 5 was observed speaking Armenian and able to communicate simple words in English. During an interview on 6/18/2025 at 1:06 p.m. with the DPCSD, the DPCSD stated that a patient’s emergency contact can be found in the OASIS start of care assessment and should also be in the patient information record. The DPCSD stated the emergency contact information should include the name of the contact person, the address, phone number and their relationship to the patient. The DPCSD further stated it is important to have an updated and current emergency contact information or each patient to have a means to get ahold of them when needed. During a concurrent interview and record review on 6/18/2025 at 1:08 p.m. with the DPCSD, Patient 5’s clinical record titled Patient Information, undated, was reviewed. Patient 5’s clinical record titled Patient Information, undated, did not indicate documentation of Patient 5’s emergency contact information. The DPCSD stated and confirmed that Patient 5’s Patient Information record did not include the patient’s emergency contact information like their name, address, relation and phone number. f. During a review of Patient 6’s clinical record titled Home Health and Plan of Care (POC) for the certification period of 4/27/2025 to 6/25/2025 indicated a Start of Care (SOC) date of 2/26/2025 with a principal diagnosis of Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Patient 6’s POC for the certification period of 4/27/2025 to 6/25/2025 indicated an order for skilled nurse frequency visits for two times a week for two weeks and one time a week for seven weeks. During a concurrent interview and record review on 6/18/2025 at 1:09 p.m. with the DPCSD, Patient 6’s clinical record titled Patient Information, undated, was reviewed. Patient 6’s clinical record titled Patient Information, undated, did not indicate documentation of Patient 6’s emergency contact information. The DPCSD stated and confirmed that Patient 6’s Patient Information record did not include the patient’s emergency contact information like their name, address, relation and phone number. During a review of the HHA’s policy and procedure (P&P), titled Contents of Clinical Record, undated, the P&P indicated that the following information will be available in the clinical record for patients receiving skilled care: C. Name, address and telephone number of family/caregiver and patient representative to be contacted in the event of emergency/death.”