Summa Home Health Care, Inc.

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to provide documented evidence that the patients and their primary caregivers received education and training to achieve their established goals as indicated in the individualized plan of care (POC) for two out of five sampled patients (Patient 4 and Patient 5) when: a. The HHA failed to provide documented evidence that education regarding fall prevention was given to Patient 4, Patient 5 and their caregiver after an incident of fall was reported. This failure had the potential for Patient 4 and Patient 5’s fall recurrence and may result in serious injury and re-hospitalization. b. For Patient 4, the HHA failed to provide documented evidence that education regarding diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control) management was given to Patient 4 and caregiver after an incident of fall occurred. This failure had the potential for Patient 4’s health condition to deteriorate requiring more care, medication and services and/or re-hospitalization. Findings: a.1. During a review of Patient 4’s “Face Sheet” (the front page of the chart summarizing basic patient information), undated. The “Face Sheet” indicated Patient 4’s Start of Care (SOC) date was 1/1/2025, with diagnoses of diabetes mellitus, Heart failure (a heart disorder which causes the heart to not pump the blood efficiently) and cerebral infarction (stroke, loss of blood flow to a part of the brain). During a review of Patient 4’s POC for the certification period of 10/28/2025 to 12/26/2025. The POC indicated Patient 4’s established goal includes “Patient/caregiver will remove all clutter from patient’s path, such as clothes, books, shoes, electrical chords, and other items, that may cause patient to trip by the end of episode” During a concurrent interview and record review on 1/7/2026 at 1:13 pm., with the Director of Patient Care Services (DPCS). Patient 4’s “[Licensed Vocational Nurse] (LVN)– Skilled Nursing Visit”, dated 12/5/2026 was reviewed. The “LVN – Skilled Nursing Visit” indicated Patient had an unwitnessed fall during the week. The DPCS stated the note did not indicate any interventions during the visit after the reported fall. The DPCS stated there was nothing for HHA and nurses to do as the incident had already happened. During an interview on 1/7/2026 at 1:48 pm., with the DPCS. The DPCS stated the visiting licensed nurses should be providing education and training regarding fall preventions; the nurses should reinforce teaching for fall safety, safe environment and for patients to ask for assistance when ambulating. The DPCS stated that one of the roles of the HHA and the nurses was to educate patients and caregivers, because the healthcare team are not present in their homes all the time. The DPCS stated not providing education and training to patients and caregivers may lead to their lack of knowledge on how to prevent falls, which would risk the patient for serious injury and possible re-hospitalization. a.2. During a review of Patient 5’s “Face Sheet”, undated. The “Face Sheet” indicated Patient 5’s Start of Care (SOC) date was 7/3/2025, with diagnoses including but not limited to hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), heart failure, cerebrovascular attack (CVA-stroke, loss of blood flow to a part of the brain), seizure (sudden surge of electrical activity in your brain that causes sudden changes in awareness and muscle control) and anxiety (a mental condition characterized by is a feeling of fear, dread, and uneasiness). During a review of Patient 5’s POC for the certification period 10/31/2025 to 12/29/2025. The POC indicated “[Skilled nurses] teaching on fall prevention measures” and Patient 5 had established goals of “patient/caregiver will remove all clutter from patient’s path, such as clothes, books, shoes, electrical cords, and other items that may cause patient to trip by end of the episode”. During a concurrent interview and record review on 1/7/2026 at 1:40 pm., with the DPCS. Patient 5’s “LVN – Skilled Nursing Visit”, dated 12/11/2025. The “LVN – Skilled Nursing Visit” indicated caregiver reported Patient 5 had a fall on 12/8/2025 and was taken to a hospital emergency room. Patient 5 was discharged the same day. The DPCS stated the visit note did not indicate any interventions to Patient 5 because the fall incident already occurred and the patient had gone to the hospital and came back with no serious injury. During an interview on 1/7/2026 at 1:48 pm., with the DPCS. The DPCS stated the visiting licensed nurses should be providing education and training regarding fall preventions; the nurses should reinforce teaching for fall safety, safe environment and for patients to ask for assistance when ambulating. The DPCS stated that one of the roles of the HHA and the nurses is to educate patients and caregivers, because the healthcare team are not present in their homes all the time. The DPCS stated not providing education and training to patients and caregivers may lead to their lack of knowledge on how to prevent falls, which would risk the patient for serious injury and possible re-hospitalization. b. During a review of Patient 4’s “Face Sheet”, undated. The “Face Sheet” indicated Patient 4’s Start of Care (SOC) date was 1/1/2025, with diagnoses of diabetes mellitus, Heart failure (a heart disorder which causes the heart to not pump the blood efficiently) and cerebral infarction (stroke, loss of blood flow to a part of the brain). During a review of Patient 4’s POC for the certification period of 10/28/2025 to 12/26/2025. The POC indicated Patient 4 is current medications include, but not limited to “Insulin Glargine (long-acting insulin that regulates the blood sugar that works slowly over approximately 24 hours) 35 units (standard measurement of quantity) subcutaneous (injection given under the skin) every day” and “Insulin Lispro (fast-acting insulin to manage blood sugar) 10 units subcutaneous three times a day”. The POC indicated the following goal “Patient will be free from signs and symptoms of [hypoglycemia] (low blood sugar in the body) /hyperglycemia (high blood sugar in the body)” During a concurrent interview and record review on 1/7/2026 at 1:15 pm., with the Director of Patient Care Services (DPCS). Patient 4’s “LVN - Skilled Nursing Visit”, dated 12/5/2025,12/14/2025, 12/27/2025 was reviewed. The DPCS stated there was no documented evidence that the nurse provided education or training to Patient 4 and the caregiver in relation to achieving this goal. The DPCS stated education regarding diabetes management should include how to appropriately use glucometer (a device that measures the sugar level in the blood), symptoms of having hypoglycemia or hyperglycemia and administering insulin injections. The DPCS stated educating the patient and the caregiver will prevent Patient 4’s DM worsening and health deterioration that may require hospitalization. During a review of HHA’s policies and procedures (P&P), titled “Patient Education Process”, undated. The P&P indicated, but not limited to, the following: - “The scope of teaching will be determined by assessing the needs…as well as by the plan of care, goals and established outcomes.” - “[Education] will focus on increasing patient and family/caregiver potential to follow the plan of care and to meet established goals” and “maintaining the patient’s health status” - “The clinician will assess, plan, implement, and evaluate the following on each patient and family/caregiver, as appropriate…prescribed treatments, basic home safety, environmental and mobility safety” - “Documentation of patient and family/caregiver education will consist of: describing what was taught to the patient…describing the patient’s response to teaching, including the level of understanding and the ability to repeat or demonstrate what was taught” and “describing teaching planned for subsequent visit” - “The patient’s and family/caregiver’s knowledge, skills, and behaviors will be assessed during home visits through an interactive process. Reinforcement of instruction will be provided as needed””

“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’s personal residence) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Comprehensive Assessment of Patients as follows: a. The Home Health Agency (HHA) failed to ensure the comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) was completed within 5 days from the start of care for one of 7 sampled patients (Patient 1). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor quality nursing care needed to maintain the patient’s quality of life and well-being. (Refer to G520). b. The HHA failed to assess the patients’ continuing need for home care services for two of 7 sampled patients (Patient 2, and Patient 3). This deficient practice resulted in the continued skilled nurse services to these patients lacking the comprehensive assessments to clearly demonstrate the continuing provision of the home health benefits. (Refer to G532). c. The HHA failed to maintain an accurate current medication profile for one of 7 sampled patients (Patient 2). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. (Refer to G536). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver mandated compliance (in a way that is decided and controlled by law) with Federal regulations for Comprehensive Assessment of Patients to ensure the provision of health care services in a safe manner are provided to certified home health patients.”

“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 interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for care planning, coordination, and quality of care of patients as follows: a. The Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to develop an individualized plan of care (POC) that included problems, goals and interventions for two of seven sampled patients (Patient 1 and Patient 5). For Patient 1, who had a diagnosis of acute appendicitis with perforation (a medical emergency where the appendix, a small worm-shaped organ attached to the large intestine, ruptures and releases bacteria into the abdominal cavity). This failure had the potential to result in Patient 1 not receiving the identified needs and services, which could lead to a decline in his health status and/or injury. For Patient 5, the HHA failed to ensure that each patient’s plan of care (POC) included all disciplines involved and clearly stated the frequency and duration of visits. (Refer to G574). b. The HHA failed to ensure that Registered Nurse (RN 1) administered Ertapenem (medication used to treat bacterial infections) Intravenous (IV- refers to a way of giving drug or other substances through a needle or tube inserted into a vein) medication as ordered by the physician for one of seven (7) sampled patients (Patient 1) due to lack of staffing. This failure put Patient 1 at increased risk to have infection and develop sepsis (a life-threatening condition that occurs when the body’s immune system overreacts to an infection that could lead to widespread inflammation and organ damage) that could lead to hospitalization and death. (Refer to G580). c. The Registered Nurse (RN 1) failed to notify the physician promptly regarding a missed visit for a patient needing intravenous (IV-a way of giving a drug or other substance through a needle or tube inserted into the vein) infusion for one of seven sample patients (Patient 1). This deficient practice placed the patients at a potential risk for complications that could affect their overall health status. *Refer to G590). d. The HHA failed to ensure effective coordination of care and services for one of 5 sampled patients (Patient 5). The agency did not ensure that care provided by the Certified Nursing Assistant (CNA ) and therapy staff was coordinated, documented, or reviewed by Director of Patient Care Services (DPCS). This deficient practice had the potential to result in uncoordinated care and lack of appropriate clinical oversight for the patients. (Refer to G606). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver mandated compliance (in a way that is decided and controlled by law) with Federal regulations for Care planning, coordination, quality of care to ensure the provision of health care services in a safe manner is provided to patients”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Clinical records as follows: The HHA failed to maintain a clinical record containing past and current information of patient receiving home health services for one of seven sampled patients (Patient 1) by failing to: 1. Ensure Patient 1 General Acute Care Hospital (GACH) Discharge order to administer Ertapenem (medication used to treat bacterial infections) Intravenous (IV- a way of giving a drug or other substance through a needle or tube inserted to a vein) every 24 hours was included in Patient 1’s plan of care. 2. Ensure Patient 1 medication and treatment orders were included on Patient’s 1 plan of care. 3. Ensure License staff document all interventions, including medication administration, treatments and services and responses to the interventions for Patient 1. 4. Ensure license staff completed an initial evaluation using the Outcome and Assessment Information Set (OASIS initial evaluation, a comprehensive evaluation of a patient’s health and needs conducted at the beginning of home health care services) on 8/3/2025 for Patient 1. 5. Ensure Patient 1 had a plan of care developed to outline the specific plan for medical, rehabilitation, and supportive services a patient needs at home 6. Ensure Patient 1 had nursing notes completed for nursing visit conducted on 8/3/2025 and 8/4/2025. 7. Ensure to complete Oasis discharge comprehensive assessment (a required evaluation of a home health patient’s clinical and functional status upon leaving the agency’s care) for Patient 1. These failures had a potential to result with miscommunication within the interdisciplinary team (a group of professionals from different fields who collaborate to address complex issues, such as patient care), medication error, inappropriate treatment and services that could cause patient suffering severe harm, hospitalization and death. (Refer to G1012). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver mandated compliance (in a way that is decided and controlled by law) with Federal regulations for Clinical Records to ensure the provision of health care services in a safe manner is provided to patients.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) was completed within 5 days from the start of care for one of 7 sampled patients (Patient 1). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor quality nursing care needed to maintain the patient’s quality of life and well-being. During a review of Patient 1’s GACH (hospital) discharge order dated 8/2/2025, indicated to a physician’s order to infuse Ertapenem 1 gram in Normal Saline 100 milliliters over 30 minutes via IV access every 24 hours via rate-flow/mini-bag every 24 hours until 8/24/2025 for intra-abdominal abscess. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/3/2025, with diagnosis that included acute appendicitis with perforation (a condition where the appendix , a small finger-shaped organ attached to the large intestine, becomes inflamed and ruptured. During a phone interview with Family Member (FM 1) 10/29/2025, at 12 p.m., FM 1 stated she was very upset that Registered Nurse (RN 1) did not show up on her scheduled visit day (FM 1 unable to remember the date) to infuse the IV antibiotic because RN 1 had to go to a court hearing. FM 1 stated the HHA did not send a replacement nurse that resulted to Patient 1 not getting her IV antibiotic to treat her abscess. FM 1 also stated she called the HHA the following day and the staff told her the HHA could not send a replacement nurse because there were a lot of patients needing help. During a review of Patient 1’s electronic medical record (EMR) indicated that HHA did not complete the initial evaluation using the Outcome and Assessment Information Set (OASIS) dated 8/3/2025. During an interview with RN 1 on 10/29/2025, at 1:30 p.m., she stated she did not complete the OASIS assessment because the HHA’s biller told them there was a problem with the patient’s insurance and the HHA would not get paid for services rendered. RN 1 also stated the comprehensive assessment must be completed no later than 5 calendar days after the start of care. During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, dated April 2020, the P&P indicated a comprehensive patient assessment will be completed within five (5) calendar days of the patient start of care. The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs.”

“Continuing need for home care CFR(s): 484.55(c)(3) The patient’s continuing need for home care; This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to assess the patients’ continuing need for home care services for two of 7 sampled patients (Patient 2, and Patient 3). This deficient practice resulted in the continued skilled nurse services to these patients lacking the comprehensive assessments to clearly demonstrate the continuing provision of the home health benefits. a. During a review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 8/26/2025, with a diagnosis of diabetes mellitus type II ( high blood sugar levels due to the body’s inability to use insulin effectively). During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the re-certification period from 8/25/2025 to 10/24/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up. During a joint home visit, on 10/31/2025, at 1 p.m., at Patient 2’s residence with the director of patient care services (DPCS), Patient 2 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory with stable gait without using any assisted device. During an interview, Patient 2 she goes visit her physician regularly as scheduled, had no falls, no wounds, had no hospitalization, and can managed her medication and diet regimen independently. During a concurrent interview and record review, on 11/2/2025, at 11 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 2’s clinical nursing visit notes, nursing assessment and the POC. The DPCS stated that for the month starting 8/25/2025 to 10/24/2025, Patient 2’s vital signs were within normal range, that he had no recent admissions to the hospital, no episodes of falls, no new medications, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 2 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 1 should have been discharged because her goals have been met and there was no need for skilled nursing services. b. During a review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 8/3/2025, with a diagnosis of hypertensive heart disease (a heart problem that develop from long term high blood pressure). During a review of Patient 3’s Home Health Certification and Plan of Care (POC) for the certification period from 8/3/2025 to 10/1/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up. During a concurrent interview and record review, on 11/2/2025, at 11:30 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 3’s clinical nursing visit notes, nursing assessment and the POC. The DPCS stated that for the month starting 8/3/2025 to 10/1/2025, Patient 3’s vital signs were within normal range, that she had no recent admissions to the hospital, no episodes of falls, no wound care, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 3 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 3 should have been discharged because his goals have been met and there was no need for skilled nursing services. During a review of the agency’s policy and procedure (P&P) titled, Discharge Criteria and Process, dated April 2020, the P&P indicated the purpose of the policy is to outline the process for discharging a patient from service. Services will be terminated when the patient meets one of the following discharge criteria: if appropriate, the physician and the organization agree that the goals of home care have been attained or are no longer attainable.”

“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 maintain an accurate current medication profile for one of 7 sampled patients (Patient 2). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. During a review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 8/26/2025, with a diagnosis of diabetes mellitus type II (high blood sugar levels due to the body’s inability to use insulin effectively). During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the re-certification period from 8/25/2025 to 10/24/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. During a joint home visit, on 10/31/2025, at 1 p.m., at Patient 2’s residence with the director of patient care services (DPCS), Patient 2 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory with stable gait without using any assisted device. During a review of Patient 2’s current medication, on 10/31/2025, at 1:30 p.m., with the DPCS, it was noted there was bottle of Edarbi (used to treat high blood pressure) 80 milligram (mg, a unit of measurement) 1 tablet orally daily with a refill date of 7/16/2025 and a bottle of Felodipine (used to treat high blood pressure) 5 mg one tab daily with a refill date of 7/16/2025. Patient 2’s current medication list provided by the HHA indicated both the Edarbi and Felodipine medications were not included in the list. During a concurrent interview with Patient 2, she stated she was taking the Edarbi and Felodipine medications daily for several months. During an interview, on 10/31/2025, at 2 p.m., with the DPCS, the DPCS stated nursing staff need to review the patient’s current medication every nurse visit and update the medication profile in the patient’s clinical record. During a review of the agency’s policy and procedure (P&P) titled, Medication Profile, dated April 2020, the P&P indicated 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, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to develop an individualized plan of care (POC) that included problems, goals and interventions for two of seven sampled patients (Patient 1 and Patient 5). For Patient 1, who had a diagnosis of acute appendicitis with perforation (a medical emergency where the appendix, a small worm-shaped organ attached to the large intestine, ruptures and releases bacteria into the abdominal cavity). This failure had the potential to result in Patient 1 not receiving the identified needs and services, which could lead to a decline in his health status and/or injury. For Patient 5, the HHA failed to ensure that each patient’s plan of care (POC) included all disciplines involved and clearly stated the frequency and duration of visits. This deficient practice resulted in patient’s needs and services not coordinated among the staff providing the care. During a concurrent home visit on 10/30/2025, at 11:30 a.m., with the DPCS preset, an interview with patient 5 (Spanish-speaking only) and Family Member 1(FM1) in the den of Patient 5’s residence. FM 1 stated that Patient 5 had a rash on his back that had been there and itching real bad for over a month. FM 1 stated that the LVN comes twice a week and that the CNA, who visits twice weekly , asked the family what for then rashes redness and itching of his back. Observation of Patient 5’s back indicated a large multiple bumpy red rash on his entire back with redness around patients 5’s cocci and buttocks area. During the home visit, the DPCS stated that she was not aware of the rash and would have to review the records and talk to the Skilled Nurse who was providing care. During a concurrent record review of patient 5’s EMR and interview with the DPCS in the HHA’s office on 11/3/2025, at 12pm., The DPCS stated the CNA providing care to patient 5 was employed through a registry due to the agency not having an in-house CNA. The DPCS confirmed there were no CNA visit notes in patient 5’s electronic medical record. The DPCS Stated CNA documentations were stored “ in a portal” and that she eeded to download and put them in the chart. The DPCS further stated she had not reviewed the CNA notes or the complete chart. During a review of Patient 5’s Home Health Certification and Plan of Care for the certification period of 9/29/2025 to 11/27/2025, with the Adm/DPCS in the HHA, it did not indicate the disciplines providing services or the frequency of visit. During an interview with the ADM/DPCA on 11/3/2025, at 11:30, in the office, she stated se did not know the POC was to have the information and that the HHA has a standard visit which is at least once a week routine. The ADM/DPCS stated she would have to ask the Skilled Nuse (SN) for the information. The ADM/DPCS was asked how does she ensure the disciplines are visiting the patient in which the ADM/DPCS stated, “they call me”. The ADM/DPCS was unable to provide the CNA/PT visit notes or any documentation the isit were being done by the various disciplines. The ADM/DPCS was unable to provide the documents and policy and procedures requested. Review of the home health certification and plan of care for patient 5 indicated a start of care date (SOC) of 2/1/2025 ,for the certification period of 9/29/2025 to 11/27/2025, With diagnosis that include hypertensive heart failure with heart failure( refers to heart problems that occur because of high blood pressure that is present for a long time), acute kidney failure( Sudden loss of kidney function when the kidneys can’t filter waste which affects fluid and electrolyte balance it can happen quickly and is often reversible with treatment Alzheimer’s disease( memory loss and other cognitive abilities that interfere with daily life), and cachexia( extreme loss of weight and muscle mass), and bed confinement status, During a review of Patient 1’s GACH discharge order dated 8/2/2025, indicated to a physician’s order to infuse Ertapenem 1 gram in Normal Saline 100 milliliters over 30 minutes via IV access every 24 hours via rate-flow/mini-bag every 24 hours until 8/24/2025 for intra-abdominal abscess. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/3/2025, with diagnosis that included acute appendicitis with perforation (a condition where the appendix , a small finger-shaped organ attached to the large intestine, becomes inflamed and ruptured. During a phone interview with Family Member (FM 1) 10/29/2025, at 12 p.m., FM 1 stated she was very upset that Registered Nurse (RN 1) did not show up on her scheduled visit day ( FM 1 unable to remember the date) to infuse the IV antibiotic because RN 1 had to go to a court hearing. FM 1 stated the HHA did not send a replacement nurse that led to Patient 1 not getting her IV antibiotic to treat her abscess. FM 1 also stated she called the HHA the following day and the staff told her the HHA could not send a replacement nurse because there are a lot of patients needing help. During a review of Patient 1’s electronic medical record (EMR) indicated that HHA did not develop a plan of care for intravenous (IV-a way of giving a drug or other substance through a needle or tube inserted into the vein) infusion management to treat Patient 1’s intra-abdominal abscess ( a collection of puss located within the abdominal cavity). During an interview, on 11/2/2025, at 12 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the HHA failed to develop a care plan for IV infusion management. During a review of the agency’s policy and procedure (P&P) titled, Home Health Certification and Plan of Care, dated 7/9/2018, the P&P indicated the Home Health Certification and Plan of Care (485) is the ordering practitioner’s order for home care services. The Plan of Care will be individualized to include, but not limited to, all treatments, procedures, medications, and services authorized to be provided by direct care staff(s). The Plan of Care shall include, but not limited to identified patient problems to include diagnoses and surgical procedures.”

“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, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that Registered Nurse (RN 1) administered Ertapenem (medication used to treat bacterial infections) Intravenous (IV- refers to a way of giving drug or other substances through a needle or tube inserted into a vein) medication as ordered by the physician for one of seven (7) sampled patients (Patient 1) due to lack of staffing. This failure put Patient 1 at increased risk to have infection and develop sepsis (a life-threatening condition that occurs when the body’s immune system overreacts to an infection that could lead to widespread inflammation and organ damage) that could lead to hospitalization and death. On 11/3/2025, at 11:40 a.m., while onsite at the agency, the Department called an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident), in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD), related to the Home Health Agency’s (HHA, medically focused care provided by skilled professionals like nurses and therapists in a patient home) failure to ensure that Registered Nurse (RN 1) administered Ertapenem (medication used to treat bacterial infections) 1 gram IV on 8/5/2025 as ordered by the physician from General Acute Care Hospital (GACH) to treat Patient 1’s intra-abdominal abscess due to lack of staffing. This failure put Patient 1 at increased risk to have infection and develop sepsis (a life-threatening condition that occurs when the body’s immune system overreacts to an infection that could lead to widespread inflammation and organ damage) that could lead to hospitalization and death. On 11/3/2025, the HHA was unable to submit an IJ removal Plan (IJRP, a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 11/3/2025 at 4 pm, the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD) with the IJ situation not removed. On 11/11/2025 the HHA was able to submit an IJ removal plan for G580 and G1012. The IJ removal plan was reviewed and accepted on 11/12/2025. On 11/12/2025 at 3:10 P.M., the survey team verified the implementation of the IJ removal while onsite and the IJ was removed in the presence of the DPCS. Findings: During a review of Patient 1’s General Acute Care Hospital (GACH) discharge order dated 8/2/2025, the discharge order indicated to infuse Ertapenem 1 gram (unit of measurement) in Normal Saline (a mixture of water and salt) 100 milliliters (ml, unit of measurement) over 30 minutes via IV access every 24 hours via rate-flow/mini-bag (a small IV bag of medication that is administered at a controlled rate using a flow rate controller) every 24 hours until 8/24/2025 for intra-abdominal abscess. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/3/2025, with diagnosis that included acute appendicitis with perforation (a condition where the appendix [a small finger-shaped organ attached to the large intestine], becomes inflamed and ruptured). During a phone interview with Family Member (FM 1) on 10/29/2025, at 12 p.m., FM 1 stated she was very upset that Registered Nurse (RN 1) did not show up on her scheduled visit day (FM 1 unable to remember the date) to infuse the IV antibiotic because RN 1 had to go to a court hearing. FM 1 stated the HHA did not send a replacement nurse that led to Patient 1 not getting her IV antibiotic to treat her abscess. FM 1 also stated she called the HHA the following day and the staff told her the HHA could not send a replacement nurse because there were a lot of patients needing help. During an interview with RN 1 on 10/29/2025, at 1 p.m., she stated she had a scheduled visit on 8/5/2025, to infuse the IV Ertapenem medication but she was unable to do the visit because she had to go to a court hearing on that day. RN 1 stated she tried looking for a replacement nurse, but they refused to do the visit because the patient lives far. During a review of Patient 1’s electronic medical record (EMR) (from 8/3/2025 to 8/10/2025), Patient 1’s EM indicated that HHA did not complete the initial evaluation using the Outcome and Assessment Information Set (OASIS) for evaluation conducted on 8/3/2025, there was no plan of care developed, no physician’s order for all patient’s medications being administered to the patient, no nursing notes completed for nursing visit scheduled dates of 8/3/2025 and 8/4/2025. A review of the HHA’s policy dated 11/2023 entitled” Administration and Documentation of Medications”, indicated that the license nurse will administer medications as ordered by the physician that can be safely administered and monitored during a home visit. License nursing personnel will administer and document medications which have been ordered as part of the plan of care and have been approved for safe administration and monitoring during a home visit.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview, and record review, the Registered Nurse (RN 1) failed to notify the physician promptly regarding the intravenous (IV-a way of giving a drug or other substance through a needle or tube inserted into the vein) infusion not administered due to the RN’s missed visit for one of seven sample patients (Patient 1). This deficient practice placed the patients at a potential risk for complications that could affect the patient’s health status and well being. During a review of Patient 1’s GACH (hospital) discharge order dated 8/2/2025, indicated to a physician’s order to infuse Ertapenem 1 gram in Normal Saline 100 milliliters over 30 minutes via IV access every 24 hours via rate-flow/mini-bag every 24 hours until 8/24/2025 for intra-abdominal abscess. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/3/2025, with diagnosis that included acute appendicitis with perforation (a condition where the appendix , a small finger-shaped organ attached to the large intestine, becomes inflamed and ruptured). During a phone interview with Family Member (FM 1) 10/29/2025, at 12 p.m., FM 1 stated she was very upset the Registered Nurse (RN 1) did not show up on her scheduled visit day ( FM 1 unable to remember the date) to infuse the IV antibiotic because RN 1 had to go to a court hearing. FM 1 stated the HHA did not send a replacement nurse that led to Patient 1 not getting her IV antibiotic to treat her abscess. FM 1 also stated she called the HHA the following day and the staff told her the HHA could not send a replacement nurse because there were a lot of patients needing help. During an interview with RN 1 on 10/29/2025, at 1 p.m., she stated she had a scheduled visit on 8/5/2025, to infuse the IV Ertapenem medication but she was unable to do the visit because she had to go to a court hearing on that day. RN 1 stated she tried looking for a replacement nurse, but they refused to do the visit because the patient lives far. RN 1 also stated she did not notify the physician regarding the missed visit. During a review of Patient 1’s electronic medical record (EMR) indicated there was no documented evidence the physician was notified regarding a missed visit for an IV antibiotic infusion to treat Patient 1’s intra-abdominal abscess (a collection of pus located within the abdominal cavity). During a review of the agency’s undated policy and procedure titled, “Care Planning Process”, indicated the purpose of this policy is to provide clinical direction to the clinicians providing direct patient care. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. Clinicians will inform the patient’s physician (or other authorized licensed independent practitioner) of any changes that suggest a need to alter the plan of care. Changes must be written, dated, and signed by the professional making the changes.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure there was an effective coordination among staffs providing care and services for one of 5 sampled patients (Patient 5). This deficient practice had the potential to result in the care and services identified in the plan of care will not be implemented among staff that could affect the patient’s health and safety. During a concurrent home visit on 10/30/2025, at 11:30 a.m., with the DPCS, an interview with Patient 5 (Spanish-speaking only) and Family Member 1(FM1) in the den of Patient 5’s residence. FM 1 stated that Patient 5 had a rash on his back that had been there and itching really bad for over a month. FM 1 stated that the LVN comes twice a week and that the CNA visits twice weekly. During the home visit it was observed Patient 5’s back had a large multiple bumpy red rashes on his entire back with redness around Patients 5’s coccyx (tailbone) and buttocks area. DPCS stated that she was not aware of the rashes and would have to review the records and would talk to the Skilled Nurse who was providing care. During a concurrent record review of Patient 5’s EMR and interview with the DPCS in the HHA’s office on 11/3/2025, at 12pm., The DPCS stated the CNA providing care to Patient 5 was employed through a registry due to the agency not having an in-house CNA. The DPCS confirmed there were no CNA visit notes in the Patient 5’s electronic medical record. The DPCS stated CNA documentations were stored “in a portal” and that she needed to download and put them in the chart. The DPCS further stated she had not reviewed the CNA notes or the complete chart. Review of Patient 5’s Home Health Certification and Plan of Care form, indicated Patient 5 was admitted to the HHA, with a start of care date of 2/1/2025, with diagnosis of Hypertensive heart disease with heart failure, acute kidney failure, cachexia, Alzheimer’s for the certification period of 9/29/2025 to 11/27/2025. The ADM/DPCS was unable to provide the HHA’s policy and procedure as requested.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to maintain a clinical record containing past and current information of patient receiving home health services for one of seven sampled patients (Patient 1) by failing to: 1. Ensure Patient 1 (General Acute Care Hospital) GACH Discharge order dated 8/2/2025 to administer Ertapenem (medication used to treat bacterial infections) Intravenous (IV- a way of giving a drug or other substance through a needle or tube inserted to a vein) every 24 hours was included to Patient 1’s plan of care. 2. Ensure Patient 1 medication and treatment orders were included on Patient’s 1 plan of care. 3. Ensure License staff document all interventions, including medication administration, treatments and services and responses to the interventions for Patient 1. 4. Ensure license staff completed an initial evaluation using the Outcome and Assessment Information Set (OASIS) on 8/3/2025 for Patient 1. 5. Ensure Patient 1 had a plan of care developed to outline the specific plan for medical, rehabilitation, and supportive services a patient needs at home. 6. Ensure Patient 1 had nursing notes completed for nursing visit conducted on 8/3/2025 and 8/4/2025. 7. Ensure to complete Oasis discharge comprehensive assessment for Patient 1. These failures had a potential to result with miscommunication within the interdisciplinary team (a group of professionals from different fields who collaborate to address complex issues, such as patient care), medication error, inappropriate treatment and services that could cause patient suffering severe harm, hospitalization and death. On 11/3/2025, at 11:450 a.m., while onsite at the agency, the Department called an IJ, in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD), related to the HHA’s failure to maintain a clinical record containing past and current information of patient receiving home health services for one of seven sampled patient (Patient 1) by failing to: 1. Ensure Patient 1 GACH Discharge order to administer Ertapenem (medication used to treat bacterial infections) Intravenous (IV- a way of giving a drug or other substance through a needle or tube inserted to a vein) every 24 hours was included to Patient 1’s plan of care. 2. Ensure Patient 1 medication and treatment orders were included on Patient’s 1 plan of care.3. Ensure License staff document all interventions, including medication administration, treatments and services and responses to the interventions for Patient 1. 4. Ensure license staff completed an initial evaluation using the Outcome and Assessment Information Set (OASIS)on 8/3/2025 for Patient 1. 5. Ensure Patient 1 had a plan of care developed to outline the specific plan for medical, rehabilitation, and supportive services a patient needs at home 6. Ensure Patient 1 had nursing notes completed for nursing visit conducted on 8/3/2025 and 8/4/2025. 7. Ensure to complete Oasis discharge comprehensive assessment for Patient 1. These failures had a potential to result with miscommunication within the interdisciplinary team (a group of professionals from different fields who collaborate to address complex issues, such as patient care), medication error, inappropriate treatment and services that could cause patient suffering severe harm, hospitalization and death. On 11/3/2025, the HHA was unable to submit an IJ removal Plan (IJRP, a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 11/3/2025 at 4 pm, the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD) with the IJ situation not removed. On 11/11/2025 the HHA was able to submit an IJ removal plan. The IJ removal plan was reviewed and accepted on 11/12/2025. On 11/12/2025 at 3:10 P.M., the survey team verified the implementation of the IJ removal while onsite and the IJ was removed in the presence of the DPCS. Review of Patient 5’s Home Health Certification and Plan Of Care form, indicated Patient 5 was admitted to the HHA, with a start of care date of 2/1/2025, with diagnosis of Hypertensive heart disease with heart failure, acute kidney failure, Cachexia ,Alzheimer’s for the certification period of 9/29/2025 to 11/27/2025. There were no CNA visit notes in patients EMR for the certification period During a concurrent home visit on 10/30/2025, at 11:30 a.m., with the DPCS preset, an interview with patient 5 (Spanish-speaking only) and Family Member 1(FM1) in the den of Patient 5’s residence. FM 1 stated that Patient 5 had a rash on his back that had been there and itching real bad for over a month. FM 1 stated that the LVN comes twice a week and that the CNA, who visits twice weekly , asked the family what for then rashes redness and itching of his back. Observation of Patient 5’s back indicated a large multiple bumpy red rash on his entire back with redness around patients 5’s cocci and buttocks area. During the home visit, the DPCS stated that she was not aware of the rash and would have to review the records and talk to the Skilled Nurse who was providing care. During a concurrent record review of patient 5’s EMR and interview with the DPCS in the HHA’s office on 11/3/2025, at 12pm., The DPCS stated the CNA providing care to patient 5 was employed through a registry due to the agency not having an in-house CNA. The DPCS confirmed there were no CNA visit notes in patient 5’s electronic medical record. The DPCS Stated CNA documentations were stored “ in a portal” and that she eeded to download and put them in the chart. The DPCS further stated she had not reviewed the CNA notes or the complete chart. During a review of Patient 5’s Home Health Certification and Plan of Care for the certification period of 9/29/2025 to 11/27/2025, with the Adm/DPCS in the HHA, it did not indicate the disciplines providing services or the frequency of visit. During an interview with the ADM/DPCA on 11/3/2025, at 11:30, in the office, she stated se did not know the POC was to have the information and that the HHA has a standard visit which is at least once a week routine. The ADM/DPCS stated she would have to ask the Skilled Nuse (SN) for the information. The ADM/DPCS was asked how does she ensure the disciplines are visiting the patient in which the ADM/DPCS stated, “they call me”. The ADM/DPCS was unable to provide the CNA/PT visit notes or any documentation the isit were being done by the various disciplines. The ADM/DPCS was unable to provide the documents and policy and procedures requested. Findings: During a review of Patient 1’s GACH discharge order dated 8/2/2025, indicated to a physician’s order to infuse Ertapenem 1 gram in Normal Saline 100 milliliters over 30 minutes via IV access every 24 hours via rate-flow/mini-bag every 24 hours until 8/24/2025 for intra-abdominal abscess. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/3/2025, with diagnosis that included acute appendicitis with perforation (a condition where the appendix , a small finger-shaped organ attached to the large intestine, becomes inflamed and ruptured. During a phone interview with Family Member (FM 1) 10/29/2025, at 12 p.m., FM 1 stated she was very upset that Registered Nurse (RN 1) did not show up on her scheduled visit day ( FM 1 unable to remember the date) to infuse the IV antibiotic because RN 1 had to go to a court hearing. FM 1 stated the HHA did not send a replacement nurse that led to Patient 1 not getting her IV antibiotic to treat her abscess. FM 1 also stated she called the HHA the following day and the staff told her the HHA could not send a replacement nurse because there are a lot of patients needing help. During a review of Patient 1’s electronic medical record (EMR) indicated that HHA did not complete the initial evaluation using the Outcome and Assessment Information Set (OASIS) dated 8/3/2025, there was no plan of care developed, no physician’s order for all patient’s medications being administered to the patient, no nursing notes completed for nursing visit scheduled dates of 8/3/2025 and 8/4/2025, and no discharge OASIS done. During an interview with RN 1 on 10/29/2025, at 1:30 p.m., she stated she did not complete the OASIS assessment, her nursing notes, the discharge OASIS and discharge summary and she did not transfer the hospital’s discharge physician’s order to their agency’s physician’s order form because the HHA’s biller told them there was a problem with the patient’s insurance and the HHA would not get paid for services rendered. A review of the HHA’s policy and procedure dated 11/2023, entitled “Contents Of The Clinical Records”, indicated a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problem and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contact personnel. The following information will be available in the clinical record for patients receiving skilled care as follows: a. Plan of treatment, plan of care b. signed and dated progress notes for each discipline rendering service c. Record and Findings of initial and ongoing assessments d. Procedures and treatments rendered e. Care planning activity based on the patient’s problem, needs, and expected outcomes f. Transfer/discharge summaries and other summary reports sent to the physician as required by law and regulation and organization policy.”